Gestational trophoblastic disease Flashcards
What percent of GTDs are benign? What are they?
80% MOLAR PREGNANCIES aka. hydatidiform moles Complete mole (90%) partial mole (10%)
What percent of GTDs are malignant? What are they?
20%
Persistent/invasive mole (10-15%)
Choriocarcinoma (2-5%)
Placental site trophoblastic tumors (very rare)
Good thing about GTD for treatment?
Extremely sensitive to chemotherapy
Epidemiology
1/1000 pregnancies of white women. There’s a lower rate in black women in USA. Varies around the world.
HIGHEST AMONG ASIANS. (Japan 1/500)
Risk factors
- Extremes in age (women under 20 slightly, women over 35 a LOT…also have higher risk of MALIGNANT disease)
- Prior hx of GTD
- Nulliparity
- Diet low in beta-carotene, folic acid, animal fat
- Smoking, infertility, spontaneous abortion, blood group A, OCP use
Baseline risk? Risk in 1 prior? 2 prior?
Baseline is 0.1%
1 prior is 1%
2 prior is 16-28%
How does complete mole form? Chromo number?
- Empty egg, one normal sperm that DUPLICATES.
- All chromos paternally derived.
- 46,XX
Placental abnormality in complete mole?
NONINVASIVE trophoblastic proliferation, so the chorionic villi swell–> hydropic degeneration–> no fetal villy
Hormone disruptions in complete mole?
B-HCG unbelievably high (>100,000 mIU/mL) and its alpha subunit mimics TSH, LH, FSH.
The LH and FSH stimulation leads to LARGE THECA LUTEIN CYSTS
TSH leads to hyperthyroidism
B-HCG leads to hyperemesis gravidarum
Early preeclampsia
Do complete moles or partial moles have a higher malignant potential?
Complete moles (15-25%, 4% risk of mets)
Partial moles only have a 2-4% and NO risk of mets
How long do you follow up hCG levels with complete mole? Partial mole?
Complete is 14 wks
Partial is 8 wks
Presentation of a complete mole?
-Irregular or heavy bleeding during early pregnancy (b/c tumor separates from decidua)
Other: hyepremesis gravidarum, preeclampsia sx like irritability, dizziness, photophobia
Passage of molar vesicles 80% Anemia 50% Size greater than dates 30-50% Bilateral theca lutein cysts 25% Hyperthyroidism 10% Trophoblastic pulm embolic 2%
In someone who doesn’t have chronic hypertension, PREECLAMPISA BEFORE 20 WEEKS IS PATHOGNOMONIC FOR MOLAR PREGNANCY
Snowstorm pattern on u/s is CONFIRMATORY TEST.
Treatment for molar pregnancy?
- Immediate D&C
- Check Rh(D) status to prepare for possibly heavy vaginal bleeding during procedure
- Treat htn and hyperthyroidism with antihypertensives (dec risk of maternal stroke) and beta-blockers to avoid thyroid storm
- Have IV access and cross-matched blood available before the D&C
- GENERAL ANESTHESIA (due to hemorrhage risk and trophoblastic embolization risk)
-Give IV oxytocin immediately after to get uterus to contract and minimize blood loss
HYSTERECTOMY IS AN OPTION TOO
DO NOT GET PREGNANT WHILE THE HCG IS BEING MONITORED!!!
Do you care about administering RhoGAM in molar pregnancies?
YES!
Timing of serial hCG titers following D&C?
Within 48 hours.
Weekly until negative for 3 consecutive weeks.
Red flag of hCG level in months following D&C?
- Plateau or rise in hCG levels
- If hCG is present greater than 6 months after the D&C
How does a partial mole form?
One egg gets fertilized by two sperm SIMULTANEOUSLY (unlike in compete mole…two sperm there is extremely rare)
80% 69XXY
hCG levels in partial molar pregnancy?
Normal or only slightly elevated
Clinical presentation of partial mole?
90% have vaginal bleeding from miscarriage or incomplete abortion in late first trimester or early second
Diagnosed later than complete
Physical exam of partial mole?
Normal usually.
Fetal heart tones PRESENT
Size less than or equal to dates
Diagnosis of partial mole?
Pelvic ultrasound shows fetus with congenital issues like IUGR, cardiac anomalies, etc.
Amniotic fluid usually reduced
SWISS CHEESE appearance
Definitive diagnosis is pathologic examination of intrauterine tissue. Treatment and follow up is same as complete mole (but partial needs HCG to be followed only 8 wks)
When does malignant GTD occur?
50% months to years after a molar pregnancy
25% after a normal pregnancy
25% after a miscarriage, ectopic, or abortion
MC malignant GTD that follows a MOLAR pregnancy?
Persistant/invasive GTD
MC malignant GTD that follows a NONMOLAR pregnancy?
Choriocarcinoma
Invasive moles pathogenesis?
Almost always occur after a molar pregnancy has been evacuated.
Hydropic villi and trophoblasts penetrate into the myometrium.
Rarely they can cause uterine rupture, hemoperitoneum, severe anemia.
Rarely metastasize and CAN spontaneously regress.
Presentation of persistent/invasive mole? Diagnosis?
Plateauing or rising hCG after molar pregnancy rx.
Abnormal uterine bleeding.
Diagnose with pelvic u/s and hCG level. Doppler shows high vascular flow.
Treatment of persistent/invasive mole?
Single agent chemo (since they’re usually nonmetastatic).
Methotrexate
Actinomycin D
If mets, use multiple agent chemo.
Follow up with hCG levels, like everything in this…
What is choriocarcinoma?
Malignant necrotizing tumor.
Pure epithelial tumor.
Sheets of anaplastic cytotrophoblasts and syncytiotrophoblasts with the absence of chorionic villi.
Spreads hematogenously…FARRRR.
More common in Asians/Africans.
1/20k-40k pregnancies in USA (exceedingly rare)
Clinical presentation of choriocarcinoma?
- Late postpartum bleeding (over 6-8wks).
- Irregular uterine bleeding YEARS AFTER normal pregnancy.
- Lung mets can cause dyspnea, hemoptysis
- CNS lesions
- Vaginal mets vaginal bleeding
Diagnosis of choriocarcinoma?
“The great imitator”; diagnosis often delayed.
- hCG levels, pelvic u/s may show uterine mass with hemorrhage and necrosis
- HIGHLY VASULAR
- CXR or chest CT for lung mets
- Abdominal/pelvic CT
- CT or MRI of brain
Treatment of choriocarcinoma?
Single agent chemo or multi agent if metastatic
Cure rate for choriocarcinoma?
90-100% for good prognosis type
50-70% for poor prognosis type
PSTT?
- Arises from placental implantation site.
- Absence of villi
- EXCESSIVE hPL!
Clinical presentation of PSTT? Diagnosis?
Irregular vaginal bleeding, maybe enlarged uterus
- Diagnose with hPL
- Chronic low levels of hCG (<100mIU/mL) bc the tumors lack proliferation of syncytiotrophoblasts (the placental layer that MAKES hCG)
- Pelvic u/s
Treatment of PSTT?
NOT REALLY SENSITIVE TO CHEMO (but rarely mets)
Hysterectomy! Follow with multi agent chemo 1 week after
