Gestational Trophoblastic Disease

DI WEN
2006-11-15

M.D., Ph.D.,

Professor & Chairman Department Of Obstetrics & Gynecology GTD Renji Hospital Affiliated to SJTU School of Medicine

introduction
Defination:
gestational trophoblastic disease (GTD) is a group of disease originated from placental villose trophoblastic cells, including hydatidiform mole, invasive mole, choriocarcinoma and a kind of less common trophoblastic cell tumor in placenta.
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introduction
Relations among the diseases:
Benign mole is considered to be abnormal formation of placenta accompanied by the special abnormal hereditary ; Invasive mole results from benign mole; Choriocarcinoma and the trophoblastic cell tumor in placenta may result from benign mole, term pregnancy, abortion and ectopic pregnancy.

Hydatidiform Mole

Introduction
Defination: hydatidiform mole means that
after pregnancy the placental trophoblastic cells proliferate abnormally, there is stromal edema, and forms vesicula which is like grape on its apparence.

Classification : hydatidiform mole is divided

into complete and incomplete type
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Etiology
the etiology is not clear Etiology of complete hydatidiform mole
Epidemiology: the morbidity of hydatidiform mole is different in different area. High risk factors: 1.nourishing status,social economy. 2.age:over 35 and 40 years old;below 20 years old. 3.hydatidiform mole history:if a patient has the history of 1 or 2 times hydatidiform mole,then the morbidity of the hydatidiform mole when pregnant again is 1% and 15~20% respectively. Genetic factors: 1.enucleate egg fertilization: chromosome karyotype of complete mole is diploid ,90% is 46XX,10% is 46XY.
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Etiology
Etiology of incomplete hydatidiform mole
the morbidity of incomplete mole is much lower than that of the complete type, and it is not associated with age. Genetic factors: chromosome karyotype of 90% incomplete mole is triploid. The most common chromosome karyotype is 69XXY,and then is 69XXX or 69XYY.
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Pathology
Complete mole Embryotic or fetal tissue Villus stromal edema Trophoblastic hyperplasia Villus outline Villus stromal blood vessel Karyotype diffuseed diffuseed regular diploid incomplete mole + localized localized irregular + triploid or tetraploid

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Partial mole

Complete mole

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Partial mole

Complete mole

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Clinical manifestation
complete mole:
vaginal bleeding after amenorrhea uterus is abnormally enlarged and become soft hyperthyroidism theca lutein ovarian cyst gestational vomitting and PIH Hyperthyroidism
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theca lutein ovarian cyst

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Clinical manifestation
partial mole:
may have the major symptoms of complete mole but it is slightly manifested. no luteinizing cyst. The histologic examination of curettage sample may confirm the diagnosis.

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Prognosis
complete mole has the latent risk of local invasion
or telemetastasis The high-risk factors includes
-HCG>100000IU/L uterine size is obviously larger than that with the same gestational time. the luteinizing cyst is >6cm If >40 years old,the risk of invasion and metastasis may be 37%, If >50 years old,the risk of invasion and metastasis may be 56%. repeated mole:the morbidity of invasion and metastasis increase 3~4 times
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Diagnosis
HCG measurement

ultrasound examination
detecting the fetal heart beat by ultrasound
Doppler
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Differential diagnosis
abortion twin pregnancy polyhydramnios

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Management
emptying uterine cavity
once the diagnosis is confirmed the uterine cavity should be emptied as soon as possible Hysterectomy over 40 years old with high-risk factors uterine size is over 14 gestational weeks management of luteinizing cyst

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Management
preventive chemotherapy
over 40 years old the -HCG is over 100kIU/L before emptying mole the HCG regresion curve is not progressively declined uterus is obviously larger than the size of the amenorrhea luteinizing cyst is >6cm there is still over hyperplasia of trophoblastic cells in the second curettage no follow up conditions
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Follow up

HCG qw till QW X 3m Q2W X 3m QM X 6m Q6M X 2y

normal

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Invasive mole

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introduction
Definition:
Invasive mole means the hydatidiform mole invade the uterine myometrium or metastasize to extrauterine tissue.

Biologic behavior:

invasive mole villus may invade myometrium or blood vessels or both, at beginning it spread locally,invade myometrium, sometimes penetrate the uterine wall and spread to the broad ligament or abdominal cavity.
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Pathology
Macro examination: different size of viscula in
myometrium,there may be or may not be primary focus in uterine cavity.when the invasion is near serosal layer Microexamination: villose structure and trophoblastic cells proliferation and differentiation deficiency.villose and trophoblastic cells can be found in most patients,and cause vascular wall necrosis and bleeding
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Clinical manifestation
irregular vaginal bleeding uterine subinvolution theca lutein cyst does not disappear after
emptying uterus abdominal pain metastatic focus manifestation
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Diagnosis
history and clinical manifestation successive measurement of HCG ultrasound examination X-ray and CT histologic diagnosis
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Choriocarcinoma

2006-11-15

GTD

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Introduction
Choriocarcinoma is a highly malignant tumor,it can
metastasize to the whole body through blood circulation , damage tissues and organs,cause bleeding and necrosis. The most common metastatic site is lung ,then vagina,brain and liver 50%gestational choriocarcinoma result from hydatidiform mole (generally occurs over 1 year after emptying the mole), the rate of occurrence after abortion or term delivery is 25% and 25% respectively, seldom occurs after ectopic pregnancy
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Pathology
macroexamination: most choriocarcinoma occurs in uterus,
the tumor diameter 2-10cm, its color, section, cancer embolus is often found in parauterine veins,ovarian luteinizing cyst may be formed

histologic

examination: under microscope the hyperplastic cytotrophoblastic cells and syntrophoblastic cells invade the myometrium and blood vessels accompanied by the bleeding and necrosis, so the cancer cells can not be found in the center
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Clinical manifestation
Vaginal bleeding Pain Uterine enlargement Mass
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Diagnosis
Clinical Features

Ultrasonography
Human Chorionic Gonadotrophin

CT
X-ray

Pathology

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Differential diagnosis
Hydatidiform mole

Invasive mole Placental site trophoblastic tumors Rudimental placenta

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Metastases
Lung Vagina Brain Liver

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anatomic staging
Stage I disease confined to uterus Stage II gestational trophoblastic tumor extending
outside uterus but limited to genital structures (adnexa, vagina, broad ligament) Stage III gestational trophoblastic disease extending to lungs with or without known genital tract involvement Stage IV all other metastatic sites
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Management
Chemotherapy Surgery
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Follow up

QM X 1 y Q3M X 2 y QY X 2y Q2Y
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Thanks for Your Attention

DI WEN
2006-11-15

M.D., Ph.D.

Professor & Chairman Department of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine GTD

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