Gestational Trophoblastic Disease

DI WEN M.D., Ph.D.,

Professor & Chairman
Department Of Obstetrics & Gynecology
2006-11-15 七年制 GTD
Renji Hospital Affiliated to SJTU School of Medicine 1
 introduction
Defination:
gestational trophoblastic disease (GTD) is
a group of disease originated from placenta
l villose trophoblastic cells, including hydat
idiform mole, invasive mole, choriocarcino
ma and a kind of less common trophoblasti
c cell tumor in placenta.

2
 introduction
Relations among the diseases:
Benign mole is considered to be abnormal formatio
n of placenta accompanied by the special abnormal
hereditary ;
Invasive mole results from benign mole;
Choriocarcinoma and the trophoblastic cell tumor i
n placenta may result from benign mole, term pregn
ancy, abortion and ectopic pregnancy.

3
Hydatidiform Mole

4
 Introduction
Defination: hydatidiform mole means that aft
er pregnancy the placental trophoblastic cells p
roliferate abnormally, there is stromal edema, a
nd forms vesicula which is like grape on its app
arence.

Classification : hydatidiform mole is divided

into complete and incomplete type

5
 Etiology
the etiology is not clear
Etiology of complete hydatidiform mole
Epidemiology: the morbidity of hydatidiform mole is different in different ar
ea.
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 hydati
diform mole,then the morbidity of the hydatidiform mole when pregnant agai
n is 1% and 15~20% respectively.
Genetic factors:
1.enucleate egg fertilization: chromosome karyotype of complete mole is dip
loid ,90% is 46XX,10% is 46XY.
6
7
 Etiology

Etiology of incomplete hydatidiform mole

the morbidity of incomplete mole is much lo
wer than that of the complete type, and it is
not associated with age.
Genetic factors: chromosome karyotype of 9
0% incomplete mole is triploid. The most co
mmon chromosome karyotype is 69XXY,and
then is 69XXX or 69XYY.

8
9
 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

10
 Partial mole

Complete mole

11
 Partial mole

Complete mole

12
 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

13
theca lutein ovarian cyst

14
 Clinical manifestation

partial mole:
may have the major symptoms of complete mol
e but it is slightly manifested. no luteinizing cyst
. The histologic examination of curettage sampl
e may confirm the diagnosis.

15
 Prognosis
complete mole has the latent risk of local invasion
or telemetastasis
The high-risk factors includes
β-HCG>100000IU/L
uterine size is obviously larger than that with the same gesta
tional time.
the luteinizing cyst is >6cm
If >40 years old,the risk of invasion and metastasis may be 3
7%, If >50 years old,the risk of invasion and metastasis may
be 56%.
repeated mole:the morbidity of invasion and metastasis incr
ease 3~4 times
16
 Diagnosis

HCG measurement

ultrasound examination

detecting the fetal heart beat by ultrasound

Doppler

17
18
 Differential diagnosis

 abortion
 twin pregnancy
 polyhydramnios

19
 Management
emptying uterine cavity
once the diagnosis is confirmed the uterine c
avity 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

20
 Management
preventive chemotherapy
over 40 years old
the β-HCG is over 100kIU/L before emptying mole
the HCG regresion curve is not progressively declin
ed
uterus is obviously larger than the size of the ameno
rrhea
luteinizing cyst is >6cm
there is still over hyperplasia of trophoblastic cells i
n the second curettage
no follow up conditions

21
 Follow up

HCG qw till normal

QW X 3m
Q2W X 3m
QM X 6m
Q6M X 2y

22
Invasive mole

23
 introduction
 Definition: Invasive mole means the hydatidifor
m mole invade the uterine myometrium or metasta
size to extrauterine tissue.
 Biologic behavior: invasive mole villus may in
vade myometrium or blood vessels or both, at begi
nning it spread locally,invade myometrium, somet
imes penetrate the uterine wall and spread to the b
road ligament or abdominal cavity.

24
 Pathology

 Macro examination: different size of viscula in m

yometrium,there may be or may not be primary fo
cus in uterine cavity.when the invasion is near ser
osal layer……
 Microexamination: villose structure and trophobla
stic cells proliferation and differentiation deficienc
y.villose and trophoblastic cells can be found in m
ost patients,and cause vascular wall necrosis and b
leeding
25
 Clinical manifestation

 irregular vaginal bleeding

 uterine subinvolution
 theca lutein cyst does not disappear after e
mptying uterus
 abdominal pain
 metastatic focus manifestation

26
 Diagnosis
history and clinical manifestation
successive measurement of HCG
ultrasound examination
X-ray and CT
histologic diagnosis

27
 Choriocarcinoma

2006-11-15 七年制 GTD 28

 Introduction
Choriocarcinoma is a highly malignant tumor,it can met
astasize to the whole body through blood circulation , d
amage tissues and organs,cause bleeding and necrosis.
The most common metastatic site is lung ,then vagina,b
rain and liver
50%gestational choriocarcinoma result from hydatidifor
m mole (generally occurs over 1 year after emptying the
mole), the rate of occurrence after abortion or term deli
very is 25% and 25% respectively, seldom occurs after
ectopic pregnancy

29
 Pathology
 macroexamination: most choriocarcinoma occurs in uteru
s, the tumor diameter 2-10cm, its color, section, cancer em
bolus is often found in parauterine veins,ovarian luteinizin
g cyst may be formed

 histologic examination: under microscope the hyperplasti

c cytotrophoblastic cells and syntrophoblastic cells invade
the myometrium and blood vessels accompanied by the ble
eding and necrosis, so the cancer cells can not be found in
the center

30
31
 Clinical manifestation
Vaginal bleeding
Pain
Uterine enlargement
Mass

32
 Diagnosis
Clinical Features
Ultrasonography
Human Chorionic Gonadotrophin
CT
X-ray
Pathology

33
 Differential diagnosis
 Hydatidiform mole
 Invasive mole
 Placental site trophoblastic tumors
 Rudimental placenta

34
 Metastases
Lung
Vagina
Brain
Liver

35
36
 anatomic staging

Stage I disease confined to uterus

Stage II gestational trophoblastic tumor extending
outside uterus but limited to genital structures (adn
exa, vagina, broad ligament)
Stage III gestational trophoblastic disease extendi
ng to lungs with or without known genital tract inv
olvement
Stage IV all other metastatic sites

37
 Management

Chemotherapy
Surgery

38
 Follow up

QM X 1 y
Q3M X 2 y
QY X 2y
Q2Y
39
 Thanks for Your Attention

DI WEN M.D., Ph.D.

Professor & Chairman
Department of Obstetrics & Gynecology
2006-11-15 七年制 Renji Hospital
GTDAffiliated to SJTU School of Medicine 40