GTD

Gestational Trophoblastic Disease

 Definition
• A heterogeneous group of interrelated lesions
arising from abnormal proliferation of
trophoblastic epithelium of the placenta
• It is maternal tumor arising from abnormal
fetal tissue (trophoblastic elements) rather
than maternal tissue
• It is most curable gynecologic malignancy even in the
presence of widespread dissemination and one of
the few that may allow for the preservation of
fertility-------very sensitive for chemotherapy
 Histologic classification
• Hydatidiform mole: 80%
• Invasive mole: 10%-15%
• Choriocarcinoma (chorioepithelioma): 2-5%
• Placental site trophoblastic tumors: very rare
 Clinical types
• Benign trophoblastic disease: hydatidiform mole
a. complete hydatidiform mole.
b. partial hydatidiform mole----usually have more
benign course
• Malignant trophoblastic disease(also called
gestational trophoblastic neoplasia[GTN]) and have
the potential for local invasion and metastasis
a. Metastatic
b. Non metastatic
Relationship of hydatidiform mole,
Invasive Mole, & Choriocarcinoma
Hydatidiform mole - Abortion( induced/spont)
-Term pregnancy
-Ectopic

Invasion mole Choriocarcinoma.

 Hydatidiform Mole
• Molar pregnancy
• It is a pregnancy characterized by neoplastic
proliferation of the trophoblast in which the terminal
villi are transformed into vesicles filled with clear
viscid material
• Most common form of GTD---80% of cases of GTD
• Categories(Based on gross morphology & karyotype)
complete mole ----90%
partial mole --------10%
 Etiology
• Remains unclear, but it appears to be due to
abnormal gametogenesis and fertilization
• There are many associated risk factors
 Associated Risk factors
• Extremes of maternal age: <20yrs and >35 yrs----risk for
complete mole was increased (2.0-fold for >35yrs; 7.5-fold
>40 yrs and 10 times >45 years than those younger ages
• Prior history of GTD: if prior one GTD (1% risk) and two GTD
(16%-28% risk)
• Nulliparity >70% of women with GTD are nullipara
• Dietary deficiency: diet low in beta-carotene/ vitamin A,
protein/folic acid, and animal fat
• Geographic area-----high in Asia
• Other possible factors: smoking, infertility, spontaneous
abortion, blood group A, and a history of OCP use
 Incidence
• Vary in different regions of the world.
 1 /1500-2000 pregnancies in the U.S. & Europe
 1 / 500-600 pregnancies in some Asian
countries------China:1/1238
• Complete mole is more common than incomplete
 Complete Hydatidiform Mole
• The mass of tissue is completely made up of abnormal cells.
• Fetal or embryonic tissue is absent
• Usually arise from an ovum that has been fertilized by a
haploid sperm, which then duplicates its own
chromosomes.
• The ovum nucleus may be either absent or inactivated
• The molar chromosomes are entirely of paternal origin,
although mitochondrial DNA is of maternal origin so it is
actually a paternal allograft in the mother.
• It exhibit characteristic non invasive diffuse trophoblastic
hyperplasia and diffuse swelling of chorionic villi.
• Absent trophoblastic stromal inclusion
Complete Hydatidiform Mole
 Partial hydatidiform mole
• Partial mole-----the mass may contain both these
abnormal cells and often a fetus that has severe
defects
• In partial mole the fetus will be consumed ( destroyed)
by the growing abnormal mass very quickly(shrink)
• Arise from fertilization of an active ovum by two sperm
• Characterized by focal swelling of chorionic villi and
focal trophoblastic hyperplasia and contain some
normal appearing chorionic villi or fetal tissue.
• Marked scalloping of chorionic villi and trophoblastic
stromal inclusions.
Partial hydatidiform mole
 Cytogenetics
• Complete molar pregnancy- Chromosomes are paternal ,
diploid
 46,XX in 90% cases
 46,XY in 10% (in this case an apparently empty egg is
fertilized by two sperm)
• Partial molar pregnancy----Chromosomes are paternal and
maternal. Generally have a triploid karyotype (69
chromosomes); the extra haploid set of chromosomes usually
is derived from the father
 69,XXY in 80%
 69,XXX or 69,XYY in 10-20%
Karyotype of complete hydatidiform
mole
Karyotype of partial hydatidiform mole
 Sign and symptoms of molar
pregnancy
• Vaginal bleeding
• Excessive Uterine Size relative to gestational age
( with no fetal heart beating and fetal movement)
• Preeclampsia: once observed in 27% of pts
• Hyperemesis Gravidarum
• Hyperthyroidism
• Partial mole might not have classical s/s
 Dx
• Suspicion---- classic sign and symptoms
• Quantitative beta-HCG----unusually high titer of HCG
• Ultrasonography:
 complete mole U/S is a reliable and sensitive technique for
the diagnosis of complete molar pregnancy. Complete
moles produce typical USG image, known as a
“snowstorm” pattern
 Partial mole U/S may contribute if both focal cystic spaces
in the placental tissues and an increase in the transverse
diameter of the gestational sac is seen
A sonographic findings of a molar pregnancy. The
characteristic “snowstorm” pattern is evident.
 ddx
• Abortion
• Multiple pregnancy
• Polyhydramnios
 Mgt outlines
• Uterine evacuation------Suction curettage
• Hysterectomy
• Prophylactic Chemotherapy
• Follow-up