Gestational Trophoblastic Disease Flashcards
Recurrence rate of molar pregnancy
1/100
Diagnosis
- Abnormal bleeding
- Absent fetal heart tones
- Cystic ovarian enlargement (theca lutein cysts)
- Excessively high beta‐hCG
- “Snowstorm” appearance of ultrasound
- Expulsion of vesicles
Complete Mole
• 46 XX or XY • 1 sperm, no egg • NO fetus, fetal RBC • Diffuse villous edema • Uterine size > 50% gestational age • 15‐25% have theca lutein cysts • 15‐20 % postmolar malignant sequelae
Partial Mole
69 XXX or XXY • 2 sperm, 1 egg • Fetus / fetal parts often present • Usually with fetal RBCs • Variable, focal villous edema • Small for gestational age • Rare theca lutein cysts • < 5% postmolar malignant sequelae
Violaceous friable nodule on the cervix after pregnancy
DO NOT BIOPSY!! – Metastatic gestational trophoblastic disease will hemorrhage • Order a serum B – hCG • In real life, you would likely obtain simultaneous ultrasound / imaging
Treatment of Molar Gestation
Ensure medical stability • Adequate history • Thorough physical exam (for metastasis) • Chest radiography • Beta‐hCG • Evacuate uterus • Consider hysterectomy if appropriate
Prior to evacuation • CBC • PT/PTT/INR • Renal / Liver function • Blood type and antibody screen • hCG • CXR • +/‐ TSH (+ if thyroid storm) • +/‐ rh immunoglobulin
Operative considerations
• Consider ultrasound guidance
• Oxytocin after cervix is dilated and several
hours postoperative
• Consider misoprostol
• If the patient is in thyroid storm, unlike any
other situation, the treatment is surgery –
control symptoms and proceed
Follow-up of Gestational Trophoblastic disease
CONTRACEPTION • B‐hCG levels – Weekly while abnormal – Monthly for 6 months after normal (<5) • Frequent pelvic exams • Attempt pregnancy – after 6‐12 months of normal B‐hCG • 1‐2% risk in future pregnancies
Gestational Trophoblastic Disease Diagnosis
hCG increase of more than 10% over a 2 week
duration (3 values: d 1,7,14)
• hCG plateau +/‐ 10% over a 3 week duration (4
values)
• Persistence of hCG for more than 6 months
post evacuation
Abnormal bleeding more than 6 weeks after
any pregnancy
• Neurological symptoms
• Metastasis to other organs
• Evaluate for metastasis – History and Physical – CT chest, abdomen and pelvis – Head CT or MRI, if symptoms • Establish a prognostic score to predict resistance to single‐agent chemotherapy
Treatment of gestational trophoblastic neoplasm
Treatment of low‐risk GTN (0‐6)
• Single agent chemotherapy
– Methotrexate
– Actinomycin D
• Treat for 2 cycles beyond normal B‐hCG
• Alternate agent if fails first therapy
• If fail both single agents, multi‐agent therapy
• Hysterectomy may shorten number of courses
in patients that have completed childbearing
Treatment of high‐risk GTN ( >6) • Multiagent chemotherapy – EMA‐CO • Etoposide, methotrexate, actinomycin, cytoxan, vincristine
• Multimodal therapy
– Resect lung, liver, spleen, renal lesions
• Irradiate metastasis (esp. brain)
• >10% recurrence after therapy
Treatment Outcomes
• Survival – Non‐metastatic 98‐100% – Metastatic low risk 98‐100% – High‐risk 65‐70% • Recurrence Risk – Non‐metastatic 2.5% – Metastatic • Good prognosis – 4% • Poor prognosis – 12%
Placental Site Trophoblastic tumor (PSTT)
• Pathologic diagnosis • hCG not a marker, hPL (human placental lactogen) • Arise from intermediate trophoblasts • 20% present with extrauterine metastases • Hysterectomy recommended due to chemotherapy resistance • Chemotherapy used as an adjuvant – EMA‐CO or EMA‐EP
Phantom hCG
Heterophilic antibody (HAMA response) – Human Anti‐bodies against animal derived antigens used in the assays – Patients often work with animals (vet, research lab) • Usually B‐hCG 100‐500 mIU/ml • Urine pregnancy test is negative • Serial Dilution studies – Won’t be linear if phantom • Some labs “preabsorb” to remove the heterophilic antibody – If negative after removal = phantom
