Gestational Trophoblastic Diseases: A Review for PG

PreparationDr. Prithwiraj Maiti

Intern, R.G.Kar Medical College, KolkataFounder of Pgblaster India

Author of the following titles (Both published by Jaypee Brothers): A Practical Handbook of Pathology Specimens and Slides &

An Ultimate Guide to Community Medicine

Table of contents

• Introduction• Classification• Complete and partial mole:

1. Differences 2. Associated conditions3. Clinical features4. Diagnosis

Management5. Follow-up6. Role of prophylactic chemotherapy

• Choriocarcinoma• Residual/ Invasive mole.

Introduction

• GTDs are a spectrum of diseases arising from trophoblastic cells in placenta.

Classification of GTDs

• Hydatidiform mole: Complete and partial• Invasive mole• Choriocarcinoma.

Complete and Partial moleDifferences

Features Complete mole Partial moleFetus/ embryo Absent PresentTrophoblastic proliferation

Marked Minimal

Villous edema Marked FocalKaryotyping Diploid:

46 XX46 XY

Triploid:69 XXX69 XXY69 XYY

p57 immunostaining Negative Positive

Associated Conditions

• Pre-eclampsia (present in 50% of cases)• Theca-lutein cyst: Causing unilateral/ bilateral enlargement of ovary• Thyrotoxicosis like features (due to ↑chorionic thyrotropin production)• Hyperemesis (due to ↑hCG production).

Clinical features of molar pregnancy

• Period of amenorrhea• Vaginal bleeding• Lower abdominal pain• Expulsion of grape like vesicles per vagina (diagnostic)• Size of uterus is usually more than the period of amenorrhea• Feel of uterus is firm and elastic (due to absence of amniotic sac)• Fetal heart sound (FHS) not audible• Features of associated conditions, if present [Ex: Hypertension and

proteinuria (pre-eclampsia), uni/bi-lateral enlargement of ovary (theca-lutein cyst), tachycardia/ tremor (thyrotoxicosis), excessive vomiting (hyperemesis)].

Diagnosis

• USG: Classical snow-storm appearance (created by multiple placental vesicles filling the uterine cavity)• Serial estimation of serum β-hCG levels (high

levels are seen in molar pregnancy due to excessive production by trophoblastic cells)• Definitive diagnosis is made only by

histopathological examination of the products of conception.

Management

• If mole is in the process of expulsion: Suction-evacuation• If uterus is inert and os closed: Slow dilatation of cervix followed by

suction-evacuation• Most common immediate complication after evacuation is bleeding• Special management:

IndicationsHysterectomy Hysterotomy

Age > 35 years Profuse vaginal bleedingFamily completed Unfavorable cervixUncontrollable hemorrhage/ perforation during suction-evacuation

Perforation during suction-evacuation

Follow up after definitive management

• Must for all patients• Done for at least 1 year as the occurrence of choriocarcinoma from a

complete mole is highest during this period• Usually serum β-hCG becomes negative after 6-8 weeks of molar

evacuation• OCPs are the preferred mode of contraception during this period• IUDs are not to be inserted until the β-hCG level is undetectable

because of the risk of uterine perforation if an invasive mole is present.

Role of prophylactic chemotherapy

• Drug of choice: Methotrexate.• Indications:

1. If the hCG level fails to become normal by 10-12 weeks2. Rising hCG levels after reaching normal levels3. Post evacuation hemorrhage (reflecting residual trophoblastic

activity)4. When follow up visits are not adequate5. Evidences of metastasis.

Choriocarcinoma

• Extremely malignant, commonest cause of systemic metastasis among gynecological malignancies• Most common complication of choriocarcinoma is vaginal bleeding• Most common site of metastasis is lung• Those choriocarcinoma arising after full term pregnancy has the worst

prognosis• Management is by chemotherapy.

Residual/ Invasive mole

• Invasive moles originate almost exclusively from complete/ partial molar gestations • These are characterized by presence of whole chorionic villi that

accompany excessive trophoblastic overgrowth and invasion • These tissues penetrate deep into the myometrium; sometimes

involving the peritoneum, adjacent parametrium or vaginal vault• There is no evidence of muscle necrosis• Clinical features are: persistent hemorrhage and uterine perforation• Management: Chemotherapy.

Chemotherapeutic regimen for GTDs

• Single agent: Methotrexate• Multiple agents (EMACO Regimen):

E. EtoposideM. MethotrexateAC. Actinomycin-DO. Oncovin (Vincristine).

Thank you