Gynecology [MOLES]

Benign Moles (aka Gestational Trophoblastic Disease)

Moles aren’t cancerous, but they are potentially premalignant as
choriocarcinoma may arise from Moles. Let’s discuss the
precancer before getting to the cancer.

A complete mole is “complete.” It’s a product of normal

fertilization, has a “completely” normal number of chromosomes
(46), and is “completely” molar; there are no fetal parts. It’s a
product of a broken egg. One single sperm gets inside one single
egg, but that egg has no nucleus, so the sperm spontaneously
doubles its chromosomes. Though normal in the number of
chromosomes, it isn’t normal in chromosome complement; all the
genetic material is of the sperm.

An incomplete mole is “incompletely molar” in that it contains Complete Mole Incomplete Mole
some fetal parts, doesn’t have the normal number of
chromosomes (69), and is a product of two separate sperm Each letter represents 23 chromosome, S: Sperm, E: Egg
fertilizing one normal egg. Aside from the differences in
fertilization, genetic content, and presence of fetal parts, all moles
present the same way.

A mole grows faster, produces more B-HCG, and looks different

than a normal pregnancy on exam and ultrasound. That being
said, there are a couple of ways it can present. If the B-HCG is
Persistence of B-HCG
super high or there’s a size-date discrepancy (it’s growing too
suggests chorio
fast), there’s a chance there is a molar pregnancy. Because the B-
HCG is elevated so high and B-HCG “looks like” TSH, the
patient may present with hyperthyroidism. But B-HCG also
causes “morning sickness,” presenting with nausea and vomiting
in the first trimester. Too much B-HCG (levels can be > 100,000)
causes Hyperemesis Gravidarum - a severe, dehydrating
morning sickness or one that lasts beyond the first trimester. A Normal return to baseline
pelvic exam may demonstrate a grape-like mass expelled into the
vagina through the cervix. A pelvic ultrasound will reveal a
snowstorm appearance of the mass in the uterus. A suction
curettage will reveal the grape-like mass.

Track the HCG weekly to assure it was all gotten. It should Stage Concept Treatment
decline linearly. Put her on OCPs to prevent pregnancy; if she I Uterus Methotrexate then Actinomycin
gets pregnant it’s impossible to be sure if it’s an invasive mole or D
a regular pregnancy! Or
TAH
II Genitals Etoposide, Methotrexate,
Invasive Moles and Choriocarcinoma
Actinomycin D, and
Any pregnancy - molar or regular - can result in a cancer:
Carboplatin
Choriocarcinoma. It’s a cancer of gestational contents. After a +/- Surgery
miscarriage, normal delivery, or molar pregnancy, if there’s III Mets to SAA
elevation of the B-HCG or its symptoms (listed above), suspect Lungs only
chorio. Diagnose it with an ultrasound first, cut it out with a IV Mets to Beyond Scope
curettage, and stage it with a CT scan. For localized disease anywhere
(Stage I) use Methotrexate followed by Actinomycin D (fertility else
sparing) or TAH (fertility complete). For resistant disease, use
MAC. For advanced stage disease, more aggressive chemo is All disease gets contraception for a minimum of 12
required: Etoposide, Methotrexate, Actinomycin D, and months with serial B-HCG monitoring.
Carboplatin.
MAC is Methotrexate, Actinomycin D, and
Cyclophosphamide; it’s only used in refractory disease.

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