Gestational Trophoblastic diseases

Question 1

What is Gestational trophoblastic malignancy (GTM)?

Answer 1

GTD with local invasion and metastasis. Include invasive mole, choriocarcinoma, placental site trophoblastic tumor.

Question 2

What is the aetiology of Gestational trophoblastic malignancy (GTM)?

Answer 2

Abnormal chromosomal material of placental tissue.

· Invasive moles always form from hyatidiform nuclei.

· Choriocarcinoma often after molar pregnancy, viable, miscarriage or ectopic

RF extreme of age, ethnicity (Asian), previous GTD, diet (low fat, low B carotene)

Question 3

What is the epidemiology of Gestational trophoblastic malignancy (GTM)?

Answer 3

Follows 25% complete and 2% partial moles. 1/20k pregnancies.

Question 4

What is in the history of Gestational trophoblastic malignancy (GTM)?

Answer 4

Persistent PV bleed, HEMG, lower abdo pain.

Symptoms of lung, brain and bladder/bowel mets.

Question 5

What is in the examination of Gestational trophoblastic malignancy (GTM)?

Answer 5

Excessive uterine size for gestation.

Question 6

What is the pathology of Gestational trophoblastic malignancy (GTM)?

Answer 6

Invasive mole: characteristic of hyatidiform mole, with invasion into myometrium, necrosis and haemorrage.

Choriocarcinoma: Cytotrophoblast and syncitiotrophoblast without formed choronic villi invade myometrium.

Placental site trophoblastic tumor: intermetidate trophoblasts infiltrate myometrium without causing tissue distruction. Contains HPL.

All metastasize promptly, especially to lungs, pelvis and brain.

Question 7

What investigations do you do for Gestational trophoblastic malignancy (GTM)?

Answer 7

Blood: serum BHCG (high, persistently high after EPRC),

CT CAP, MRI brain.

Question 8

What is the management of Gestational trophoblastic malignancy (GTM)?

Answer 8

Manage in specialist centres CXH, sheffield, dunde. Chemotherapy with MTX. Hysterecromt for placental site trophoblastic tumor.

Question 9

What are the complications/ prognosis of Gestational trophoblastic malignancy (GTM)?

Answer 9

Metastasis, side effects of chemotherapy.

Non metastatic and low risk metastatic diseaseL 100% cure rate with chemo.

High risk metastatic disease: 75% cure rate with chemo.

Question 10

What is Gestational trophoblastic disease (hyaditiform nuclei) (GTD)?

Answer 10

Benign tumor of trophoblastic tissue.

Question 11

What is the aetiology of Gestational trophoblastic disease (hyaditiform nuclei) (GTD)?

Answer 11

Abnormal fertilisation.

· Complete moles: diploid and paternal in origin, no fetal tissue, usually arise from duplication of haploid sperm after fertilisation of an empty ovum, or from dispermic fertilisation of an empty ovum.

· Partial moles: Triploid with two sets of paternal haploid genes, and one set of maternal haploid genes following dispermic fertilisation of an ovum, may contain fetal parts or red blood cells.

Question 12

What is the epidemiology of Gestational trophoblastic disease (hyaditiform nuclei) (GTD)?

Answer 12

1/1500 pregnancies

Question 13

What is in the history of Gestational trophoblastic disease (hyaditiform nuclei) (GTD)?

Answer 13

PV bleeding, hyperemesis (very high BHCG), symptoms of hyperthyroidism rarely.

Question 14

What is in the examination of Gestational trophoblastic disease (hyaditiform nuclei) (GTD)?

Answer 14

Uterus larger than expected for gestational age, rarely hyperthryoidism signs (BHCG mimics TSH at very high levels)

Question 15

What is the pathology of Gestational trophoblastic disease (hyaditiform nuclei) (GTD)?

Answer 15

Macro: Grape like appearance in complete moles, partial moles may contain recognisable fetal tissue.

Micro: hydropic villi, atypical hyperplasic trophoblasts in complete moles, focal vili swelling and trophoblastic hyperplasia in partial moles.

Question 16

What investigations do you do for Gestational trophoblastic disease (hyaditiform nuclei) (GTD)?

Answer 16

Bloods: BHCG grossly elevated.

Imaging: pelvic USS (snowstorm appearance, vesicles and cysts)

Question 17

What is the management of Gestational trophoblastic disease (hyaditiform nuclei) (GTD)?

Answer 17

Surgical: EPRC (avoid uterotonics to avoid dissemination)

Monitor: serial BHCG monitoring in specialist centre (CXH, Sheffield, Dundee). MTX if rising BHCG levels, Avoid pregnancy for 6 months.

Question 18

What are the complications/ prognosis of Gestational trophoblastic disease (hyaditiform nuclei) (GTD)?

Answer 18

Progress to malignancy in 30% complete, 3% partial. Risk of recurrence 1-2%. .