Gestational Trophoblastic Diseases

LIU Sui-ling

Third Affiliated Hospital of Sun Yat-sen University

shelleyliu@21cn.com

• Gestational Trophoblastic Diseases(GTD)– Hydatidiform mole– Invasive mole– Choriocarcinoma– Placental-site trophoblastic tumor (PSTT)

• Features– Derived from fetal tissue– Composed of syncytiotropho-blastic and cytot

rophoblastic cell except PSTT– In PSTT, only the intermediate trophoblasts

Ovum

conceptus

sperm

Fetus

Placenta

Fetal membrane

Amniotic fluid

Umbilical cord

Normal placenta

Normal villi

HYDATIDIFORM MOLE

Hydatidiform mole

• Incidence– Area– Economic status– Age– Diet

• Recurrent rate＜ 2%

Hydatidiform mole

• Etiology– Cytogenetic study

• euploid • paternal in origin

• Pathogenesis– Homozygous conceptus with propensity for alt

ered growth

Hydatidiform mole

• Pathology– Classic findings

• Edema of the villous stroma• Avascular villi• Nests of proliferating syncytiotrophoblastic or cytotr

ophoblastic elements surrounding villi

– Classification• Complete hydatidiform mole• partial hydatidiform mole

Complete hydatidiform mole

Multiple grapelike vesicles

Microscopic findings of hydatidiform mole

Partial hydatidiform mole

Partial hydatidiform mole with fetus

Microscopic findings of partial hydatidiform mole

HYDATIDIFORM MOLE comparison of complete and partial hydatidiform mole

Complete Partial

Karyotype Diploid（ 46,XX or 46,XY) Triploid(69,XXX or 69,XXY)

Embryo Absent PresentVilli Hydropic Few hydropicTrophoblasts Diffuse hyperplasia Mild focal hyperplasiaImplantation-site trophoblast Diffuse atypia Focal atypiaFetal RBCs Absent Presentβ-hCG High(＞ 50,000) Slight elevation(＜ 50,00

0)Frequency of classical clinical symptoms Common RareRisk for persistent GTT 20%-30% ＜ 5%

HYDATIDIFORM MOLE

• CLINICAL FINDINGS– Symptoms And Signs

• Abnormal uterine bleeding• Nausea and vomiting• Excessive uterine size for gestational date• Multiple theca lutein cysts• Pain• Preeclampsia• Hyperthyroidism

HYDATIDIFORM MOLE

• Laboratory Findings– hCG– The amount of hCG correlates closely with the

number of viable tumor cells– β-hCG decline to normal within 14 weeks follo

wing evacuation of a molar pregnancy

• Special examinations– ultrasound

Ultrasound pattern of hydatiform mole

HYDATIDIFORM MOLE

• DIFFERENTIAL DIAGNOSIS– Normal pregnancy

• TREATMENT– Evacuation

• Suction curettage• Gentle sharp currettage• Oxytocin• Pathologic study• Laparotomy setup• hysterectomy

HYDATIDIFORM MOLE

• Prophylactic chemotherapy– Controversial– Patients with complete hydatidiform mole at hi

gh risk• Age>35• History of prior molar pregnancy• Poor followup

HYDATIDIFORM MOLE

• Surveillance following molar pregancy– Important

• The incidence of malignant disease is 20%～ 30%

– Serial β-hCG determinations• Weekly determination to nondetectable β-hCG leve

l• Monthly determination for at least 1 year

– Oral contraceptives

Case of hydatidiform mole• 25 years old, G1P0A0, admitted to hospital at Aug.3-200

9 because of “Cessation of menstruation for 10 weeks, abnormal uterine bleeding for one week”.

• History: The LMP of the patient was May.25-2009. She was diagnosed “early pregnancy” at 6 weeks. She complained of small amount of uterine bleeding for week. Furthermore, she felt nausea and vomiting from 2 days before.

• Physical examination: T 36.5 BP 150/110mmHg (BB℃P120/70mmHg) R 20/min P 92/min. Normal signs of lung and heart. Both lower limbs had pitting edema. Gynecological conditions: Uterine fundus at the level of umbilcus. 6-cm adnexal masses were palpated at both side of uterus.

• Assistant examinations: HGB 90g/L;

Case of hydatidiform mole

• Diagnosis

1 hydatidiform mole

2 Preeclampsia

3 Anemia

• Assistant examinationsβ-hCG ultrasound

• TREATMENTEvacuation

MALIGNANT GESTATIONAL TROPHOBLASTIC

NEOPLASIA

• Reference

http://www.china-obgyn.net/lecture/Index.html

MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA

• PATHOLOGY– Invasive mole

• Hydatidiform mole that invades the myometrium or adjacent structure

• Microscopic findings are the same as in hydatidiform

– Choriocarcinoma• Pure epithelial tumor composed of syncytiotropho-blastic and

cytotrophoblastic cell• Sheets or foci of trophoblasts, hemorrhage and necrosis• No villi

Invasive mole

Microscopic findings in invasive mole

Uterus of choriocarcinoma

Trophoblasts of choriocarcinoma

MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA

• DIAGNOSIS – history– Pelvic examination

• Enlarged uterus • Ovarian enlargment

– X-ray– CT– Serum hCG– Hematologic counts– Hepatic and renal function

vaginal metastasis of choriocarcinoma

MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA

• TREATMENT – Nonmetastatic Gestational Trophoblastic Disease

• Single-agent chemotherapy– Medicine

» Methotrexate» Dactinomycin

– Course and interval– Treatment cycles– Followup

» β-hCG , blood count, liver and renal function

• Combined chemotherapy and hysterectomy

MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA

– Metastatic Gestational Trophoblastic Disease • Chemotherapy

– Single-agent– Multiple-agent

MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA

• CLINICAL CLASSIFICATION OF MALIGNANT GESTATIONAL TROPHOBLASTIC DISEASES

1. National Cancer Institute

2. World Health Organization– Low risk – Medium risk– High risk

3. Revised FIGO

MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA

Categorization of gestational trophoblastic neoplasia(National Cancer Instit

ute)A. Nonmetastatic disease: No evidence of disease outside uterus.B. Metastatic disease: Any disease outside uterus.

1. Good-prognosis metastatic disease- a. Short duration(＜ 4 months) b. Serum β-hCG ＜ 40,000 mIU/ml c. No metastasis to brain or liver. d. No significant prior chemotherapy

2. Poor-prognosis metastatic disease- a. Long duration(＞ 4 months) b. Serum β-hCG ＞ 40,000 mIU/ml c. Metastasis to brain or liver. d. Unsuccessful prior chemotherapy e. Gestational trophoblastic neoplasia following term pregnancy

MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA

• A Good-prognosis patients– Single-agent chemotherapy– Remission

• B Poor-prognosis patients– Combined chemotherapy

• Patients with poor-prognosis risk factors

• Revised FIGO ⅢC and Ⅳ• WHO scores ＞ 7

– Regimens• MAC• CHAMOCA• EMA/CO

– Remission

PLACENTAL-SITE TROPHOBLASTIC TUMOR

(PSTT)

PLACENTAL-SITE TROPHOBLASTIC TUMOR(PSTT)

• PSTT occur with any type of pregnancy• derived from the intermediate trophoblasts• Invade myometrium and lymphatics• Treatment

– Hysterectomy– Partial uterine resection– Chemotherapy for metastatic cases

• EP-EMA• EMA/CO• Adverse outcomes

Thank you