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Obs/gyn > GTD/GTN > Flashcards

GTD/GTN Flashcards

1
Q

Hydatidiform moles are excessively edematous immature placentas, These include:

A

benign complete hydatidiform mole and

partial hydatidiform mole and the malignant invasive mole.

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2
Q

Nonmolar trophoblastic neoplasms include:

A

choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor.

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3
Q

The classic histological findings of molar pregnancy include:

A

trophoblast proliferation and villi with stromal edema

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4
Q

GTN more frequently follows complete or partial

hydatidiform mole ?

A

complete hydatidiform mole.

GTN develops after evacuation in 15 to 20 percent of patients with complete moles

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5
Q

for GTD, adolescents and women aged 36 to 40 years have a __fold risk, but those older than 40 have an almost ___fold risk

A

adolescents and women aged 36 to 40 years have a twofold risk, but those older than 40 have an
almost tenfold risk

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6
Q

With a prior complete mole, the risk of another mole is __%, and with a previous partial mole, the rate is__%. After two prior complete moles, approximately
__% of women have
a third mole

A

0.9 percent with prev 1 complete
0.3 percent with prev partial mole
20 percent with 2 prev complete moles

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7
Q

The median time for such resolution is _ weeks for partial moles and _ weeks for complete moles.

A

The median time for such resolution is 7 weeks for partial moles and 9 weeks for complete moles.

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8
Q

complete moles have a ___ percent incidence of malignant sequelae, compared with ____ percent following partial moles.

A

complete moles have a 15 to 20 percent incidence of malignant sequelae, compared with 1 to
5 percent following partial moles.

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9
Q

GTN almost always develop with or after some form of recognized pregnancy. most commonly after?

A

Half follow hydatidiform mole, a fourth follow miscarriage or tubal pregnancy, and another fourth develop after a
preterm or term pregnancy

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10
Q

The most common finding with GTN

A

irregular bleeding associated with uterine subinvolution.

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11
Q

the most common trophoblastic neoplasms that follow hydatidiform mole

A

Invasive Mole or persistent trophoblastic disease in 10-15%

Choriocarcinoma 2-3%

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12
Q

This is the most common type of trophoblastic neoplasm to follow a term pregnancy or a miscarriage, and only a third of cases follow a molar gestation

A

Gestational Choriocarcinoma

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13
Q

Choriocarcinoma is composed of which cells?

A

reminiscent of early cytotrophoblast and syncytiotrophoblast,

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14
Q

Choriocarcinomas are commonly accompanied by ovarian

A

theca-lutein cysts.

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15
Q

Placental Site Trophoblastic Tumor, This rare tumor arises from

A

intermediate trophoblasts at the placental site. These

tumors have associated serum β-hCG levels that may be only modestly elevated.

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16
Q

Treatment of placental site trophoblastic tumor

A

by hysterectomy is preferred because these locally invasive tumors are usually resistant to chemotherapy

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17
Q

Epithelioid Trophoblastic Tumor This rare tumor develops from

A

chorionic-type intermediate trophoblast.

The uterus is the main site of involvement, and bleeding and low hCG levels are typical findings

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18
Q

Primary treatment of Epithelioid Trophoblastic Tumor

A

hysterectomy because this tumor is relatively resistant to chemotherapy but Metastatic disease is common, and combination chemotherapy is employed.

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19
Q

Single-agent chemotherapy protocols are usually sufficient for nonmetastatic or low-risk metastatic neoplasia what is it ?

A

methotrexate alternating daily with folinic acid for 1 week followed by 6 rest days. or actinomycin D

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20
Q

Combination chemotherapy is given for high-risk GTN disease, and reported cure rates approximate 90 percent

A

EMA-CO, which includes etoposide, methotrexate,

actinomycin D, cyclophosphamide, and Oncovin (vincristine).

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21
Q

Frequent causes of death in GTN:

A

hemorrhage from metastatic sites, respiratory failure,

sepsis, and multiorgan failure due to widespread chemoresistant disease.

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22
Q

serosurveillance of low- or high-risk GTN disease:

A

once serum β-hCG levels are undetectable, serosurveillance is continued for 1 year.

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23
Q

quiescent hCG

A

A small number of women during surveillance, despite no evidence of metastases, will be found to have very low β-hCG levels that plateau. This phenomenon is called quiescent hCG and presumably is caused by dormant trophoblast. Close observation without therapy is recommended, but 20 percent will eventually have recurrent active and progressive trophoblastic neoplasia

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24
Q

risk for developing trophoblastic disease in a subsequent pregnancy

A

2-percent
During the next pregnancy, 98 out of 100 women will have a normal pregnancy and two women will have recurrent molar pregnancy.
(RCOG)

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25
Q

Complete mole derived from

A

Paternal origin “single haploid sperm + empty ovum”=(46 xx)

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26
Q

Partial mole derived from

A

Paternal + Maternal resulting Triploid (dispermy + ovum)= 69 XXY (commonly) or 69 Xxx

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27
Q

DDx of partial hydatiform :

A
  • Beck-weidmann syndrome

- placental angiomatous malformation

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28
Q

How to differentiate btw maternal and paternal origin of miscarriage vs. GTD

A

Absence of P57 immunostaining means (paternal)
Its Presence means either:
(PMH or normal pregnancy)

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29
Q

Absence of trophoblastic strongly inclusions, dx?

A

Complete mole

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30
Q

Histo shows Presence of trophoblastic scalloping and stroma inclusions, dx?

A

Partial hydatidiform mole

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31
Q

If pregnancy with GTD continued, risky of which complications?

A

> 16 wks , 25% of pt will have medical complications related to high levels of B-HCG, risk of thyroid storm and Theca lutein cyst.
25% chance of achieving a live birth.There is an increased risk of early fetal loss (40%) and premature delivery (36%). The incidence of pre-eclampsia is variable, with rates as high as 20%

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32
Q

What raise your suspicion of invasive mole?

A
  • > 45 yrs
  • prev hydatidiform mole
  • Bhcg > 100k
  • uterine large than date
  • bilateral ovarian enlargement > 8cm
33
Q

The other name of invasive mole:

A

Choreoadenoma destruens

34
Q

Cure rate of low risk < or=7 with single chemotherapy

A

95%

35
Q

Actinomycin D dose: (in GTN)

A

1.25 mg/m2 IV every 2 wks

36
Q

Cure rate of high risk FIGO >7 GTN

A

75%

37
Q

Treatment of high risk GTN:

A 
EMA-CO
Etopsoide “alkylating agent”
Methotrexate
Actinomycin D
Cyclophosphamide 
Oncovin “vicristin” > M-Phase

Treatment is continued, in all cases, until the hCG level has returned to normal and then for a further 6 consecutive weeks.

38
Q

The incidence of molar after 2 molar pregnancies is

A

15-20%

39
Q

Gestational choriocarcinoma incidence

A

occurs in approximately 1 in 20,000–40,000 pregnancies: approximately 50% after term pregnancies, 25% after molar pregnancies, and the remainder after other gestational events.
Additionally, complete moles have a 2–3% absolute risk of developing choriocarcinoma, which is more than 2,000-fold higher than the risk of other antecedent pregnancies.

40
Q

Postmolar malignant sequelae in partial mole and complete mole:

A

In partial mole: <5%

In complete mole: 6–32%

41
Q

Medical complications of molar pregnancy:

A

pregnancy-induced hypertension, hyperthyroidism, anemia, and hyperemesis gravidarum, are more frequently seen among patients with complete moles

42
Q

15 –25% of patients with ________ moles will have theca lutein cysts with ovarian enlargement of more than 6 cm

A

complete

43
Q

(FIGO)‘s hCG criteria for the diagnosis of postmolar gestational trophoblastic disease:

A
  1. hCG level plateau of 4 values plus or minus 10% recorded over a 3 week duration (days 1, 7, 14, and 21)
  2. An hCG level increase of more than 10% of 3 values recorded over a 2-week duration (days 1, 7, and 14)
  3. Persistence of detectable hCG for more than 6 months after molar evacuation
44
Q

invasive mole is used to describe disease confined to the uterus and is characterized by the presence of edematous chorionic villi with trophoblastic proliferation that invade directly into the myometrium.
Dx and Management?

A

Most cases are clinically diagnosed and are not determined histologically. Dilation and curettage (D&C) should be avoided to prevent morbidity and mortality caused by uterine perforation.

45
Q

characterized by absence of villi with proliferation of intermediate trophoblast cells

A

Placental site trophoblastic tumors

46
Q

placental site trophoblastic tumors management:

A

(not as sensitive to chemotherapy)
Surgery assumes a critical role in the management of placental site trophoblastic tumors, usually confined to the uterus > hysterectomy

47
Q

For patients in whom hydatidiform moles are suspected before evacuation, the following tests are recommended:

A
  • Complete blood count with platelet determination
  • Clotting function studies
  • Renal and liver function studies
  • Blood type with antibody screen
  • Determination of hCG level
  • Preevacuation chest X-ray
48
Q

hydatidiform moles treatment:

A

the preferred method of evacuation is suction D&C. Medical induction of labor with oxytocin or prostaglandin and hysterotomy are not recommended for evacuation because they increase blood loss and may increase the risk for malignant sequelae when compared with suction D&C

49
Q

What is the optimum follow-up following a diagnosis of GTD?

A

Follow up after GTD is increasingly individualised.
If hCG has reverted to normal within 56 days of the pregnancy event then follow up will be for 6 months from the date of uterine evacuation.
If hCG has not reverted to normal within 56 days of the pregnancy event then follow-up will be for 6 months from normalisation of the hCG level.
All women should at the end of any future pregnancy, whatever the outcome of the pregnancy. hCG levels are measured 6-8 weeks after the end of the pregnancy to exclude disease recurrence.

50
Q

When can women whose last pregnancy was a complete or partial hydatidiform molar pregnancy try to conceive in the future and what is the outcome of subsequent pregnancies?

A

Women should be advised not to conceive until their follow-up is complete.
Women who undergo chemotherapy are advised not to conceive for 1 year after completion of treatment.
The risk of a further molar pregnancy is low (1/80)

51
Q

Hydatidiform mole incidence

A

occurs in 1/600 abortion or 1/1200 pregnancy

52
Q

Choriocarcinoma incidence

A

occurs in 1/20,000-40,000

53
Q

personal history of GTD increases the risk of devdoping a molar gestation in a subsequent pregnancy at least —fold.

A

personal history of GTD increases the risk of devdoping a molar gestation in a subsequent pregnancy at least tenfold.

54
Q

complete moles generally have two prominent features:

A

(1) trophoblastic proliferation and (2) hydropic villi

55
Q

Partial moles are optimally diagnosed when three or fow: major diagnostic criteria are demonstrated:

A

(1) two populations of villi, (2) enlarged, irregular, dysmorphic villi (with trophoblast inclusions), (3) enlarged, cavitated villi (more or equal to 3 to 4 mm), and (4) syncytiotrophoblast hyperplasia/atypia (Chew, 2000).

56
Q

p57KlP2

A

is a nuclear protein whose gene is paternally imprinted and matemally expressed.

57
Q

partial mole Vs. nonmolar hydropic abortus

A

For distinction of both of which express p57, evaluation of ploidy can be used. Most partial moles are triploid or near triploid, and laboratory karyotyping to look for triploidy can be completed. Importantly, not all triploid gestations represent a partial hydatidiform mole. Thus, triploidy is not solely diagnostic of partial hydatidifOrm mole but serves as an informative adjunct when applied in the context of histologic findings suggestive of the mole type. Molecular genotyping is a newer technique that determines not only ploidy but also the parental source of polymorphic allies. Thus, it can distinguish among a diploid diandric genome (complete mole), a triploid diandric-monogynic genome (partial mole), or biparental diploidy (nonmolar abortus) (Ronnett, 2011).

58
Q

Preoperative/intra-op preparation of molar pregnancy

A

Prostanoids to ripen the cervix are not recommended as these can induce uterine contractions, which might increase the risk of trophoblastic embolization to the pulmonary vasculature (Seckl, 2010).
patients are evaluated for associated medical complications. A complete blood count (CBC) and measures of liver, renal, and thyroid function tests are done. Because of the tremendous vascularity of these placentas, blood products should be available prior to the evacuation of larger moles, and adequate infusion lines established. Other uterotonic agents, such as methylergonovine maleate (Methergine} and carboprost tromethamine (Hemabate}, can be administered for heavy bleeding refractory to oxytocin (Pitocin} infusion alone.

59
Q

GTN develops after evacuation in – to – percent of patients with complete moles

A

GTN develops after evacuation in 15 to 20 percent of patients with complete moles.
Of those women who develop GTN, three quarters have locally invasive molar disease and the remaining one quarter develops metastases.

60
Q

GTN develops in only – to – percent of patients with partial moles following evacuation

A

GTN develops in only 4 to 6 percent of patients with partial moles following evacuation

Malignant transformation into metastatic choriocarcinoma does occur after partial mole evacuation, but this is rare (0.1 percent)

61
Q

postmolar surveillance with serial quantitative serum B-hCG levels

A

Titers are monitored following uterine evacuation at least every 1 to 2 weeks until they become undetectable. After undetectable B-hCG levels are achieved, subsequent monthly levels are drawn during 6 months of surveillance for all patients with a molar gestation (Sebire, 2007).

62
Q

The risk of GTN after spontaneous B-hCG normalization following molar pregnancy is – percent

A

<0.5 %

63
Q

The true incidence of GTD developing outside the uterine cavity approximates

A

1.5 per 1 million births (Gillespie, 2004).
More than 90 percent of suspected cases will reflect an overdiagnosis of florid extravillous trophoblastic proliferation in the fallopian tube (Burton, 2001; Sebire, 2005b). As with any ectopic pregnancy, initial management usually involves surgical removal of the conceptus and histopathologic evaluation.

64
Q

Management of molar pregnancy with Coexistent Fetus

A

Because the risk of malignancy is unchanged with advancement of gestational age, pregnancy continuation may be allowed, provided that severe maternal complications are manageable and fetal growth is normal (Lin, 2017). Importantly, these cases should be distinguished early from a single partial molar pregnancy with its abnormal associated fetus. Fetal karyotyping to con6rm a normal fetal chromosomal pattern is recommended (Marcorelles, 2005; Matsui, 2000).

65
Q

the diagnosis of choriocarcinoma

A

is ddayed for months due to subtle signs and symptoms. Most patients present with intermensttual bleeding, and high f3·hCG levels are detected (l..ok, 2006). Thus, abnormal bleeding for more than 6 weeks following any pregnancy warrants evaluation .

66
Q

Placental-Site Trophoblastic Tumor This tumor consists predominantly of

A

intermediate trophoblasts at the placental site

67
Q

the primary treatment for nonmetastatic PSTT

A

Hysterectomy, due to its relative insensitivity to chemotherapy. In particularly motivated patients, fertility-sparing procedures have mixed results.

68
Q

Management of Metastatic PSTT

A

has a much poorer prognosis than its postmolar GTN counterparts. As a result, aggressive combination chemotherapy is indicated. Regimens of etoposide, methotrexate, and dactinomycin (actinomycin D) that alternate with etoposide and cisplatin (EMAIEP) are considered the most effective (Newlands, 2000). Radiation, however, also may have a role. The overall 1 0-year survival is 70 percent, but patients with metastases, especially stage IV disease, have a much worse prognosis (Hassadia, 2005; Hyman, 2013; Schmid, 2009).

69
Q

Epithelioid trophoblastic tumor (ETT) develops from neoplastic transformation of which Placental cells

A

chorionic-type intermediate trophoblast. Microscopically, this tumor resembles PSTT, but the cells are smaller and display less nuclear pleomorphism.

70
Q

Patients with GTN undergo a thorough pretreatment assessment to determine disease extent

A

The initial evaluation may be limited to pelvic examination, chest radiograph, and pelvic sonography or abdominopelvic computed tomography (CT) scanning. Laboratory tests include CBC, ~-hCG levels, and measure of liver, renal, and thyroid function.

71
Q

FIGO Criteria for Gestational Trophoblastic Neoplasia Diagnosis

A

~-hCG level plateau persists in four measurements during a period of 3 weeks or longer (days 1, 7, 14, and 21) ~-hCG level rise in 3 weekly consecutive measurements or longer, over a period of 2 weeks or more (days 1, 7, and 14)
~-hCG level remains elevated for 6 months or more
~Histologic diagnosis of choriocarcinoma

72
Q

After evacuation, - to - percent of complete moles develop metastatic choriocarcinoma

A

After evacuation, 3 to 4 percent of complete moles develop metastatic choriocarcinoma

73
Q

risk factors for developing post molar gestational trophoblastic neoplasia are

A

the presence of theca lutein cysts greater than 6 cm, β-hCG concentration greater than 100,000 mIU/mL, large uterine size, and age older than 40 years.

74
Q

Candidates of post-molar evacuation GTN second D&C are:

A

low risk WHO + less likely of being lost to follow-up, have contraindications to conventional chemotherapy, and have serum β-hCG concentrations lower than 1,500 mIU/mL,

75
Q

What is the most common molar pregnancy karyotype and parental chromosomal origin diploid or haploid ?

A

Complete moles are diploid and their chromosomes are purely paternal. In 90% of the complete moles, the karyotype is 46XX and in 10% it is 46XY.

76
Q

In high risk GTN, multiagent chemotherapy has response rate—% and long-term survival rates —%

A

complete response rates of greater than 70% and long-term survival rates of greater than 90%. In contrast with the other forms of GTN, placental-site trophoblastic tumors and epithelioid trophoblastic tumors are relatively chemoresistant, and hysterectomy with lymph node dissection is recommended because of the high risk of lymphatic metastases.

77
Q

With a prior complete mole, the risk of another mole is – percent, and with a previous partial mole, the rate is – percent. After two prior complete moles, approximately – percent of women have a third mole.

A

With a prior complete mole, the risk of another mole is 0.9 percent, and with a previous partial mole, the rate is 0.3 percent. After two prior complete moles, approximately 20 percent of women have a third mole.

78
Q

DDx of Twin Pregnancy normal fetus with molar pregnancy + How to differentiate?

A

ese cases must be distinguished from a single partial molar pregnancy with its associated abnormal fetus. Other potential diagnoses include placental mesenchymal dysplasia, subchorionic hematoma, or chorioangioma. To help distinguish among these, chorionic villus sampling, amniocentesis, or fetal cord blood sampling coupled with fetal karyotyping aid confirmation

Obs/gyn (55 decks)

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