Gestational Trophoblastic Disease

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Gestational Trophoblastic Disease
Dr. Atif Ali M.D., Pathology,
Assistant
Professor
Department Of Pathology
Faculty of Medicine, Majmaah University
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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.

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Hydatidiform Mole
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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.ageover 35 and 40 years oldbelow 20
  years old.
• 3.hydatidiform mole historyif 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 1520
  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 incomplete mole
• Embryotic or fetal tissue -
  
• Villus stromal edema diffuseed
  localized
• Trophoblastic hyperplasia diffuseed
  localized
• Villus outline
  regular irregular
• Villus stromal blood vessel -
  
• Karyotype
  diploid 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
• theca lutein ovarian cyst
• gestational vomiting 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
• ß-HCGgt100000IU/L
• uterine size is obviously larger than that with
  the same gestational time.
• the luteinizing cyst is gt6cm
• If gt40 years old,the risk of invasion and
  metastasis may be 37, If gt50 years old,the risk
  of invasion and metastasis may be 56.
• repeated molethe morbidity of invasion and
  metastasis increase 34 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 ß-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 gt6cm
• there is still over hyperplasia of trophoblastic
  cells in the second curettage
• no follow up conditions

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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
• Micro examination villous structure and
  trophoblastic cells proliferation and
  differentiation deficiency. villous 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
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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
• 50gestational 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