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Gestational Trophoblastic Disease What you need to know for the “once-every-10-years”patient Marisa Adelman, MD © UNIVERSITY OF UTAH HEALTH Definition • Gestational Trophoblastic Disease (GTD): Benign and malignant tumors of the uterus, arising from placental tissue. • Hydatidiform Moles (HM): benign, premalignant disease • Complete mole • Partial mole • Gestational Trophoblastic Neoplasia (GTN): malignant disease • Invasive mole • Choriocarcinoma • Intermediate trophoblastic tumors (ITT) • Placental site trophoblastic tumor (PSTT) • Epithelioid trophoblastic tumor (ETT) © UNIVERSITY OF UTAH HEALTH Classification GTD HM GTN 80% 20% Complete mole Partial mole Persistent mole Invasive mole Choriocarcinoma ITT (30% all GTD) (40% all GTD) (non-invasive) 15% PSTT ETT © UNIVERSITY OF UTAH HEALTH Epidemiology GTD subtype Incidence Overall 1.67 per 1,000 deliveries Hydatidiform mole 1.36 per 1,000 deliveries Complete hydatidiform mole 0.52 per 1,000 deliveries Partial hydatidiform mole 0.67 per 1,000 deliveries Choriocarcinoma 3 per 100,000 deliveries Placental site trophoblastic tumor 0.9 per 100,000 deliveries Epithelioid trophoblastic tumor 0.1 per 100,000 deliveries Trends in incidence for gestational trophoblastic disease over the last 20 years in a population-based study. Eybouts YK, et al. Gynecol Oncol 2016;140:70-5. © UNIVERSITY OF UTAH HEALTH Epidemiology • Age may play a role in the risk of molar pregnancy. • Increased relative risk of molar pregnancy at the extremes of maternal age (≥45 years old and ≤15 years old) • The risk is greatest for complete moles at the upper extreme of maternal age. • May be due to fertilization of an abnormal oocyte at the beginning and end of the female reproductive period. • May observe chromosomally deficient oocytes, allowing either dispermic fertilization, or monospermic nuclear duplication. • The majority of molar pregnancies, however, occur in the middle of the reproductive period. Trends in incidence for gestational trophoblastic disease over the last 20 years in a population-based study. Eybouts YK, et al. Gynecol Oncol 2016;140:70-5.; Risk of partial and complete hydatidiform molar pregnancy in relation to maternal age. Sebire NJ, et al. BJOG. 2002;109:99-102. © UNIVERSITY OF UTAH HEALTH Genetics • Complete mole • Result from abnormal fertilization of an ovum lacking nuclear DNA Duplication of a single sperm genome Dispermy • Partial mole • Results from abnormal fertilization of an ovum retaining its nuclear DNA Duplication of a single sperm genome (uncommon) Dispermy © UNIVERSITY OF UTAH HEALTH Genetics: complete mole Chromosome duplication 46 23 X 46 XX Diploid + XX Monospermic Empty ovum 46 23 X or Y 46 XX + XX Diploid Empty ovum Dispermic 23 X or Y 46 46 XY XX © UNIVERSITY OF UTAH HEALTH Genetics: partial mole 46 69 XXX XX 23 X or Y 46 + 23 X 69 XXY + XX Triploid Dispermic 23 X or Y Most common 46 69 XYY XX Rare © UNIVERSITY OF UTAH HEALTH Postmolar GTD Develops in 15-20% of complete moles Develops in 1-5% of partial moles • Invasive mole: • Arises from extension of villous trophoblast (from HM) into the myometrium via tissue or venous channels. • Choriocarcinoma • Arises from villous trophoblast following various types of pregnancy: • HM (50%) • Term or preterm pregnancy (25%) • Tubal pregnancy or abortion (25%) • Intermediate trophoblastic tumors • Arises from interstitial trophoblast at the placental implantation site following mostly non-molar pregnancies. • ETT is a rare variant of PSTT, resulting in neoplastic transformation of intermediate trophoblast years after a term delivery. • Has a greater propensity for lymphatic spread. • Metastases are noted in 30-50% of cases, most commonly to the lungs. © UNIVERSITY OF UTAH HEALTH Early placental development This occurs between the morula and blastocyst stage of development. Avagliano, L. (2016, August 12). Histology of the Human Placenta. Retrieved from https://www.semanticscholar.org © UNIVERSITY OF UTAH HEALTH Early placental development The syncytiotrophoblast penetrates the uterine wall The cytotrophoblast differentiates beneath the syncytiotrophoblast Avagliano, L. (2016, August 12). Histology of the Human Placenta. Retrieved from https://www.semanticscholar.org © UNIVERSITY OF UTAH HEALTH Early placental development The cytotrophoblast undergo rapid division, expanding the syncytiotrophoblast Avagliano, L. (2016, August 12). Histology of the Human Placenta. Retrieved from https://www.semanticscholar.org © UNIVERSITY OF UTAH HEALTH Early placental development Formation of cytotrophoblastic anchoring columns. Extravillous trophoblast invades the maternal decidua Avagliano, L. (2016, August 12). Histology of the Human Placenta. Retrieved from https://www.semanticscholar.org © UNIVERSITY OF UTAH HEALTH Correlation with GTN • Villous trophoblast • Cytotrophoblast invasive mole, choriocarcinoma • Syncytiotrophoblast invasive mole, choriocarcinoma • Extravillous trophoblast • Intermediate trophoblast PSTT and ETT © UNIVERSITY OF UTAH HEALTH Workup of HM • H&P • Pelvic ultrasound • Quantitative hCG • CBC • Liver, renal, and thyroid function tests • Blood type and screen • Chest x-ray Case courtesy of Dr Rengarajan R, Radiopaedia.org, rID: 23843; Case courtesy of Dr Avni K P Skandhan, Radiopaedia.org, rID: 25306 © UNIVERSITY OF UTAH HEALTH Treatment of HM • Suction D&C (preferably under ultrasound guidance) • Hysterectomy can be considered as an alternative if not desiring future fertility • Rho (D) administration where appropriate • Use of uterotonics during and following the procedure • Histopathologic review and possible genetic testing to confirm diagnosis • Flow cytometry to determine ploidy • Differentiate complete from partial moles • Biomarkers to identify the absence of paternally imprinted, but maternally expressed genes • Differentiate between complete moles and non-molar hydropic abortions Genest DR, Dorfman DM, Castrillon DH. Ploidy and imprinting in hydatidiform moles: complementary use of flow cytometry and immunohistochemistry of the imprinted gene product p57KIP2 to assist molar classification. J Reprod Med 2002;47:342-46. © UNIVERSITY OF UTAH HEALTH Prophylactic chemotherapy for HM • May reduce the incidence of postmolar GTN by 3-8% • May be considered in women with complete HM, at high risk for malignant transformation: • Age > 40 years old • hCG levels >100,000 mIU/mL • Excessive uterine enlargement • Theca lutein cysts > 6 cm. • NCCN Guidelines: prophylactic methotrexate or dactinomycin can be considered for patients deemed at high risk for post-molar GTN. Kim DS, Moon H, Kim KT, et al. Effects of prophylactic chemotherapy for persistent trophoblastic disease in patients with complete hydatidiform mole. Obstet Gynecol. 1986;67:690–94. Limpongsanurak S. Prophylactic actinomycin D for high-risk complete hydatidiform mole. J Reprod Med. 2001;46:110–16. Wang Q, Fu J, Hu L, et al. Prophylactic chemotherapy for hydatidiform mole to prevent gestational trophoblastic neoplasia. Cochrane Database of Systematics Reviews 2017;9. © UNIVERSITY OF UTAH HEALTH Prophylactic chemotherapy for HM • Although it may reduce the risk of progression to GTN in women who are at high-risk of malignant transformation, it also: • May increase drug resistance, • May delay treatment of GTN • Would expose women to toxic side effects • Cannot be routinely recommended, and: • Would only reduce the risk of needing full-scale chemotherapy • Would not eliminate the need for monitoring and follow-up Prophylactic chemotherapy for hydatidiform mole to prevent gestational trophoblastic neoplasia. Wang Q, et al. Cochrane Database of Syst Rev. 2017;9. © UNIVERSITY OF UTAH HEALTH Follow-up of HM • Quantitative hCG monitoring • hCG assay every 1-2 weeks until 3 consecutive normal levels. • hCG asses twice in 3 month intervals following initial normalization • Assay should be capable of detecting all forms of hCG (beta-hCG, core hCG, nicked-free beta, beta core, hypoglycosylated forms), as the molecules associated with HM tend to be more heterogenous and degraded. Cole LA. Human chorionic gonadotropin and associated molecules. Expert Rev Mol Diagn 2009;9:51-73. Muller CY, Cole LA. The quagmire of hCG and hCG testing in gynecologic oncology. Gynecol Oncol 2009;112:663-72. © UNIVERSITY OF UTAH HEALTH Recurrence, development of GTN • Risk of recurrence is <2% after a single molar pregnancy • Increased risk of CHM in woman with NLRP7 or KHDC3L gene mutations. • Reported incidence of GTN after molar pregnancy is 18-29% • 15-20% CM’s • 1-5% PHM’s • 2-3% of HM’s progress to choriocarcinoma • Once hCG level normalized, recurrent elevation occurs in <1%. Sebire NJ, Fisher, RA, Foskett M, et al. Risk of recurrent hydatidiform mole and subsequent pregnancy outcome following complete or partial hydatidiform molar pregnancy. Br J Obstet Gynaecol 2003;110:22-26. © UNIVERSITY OF UTAH HEALTH Risk of GTN after hCG normalization • The overall risk of developing GTN after normalization of hCG is approximately 0.3%. • 0-0.1% risk after a PHM • 0.3-0.6% risk after a CHM • 0-9.5% risk after a multiple pregnancy involving HM • Patients who required >56 days (8 weeks) to achieve a normal hcg level may have as much as a 10-fold increased risk of developing GTN. • May consider stopping surveillance: • At the time of normalization, following a PHM. • 6 months after normalization, following a CMH. • 12 months after normalization, following a multiple pregnancy involving HM Risk of gestational trophoblastic neoplasia after hCG normalization according to hydatidiform mole
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