Medical Archive

Hydatidiform mole

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Features	Complete mole	Partial mole
Fetal or embryonic tissue	Absent	Present
Hydatidiform swelling of chorionic villi	Diffuse (hydropic villi)	Focal
Trophoblastic hyperplasia	Diffuse	Focal
Scalloping of chorionic villi	Absent	Present
Trophoblastic stromal inclusions	Absent	Present
Karyotype	46,XX (90%, 1 sperm w/ duplicate);  46,XY (rare, 2 sperm)	69,XXX 69,XXY
Risk factor	Age >35, Malnutrition Low intake of Vit.A	Oral contraceptives Irregular mens Hx
Symptom	Vaginal bleeding – m/c	equivocal
Size	50% larger than GA	Smaller than GA
USG	‘Snowstorm’, ‘Honeycomb’	?in transverse diameter
Accompanying theca lutein cyst	20%, spontaneously regress with molar evacuation	None
Medical complication	25%, preeclampsia, hyperemesis gravidarum	None
Risk of choriocarcinoma	2-3%	minimal

Epidemiology

Pathology and cytogenetics

Advances in Pathologic Diagnosis

Familial Recurrent Molar Pregnancy

Clinical Features

Natural History

• Progression
  • 15%: invasive moll, 4%: metastatic moll
  • Invasive moll
    • Villi invading the myometrium on a hysterectomy specimen.
    • High risk: hCG >10^5 mIU/mL, Excessive uterine enlarge, Theca lutein cyst >6cm

Diagnosis

?hCG ? pelvic USG ? suction curettage

Can present with theca lutein cysts, bilateral multiloculated ovarian cysts that are associated with ovarian hyperstimulation from markedly elevated ?-hCG levels – resolve after treatment of the hydatidiform mole when ß-hCG levels decreases.

Treatment

Suction curettage

Hysterectomy

Can’t prevent metastasis.

Prophylactic chemotherapy

In High risk complete mole or with metastasis (unless want pregnancy)

Follow-Up

Human chorionic gonadotropin (?-hCG)

Every week, decrease 3 weeks in a row (became normal in 8th week)
Every month, till remain normal 6 months in a row
If abnormal… Pelvic exam + Chest XR + Pelvic CT + Brain CT/MRI

Contraception

Pregnancy not allowed ? OCs
After 6 months of undetectable ?-hCG levels, patients who are interested can attempt conception.

Gestational Trophoblastic Neoplasia

Choriocarcinoma	Placental-site trophoblastic tumor (PSTT)
?? ????, ??? ?? CTx? ?? – low risk(0-6?)??? ?????? ??? ???? ??? ?? ??.	??? ??? ??. ??? ?? hCG ? CTx? ? ??. Need Hysterectomy Lung meta (80%)

Germ cell ??? gestational complication ??? GTN?? CTx ??? ???.

Nonmetastatic Disease

Metastatic Disease

Most commonly to the lungs and vagina.

• Vaginal metastasis
  • Bloody or purulent vaginal discharge.
  • Friable (vascular) vaginal lesion.

Staging and Prognostic Score

FIGO staging

I uterus
II adnexa, vagina
III lung
IV other

Low risk: ?4
middle risk: 5~7
High risk: ?8

Diagnostic Evaluation

Uterine subinvolution or Asymmetric enlargement
Persistently ?hCG, irregular vaginal bleeding, Theca lutein cyst

After non-molar pregnancy: always choriocarcinoma, not H-mole

• Pathology
  • Choriocarcinoma
    • Sheets of anaplastic cytotrophoblasts and syncytiotrophoblasts and no villi.
  • Placental site trophoblastic tumor
    • Proliferation of intermediate trophoblasts. Produce hPL

• Standard w/u
• Metastatic w/u
  • Chest XR or CT
  • US or AP CT
  • Brain CT/MRI

Management of GTN

I
Single-agent CTx / hysterectomy + adj CTx

II, III Lr
Single-agent CTx (MTX-FA; folinic acid, Act-D; actinomycin-D

II, III Hr
Combined CTx (EMA-CO; Etoposide,  MTX, Act-D, CYC, vincristine)

IV
Combined CTx, brain involve ? irradiation, liver involve ? TACE, resec

Prognosis
WHO prognostic scoring: High risk ?7 points
Don’t count lung metastasis!

Chemotherapy

Single-Agent Treatment

In low risk (0~6?)

Methotrexate with folinic acid

Combination Chemotherapy

In high risk (7? ??)

• EMA-CO
  1. Etoposide
  2. methotrexate
  3. Actinomycin-D
  4. Cyclophosphamide
  5. Vincristine

Management of Refractory GTN

Duration of Therapy

False-Positive hCG Tests

Persistent Low-Level “Real” hCG

Subsequent Pregnancies

You can anticipate normal pregnancy! (increased recurrence rate: 1%)
1st trimester: pelvic USG
Until 6 weeks after delivery: ?-hCG to r/o occult trophoblastic neoplasia

Pregnancies After Uncomplicated Hydatidiform Mole

Pregnancies After GTN