gestational trophoblastic tumors (gtt) gestational trophoblastic disease (gtd)
TRANSCRIPT
GESTATIONAL TROPHOBLASTIC TUMORS
(GTT)GESTATIONAL
TROPHOBLASTIC Disease (GTD)
Learning Objective
At the end of this session, I would like you to be able to:
1. Have an idea about GTT2. Diagnose GTT3. Know how to manage GTT4. Know how to monitor GTT
It is a diverse group of tumors 80%- 90% benign.
Abnormalities of trophoblasts
Resulting from abnormal events occurring at or shortly after fertilization
GTT follow normal or abnormal pregnancy
Contains paternal genes
Types:Benign Hydatidiform mole 80%-90% Malignant Invasive mole Persistent trophoblastic tumor Choriocarcinoma Placental site tumors (Rare)
Unique about GTT Cure almost 100% Sensitive marker- secreted by all types Allow:- Accurate assessment- Follow-up
Epidemiology: - Varies- More in far east- Diet- More in extreme of reproductive ages- Risk of having another mole is 1- 3%
Hydatidiform mole:Results from abnormal events occur at or
shortly after fertilization, ? Abnormal gametogensis
Types: Histoligically Cytogenically - Complete mole - Partial mole
Genetic composition Complete (diploid karyotype
&paternal in origin• Chromosomes = 46 xx• Both xx, are paternally derived Fertilization of abnormal egg- no nucleus Haploid sperm 23x empty egg sperm
duplicate 46xx diploid(>90%)
< 20% empty ovum fertilized by 2 sperm resulting in 46xy
12- 25 % progress to Gestational Trophoblastic Tumor
Partial mole Chromosomes, triploid 69 xxy (80%) Minority triploid 69 xxx 20%(dispermic) Maternal& paternal genes Often present with fetal tissue - Fetus may be abnormal - Rarely reach term 5% progress to persistent gestational
trophoblastic tumor
Hydatidiform mole: - Confined to the uterine cavity - Occasionally trophoblastic-Embolic to
lungsPartial mole• some hydropic villi.• other villi normal. • less hyperplasia of trophoblast.• some fetal vessels or fetal Rbc.
Complete mole• all villi hydropic oedematous•all trophoblast are hyperplasia• absence of fetal blood vesselsGreater risk of becoming malignant
Hydatidiform mole:Symptoms: • majority >90% have irregular vaginal
bleeding 1st, 2nd trimester (does not indicate a problem)
• bleeding is painless• may expel vesicles • 1/3 excessive nausea/ vomiting, Why?? hyperemesis gravidarum 25%• pre-eclampsia occurs Early <24 weeks
gestation 3-12%What other conditions in pregnancy, when PET
occurs early???•hyperthyroidism 2- 10%, test before surgery• Theca luteal cysts, bilateral
Signs: Pale complexion Tachycardia sign of thyrotoxicosis Tachypnea- sign of pulmonary Embolism Uterus: Enlarged 50% Theca luteal cyst, 10-15% Secondary post partum bleeding (PPH) Persistent bleeding , should always
think GTT/GTD What should you do??
Partial Mole
More common May be undetected May not appear abnormal on
Ultrasound (USS) USS ordered for ?? Histopathology of Retained
product of conception (RPOC) partial or complete.
SNOWSTORM APPEARANCE OF MOLAR PREGNANCY
Requirement for chemotherapy
H mole may not regress spontaneously and require chemotherapy, more common with??
10-17% of H. mole result in invasive mole
3% of mole progress to choriocarcinoma
Diagnosis: High index of suspicious from clinical
data Quantatative beta-hCG Ultrasound shows _______ appearanceDifferential diagnosis:1. ________________2. ________________ Chest x-ray ??
Laboratory investigations: Full blood count? Blood group – Rh________? Coagulation profile? Liver function test Renal function test base line? Chest film
Treatment: Pre-requisites1. ____________2. ____________
Surgery
Blood cross match in theatre Syntocinon infusion
Dilation – suction evacuationComplication 1. ___________?2. ___________?Hysterectomy:When _________? _________?
Complication: Uterine perforation Uterine haemorrhage
Monitoring: Serum- β human chronic gonadotrophin What happens to βhCG ?- Initially- Post evacuation – immediate - 6-8 weeks post evacuation
Follow-up- Weekly βhCG, until 3 consecutive normal values - Monthly βhCG , until 6 months- Contraception??- History of molar pregnancy, Postpartum check
βhCG at delivery, 6 and 10 weeks- Repeat H> mole occur in 1-3 %, have greater risk
of invasive or choriocarcinoma
Chemotherapy: Prophylactic not justified >79%
spontaneous remission
When does chemotherapy is indicated in hydatidiform mole?
Invasive mole: Villi penetrate myometrium 5 – 10 % preceded by hydatidiform
mole βhCG persistently high after
evacuation of hydatidiform mole Locally invasive Rarely metastases to:- Vagina- Lung- Brain
Placental site trophoblast tumor Extremely rare Occur after non-molar pregnancy Sheets of cytotrophoblasts only When melastasis occur – fatal βhCG levels are relatively low Relatively chemotherapy-resistant Surgery has been the main stay of
treatment
Choriocarcinoma: Metastastatic Non-metastataticHistopathology: - Invade uterine wall- Metastasis- Sheet of cytotrophoblast and
synchiotriphoblast No identifiable villi
Choriocarcinoma: 50% of choriocarcinoma have
preceding hydatidiform mole 50% of choriocarcinoma follow:- Ectopic - Abortion - Normal pregnancy • Trophoblast after normal pregnancy
almost always choriocarcioma
Choriocarcinoma Subdivided into:Good Poor prognosisLow risk and high risk
Depending on:Site Size of metastasisClinical variables
Good Prognostic Factor:1. Initial βhCG < 40,000 miu/L 2. Therapy started within 4 months of
antecedent pregnancy3. Metastasis only to lung or pelvis4. No prior chemotherapy.
Poor Prognostic Factor: βhCG > 40,000 miu/L (initial) Therapy > 4 months from the
pregnancy Metastasis to brain or liver failed response to a single agent of
chemotherapy Choriocarcinoma following full term
pregnancy.
FIGO Staging for GTT
StageDescription
Chemotherapy
Methotrexate Etoposide Actinomycin D Cyclophosphomide Oncovin Folinic acid IM
Further Reading
www.hmole-chorio.org.uk www.swot.org.uk www.rcog.org.uk/guidelines
Questions time
Molar pregnancy Never include a fetus Commonly present with vaginal bleeding in
early pregnancy If complete contains only paternal genes HCG levels will lower than normal in early
pregnancy May result in a need for chemotherapy
GTT
There is a decreased incidence with increasing age
It gives typical USS appearance It is monitored post evacuation by
urinary oestriol It can be treated with trimthoprate
Following a diagnosis of a molar pregnancy
Serum hCG level should fall to within normal range in the first 4 weeks
Pregnancy should be avoided by inserting IUCD
Hysterectomy reduces the necessity for hCG monitoring
Clinical case scenario
Mrs. F is a 22 years old ward clerk. She is 8 weeks pregnant, and is complaining of severe nausea and vomiting, the uterus is compatible with 14 weeks. What is the differential diagnosis??