GESTATIONAL TROPHOBLASTIC DISEASES

 abnormal proliferation of trophoblastic (placental) tissue

 molar pregnancies (partial and complete)
 invasive moles
 choriocarcinomas
 placental site trophoblastic tumors

 ability to produce hCG: both as a tumor marker for diagnosing the disease and as a tool for measuring
the effects of treatment.
 most curable gynecologic malignancy.

I. BENIGN GTD
 molar pregnancies (hydatidiform moles)

Physical Examination
 expulsion of grapelike molar clusters into the vagina or blood in the cervical os.
 Occasionally, may find large bilateral theca lutein cysts that result from high levels of B-hCG.
 abdominal exam: absent FHTs and size/date discrepancies.

Diagnostic Evaluation
 serum p-hCG levels can be extremely high (>lOO,OOO mIU/mL), relative to values for normal
pregnancy.
 Confirmation of GTD pelvic UTZ: "snowstorm" pattern

Differential Diagnosis
multiple gestation pregnancy, erythroblastosis fetalis, intrauterine infection fibroids, threatened abortion,
ectopic pregnancy, or normal intrauterine pregnancy.
Treatment: immediate removal of the uterine contents
1) dilation and suction evacuation (D&E)  intravenous oxytocin
2) completed childbearing, hysterectomy is an alternate therapy.

INCOMPLETE MOLES: normal ovum is fertilized by two sperm simultaneously

Clinical Manifestations : History
 delayed menses and a pregnancy diagnosis.
 Present with miscarriage or missed abortions  may be diagnosed later
COMPLETE MOLES: fertilization of an enucleate ovum or "empty egg," one whose nucleus is  Diagnosis is often made on pathologic examination of the products of
missing or nonfunctional, by one normal sperm  conception.
 Universal avascular villi; higher malignant potential  May have similar but much less severe symptoms

Risk Factors Physical Examination: typically normal except for the absence of FHTs
 women under age 20 or over age 40. Treatment: immediate removal of the uterine contents.
 Paternal: >45 y/o
 Diet: Low carotene and animal fat  Chemoprophylaxis may be useful in situations where patients are at high risk of postmolar GTD
 areas where the diet is low in beta-carotene and folic acid and when post-evacuation surveillance is doubtful
 had prior miscarriages or a prior history of GTD  Advanced maternal age >35
Clinical Manifestations : History  Gravidity >4
 MC presenting symptom: irregular or heavy vaginal bleeding during early pregnancy (painless  Uterine size larger than gestation by >6weeks
but may be associated with uterine contractions)  Serum bhCG titer > 100,000 mlU/ml
 d/t high HCG  Theca lutein cysts >6cm
1) severe nausea and vomiting (from hyperemesis gravidarum);  Presence of any medical complication
2) irritability, dizziness, and photophobia (from preeclampsia); or  Repeat molar pregnancy
3) nervousness, anorexia, and tremors (from hyperthyroidism).
In fact, preeclampsia occuring prior to 22 weeks gestation is pathoneumonic for molar
pregnancy MALIGNANT GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Carvy Mea B. Torida
  Invasive moles, choriocarcinoma and PSTT
 50%: occurs months to years after a molar pregnancy.
 One distinguishing feature: extreme sensitivity to chemotherapy.
 NONMETASTATIC: Methotrexate or actinomycin D

INVASIVE MOLES
 malignant transformation of a persistent benign disease or recurrence of GTD
 penetrate locally into the myometrium, sometimes reaching through to the peritoneal cavity.
Despite this, invasive moles rarely metastasize  respond well to chemotherapy

Clinical Manifestations : History

 as a result of plateauing or rising l)-heG after treatment for a molar pregnancy.

CHORIOCARCINOMA
 pure epithelial tumor: syncitio- and cyto-trophoblast
 often metastatic spreads hematogenously to lungs, vagina, pelVis, b rain, liver, intestines, and
kidneys.
 GROSS: necrotic hemorrhagic masses or nodules
 MICROSCOPIC: exuberant trophoblastic growth WITHOUT villous pattern!
TREATMENT:
 Chemotherapy
MAC DRUG COMBI:
 Methotrexate: 0.3-0.4mg/kg BW/day IM on days 1-5
 Actinomycin D: 10-12mcg/ kg BW/day SIVP on days 1-5
 Cyclophosphamide: 3mg/kg BW/day PO on days 1-5 or
 Chlorambucil: 0.2mg/ kg BW/day PO on days 1-5
EMA-CO chemotherapy
 Course 1: (EMA) etoposide, methotrexate, actinomycin d
 Course 2: (CO) vincristine, Cyclophosphamide
 hysterectomy

 Serial monitoring of bhCG to detect malignant degeneration

 Weekly until normal for 2 values  every 2 wks for 3months  monthly for 6-
12mos  every 6mos for 1-2 yrs  ANNUALLY
 CXR initially and rpt if abnormal or if HCG plateaus or rises
 Pregnancy after a molar pregnancy: May be allowed after 6 months of normal serum bhCG level

Carvy Mea B. Torida