GESTATIONAL TROPHOBLASTIC NEOPLASIA

GTN

Clinical spectrum including all neoplasms that derive from abnormal placental (trophoblastic) proliferation
PREGNANCY GONE WRONG
Molar pregnancy is most common.
o Problem with proliferation of placenta itself
- Does not develop into complete fetus
o Complete mole DNC
o Incomplete mole
Persistent or malignant disease will develop in approximately 20% of patients with molar pregnancy. IF
WASN'T FULLY ADDRESSED IT'S A PERSISTANT MOLE
o Tx DNC w either chemo or sx

CLASSIFICATION OF GESTATIONAL TROPHOBLASTIC NEOPLASM

Hydatidiform mole (Primary nonmalignant nonmetastatic disease)
o Complete Mole
- Does not have fetal parts
o Partial Mole
- Has fetal parts
Persistent nonmetastatic gestational trophoblastic neoplasias
o Molar pregnancy is evacuate but tissue is left behind
o Out put of tissue persists within the system
o Treat with methotrexate
o Can be metastatic this type of tissue is found in other locations
Metastatic gestational trophoblastic neoplasia
o Good prognosis metastatic disease
o Poor prognosis metastatic disease
Placental site tumors (malignant, usually nonmetastatic)
CLINICAL FEATURES
Clinical presentation of pregnancy
o This symptoms are EXTREME i.e. hyperemesis gravidarum, EXTREME NAUSEA
Reliable means of diagnosis by pathognomonic ultrasound findings
Specific tumor marker
o Quantitative serum human chorionic gonadotropin (hCG) OUT OF PROPRTION FOR TIME FRAME
YOU WOULD ANTICIPATE FOR PREGNANCY
- VERY high 100,000s
- Tells you pregnancy is not normal
- A LOT OF TIMES COMPLAIN OF VAG BLEEDING AS WELL
HYDATIDIFORM MOLE
Replacement of normal placental trophoblastic tissue by hydropic placental villi
o Complete mole no identifiable embryonic or fetal structures
o Partial moles focal trophoblastic proliferation, degeneration of the placenta, and identifiable fetal
or embryonic structures
Mirror syndrome uterine edema taken on by mother, in legs and lungs usu.
EPIDEMIOLOGY
Highest incidence among Asian women living in Asia (1 in 200 pregnancies)
Incidence in US is approximately 1 in 1500 pregnancies
Associated with low dietary carotene consumption and vitamin A deficiency
o Maybe why Asian pop is at risk
Partial moles are associated with h/o infertility and spontaneous abortion
CLINICAL PRESENTATION
Abnormal bleeding most characteristic presenting symptom
Confirmed pregnancy
o hCG discrepancy with value received and US results VERY HIGH OR GESTATIONAL AGE DOESN'T
CORRELATE, EXAGERATED SYMPTOMS OF PREGNANCY, BLEEDING
Uterine size and date discrepancy

Exaggerated subjective symptoms of pregnancy

Severe nausea and vomiting
Marked gestational HTN
Proteinuria
Any women who presents with findings suggestive of severe HTN prior to 20 wks in
pregnancy, a molar pregnancy should be immediately suspected
o If theyve never had HTN prior
US imaging confirms dx snowstorm appearance
o No detectable fetus, BECAUSE OLD DAYS US WASN'T
GREAT

AS

TREATMENT OF MOLAR PREGNANCY

Prompt evacuation of uterine contents d/t malignant potential
o Must get all the tissue
o Dilation and suction curettage followed by gentle sharp
curettage BECAUSE DON'T WANT TO LEAVE ANYTHING
BEHIND CAN BECOME PERSISTANT MOLE
Larger moles associated with uterine atony and excessive blood loss
o Increase risk PROM
Risk of pulmonary complications associated with trophoblastic emboli (tissue seeds into lungs)*
HYDROPD FETALIS AND MOM MIRRORS THAT, PULM EDEMEA ETC MIRRORS SYNDROME
POSTEVACUATION MANAGEMENT
Monitor closely for 6 to 12 months
o hCG 2-3 times a week initially until they start to decrease IF DON'T COME DOWN FREQUENTLY
THEN AT RISK FOR GETTING MILE
o If they do not normalize, start methotrexate
- **must be compliant with follow up, give PPX if non-compliance is suspected
Rh-negative patients should be given Rh-immune globulin
Periodic physical exam
Quantitative hCG levels should be checked within 48hrs and then every 1 to 2 weeks while elevated, and
at 1 to 2 months thereafter
During the first year the patient should be treated with OCPs because of risk of recurrence
o Starts OCPs very soon
GESTATIONAL TROPHOBLASTIC NEOPLASIA (GTN) MOLAR PREG CAN BECOME PRSTATN OR INVASIVE
OR CAN HAVE CHORIOCARCINOMA (MALIGNANCY SIM TO MOLAR PREG OR PSTT)
Persistent/Invasive Mole
o If beta hCG does not normalize
Choriocarcinoma
o Malignancy within placental tissue itself
Placental-Site Trophoblastic Tumor (PSTT)
INVASIVE MOLE
Myometrial invasion by hydatidiform mole
1 in 15,000 pregnancies
10-17% of hydatidiform moles will progress to invasive moles
Usually diagnosed months after evacuation of a complete mole, when hCG levels do not fall
appropriately as persistent metastatic or nonmetastatic GTD
PERSISTENT GTD- NEED TO RULE OUT THERE ISNT ANOTHER PREGNANCY NOT ANOTHER MOLE
hCG levels that rise or reach a plateau are an indication of persistent disease
Need further treatment after a new pregnancy has been ruled out
o Methotrexate alone not enoug
Definition of persistent molar disease and need for chemotherapy (at least one of the following): HOW
LONG BHCG HAS TO BE EVALUATED BEFORE DIAGNOSED AS PERSISTANT MOLE
o B-hCG plateau for 4 values for 3 weeks
o B-hCG increase of 10% for 3 values for 2 weeks
o B-hCG persistence 6 months after molar evacuation
o Histopathologic diagnosis of choriocarcinoma- DIFF IN TISSUE FROM DNC ABSENCE OF THE VILA

o Presence of metastatic disease

Require chest x-ray for metastatic disease
Also do CT scan for other mets in body

CHORIOCARCINOMA
Most aggressive type of GTN
Abnormal trophoblastic hyperplasia
Absence of chorionic villi- WONT BE ABLE TO TELL TILL PATHOLOGY WILL BE ABLE TO TELL IF PARTIAL,
COMPLETE, CHORIOCARCINMA IF COMES BACK AS CHORICARCINOMA HAVE TO WORK UP WITH OTHER
IMAGING STUDIES
Direct invasion of myometrium
Vascular spread to distant sites:
o Lungs
o Brain
o Liver
o Pelvis and vagina
o Spleen, intestines, and kidney
TREATMENT NOT PERSISTATNT SURGERY
Nonmetastatic persistent GTN is completely treated by single agent chemotherapy
o Methotrexate OR (if intolerable secondary to liver dysfunction), then go to..
o Actinomycin D
Metastatic GTN prognosis is more complex
o Good prognosis
o Poor prognosis

R. GIVE PATIENT A SCORE ON WHERE THEY FALL IF GOOD OR POOR PROGNOSIS.

EMACO

A score of 7 or above classifies metastatic GTN as high-risk, WHEN THEY GET THIS SCORE requiring
multi-agent chemotherapy COMBINATION OF ALL THESE, FOR (INV MOLE BECOMES PERSISTENT MET DISEASE) OR
CHORIOCARCINOMA

o Etoposide
o Methotrexate
o Actinomycin D
o Cyclophosphamide
o Oncovin (vincristine)
Need to be in monitored settings for SEs
Adjuvant radiotherapy is sometimes performed with patients who have brain or liver metastasis
Cure rates for non-metastatic and good-prognosis metastatic disease approach 100%
o Still need to worry about subsequent h. mole
Cure rates for poor-prognosis metastatic diseases are 80% to 90%- ONLY POOR PROGNOSIS WILL NEED
EMACO

PLACENTAL-SITE TROPHOBLASTIC TUMOR (PSTT)

Most common symptom is vaginal bleeding

Tend to: TREATMENT JUST TO REMOVED ALSO NEED TO GOOLD BHCG IF NOT COMING DDOWN WILL
PRBLY NEED HYSTERECTOMY
o Remain in uterus, rarely metastatic
- Making hysterectomy curative, Infertility will ensue
o Disseminate late
o Produce low levels of B-hCG compared to other GTN, better followed by human placental lactogen
levels
o Be resistant to chemotherapy (treat with surgery)

NOTES: If patient experiences spontaneous abortion, need to check if pregnancy was h. mole beta hCG will be
extremely high