GTD Flashcards
All forms of GTD are characterized by a distinct tumor marker
the beta subunit of human chorionic gonadotropin (hCG
types of GTD
Hydatidiform mole (complete or partial) Persistent/invasive gestational trophoblastic neoplasia (GTN) Choriocarcinoma Placental site trophoblastic tumors .
Complete and partial hydatidiform moles result of
of an aberrant fertilization event that leads to a proliferative process.
Malignant GTD can develop from
molar pregnancy or can arise after any gestational experience: spontaneous or induced abortion, ectopic pregnancy, or preterm and term pregnancy
RISK FACTORS
Extremes of age
older than age 35 and slightly increased in those under age 20
Assisted reproductive technology
History of previous GTD
Current smoking (>15 cigarettes per day)
Maternal blood type AB, A, or B.
History of infertility, nulliparity.
use of oral contraceptives (however, oral contraceptives do not increase the risk of developing postmolar GTD )
CLINICAL MANIFESTATIONS in general
Vaginal bleeding Enlarged uterus Pelvic pressure or pain Theca lutein cysts Anemia Hyperemesis gravidarum Hyperthyroidism Preeclampsia before 20 weeks of gestation Vaginal passage of hydropic vesicles
Complete hydatidiform mole result of
a result of fertilization of an empty ovum by two sperms or a single sperm that duplicates, resulting in a 46 XX or 46 XY karyotype.
Complete hydatidiform mole s & s hcg level
The presence of a complete mole (which lacks a fetus) often leads to excessive uterine size for the expected “gestational age
The marked elevation in serum hCG associated with a complete mole can lead to complications. These include ovarian enlargement due to theca lutein cysts; hyperemesis gravidarum; early development of preeclampsia (before 20 weeks of gestation); and hyperthyroidism, which is most often subclinical]. These complications occur in approximately 25 percent of .
more than 100,000 hcghyd
Partial hydatidiform mole result of
A partial mole is the result of fertilization of a haploid ovum by two sperm or duplication of one sperm, resulting in a triploid karyotype (69 XXY, 69 XXX, 69 XYY
partial hydatidiform s & s and hcg level
Partial moles are the only type of GTD that are associated with the presence of a fetus, and fetal cardiac activity may be detected. However, there is a high rate of intrauterine death related to triploidy.
Thus, a partial mole is often misdiagnosed as an incomplete or missed abortion and the correct diagnosis of GTD is made only after histologic review of the surgical specimen.
These pregnancies are infrequently associated with excessive uterine size, ovarian enlargement, preeclampsia, hyperemesis, or hyperthyroidism because hCG levels are generally lower than those observed with a complete mole
hydatidiform evaluation tests
Human chorionic gonadotropin
Ultrasound
blood tests
Radiographic evaluation includes pelvic ultrasound
Chest imaging
CT scan or magnetic resonance imaging (MRI) of the brain
. Cerebral involvement can also be assessed by measuring beta-hCG levels in the cerebrospinal fluid (CSF)
us findings in hydatidiform
Complete mole
The absence of an embryo or fetus
No amniotic fluid
Central heterogeneous mass with numerous discrete anechoic spaces, which correspond to diffuse hydatidiform swelling of the hydropic chorionic villi. This has classically been described as a “snowstorm pattern” on older ultrasounds
Theca lutein cysts
Partial mole
A fetus is present, may be viable, and is often growth restricted
Amniotic fluid is present, but may be reduced
Focal anechoic spaces and/or increased echogenicity of chorionic villi (swiss cheese pattern)
Increased transverse diameter of the gestational sac
Theca lutein cysts are usually absent
Management of hydatidiform mole
suction curettage
Patients who have no desire for future fertility may opt for hysterectom
suction curettage procedure
Under adequate anesthesia, oxytocin is administered and the cervix is dilated to allow passage of the suction cannula.
During dilation of the cervix, brisk uterine bleeding is often encountered, which generally slows significantly once suction evacuation has commenced. Heavy bleeding is nearly always self-limited, and inappropriate transfusion should be avoided.
A suction catheter of 12 mm is usually sufficient to evacuate a complete molar pregnancy since there is no fetus. A larger catheter may be needed to evacuate a partial mole with a coexistent fetus greater than 12 weeks of gestation.
The suction curette is not advanced to the fundus; instead, it is placed just inside the internal os.
Vacuum pressures of 50 to 60 cm Hg are then applied and the hydropic placental tissue is drawn
As additional tissue is evacuated, the uterus will contract and the suction curette may then be advanced to the fundus.
Suction curettage can be performed under ultrasound guidance if needed to facilitate the procedure and confirm complete evacuation of uterine contents.
Intravenous oxytocin is administered, and for uteri over 14-weeks size, we suggest fundal massage to stimulate myometrial contraction
Malignant GTD symptom
The most common symptom is vaginal bleeding. Uterine rupture resulting in hemoperitoneum is rare, but may occur in patients who do not comply with recommended follow-up.
Characteristics that increase the likelihood of GTN after molar evacuation include
Large theca lutein cysts (≥6 cm), Excessively enlarged uterus for dates, Age over 40, previous GTD, Initial hCG >100,000 mIU/mL, The presence of hyperplasia or atypia on histology. Heterozygosity (dispermic moles
after molar vs non after molar GTD
after molar usually persistent GTN
non molar all most always choriocarcinoma
Choriocarcinoma symptoms
. The typical clinical presentation is late postpartum bleeding, which persists beyond the usual six to eight weeks. Primary or secondary postpartum hemorrhage are other common presentations. However, abnormal vaginal bleeding may develop a year or more after an antecedent pregnancy. Hemorrhage can be severe if the tumor erodes through the myometrium or uterine vessels. Respiratory symptoms (eg, cough, chest pain, hemoptysis) or signs of gastrointestinal, urologic, and intracerebral bleeding are indicative of metastatic disease. Hepatic involvement from advanced disease may cause epigastric or right upper quadrant pain. Physical examination often reveals an enlarged uterus and bilateral ovarian cysts. Vaginal metastases are present in about 30 percent of cases; these lesions are very vascular and prone to bleeding; they may also become infected
DIAGNOSIS OF MALIGNANT DISEASE
hCG levels should be monitored serially after treatment of a molar pregnancy. In a representative study, the average times to normalization of serum hCG after a complete or partial mole were 99 and 59 days, respectively
According to FIGO criteria, the presence of persistent (malignant) GTD after evacuation of a complete or partial molar pregnancy should be suspected if any of the following is present :
A serum hCG concentration that plateaus (decline of less than 10 percent for at least four values over three weeks)
A serum hCG concentration that rises (increase more than 10 percent of three values over two consecutive weeks eg, day 1, 7, 14)
Persistence of detectable serum hCG for more than six months after molar evacuation
The histologic identification of choriocarcinoma
The presence of metastatic disease usually implies the presence of choriocarcinoma rather than invasive mole.
Approximately 90 percent of these cases represent invasive mole, and <10 percent are choriocarcinomas; PSTTs are rare.
ROLE OF U/S IN MALIGNANT DISEASE
Invasive mole typically appears as one or more poorly defined masses in the uterus with anechoic areas. Color Doppler of the anechoic areas reveals high vascular flow. Invasion into the myometrium may be visualized.
Choriocarcinoma and PSTT — Choriocarcinoma appears as a mass enlarging the uterus, with a heterogeneous appearance that correlates with areas of necrosis and hemorrhage. The tumor is usually markedly hypervascular on color Doppler . The tumor may extend into the parametrium
Staging and prognostic stratification
Stage I — All patients with persistently elevated beta-hCG levels and tumor confined to the uterus.
Stage II — The presence of tumor outside of the uterus, but limited to the vagina and/or pelvis.
Stage III — Pulmonary metastases with or without uterine, vaginal, or pelvic involvement.
Stage IV — All other metastatic sites (eg, brain, liver, kidneys, gastrointestinal tract).
All stages were further stratified as A, B or C depending on the presence or absence of one or both of two risk factors for recurrence (beta-hCG ≥100,000 mIU/mL, or the detection of disease more than six months followed termination of an antecedent pregnancy).
Single-agent chemotherapy
Methotrexate with and without leucovorin
Dactinomycin
Multiagent chemotherapy
(EMA/CO
Etoposide — 100 mg/m 2 IV over 30 minutes on days 1 and 2
Methotrexate — 100 mg/m 2 IV push followed by 200 mg/m 2 IV over 12 hours on day 1
Dactinomycin — 0.5 mg IV bolus on days 1 and 2
Leucovorin calcium — 15 mg orally every 12 hours for four doses, starting 24 hours after start of MTX
Cyclophosphamide — 600 mg/m 2 IV on day 8
Vincristine Oncovin®) — 1.0 mg/m 2 IV on day 8
when to stop Chemotherapy
Assessment of response —All women with GTD should be monitored with weekly serial measurements of serum beta-hCG during therapy. Remission is defined as three consecutive normal hCG values (less than 5 milli-international units/mL) over 14 to 21 days.
When weekly or biweekly single agent chemotherapy regimens are used, the regimen is continued until the third negative result is obtained. When infusional MTX is given as a one-time dose, hCG levels are followed weekly, with additional therapy given only if an inadequate response is observed.
When combination chemotherapy with EMA/CO is used, the regimen is repeated every two weeks until normalization of beta-hCG, and then generally continued for an additional three cycles (six weeks). After remission is achieved, serum beta-hCG should be measured monthly until monitoring has shown one year of normal hCG levels
