12 trophoblast

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12 trophoblast

  1. 1. Gestational Trophoblastic Diseases LIU Sui-ling Third Affiliated Hospital of Sun Yat-sen University shelleyliu@21cn.com
  2. 2. <ul><li>Gestational Trophoblastic Diseases(GTD) </li></ul><ul><ul><li>Hydatidiform mole </li></ul></ul><ul><ul><li>Invasive mole </li></ul></ul><ul><ul><li>Choriocarcinoma </li></ul></ul><ul><ul><li>Placental-site trophoblastic tumor (PSTT) </li></ul></ul>
  3. 3. <ul><li>Features </li></ul><ul><ul><li>Derived from fetal tissue </li></ul></ul><ul><ul><li>Composed of syncytiotropho-blastic and cytotrophoblastic cell except PSTT </li></ul></ul><ul><ul><li>In PSTT, only the intermediate trophoblasts </li></ul></ul>
  4. 4. <ul><li>Ovum </li></ul><ul><li>conceptus </li></ul><ul><li>sperm </li></ul>Fetus Placenta Fetal membrane Amniotic fluid Umbilical cord
  5. 5. Normal placenta
  6. 6. Normal villi
  7. 7. HYDATIDIFORM MOLE
  8. 8. Hydatidiform mole <ul><li>Incidence </li></ul><ul><ul><li>Area </li></ul></ul><ul><ul><li>Economic status </li></ul></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Diet </li></ul></ul><ul><li>Recurrent rate </li></ul><ul><ul><li>< 2% </li></ul></ul>
  9. 9. Hydatidiform mole <ul><li>Etiology </li></ul><ul><ul><li>Cytogenetic study </li></ul></ul><ul><ul><ul><li>euploid </li></ul></ul></ul><ul><ul><ul><li>paternal in origin </li></ul></ul></ul><ul><li>Pathogenesis </li></ul><ul><ul><li>Homozygous conceptus with propensity for altered growth </li></ul></ul>
  10. 10. Hydatidiform mole <ul><li>Pathology </li></ul><ul><ul><li>Classic findings </li></ul></ul><ul><ul><ul><li>Edema of the villous stroma </li></ul></ul></ul><ul><ul><ul><li>Avascular villi </li></ul></ul></ul><ul><ul><ul><li>Nests of proliferating syncytiotrophoblastic or cytotrophoblastic elements surrounding villi </li></ul></ul></ul><ul><ul><li>Classification </li></ul></ul><ul><ul><ul><li>Complete hydatidiform mole </li></ul></ul></ul><ul><ul><ul><li>partial hydatidiform mole </li></ul></ul></ul>
  11. 11. <ul><li>Complete hydatidiform mole </li></ul>
  12. 12. Multiple grapelike vesicles
  13. 13. <ul><li>Microscopic findings of hydatidiform mole </li></ul>
  14. 14. <ul><li>Partial hydatidiform mole </li></ul>
  15. 15. Partial hydatidiform mole with fetus
  16. 16. <ul><li>Microscopic findings of partial hydatidiform mole </li></ul>
  17. 17. HYDATIDIFORM MOLE <ul><li>comparison of complete and partial hydatidiform mole </li></ul><ul><li>Complete Partial </li></ul><ul><li>Karyotype Diploid ( 46,XX or 46,XY) Triploid(69,XXX or 69,XXY) </li></ul><ul><li>Embryo Absent Present </li></ul><ul><li>Villi Hydropic Few hydropic </li></ul><ul><li>Trophoblasts Diffuse hyperplasia Mild focal hyperplasia </li></ul><ul><li>Implantation-site </li></ul><ul><li>trophoblast Diffuse atypia Focal atypia </li></ul><ul><li>Fetal RBCs Absent Present </li></ul><ul><li>β -hCG High( > 50,000) Slight elevation( < 50,000) </li></ul><ul><li>Frequency of classical </li></ul><ul><li>clinical symptoms Common Rare </li></ul><ul><li>Risk for persistent GTT 20%-30% < 5% </li></ul>
  18. 18. HYDATIDIFORM MOLE <ul><li>CLINICAL FINDINGS </li></ul><ul><ul><li>Symptoms And Signs </li></ul></ul><ul><ul><ul><li>Abnormal uterine bleeding </li></ul></ul></ul><ul><ul><ul><li>Nausea and vomiting </li></ul></ul></ul><ul><ul><ul><li>Excessive uterine size for gestational date </li></ul></ul></ul><ul><ul><ul><li>Multiple theca lutein cysts </li></ul></ul></ul><ul><ul><ul><li>Pain </li></ul></ul></ul><ul><ul><ul><li>Preeclampsia </li></ul></ul></ul><ul><ul><ul><li>Hyperthyroidism </li></ul></ul></ul>
  19. 19. HYDATIDIFORM MOLE <ul><li>Laboratory Findings </li></ul><ul><ul><li>hCG </li></ul></ul><ul><ul><li>The amount of hCG correlates closely with the number of viable tumor cells </li></ul></ul><ul><ul><li>β -hCG decline to normal within 14 weeks following evacuation of a molar pregnancy </li></ul></ul><ul><li>Special examinations </li></ul><ul><ul><li>ultrasound </li></ul></ul>
  20. 20. Ultrasound pattern of hydatiform mole
  21. 21. HYDATIDIFORM MOLE <ul><li>DIFFERENTIAL DIAGNOSIS </li></ul><ul><ul><li>Normal pregnancy </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>Evacuation </li></ul></ul><ul><ul><ul><li>Suction curettage </li></ul></ul></ul><ul><ul><ul><li>Gentle sharp currettage </li></ul></ul></ul><ul><ul><ul><li>Oxytocin </li></ul></ul></ul><ul><ul><ul><li>Pathologic study </li></ul></ul></ul><ul><ul><ul><li>Laparotomy setup </li></ul></ul></ul><ul><ul><ul><li>hysterectomy </li></ul></ul></ul>
  22. 25. HYDATIDIFORM MOLE <ul><li>Prophylactic chemotherapy </li></ul><ul><ul><li>Controversial </li></ul></ul><ul><ul><li>Patients with complete hydatidiform mole at high risk </li></ul></ul><ul><ul><ul><li>Age>35 </li></ul></ul></ul><ul><ul><ul><li>History of prior molar pregnancy </li></ul></ul></ul><ul><ul><ul><li>Poor followup </li></ul></ul></ul>
  23. 26. HYDATIDIFORM MOLE <ul><li>Surveillance following molar pregancy </li></ul><ul><ul><li>Important </li></ul></ul><ul><ul><ul><li>The incidence of malignant disease is 20% ~ 30% </li></ul></ul></ul><ul><ul><li>Serial β -hCG determinations </li></ul></ul><ul><ul><ul><li>Weekly determination to nondetectable β -hCG level </li></ul></ul></ul><ul><ul><ul><li>Monthly determination for at least 1 year </li></ul></ul></ul><ul><ul><li>Oral contraceptives </li></ul></ul>
  24. 27. Case of hydatidiform mole <ul><li>25 years old, G1P0A0, admitted to hospital at Aug.3-2009 because of “Cessation of menstruation for 10 weeks, abnormal uterine bleeding for one week”. </li></ul><ul><li>History: The LMP of the patient was May.25-2009. She was diagnosed “early pregnancy” at 6 weeks. She complained of small amount of uterine bleeding for week. Furthermore, she felt nausea and vomiting from 2 days before. </li></ul><ul><li>Physical examination: T 36.5℃ BP 150/110mmHg (BBP120/70mmHg) R 20/min P 92/min. Normal signs of lung and heart. Both lower limbs had pitting edema. Gynecological conditions: Uterine fundus at the level of umbilcus. 6-cm adnexal masses were palpated at both side of uterus. </li></ul><ul><li>Assistant examinations: HGB 90g/L; </li></ul>
  25. 28. Case of hydatidiform mole <ul><li>Diagnosis </li></ul><ul><ul><li>1 hydatidiform mole </li></ul></ul><ul><ul><li>2 Preeclampsia </li></ul></ul><ul><ul><li>3 Anemia </li></ul></ul><ul><li>Assistant examinations </li></ul><ul><ul><li>β -hCG ultrasound </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>Evacuation </li></ul></ul>
  26. 29. MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA
  27. 30. <ul><li>Reference </li></ul><ul><li>http:// www.china-obgyn.net/lecture/Index.html </li></ul>
  28. 31. MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA <ul><li>PATHOLOGY </li></ul><ul><ul><li>Invasive mole </li></ul></ul><ul><ul><ul><li>Hydatidiform mole that invades the myometrium or adjacent structure </li></ul></ul></ul><ul><ul><ul><li>Microscopic findings are the same as in hydatidiform </li></ul></ul></ul><ul><ul><li>Choriocarcinoma </li></ul></ul><ul><ul><ul><li>Pure epithelial tumor composed of syncytiotropho-blastic and cytotrophoblastic cell </li></ul></ul></ul><ul><ul><ul><li>Sheets or foci of trophoblasts, hemorrhage and necrosis </li></ul></ul></ul><ul><ul><ul><li>No villi </li></ul></ul></ul>
  29. 32. Invasive mole
  30. 33. Microscopic findings in invasive mole
  31. 34. Uterus of choriocarcinoma
  32. 35. Trophoblasts of choriocarcinoma
  33. 36. MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA <ul><li>DIAGNOSIS </li></ul><ul><ul><li>history </li></ul></ul><ul><ul><li>Pelvic examination </li></ul></ul><ul><ul><ul><li>Enlarged uterus </li></ul></ul></ul><ul><ul><ul><li>Ovarian enlargment </li></ul></ul></ul><ul><ul><li>X-ray </li></ul></ul><ul><ul><li>CT </li></ul></ul><ul><ul><li>Serum hCG </li></ul></ul><ul><ul><li>Hematologic counts </li></ul></ul><ul><ul><li>Hepatic and renal function </li></ul></ul>
  34. 37. vaginal metastasis of choriocarcinoma
  35. 38. MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA <ul><li>TREATMENT </li></ul><ul><ul><li>Nonmetastatic Gestational Trophoblastic Disease </li></ul></ul><ul><ul><ul><li>Single-agent chemotherapy </li></ul></ul></ul><ul><ul><ul><ul><li>Medicine </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Methotrexate </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dactinomycin </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Course and interval </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Treatment cycles </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Followup </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>β -hCG , blood count, liver and renal function </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Combined chemotherapy and hysterectomy </li></ul></ul></ul>
  36. 39. MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA <ul><ul><li>Metastatic Gestational Trophoblastic Disease </li></ul></ul><ul><ul><ul><li>Chemotherapy </li></ul></ul></ul><ul><ul><ul><ul><li>Single-agent </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Multiple-agent </li></ul></ul></ul></ul>
  37. 40. MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA <ul><li>CLINICAL CLASSIFICATION OF MALIGNANT GESTATIONAL TROPHOBLASTIC DISEASES </li></ul><ul><ul><li>National Cancer Institute </li></ul></ul><ul><ul><li>World Health Organization </li></ul></ul><ul><ul><ul><ul><li>Low risk </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Medium risk </li></ul></ul></ul></ul><ul><ul><ul><ul><li>High risk </li></ul></ul></ul></ul><ul><ul><li>3. Revised FIGO </li></ul></ul>
  38. 41. MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA <ul><ul><li>Categorization of gestational trophoblastic neoplasia( National Cancer Institute ) </li></ul></ul><ul><ul><li>Nonmetastatic disease: No evidence of disease outside uterus. </li></ul></ul><ul><ul><li>Metastatic disease: Any disease outside uterus. </li></ul></ul><ul><li>1. Good-prognosis metastatic disease- </li></ul><ul><li>a. Short duration( < 4 months) </li></ul><ul><li>b. Serum β -hCG < 40,000 mIU/ml </li></ul><ul><li>c. No metastasis to brain or liver. </li></ul><ul><li>d. No significant prior chemotherapy </li></ul><ul><li>2. Poor-prognosis metastatic disease- </li></ul><ul><ul><li>a. Long duration( > 4 months) </li></ul></ul><ul><ul><li>b. Serum β -hCG > 40,000 mIU/ml </li></ul></ul><ul><ul><li>c. Metastasis to brain or liver. </li></ul></ul><ul><ul><li>d. Unsuccessful prior chemotherapy </li></ul></ul><ul><ul><li>e. Gestational trophoblastic neoplasia following term pregnancy </li></ul></ul>
  39. 42. MALIGNANT GESTATIONAL TROPHOBLASTIC NEOPLASIA <ul><li>A Good-prognosis patients </li></ul><ul><ul><li>Single-agent chemotherapy </li></ul></ul><ul><ul><li>Remission </li></ul></ul><ul><li>B Poor-prognosis patients </li></ul><ul><ul><li>Combined chemotherapy </li></ul></ul><ul><ul><ul><li>Patients with poor-prognosis risk factors </li></ul></ul></ul><ul><ul><ul><li>Revised FIGO Ⅲ C and Ⅳ </li></ul></ul></ul><ul><ul><ul><li>WHO scores > 7 </li></ul></ul></ul><ul><ul><li>Regimens </li></ul></ul><ul><ul><ul><li>MAC </li></ul></ul></ul><ul><ul><ul><li>CHAMOCA </li></ul></ul></ul><ul><ul><ul><li>EMA/CO </li></ul></ul></ul><ul><ul><li>Remission </li></ul></ul>
  40. 43. PLACENTAL-SITE TROPHOBLASTIC TUMOR (PSTT)
  41. 44. PLACENTAL-SITE TROPHOBLASTIC TUMOR (PSTT) <ul><li>PSTT occur with any type of pregnancy </li></ul><ul><li>derived from the intermediate trophoblasts </li></ul><ul><li>Invade myometrium and lymphatics </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Hysterectomy </li></ul></ul><ul><ul><li>Partial uterine resection </li></ul></ul><ul><ul><li>Chemotherapy for metastatic cases </li></ul></ul><ul><ul><ul><li>EP-EMA </li></ul></ul></ul><ul><ul><ul><li>EMA/CO </li></ul></ul></ul><ul><ul><ul><li>Adverse outcomes </li></ul></ul></ul>
  42. 45. Thank you

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