13- Gestational Trophoblastic Diseases Quiz
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Questions and Answers

What is the most common type of gestational trophoblastic disease?

  • Placental-site trophoblastic tumors (PSTTs)
  • Hydatidiform moles (correct)
  • Invasive moles
  • Choriocarcinomas

Which risk factor significantly increases the likelihood of developing gestational trophoblastic neoplasia?

  • Women with a history of nulliparity (correct)
  • Women with a high socioeconomic status
  • Women aged 30 to 35
  • Blood group O women impregnated by group A men

Which type of hydatidiform mole is usually euploid and paternal in origin?

  • Complete mole (correct)
  • Choriocarcinoma
  • Triploid mole
  • Partial mole

What is a common clinical sign of hydatidiform mole?

<p>Vaginal expulsion of vesicles (D)</p> Signup and view all the answers

What is the chromosomal composition typically associated with a complete hydatidiform mole?

<p>46,XX or 46,XY (A)</p> Signup and view all the answers

Which dietary factors are associated with an increased risk of hydatidiform moles?

<p>Deficiency in protein, folic acid, and beta-carotene (C)</p> Signup and view all the answers

What condition is characterized by the rapid enlargement of the uterus with an absence of an intact fetus?

<p>Molar pregnancy (A)</p> Signup and view all the answers

What is a potential indication of 'phantom' hCG levels in a patient?

<p>Plateau of hCG values at low levels (B)</p> Signup and view all the answers

What best describes the 'hook effect' in hCG testing?

<p>It can cause a false-negative result when serum hCG levels are extremely elevated. (C)</p> Signup and view all the answers

Which of the following is NOT a criterion for diagnosing malignant gestational trophoblastic neoplasia?

<p>Elevated hCG levels at 3 months post-evacuation (D)</p> Signup and view all the answers

In the context of malignant gestational trophoblastic neoplasia, what is the recommended action if imaging shows no evidence of metastatic disease but hCG remains elevated?

<p>A second uterine curettage may be of benefit. (A)</p> Signup and view all the answers

Which classic microscopic finding is NOT associated with moles?

<p>Presence of villi (D)</p> Signup and view all the answers

What constitutes the most common malignant lesion in gestational trophoblastic neoplasia?

<p>Nonmetastatic malignant gestational trophoblastic disease (C)</p> Signup and view all the answers

What percentage of patients with hydatidiform moles develop invasive moles?

<p>10-15% (C)</p> Signup and view all the answers

Which finding is characteristic of choriocarcinoma?

<p>Sheaths of trophoblasts with hemorrhage (D)</p> Signup and view all the answers

What is the primary source of placental-site trophoblastic tumors (PSTT)?

<p>Intermediate trophoblasts (B)</p> Signup and view all the answers

What complication is associated with invasive moles?

<p>Uterine rupture (C)</p> Signup and view all the answers

Which gestational event is most commonly associated with choriocarcinoma?

<p>Hydatidiform mole (B)</p> Signup and view all the answers

Which statement about PSTT is false?

<p>Characterized by elevated hCG levels (D)</p> Signup and view all the answers

What is the incidence rate of choriocarcinoma in the United States?

<p>1 in 40,000 pregnancies (A)</p> Signup and view all the answers

Which of the following is NOT a clinical presentation of choriocarcinoma?

<p>Persistent vomiting (D)</p> Signup and view all the answers

What symptom is observed in over 90% of patients with molar pregnancies?

<p>Abnormal uterine bleeding (D)</p> Signup and view all the answers

Which ultrasound finding is characteristic of a molar pregnancy?

<p>Multiple hypoechoic areas described as a 'snowstorm' pattern (C)</p> Signup and view all the answers

What is a common laboratory finding in gestational trophoblastic neoplasms?

<p>Elevated hCG production (B)</p> Signup and view all the answers

What indicates a potential ongoing disease process after a molar pregnancy evacuation?

<p>Constant hCG levels (A)</p> Signup and view all the answers

Which complication can arise from the deportation of trophoblastic tissue to the lung?

<p>Pulmonary insufficiency (C)</p> Signup and view all the answers

Which of the following is a pathognomonic sign for a molar pregnancy?

<p>Preeclampsia in the first trimester (B)</p> Signup and view all the answers

What is a possible finding in the diagnosis of a partial mole during an ultrasonogram?

<p>Focal areas of trophoblastic changes and fetal tissue (B)</p> Signup and view all the answers

Which symptom can occur in 10% of patients with a molar pregnancy due to hCG stimulation?

<p>Hyperthyroidism (A)</p> Signup and view all the answers

What is the primary tool for diagnosing and monitoring gestational trophoblastic disease?

<p>Quantitative hCG levels (A)</p> Signup and view all the answers

Which differential diagnosis may show an intrauterine mass during imaging?

<p>Choriocarcinoma (D)</p> Signup and view all the answers

What is the recommended method for the evacuation of a hydatidiform mole?

<p>Suction curettage under general anesthesia (B)</p> Signup and view all the answers

What follow-up monitoring is essential after the evacuation of a molar pregnancy?

<p>Serial hCG determinations (C)</p> Signup and view all the answers

Patients with which type of hydatidiform mole are at higher risk for malignant sequelae?

<p>Metastatic trophoblastic disease (A)</p> Signup and view all the answers

What percentage of patients may experience spontaneous regression of hCG values to normal after a hydatidiform mole evacuation?

<p>80.7% (A)</p> Signup and view all the answers

What is the significance of administering Rh immune globulin after the evacuation of a hydatidiform mole?

<p>To prevent Rh sensitization in Rh-negative patients (D)</p> Signup and view all the answers

What should be done if hCG levels plateau or increase after 8 weeks of evacuation?

<p>Initiate prophylactic chemotherapy (B)</p> Signup and view all the answers

In patients with high-risk features for malignant gestational trophoblastic disease, what is critical to determine?

<p>Serial hCG titer monitoring (A)</p> Signup and view all the answers

What factors increase the risk for malignant gestational trophoblastic disease?

<p>Larger uterus size and higher hCG titer (A)</p> Signup and view all the answers

What is the standard timeframe for the normalization of hCG levels after evacuation of a hydatidiform mole?

<p>By the eighth week (C)</p> Signup and view all the answers

In what circumstance should prophylactic chemotherapy typically be considered after a hydatidiform mole?

<p>With rising or plateauing hCG levels (A)</p> Signup and view all the answers

Flashcards

Hydatidiform mole

The most common form of gestational trophoblastic disease, a benign tumor of the placenta; characterized by grape-like vesicles filling the uterus.

Gestational trophoblastic disease (GTD)

A group of abnormal cell growths arising from the developing placenta.

Complete mole

A type of hydatidiform mole that is usually paternal in origin and has an abnormal chromosome number.

Partial mole

A type of hydatidiform mole that is triploid, resulting from fertilization of an egg by one normal sperm and one duplicated sperm.

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Risk factors for GTD

Factors that increase the likelihood of developing gestational trophoblastic disease, including advanced maternal age (under 20 or over 40), nulliparity, low socioeconomic status, and poor diet.

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Diagnosis clues of GTD

Symptoms such as uterine bleeding in the first trimester, vaginal expulsion of vesicles, absence of fetal heart tones, significant uterine enlargement, and unusually high levels of HCG.

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Placental-site trophoblastic tumor (PSTT)

A type of GTD derived from intermediate trophoblastic cells, distinct from moles.

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Phantom hCG

A false-positive hCG result caused by nonspecific heterophile antibodies interfering with the hCG immunometric sandwich assays. It does not correlate with pregnancy.

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Hook Effect

A false-negative or low hCG value in the presence of extremely elevated hCG levels. The antibodies in the assay become saturated, leading to inaccurate readings.

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GTN Diagnostic Criteria

Diagnosis often involves monitoring hCG levels, imaging for metastases, and tissue diagnosis. Rising hCG, plateaus, or elevated levels at 6 months post-evacuation are concerning signs.

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Nonmetastatic Malignant GTN

The most common type of malignant GTN, where the cancer is confined to the uterus. Diagnosis typically occurs during post-molar surveillance.

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hCG levels in molar pregnancy

Human chorionic gonadotropin (hCG) levels are significantly elevated in molar pregnancies, serving as a key diagnostic marker.

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Ultrasound findings in molar pregnancy

Ultrasound typically reveals a characteristic 'snowstorm' pattern with multiple hypoechoic areas representing hydropic villi.

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What is the most common presenting symptom of a molar pregnancy?

Abnormal uterine bleeding is the most common presenting symptom, occurring in over 90% of patients.

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Uterine size in molar pregnancy

The uterus may be larger than expected for the gestational age in half of patients with a molar pregnancy.

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Theca lutein cysts

These cysts, found on one or both ovaries, are seen in 15-30% of women with molar pregnancies.

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Preeclampsia in early pregnancy

Preeclampsia occurring in the first or early second trimester is a strong indication of a possible molar pregnancy.

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Hyperthyroidism in molar pregnancy

hCG can stimulate thyrotropin receptors leading to hyperthyroidism in about 10% of patients.

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Monitoring hCG levels in GTD

Monitoring hCG levels is crucial for diagnosis, treatment and surveillance of gestational trophoblastic neoplasms.

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What does a rising or plateauing hCG level indicate?

A rising or plateauing hCG level after evacuation of a molar pregnancy suggests that viable tumor may still persist.

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Complications of molar pregnancy

Complications include pulmonary insufficiency due to trophoblastic tissue embolization, and possible spontaneous regression of ectopic trophoblastic tissues.

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Invasive Mole

A rare, locally invasive type of gestational trophoblastic disease (GTD) that can penetrate the myometrium and potentially lead to uterine rupture and hemoperitoneum. It develops in 10-15% of patients with a hydatidiform mole and can spontaneously regress.

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Choriocarcinoma

A malignant form of GTD that can spread throughout the body. It occurs in 2-5% of GTD cases and often develops after a hydatidiform mole. It is a pure epithelial tumor composed of syncytiotrophoblastic and cytotrophoblastic cells.

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What's the incidence of choriocarcinoma in the US?

The incidence of choriocarcinoma in the United States is 1 in 40,000 pregnancies.

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What are some common presenting symptoms of choriocarcinoma?

Common symptoms include late vaginal bleeding in the postpartum period, an enlarged uterus, enlarged ovaries, and vaginal lesions.

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Microscopically, what are the features of choriocarcinoma?

Histologic evaluation shows sheets or foci of trophoblasts on a background of hemorrhage and necrosis, but no villi are present.

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What distinguishes PSTT?

PSTT is derived from the intermediate trophoblasts of the placental bed, with minimal or absent syncytiotrophoblastic tissue. As syncytiotrophoblastic cells are generally absent from this tumor, minimal amounts of hCG are released in relation to the tumor burden.

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How does PSTT compare to other GTDs?

Unlike other GTDs, PSTT releases minimal amounts of hCG due to the absence of syncytiotrophoblastic cells. This can make diagnosis more challenging.

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What is the clinical management of patients with CMs and PMs?

Despite the cytogenetic, pathologic, and clinical differences, the clinical management of patients with complete moles (CMs) and partial moles (PMs) is similar.

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Evacuation Method for Molar Pregnancy

Suction curettage under general anesthesia is the preferred method to remove a hydatidiform mole.

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Post-Evacuation Care for Rh-Negative Patients

Rh-negative patients should receive Rh immune globulin after evacuation to prevent sensitization.

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Prophylactic Chemotherapy for Molar Pregnancy

Methotrexate or dactinomycin may be used to prevent the development of malignant trophoblastic disease after a molar pregnancy.

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Monitoring after Molar Pregnancy

Serial hCG tests are essential to monitor for persistent or rising levels, which may indicate malignant trophoblastic disease.

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HCG Levels and Malignant Disease

Higher hCG levels and larger uterus size increase the risk of developing malignant gestational trophoblastic disease.

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Normal HCG Regression After Evacuation

In most women, hCG levels should return to normal within 8 weeks after evacuation of a molar pregnancy.

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Plateauing or Rising HCG Levels

If hCG levels plateau or increase after 8 weeks of evacuation, chemotherapy should be considered.

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Therapy for Persistent Gestational Trophoblastic Neoplasia

Chemotherapy is typically used to treat persistent gestational trophoblastic disease after evacuation of a molar pregnancy.

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Spontaneous Regression of HCG Levels

About 80% of patients experience a spontaneous return of hCG levels to normal after evacuation of a molar pregnancy.

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Chemotherapy for Persistent HCG Levels

Approximately 19% of patients require chemotherapy due to persistent or rising hCG levels after evacuation.

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Study Notes

Gestational Trophoblastic Diseases

  • These are neoplastic conditions arising from trophoblastic cells, abnormal placental tissue
  • Hydatidiform moles (complete and partial) are a common form, benign in nature
  • Gestational trophoblastic neoplasia (GTN) can be invasive (moles, choriocarcinomas, PSTTs)

Hydatidiform Molar Pregnancy

  • Two forms: Complete and Partial
  • Complete moles: Euploid, paternal in origin, sex chromatin positive (46,XX or 46,XY). Develop when an empty ovum duplicates its chromosomes or fertilized by two haploid sperm
  • Partial moles: Triploid (69,XXY, 69,XXX, or 69,XYY). The ovum with an active nucleus is fertilized by a duplicated sperm or 2 haploid ones

Diagnosis

  • Uterine bleeding in first trimester
  • Absence of fetal heart tones and fetal structures
  • Rapid uterine enlargement, larger than dates expected
  • Elevated human chorionic gonadotropin (hCG) titers

Risk Factors

  • Women younger than 20 and older than 40
  • Nulliparous women
  • Low socioeconomic status
  • Diets deficient in protein, folic acid, and beta-carotene
  • Blood group A women impregnated by group O

Invasive Mole

  • Reported in 10-15% of patients with hydatidiform mole
  • Locally invasive, invades myometrium and adjacent structures
  • Potentially ruptures uterus, causing hemoperitoneum
  • Able to spontaneously regress

Choriocarcinoma

  • Occurs in 2-5% of GTN cases
  • Incidence in US is 1 in 40,000 pregnancies
  • Can accompany or follow any pregnancy type
  • In half of cases, the antecedent event is a hydatidiform mole, another 25% follow a term pregnancy, and 25% occur after abortion
  • Pure epithelial tumor composed of syncytiotrophoblast and cytotrophoblast cells
  • Usually presents with late postpartum vaginal bleeding
  • Enlarged uterus, ovaries, vaginal lesions seen in physical exam
  • Histologic evaluation shows sheets/foci of trophoblasts on a background of hemorrhage and necrosis, no villi

Placental-site Trophoblastic Tumors (PSTTs)

  • Derived from intermediate trophoblastic cells
  • Minimal hCG amounts produced compared to other diseases
  • Secretes placental lactogen whose levels can be used to monitor treatment response
  • Generally confined to uterus, but local invasion into myometrium, lymphatics, and vasculature possible
  • Minimal or absent syncytiotrophoblastic tissue

Symptoms

  • Abnormal uterine bleeding (90%)
  • Nausea and vomiting (10%)
  • Uterine size greater than gestational age
  • Multiple theca lutein cysts in 15-30% of molar pregnancies
  • Preeclampsia in the first or early second trimester

Laboratory Findings

  • Hyperthyroidism (10%) from hCG stimulation of thyrotropin receptors
  • hCG monitoring critical for diagnosis, treatment, and follow-up
  • hCG values typically decline to nondetectable levels within 14 weeks post-evacuation of molar pregnancy

Ultrasonographic Findings

  • Multiple hypoechoic areas (snowstorm pattern) corresponding to hydropic villi
  • Absence of fetal sac or fetus
  • Theca lutein cysts
  • Focal areas of trophoblastic changes in partial moles

Differential Diagnosis

  • Normal pregnancy
  • Abortion
  • Ectopic pregnancy
  • Ultrasonography and hCG levels help differentiate

Complications

  • Pulmonary insufficiency from trophoblastic tissue deportation to lungs
  • Pulmonary emboli within 4-6 hours post molar evacuation
  • Spontaneous regression of ectopic trophoblastic tissues

Treatment

  • Evacuation, method varies but most common is suction curettage under general anesthesia – Rh-negative patients should receive Rh immune globulin post-evacuation
  • Monitoring of serial hCG levels after treatment
  • Chemotherapy (single or combination) indicated if hCG levels don't return to normal or plateau/increase post-evacuation.

Prophylactic Chemotherapy

  • Controversy, and methotrexate or dactinomycin are used after confirming complete molar pregnancy
  • Surveillance after the expulsion of the mole is critical, particularly for malignant disease
  • Three-quarters of patients with non-metastatic trophoblastic disease and half of patients with metastatic trophoblastic disease will develop tumors after mole, other half a few weeks after term pregnancy, abortion or ectopic pregnancy

Low-Risk Patients

  • Metastases confined to lungs or pelvis
  • hCG levels below 40,000 mIU/mL at treatment onset
  • Treatment is started within 4 months of disease onset

High-Risk Patients

  • hCG levels >40,000 mIU/mL
  • Disease diagnosis > 4 months after molar pregnancy
  • Brain or liver metastases
  • Prior failed chemotherapy
  • Onset after term gestation
  • Poor response (<40%) to single-agent therapy

Central Nervous System Involvement

  • Brain metastases frequently occur with choriocarcinoma
  • Whole-brain or whole-liver irradiation concomitantly with combination chemotherapy is important if CNS is involved due to risk of hemorrhagic lesions

Placental-Site Trophoblastic Tumor (PSTT)

  • Resistant to chemotherapy, hysterectomy is often preferred
  • Partial uterine resection possible for those wishing to retain fertility
  • EMA-EP is preferred over EMACO in cases of metastatic disease

Non-metastatic Malignant GTN

  • Trophoblastic disease confined primarily to the uterus.
  • Diagnosis during post molar surveillance period.
  • Single agent chemotherapy or combination chemotherapy plus hysterectomy are treatment options, depending on the preservation of fertility

Metastatic Gestational Trophoblastic Disease

  • Treatment options include single-agent or combination chemotherapy
  • WHO scoring system determines low/high risk groups for treatment
  • Factors like age, antecedent pregnancy type, interval from pregnancy to chemotherapy, pretreatment hCG levels, tumor size, number/site of metastases, and prior chemotherapy are crucial for prognostication

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