Gestational Trophoblastic Disease Definitions • Gestational Trophoblastic Neoplasia (GTN) chorioadenoma destruens, metastasizing mole, choriocarcinoma. – Non-metastatic gestational trophoblastic neoplasia: process is confined to the uterus – Metastatic gestational trophoblastic neoplasia: metastases are demonstrated in the lung/vagina and/or in brain, liver, kidney or elsewhere • Hydatidiform mole: Gestational Trophoblastic Disease (GTD). Classification • Hydatidiform mole – Complete mole – Partial mole • Invasive mole • Placental-site trophoblastic tumor • Choriocarcinoma Complete Hydatidiform Mole • Pathology – Identifiable embryonic/fetal tissue Θ – Chorionic villi: generalized hydatidiform swelling, diffuse trophoblastic hyperplasia • Chromosomes: 46XX karyotype, molar chromosomes paternal origin Partial Hydatidiform Mole • Pathology: – Chorionic villi with focal hydatidiform swelling and cavitation – Villous scalloping – Focal trophoblastic hyperplasia – Prominent stromal trophoblastic inclusions – Identifiable embryonic or fetal tissue • Chromosomes: triploid karyotype (69 chromosomes) Clinical Features • Complete Hydatidiform Mole – Vaginal bleeding – Excessive uterine size – Toxemia – Hyperemesis gravidarum – Hyperthyroidism – Trophoblastic embolization – Theca lutein ovarian cyst • Partial Hydatidiform Mole: signs & symptoms of incomplete / missed abortion Diagnosis • USG : vesicular sonographic pattern “snowstorm” pattern Follow-up • Human Chorionic Gonadotropin Contraception • IUD normal hCG level • First choice: – Hormonal contraception – Barrier methods Malignant Gestational Trophoblastic Neoplasia • Nonmetastatic Disease • Metastatic Disease Nonmetastatic Disease • Signs & symptoms: – Irregular vaginal bleeding – Theca lutein cysts – Uterine subinvolution or asymmetric enlargement – Persistently elevated serum hCG levels • Histology: anaplastic syncytiotrophoblast & cytotrophoblast w/o chorionic villous structure Placental-site Trophoblastic Tumor • Consist of: intermediate trophoblast & a few syncytial elements • Produce small amount of hCG & human placental lactogen • Tend to remain confined to the uterus • Metastasizing late • Insensitive to chemtotherapy Metastatic Disease Sites of metastatic spread: • Pulmonary: – Signs: chest pain, cough, hemoptysis,d yspnea, asymptomatic lesion – Radiographic patterns: an alveolar or “snowstrom” pattern; discrete, rounded densities; pleural effusion; an embolic pattern caused by pulmonary arterial occlusion Metastatic Disease Sites of metastatic spread: • Vaginal: highly vascular, appear reddened or violaceous • Hepatic: epigastric or right upper quadrant pain Glisson’s capsule; hepatic lesions: hemorrhagic & friable & may rupture exsanguinating intraperitoneal bleeding • Central Nervous System: brain metastasis was preceded by pulmonary &/or vaginal involvement; acute focal neurologic deficits. Metastatic Disease Diagnostic evaluation: • Pretreatment evaluation: 1. 2. 3. 4. A complete hystory & physical examination Measurement of the serum hCG value Hepatic, thyroid, & renal function tests Determination of baseline peripheral MBC & platelet counts Metastatic Disease Diagnostic evaluation: • Metastatic work-up: 1. 2. 3. 4. A chest radiograph USG / CT scan of the abdomen & pelvis Measurement of CSF hCG level Angiography of abdominal & pelvic organs FIGO Staging • Stage I: Gestational trophoblastic tumors strictly confined to the uterine corpus • Stage II: Gestational trophoblastic tumors extending to the adnexa or to the vagina, but limited to the genital structures • Stage III: Gestational trophoblastic tumors extending to the lungs, w/ or w/o genital tract involvement • Stage IV: all other metastatic sites. FIGO (WHO) Risk Factor Scoring w/ FIGO Staging 0 1 2 Age Antecedent pregnancy Interval months from Index Pregnancy Pretreatment hCG Milli IU/MI < 40 40 Hydatidifor m Mole Abortion Term <4 4–6 7 – 12 < 103 103-104 Largest tumor size including uterus 3 – 4 cm Site of metastases including uterus Spleen kidney Number of metastases identified Previous failed chemotherapy 1–4 4 > 12 >104-105 >105 5 cm GI tract 5–8 Single drug Brain liver >8 2 or more drugs Management of Gestational Trophoblastic Disease Figure 2: Management of Trophoblastic Neoplasia Figure 3: Management of Trophoblastic Neoplasia Management of Trophoblastic Disease Subsequent pregnancies •Pregnancies after Hydatidiform Mole: patients with a complete molar pregnancy are at no increased risk of obstetric complications. •For any subsequent pregnancy, these things are recommended: – A pelvic USG during the 1st trimester – A thorough histologic review of the placenta or products of conception – An hCG measurement 6 weeks after completion of the pregnancy to exclude occult trophoblastic neoplasia Subsequent pregnancies Pregnancies after Persistent GTN • Patients w/ GTN who are treated successfully w/ chemotherapy can expect normal reproduction. • Frequency of congenital melformations was not increased, although chemotherapeutic agents have teratogenic & mutagenic potential.