Module 17 : Gestational Trophoblastic Neoplasia Flashcards
what is the function of the trophoblast
- gain access to maternal circulation
- infiltrate maternal tissue
- invade vessles
- transported to lungs
what is a hydatidiform mole
- refers to cystic degeneration of chorionic villi in molar pregnancy
what 2 things does hydatidiform mole encompass
- complete and partial molar pregnancy
what is a molar pregnancy in general
- abnormal proliferation of pregnancy related to trophoblast with progressive malignant potential
what are the 4 molar pregnancies
- complete
- partial
- invasive
- choriocarcinoma
what increases risk of molar pregnancy
- increase maternal age
- prior molar pregnancy
- asian ancestry
what is the most common GTN
- complete molar pregnancy
what is a complete molar pregnancy
- often benign if treated early
-
what is the karyotype for complete molar pregnancy
- 46xx or 46yy
- chromosomes are exclusively paternal
+ ovum with absent or inactive maternal chromosomes is fertilized by a normal haploid sperm which duplicate to get diploid - 46xy
+ exclusively paternal
+ occasionally empty ovum can be fertilized by 2 sperm
US look of complete molar pregnancy
- no fetus
- no normal placenta
- placenta replaced by abnormal hydropic chorionic villi with excessive trophoblastic proliferation
what are the signs and symptoms of complete molar pregnancy
- larger for dates
- bleeding
- INCREASED HCG > 100,00
sonographic features of complete mole
- 1st trimester look like incomplete abortion
- 2nd = echogeinc tissue that expands into endo canal with multiple cystic spaces that range in size up to 2 cm GRAPE
- ovarian theca lutean cysts bilateral occur
what is a partial molar pregnancy
- triploid (69)
- one set of maternal chromosomes and 2 sets of paternal chromosomes
- results from fertilization of normal ovum and 2 haploid sperm
- diandric triploidy
what is the pathology of partial molar pregnancy
- abnormal fetus with triploid karyotype
- symmetric IUGR
- large hydropic placental tissue
sonographic appearance of maternal partial mole
- aka triploidy syndrome
- placenta small
- asymmetric IUGR
- mother may develop early pre eclampsia
what are the treatments of complete or partial molar pregnancy
- evacuation of uterine content
- hCG titer sampling weekly or monthly for a yar
- avoid pregnancy for 1 year
is it possible to have a complete mole with a twin
- yes
- a normal pregnancy with a normal placenta and a molar placenta seen separately
what is persistent trophoblastic neoplasia
- PTN
- invasive mole and choriocarcinoma are referred to as PTN
- malignant potential
- MOST CURABLE GYNE MALIGNANCY
is PTN a life threatening condition
- yes
- occurs in setting of molar pregnancy
what are some rare cases where PTN can occur
- normal term delivery
- spontaneous abortion
- ectopic pregnancy
what is an invasive mole
- aka chorioadenoma destruens
- most common form of PTN
what is the history of an invasive mole
- presence of chorionic villi and proliferating trophoblast deep in myometrium
what are the stages of invasive mole spread
- confined to uterus
- spread to adjacent organs and vasculature
- embolism to distant sites
what is a choriocarcinoma
- starts as a molar pregnancy
- present as miscarries, abortions, normal pregnancy
what is the histology of choriocarcinoma
- abnormal proliferation trophoblast with no formed villi
what are the stages of choriocarcinoma
- invades myometrium
- invasdes vasculature causes hemorrhage
- necrosis
- distant mets common
what are the signs and symptoms of choriocarcinoma and invasive mole
- vaginal bleeding
- respiratory compromise
what is the treatment of PTN
- follow serum hCG after evacuation
- diagnosis can be hard if many systems affected
what are the sonographic features of PTN
- NEED EV
- focal echogenic nodule in myometrium
- lesions may appear hyperehoi complex or multicystic
- uterus bulky
- uterus heterogeneous and lobulated
- see extension of tumor into other pelvic structures
does ultrasound differentiate between forms of PTN
- no pathology does
what are the DDX of PTN
- adenomyosis
- fibroids
- AV malformation
what are the color doppler features of the PTN
- color aliasing does to AV shunting
- chaotic vascular arrangement
- size of lesion look larger with color doppler than on gray scale
what are the suplex doppler features of PTN
- increase peak systolic velocity
+ > 50 - low resistive index
+ RI < 0.5
does doppler play a greater role in diagnosis of PTN or of diagnosis of primary molar pregnancy
- PTN
DDX of doppler diagnosis of PTN
- color and duplex doppler features are typical of trophoblastic flow either normal or abnormal
- same doppler profiles seen with early pregnancy missed abortion or RPOC, PID, abcesses, ovarian tumors
what would help distinguish between PTN and conditions with similar doppler profiles
- serum hCG and sonographic appearance
what is sonography mainly used for with PTN
- stage and monitor response to therapy
- proffered over angio because safer
what is the therapy for PTN
- non metastatic PTN very good prognosis
- treated with methotrexate
what are the 2 categories of PTN
- low risk = chemo
- high risk
characteristics of high risk metastatic PTN
- having disease > 4months
- pretreatments hCG level > 40,000
- presence of liver or brain mets
- poor prognosis
what is the treatment of high risk PTN
- multiagnet chemo
- radiotherapy
- surgery
what is a non gestational trophoblastic neoplasia
- choriocarcinoma can occur with dysgerminoma of the ovary
+ ovarian counterpart to seminoma
+ highly malignant germ cell tumor produces hCG
