B23. Gestational throphoblast neoplasia (invasive mole, choriocarcinoma); diagnosis and therapy

Last updated on June 9, 2021 at 22:48

Definition and epidemiology

Gestational trophoblast neoplasia (GTN) is a malignant type of gestational trophoblastic disease, a condition caused by proliferation of trophoblasts. It’s sometimes called just malignant gestational trophoblastic disease.

GTN may arise from a hydatidiform mole, abortion, or normal pregnancy.

They’re rare but they are the most malignant cancers of the female genital tract.

Risk factors

  • Old age
  • Previous gestational trophoblastic disease
  • Pathologic eggs
  • Vitamin A deficiency
  • Dietary protein deficiency

Classification

  • Invasive mole
  • Choriocarcinoma
  • Placental site trophoblastic tumour
  • Epithelioid trophoblastic tumour

An invasive mole is a hydatidiform mole which is invasive and has excessive trophoblastic proliferation. It invades into the myometrium, penetrating the uterine wall, and metastasises through the circulation. Metastasis is most often to the lung.

Choriocarcinoma is a highly malignant gestational trophoblast neoplasia. The main difference between invasive moles and choriocarcinoma is that there is no villous pattern in choriocarcinoma. The tumour appears as an irregular haemorrhagic growth in the uterine walls.

Clinical features

GTN may present in various ways:

  • Patients who underwent treatment for molar pregnancy and the β-hCG monitoring has shown a stagnation or increase in the hormone
  • Patients may present with continuing amenorrhoea or inadequate uterine regression after a molar or a normal pregnancy
  • Patients may present with symptoms of lung metastasis, like coughing or haemoptysis.
  • Patients may experience hyperthyroidism due to the high hCG level
  • Patients may present with symptoms of vaginal metastasis, like vaginal bleeding

Diagnosis and evaluation

The ultrasound is enlarged compared to the gestational age. Bilateral theca lutein cysts of the ovary may be present.

Ultrasound is obligatory and may show enlarged uterus and a highly vascularised mass in the uterus.

The hCG concentration is significantly higher than normal, and no foetal vital signs can be detected.

Chest metastases are common, and all patients suspected to have GTN should undergo chest x-ray.

Treatment

Treatment of invasive mole is the same as for choriocarcinoma.

The prognosis of choriocarcinoma has improved since the introduction of chemotherapeutic drugs. The first choice is methotrexate. In case of liver or kidney dysfunction, actinomycin D may be used.

Post-treatment evaluation

Serum β-hCG and SP1 must be monitored in the time after the treatment to make sure there is no recurrence. Normalisation of the values may take months. If the values stop decreasing, or they start increasing, a recurrence is likely. In these cases, hysterectomy is performed. Radiation is used to treat liver or brain metastases.


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B22. Hydatiform mole; symptoms, types, endocrinology and therapy

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B24. Gonadal ovarian tumors

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