Gestational Trophoblastic Disease

Question 1

Gestational Trophoblastic Disease

Answer 1

From abnormal proliferation of placental = trophoblastic tissue (unique - fetal origin)

Malignant versions very chemosensitive (really curable; can preserve fertility)

Question 2

Gestational Trophoblastic Disease tumor marker

Answer 2

Make hCG (tumor marker; for dx & following progression)

Question 3

Potential consequences of Gestational Trophoblastic Disease

Answer 3

Remember hCG has common alpha subunit with LH/FSH/TSH

Can result in theca lutein cysts, hyperthyroidism, early PEC, hyperemesis

Question 4

Benign GTD = “molar pregnancies” = “hyatidiform moles”

Answer 4

Highest in Asian women esp Japan (1/500!); extreme age, prior GTD; nullips are big risk factors too

Question 5

Diagnosis of benign GTD

Answer 5

Dx: sx as described above, bleeding + early PEC, hyperthyroidism, etc.
PE: Uterus S>D; may see grape like clusters at os, palpate big theca lutein cysts
Pelvic U/S: “snowstorm” pattern
Definitive dx: pathologic examination

Question 6

Complete / Classic Mole (90%) genetics

Answer 6

46,XX (all paternal)

Question 7

Partial / Incomplete Mole (10%) genetics

Answer 7

69,XXY (extra paternal set)

Question 8

Complete / Classic Mole pathology

Answer 8

No coexistent fetus / fetal RBC

Hydropic (swollen, ‘grape like’) villi

Question 9

Partial / Incomplete Mole pathology

Answer 9

Coexistent fetus / RBC

No hydropic villi

Question 10

Complete / Classic Mole presentation

Answer 10

No embryo
Presents with abnormal vaginal bleeding
Classic sx (hyperemiesis gravidarum, early PEC, hyperthyroidism, anemia, really big uterus S»D) common
Theca lutein cysts in 25%
hCG really high (>100,000), takes 14 wks to normalize

Question 11

Partial / Incomplete Mole presentation

Answer 11

Yes embryo
Presents like missed Ab
Classic sx rare
Uterus S=D
Rare theca lutein cysts
hCG slightly elevated, takes 8 wks to normalize

Question 12

Complete / Classic Mole malignant potential

Answer 12

15-25% nonmetastatic malignancy

4% metastatic malignancy

Question 13

Partial / Incomplete Mole malignant potential

Answer 13

2-4% nonmetastatic

Question 14

Treatment of benign GTD

Answer 14

IMMEDIATE D&C followed by IV oxytocin
Get baseline hCG first; Rh status to see if RhoGAM needed, CXR optional(?)
May need antiHTN meds if preeclamptic
May need beta blockers (propranolol) if thyroid storm
May do hysterectomy if done childbearing

Question 15

Prognosis of benign GTD

Answer 15

95-100% cure rate
15-25% persistent disease
Follow up closely with serial hCGs until negative x 3 consecutive weeks, then monthly
Prevent pregnancy during the followup (otherwise can’t monitor hCG) with OCPs!!

Question 16

Types of malignant GTD

Answer 16

Persistent / invasive moles (75%)
Choriocarcinoma (25%)
PSTT (really rare) = placental site trophoblastic tumors

Question 17

Persistent / invasive moles (75%)

Answer 17

Arise after evacuation of molar pregnancy: hydropic villi / tropoblasts invade myomet.
Rarely metastasize; can regress spontaneously

Question 18

Persistent / invasive moles diagnosis

Answer 18

Dx: plateauing / rising hCG after tx for molar pregnancy, can have uterine bleeding

Question 19

Persistent / invasive moles treatment

Answer 19

Tx: single agent chemo (MTX / actinomycin D) if low risk, multiagent if high risk

Question 20

Choriocarcinoma(25%)

Answer 20

Pure epithelial tumor; sheets of anaplastic cytotrophoblasts without villi.

Question 21

Presentation of choriocarcinoma

Answer 21

Malignant, necrotizing, arises weeks/years after pregnancy
Often metastatic, can spread hematogenously (lungs / vagina / pelvis / brain / liver / GI)
Present with late postpartum bleeding or irregular bleeding years later
Mets to lungs → cough, resp distress, hemoptysis

Question 22

Diagnosis of choriocarcinoma

Answer 22

Only a positive beta-HCG in a reproductive-aged woman who has a history of a recent pregnancy (term, miscarriage, termination, mole) is necessary to establish the diagnosis

(Tissue diagnosis is the standard in establishing a diagnosis of most all malignancies, with the exception of choriocarcinoma.)

Question 23

Work up for choriocarcinoma

Answer 23

Get hCG, CBC/coags, pelvic U/S (doppler → really vascular), CXR/chest CT for lungs, abd/pelvic CT or MRI to look for mets as well

Question 24

Treatment for choriocarcinoma

Answer 24

Tx: single agent chemo / multiagent chemo depending on prognosis

Question 25

PSTT (really rare) = placental site trophoblastic tumors

Answer 25

Arise from placental implantation site; no villi, intermediate trophoblasts proliferating
Persistent irregular vaginal bleeding + big uterus
Chronic low levels of hCG (no syncitiotrophoblasts proliferating)

Question 26

Treatment of PSTT

Answer 26

Treat with hysterectomy → multiagent chemo 1 week later to prevent recurrence

Question 27

Malignant GTD

Answer 27

Metastatic if beyond uterus; bad prognosis if metastatic and bHCG > 40,000, duration > 4mo, mets to brain or liver, chemo failure, GTD after a term pregnancy
Staging not clinically useful
Really chemosensitive - NO ROLE FOR SURGERY unless high risk or PSTT
Follow bHCG