2006-11-15 七年制 GTD 1

Gestational Trophoblastic Disease

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

Professor & Chairman

Department Of Obstetrics & Gynecology

Renji Hospital Affiliated to SJTU School of Medicine

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introductionDefination:

gestational trophoblastic disease (GTD) is a group of disease originated from placental villose trophoblastic cells, including hydatidiform mole, invasive mole, choriocarcinoma and a kind of less common trophoblastic cell tumor in placenta.

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introductionRelations among the diseases:

Benign mole is considered to be abnormal formation of placenta accompanied by the special abnormal hereditary ;

Invasive mole results from benign mole;

Choriocarcinoma and the trophoblastic cell tumor in placenta may result from benign mole, term pregnancy, abortion and ectopic pregnancy.

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Hydatidiform Mole

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Introduction Defination: hydatidiform mole means that aft

er pregnancy the placental trophoblastic cells proliferate abnormally, there is stromal edema, and forms vesicula which is like grape on its apparence.

Classification : hydatidiform mole is divided into complete and incomplete type

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Etiology

the etiology is not clearEtiology 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 hydatidiform mole,then the morbidity of the hydatidiform mole when pregnant again is 1% and 15~20% respectively.

Genetic factors:

1.enucleate egg fertilization: chromosome karyotype of complete mole is diploid ,90% is 46XX,10% is 46XY.

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Etiology

Etiology of incomplete hydatidiform molethe morbidity of incomplete mole is much lower than that of the complete type, and it is not associated with age.

Genetic factors: chromosome karyotype of 90% incomplete mole is triploid. The most common chromosome karyotype is 69XXY,and then is 69XXX or 69XYY.

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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

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Complete mole

Partial mole

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Complete mole

Partial mole

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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

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theca lutein ovarian cyst

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Clinical manifestation

partial mole:

may have the major symptoms of complete mole but it is slightly manifested. no luteinizing cyst. The histologic examination of curettage sample may confirm the diagnosis.

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Prognosiscomplete mole has the latent risk of local invasion

or telemetastasisThe high-risk factors includes

β-HCG>100000IU/Luterine size is obviously larger than that with the same gestational time.the luteinizing cyst is >6cmIf >40 years old,the risk of invasion and metastasis may be 37%, If >50 years old,the risk of invasion and metastasis may be 56%.repeated mole:the morbidity of invasion and metastasis increase 3~4 times

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Diagnosis

HCG measurement

ultrasound examination

detecting the fetal heart beat by ultrasound Doppler

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Differential diagnosis

abortion twin pregnancy polyhydramnios

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Managementemptying uterine cavity

once the diagnosis is confirmed the uterine cavity should be emptied as soon as possible

Hysterectomy

over 40 years old with high-risk factors

uterine size is over 14 gestational weeksmanagement of luteinizing cyst

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Management preventive chemotherapy

over 40 years old the β-HCG is over 100kIU/L before emptying molethe HCG regresion curve is not progressively declineduterus is obviously larger than the size of the amenorrhealuteinizing cyst is >6cmthere is still over hyperplasia of trophoblastic cells in the second curettageno follow up conditions

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Follow up

HCG qw till normalQW X 3mQ2W X 3mQM X 6mQ6M X 2y

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Invasive mole

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introduction Definition: Invasive mole means the hydatidifor

m mole invade the uterine myometrium or metastasize to extrauterine tissue.

Biologic behavior: invasive mole villus may invade myometrium or blood vessels or both, at beginning it spread locally,invade myometrium, sometimes penetrate the uterine wall and spread to the broad ligament or abdominal cavity.

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Pathology

Macro examination: different size of viscula in myometrium,there may be or may not be primary focus in uterine cavity.when the invasion is near serosal layer……

Microexamination: villose structure and trophoblastic cells proliferation and differentiation deficiency.villose and trophoblastic cells can be found in most patients,and cause vascular wall necrosis and bleeding

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Clinical manifestation

irregular vaginal bleeding uterine subinvolution theca lutein cyst does not disappear after e

mptying uterus abdominal pain metastatic focus manifestation

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Diagnosishistory and clinical manifestationsuccessive measurement of HCGultrasound examinationX-ray and CThistologic diagnosis

2006-11-15 七年制 GTD 28

Choriocarcinoma

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IntroductionChoriocarcinoma is a highly malignant tumor,it can met

astasize to the whole body through blood circulation , damage tissues and organs,cause bleeding and necrosis.

The most common metastatic site is lung ,then vagina,brain and liver

50%gestational choriocarcinoma result from hydatidiform mole (generally occurs over 1 year after emptying the mole), the rate of occurrence after abortion or term delivery is 25% and 25% respectively, seldom occurs after ectopic pregnancy

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Pathology

macroexamination: most choriocarcinoma occurs in uterus, the tumor diameter 2-10cm, its color, section, cancer embolus is often found in parauterine veins,ovarian luteinizing cyst may be formed

histologic examination: under microscope the hyperplastic cytotrophoblastic cells and syntrophoblastic cells invade the myometrium and blood vessels accompanied by the bleeding and necrosis, so the cancer cells can not be found in the center

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Clinical manifestation

Vaginal bleedingPainUterine enlargement Mass

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DiagnosisClinical Features

Ultrasonography

Human Chorionic Gonadotrophin

CT

X-ray

Pathology

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Hydatidiform mole Invasive mole Placental site trophoblastic tumors Rudimental placenta

Differential diagnosis

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Metastases

LungVaginaBrainLiver

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anatomic staging

Stage I disease confined to uterusStage II gestational trophoblastic tumor extending

outside uterus but limited to genital structures (adnexa, vagina, broad ligament)

Stage III gestational trophoblastic disease extending to lungs with or without known genital tract involvement

Stage IV all other metastatic sites

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Management

ChemotherapySurgery

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Follow up

QM X 1 yQ3M X 2 yQY X 2yQ2Y

2006-11-15 七年制 GTD 40

DI WEN M.D., Ph.D.

Professor & Chairman

Department of Obstetrics & Gynecology

Renji Hospital Affiliated to SJTU School of Medicine

Thanks for Your Attention