Gestational trophoblastic disease (GTD) Flashcards
what is GTD
tumor originating from the trophoblast, which surrounds the blastocyst and develops into the chorion and amnion
can occur during or after an intrauterine or ectopic pregnancy
which diseases characterize GTD
include hydatidiform moles (both complete and partial), invasive moles, and choriocarcinoma.
typically arise from the abnormal fertilization of the ovum or overproliferation of the trophoblast
what is a Hydatidiform mole
growth of an abnormal fertilized egg (molar pregnancy) or an overgrowth of trophoblast from the placenta.
classificcation of hytadid mole
COMPLETE -no fetal parts -caused by fertilization of an empty egg w/o chromosomes -46xx d/2 sperm splitting 90% 46xy: dispermy 46yy is non viable so is not seen -diffuse choronic villi enlargement and inflammatin -increased risk of choriocarcinoma
partial -parts of fetus present -caused by fertilization of egg containing a haploid set of chromosomes with two sperms (each of them containing a haploid set of chromosomes) tal karyotype 69XXX, 69XXY, 69XYY -reduced risk of choriocarcinoma
invasive
Trophoblasts infiltrate the myometrium and gain access to the vascular system.
Hematogenic dissemination leads to metastatic growth in different organs (brain, lungs, liver).
RF for hytadid mole
Prior molar pregnancy
History of miscarriage
Patients ≤ 15 and ≥ 35 years
clinical features of complete mole
first trimester
vaginal bleeding
Uterus size greater than normal for gestational age
pathognomic ‘bunch of grapes’ which are vesicles(inflammed fluid filled blisters) that pass through vagina
endocrine symptoms
-preeclampsia before 20th wk gestation
-Hyperemesis gravidarum(severe nausea and vom in preg)
hyperthyroidism(Very high amounts of β-hCG may lead to hyperthyroidism because β-hCG structurally resembles TSH.)
Ovarian theca lutein cysts: bilateral, large, cystic, adnexal masses that are tender to the touch
what is a theca lutein cyst
functional ovarian cyst that is thought to originate from excessive amounts of circulating gonadotropins such as β-hCG. Typically multiple and seen bilaterally, with a high association with gestational trophoblastic disease and multiple gestations. USG shows bilateral enlarged, multilocular, cystic masses of the ovaries. Usually resolve spontaneously once the source of beta-hCG is removed
clinical features of partial mole
Less severe symptoms due to β-HCG levels that are lower than in complete moles
Vaginal bleeding
Pelvic tenderness
dg if hytadiform mole
β-HCG level measurement: reveal β-HCG that is way higher than expected for the gestational age
d/2 overproduction by proliferating trophoblast cells (> 100,000 mIU/mL)
Transvaginal ultrasound
complete:
- bunch of grapes,” or “snowstorm”) d/2 cystic spaces formed by hydropic(inflamed) villi
- No amniotic fluid
- Lack of fetal heart tones
partial:
-fetal parts may be visualized.
-Fetal heart tones may be detectable.
-Amniotic fluid is present.
-Increased placental thickness
-Swiss cheese US appearance
uterine evacuation: histopathological examination of evacuated uterine specimen
what dg method provides definite diagnosis
Uterine evacuation
rx of hytadid mole
Uterine evacuation by dilation and suction curettage to prevent invasive moles and choriocarinoma
Chemotherapy (usually methotrexate) if unresolved e.g.
1) β-HCG values do not decrease.
2) Histological features of malignant GTD are present.
3) If metastases are present on chest x-ray.
prognosis of hytadiform mole
Most patients achieve normal reproductive function after recovery.
define choriocarcinoma
Highly aggressive, malignant tumor consisting of trophoblastic tissue(synciotrophoblast and cytotrophoblast)
with a tendency to metastasize early vie hematogenous route
Staging 1 low risk
Stage 2-4 high risk
etiology of choriocarcinoma
50% hydatidiform mole
25% miscarriages or ectopic pregnancy
25% normal pregnancy
how does a choriocarcinoma develop (pathophys)
Destructive growth into myometrium without chorionic villi → risk of hemorrhage and early metastasis
Stage
site of metastases if choriocinoma via hematogenic dissemination
lung (most common) vagina, brain, liver
clinical features of choriocarcinoma
Late post partum bleeding and vaginal mass
Lung mt sx: cough, dyspnoea, hemoptysis
CNS mt: headache and dizzy
very high β-HCG (initial test of choice)
Pelvic ultrasound: mass of varying appearance
Uterine dilation and curettage (D&C) also therapeutic
Histopathologic examination shows cytotrophoblasts and syncytiotrophoblasts !!without chorionic villi!!
rx of choriocarcinoma
chemotherapy (methotrexate)
Surgical treatment (e.g., hysterectomy): may be indicated to stop bleeding from cancerous lesions or to excise distant metastases especially women over 40
Same follow up as invasive
prognosis of choriocarcinoma
good prognosis if caught early
metastasis shows worse prognosis
Staging of invasive mole
Stage 1: confined to the uterus
Stage 2: metastasis to pelvis and vagina
Stage 3: metastasis to lungs
Stage 4: distant metastasis to brain and liver
Invasive mole clinical presentation
history of molar pregnancy w/ HCGrise on follow up
abnormal uterine bleeding
Dg of invasive mole
HCG lvls
Pelvic ultrasound:
X-ray base lime in case of metastasis
Liver func tests
MRI of head
Rx of gestational trophoblastic neoplasias
Low risk:
methotrexate
During treatment, the serum hCG levels are monitored every week
Once hCG is normal give 6 wk maintenance dose
Normal maintenance of hCG for 4 wks then Check every year
If hCG rise or plateau switch to actinomycin D of still low risk
High risk: (EMA-CO regimen) then ( EMA-EP) for 6 weeks
Week 1 etopiside +methotrexate +actinomycin d
Week2 cyclophosphamide and oncovin
Week3 repeat week 1
week 4 swap CO for Etopiside and a Platin derivative
What is low and high risk
WHO score of less than 7 (low-risk)
and those with a score of 7 or higher and who are at high risk of therapy failure.
Fertility
Barrier contraception only until hCG is normalised
After normalisation wait 1 year post chemo before having children
Surgical care of gestational trophoblastic neoplasia’s
Hysterectomy: if uncontrolled vaginal bleeding. may reduce total number of chemotherapy cycles for remission
Uterine or hypogastric artery ligation or embolization of feeding vessels may be needed to control hemorrhage.
repeat D&C in the presence of persistent tissue on pelvic ultrasonography
Resection of solitary metastasis
What is a placental site trophoblastic tumour
Proliferation of cytotrophoblasts at the site of placental implantation usually confined w/in the uterus
Very rare and doesn’t respond to chemo
Sx: chronic persistent bleeding weeks to mo post partum
Diagnosis: low hCG which excludes choriocarcinoma, enlarged mass on pelvic ultrasound
Rx: hysterectomy w/ prophylactic chemo
