Gestational Trophoblastic Disease Flashcards by Gretchen Hackett

What diseases are included in gestational trophoblastic disease?

Benign Hydatiform Mole: Complete or partial
Invasive Mole: Can metastasize
Choriocarcinoma

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What do the moles and choriocarcinomas secrete?

B-HCG - Can be sky high

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What basically is gestational trophoblastic disease?

Fertilization that has gone bad

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What are the majority of hydatiform moles?

Complete

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What happens in a complete hydatiform mole?

Fertilization of an “empty” egg by a haploid sperm which duplicates its chromosomes

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What is the karyotype of a complete mole normally?

46XX with both X paternally derived

-Rarely 46XY

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Are complete moles associated with a fetus?

Rarely

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What is another word for a partial mole?

Incomplete mole

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What do partial moles result from?

2 sperms fertilizing one egg

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What % of moles are partial moles?

10%

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That is the karyotype of a partial mole?

69XXY (80%) –> Extra paternal set

Can be 69XXX
Occasionally have a mosaic pattern

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Do partial moles present with a coexisting fetus?

Often

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What hCG level should you see something in the uterus?

1200…if nothing is there… think ectopic

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What are 2 CA that cross the placenta?

Choriocarcinoma

2. Melanoma

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What is an invasive mole?

A locally invasive tumor

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What % of GTD are invasive moles?

5-10%

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Do invasive moles metastasize?

Rarely

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If an invasive mole metastasizes, where does it go?

Vag or lungs… sometimes brain

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What do invasive moles represent?

Majority of patients with persistent B-HCG elevations after molar evacuation

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Why is it important to use a sharp currete and scrape uterus after a vacuum D&C?

If you leave tissue it can turn into a choriocarcinoma

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What is a frankly malignant form of GTD?

Choriocarcinoma

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How many patients with choriocarcinoma had a preceding molar pregnancy?

1/2

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What is important to do with someone who had a molar pregnancy?

Follow their HCG levels to normal… which is under 2

-Basically just keep an eye on their labs

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What have the other half of patients with choriocarcinoma have before?

Spontaneous or induced abortion, ectopic pregnancy, or normal pregnancy

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How does choriocarcinoma disseminate?

Hematogenously

What is the fancy wording for cancer that can cross the placenta?

Placental-site trophoblastic tumor

What do placental-site trophoblastic tumors consist of?

Intermediate trophoblast and a few syncytial elements

What do placental-site trophoblastic tumors produce?

Small amounts of hCG and human placental lactogen

True or False: Placental-site trophoblastic tumors remain confined to the uterus?

True

Are placental-site trophoblastic tumors sensitive to chemo and do they metastasize?

Metastasize late in course and are insensitive to chemo

Some general epidemiology facts about GTD...

1. 1/1000 to 1/1200 pregnancies in the U.S. 2. 1/1500 to 1/2000 among caucasian. 3. 1/800 among Asians in the U.S. 4. In Taiwan, 1/125 to 1/200 pregnancies. 5. Risk of developing a second molar pregnancy is 1% to 3% or 40 times greater than the risk of developing the first one.

What is the cause of GTD?

Exact cause unknown... related to defective fertilization

Where is GTD higher?

In areas where there is less B-carotene and folic acid consumed

What age group is GTD highest in?

Younger than 20, older than 40

What needs to be done if GTD happens more than once?

Counseling... look at history, do they take pre-natal vitamins, ect.

What are the 2 subtypes of hydatiform mole and are they usually benign or malignant?

1. Complete 2. Partial/Incomplete - Both are benign

How does a complete mole appear?

Vesicles or a bunch of grapes

What 3 things are complete moles pathologically associated with?

1. Hydropic villi 2. Absence of fetal vessels 3. Hyperplasia of trophoblastic tissue

What are 6 symptoms associated with a complete mole?

1. Irregular Heavy Vaginal bleeding in the first or early second trimester. 2. Usually Painless 3. Sometimes nausea or “hyperemesis”. 4. May expel vesicles. 5. May experience nervousness, anorexia and tremors associated with hyperthyroidism. 6. May experience irritability, dizziness and photophobia associated with pre-eclampsia.

What kind of vitals are seem with complete moles?

Tachycardia, tachpnea, HTN

What is seen in chest exam with complete mole?

Wheezing and rhonchi (maybe spread to lungs)

What is seen in abdomen exam with complete mole?

Absent fetal heart sounds, larger than expected uterus

What is seen in the vag with a complete mole?

Grapelike vesicles

What is the seen in the ovary with a complete mole?

1/3 will have theca-lutein cysts

What 2 things are diagnostic for a complete mole?

1. High B-HCG titers | 2. US shows snow storm pattern (snow-storm)

What is done for treatment of complete mole?

1. Suction Evacuation followed by sharp curettage. 2. I.V. Pitocin 3. Follow up includes B-hCGs every 2-3 days until negative then weekly for three weeks then monthly times one year.

In a complete mole, B-HCG levels should decline by what time period after treatment?

12-16 weeks

What % of patients have a spontaneous remission of a complete mole?

90%

What 2 things should be done with complete mole for monitoring?

CXR and Liver Enzymes

When should chemotherapy (usually methotrexate or Actinmycin-D) be started with a complete mole?

If B-HCG levels plateau or rise at any time

What can be done for a complete mole in age appropriate patients (over 40, ect.)?

Hysterectomy

Where do gynecological cancers like to metastasize to?

Lung, liver, brain

What is the most common gyn CA?

Endometrial - Them ovarian (which is also most deadly), then cervical, then vulvar, then vaginal, then fallopian - Worldwide, cervical CA is most common gyn CA, but no here because of vaccines and pap smears)

What factors are associated with high risk of developing persistence after complete molar pregnancy?

1, Age>40 2. Prior molar pregnancy 3. Uterine size greater than dates 4. Prominent Theca- Lutein Cysts 5. Serum hCG>100,000 mIU/mL 6. Preeclampsia 7. Hyperthyroidism 8. Trophoblastic Embolization

What is a partial mole associated with?

A developing fetus

What kind of features are seen with a partial mole?

Similar pathologic and clinical features as patients with compelte moles, only less severe

When are partial moles diagnosed?

Later than complete moles

How do partial moles present?

Spontaneous or missed abortion

True or False: Most patients are big for dates with partial moles?

FALSE- Most patients are small for dates

What can US indicate in a partial mole?

Molar degeneration with developing fetus

If pre-eclampsia occurs with a partial mole, when will it happen?

One month later than a compelte mole

Are partial moles more or less likely to metastasize compared to a complete mole?

Less likely

What are the symptoms of a choriocarcinoma?

1. Vaginal Bleeding but occasionally amenorrhea. 2. Respiratory: Hemoptysis 3. CNS: Headaches, dizzy spells and blacking out. --> Brain mets 4. GI: Rectal Bleeding

What are 4 signs of a choriocarcinoma?

1. Uterine enlargement 2. firm discolored mass in vagina 3. Acute abdomen from ruptured uterus, theca-lutein cyst or liver. 4. Neurologic Signs

How is a choriocarcinoma diagnosed?

Persistent elevated B-HCG

How is a choriocarcinoma worked up?

Same as a molar pregnancy, but it should include a CT scan

What needs to be scanned with choriocarcinoma?

Essentially the whole body - Abdomen, pelvis, head -Also do a LP to see if it is in the CNS

In patients with a good prognosis, what is the treatment for choriocarcinoma?

1. Methotrexate | 2. Actinomycin-D

What constitutes good prognosis for choriocarcinoma?

- Between 20-40 years old | - HCG under 100,000

In patients with a poor prognosis, what is treatment for choriocarcinoma?

1. Combination chemotherapy 2. MAC : methotrexate, actinomycin-D, Cyclophosphamide. 3. EMA-CO: 6 drugs.

What is done for metastic GTD (choriocarcinoma)?

If metastatic to brain or liver... radiation is often used in conjunction with chemo

What is done for follow up with a choriocarcinoma?

1. Follow these patients closely 2. Titers every month for 1-2 years depending on prognosis--> Then every 3 months for 5 years 3. Avoid pregnancy **This is different from molar...more frequent

After a molar evacuation, patients should be advised to avoid pregnancy for how long?

1 year (this is for a benign or partial mole)

What should be given after a molar evacuation?

A reliable contraceptive

For metastatic patients with a good prognosis, what is the cure rate?

95-100%

For metastatic patients with a poor prognosis, what is the cure rate?

50-70%

What do the majority of patients who die from GTD have?

Brain or liver mets