Gestational Trophoblastic diseases

Range of neoplastic conditions with abnormal trophoblastic proliferation

Gestational trophoblastic disease

when should you consider Gest. Trophoblastic Dz

• in patients with positive pregnancy test and no intrauterine or ectopic pregnancy

• concurrent prominent tissue with cystic change in uterine cavity

Types of Benign Gestational Trophoblastic DZ/Tumors

• Complete hydatidiform mole (complete mole)

• Partial Mole

• Theca Lutein Cyst

What is the most common gestational trophoblastic dz?

Complete Hydatididiform mole

Complete absence of fetal tissue d/t failure of conceptus to survive

Complete Molar

What are the HCG levels for a molar pregnancy

>100,000

Pt sx’s for Complete Molar

• irregular bleeding

• Hyperemesis

• LFD - uterine size

• Transvaginal passage of grape-like vesicles

Complications of Molar Preg

• preeclampsia

• hypertension

• thyrotoxicosis

• respiratory distress

US findings 1st trimester for Complete molar pregnancy

• cluster of grapes or snowstorm appearance

• enlarged uterus with central echogenic material, numerous cystic spaces varying in size (hydropic chorionic villi) expanding the endometrial cavity

• Echogenic mass predominantly solid when villi are too small to be seen

• Variable blood flow on color Doppler. If present, seen around periphery of the mass

US findings 2nd trimester for Complete molar pregnancy

Larger cystic spaces without fetus or fetal parts, except in rare cases of complete hydatidiform mole with coexisting diploid twin

Second most common GT dz?

Partial Molar pregnancy

How is a partial mole different from complete?

• lower HCG levels

• partial— triploid, complete - diploid

• milder vaginal bleeding, occurs later than complete

US findings in partial molar pregnancy

• Enlarged placenta with focal or scattered cystic changes (“Swiss cheese pattern”)

• Gestational sac often seen with variable identification of fetal elements, amorphous echoes, or yolk sac

• When identified, fetus is abnormal with anomalies and/or growth restriction (

• Oligohydramnios

What type of pregnancy is this?

Complete Molar

what type of pregnancy is this?

Partial mole with yolk sac.

Transvaginal gray-scale transverse image shows “Swiss cheese pattern” indicating enlarged placenta with focal cystic changes (white arrows) and irregular-shaped gestational sac (yellow arrow) with yolk sac (blue arrow).

Describe this pregnancy

Partial mole with anomalous fetus. (A) Transabdominal gray-scale transverse image shows partial mole (white arrows). A fetus (blue arrow) is seen posterior to the placenta.

(B) Transabdominal gray-scale transverse image of the head of the same fetus shows frontal bone indentation, also known as the “lemon sign” (arrows). This finding is characteristic for Arnold-Chiari II malformation and myelomeningocele (not shown).

benign, functional ovarian cyst that develops due to high levels of or extreme sensitivity to the pregnancy hormone hCG (human chorionic gonadotropin).

They typically cause both ovaries to become large and filled with multiple fluid sacs.

Theca Lutein Cysts

US appearance of Theca Lutein Cysts

• Bilateral enlarged ovaries with multicystic, septated appearance

• hemorrhage into cystic components results in complex appearance

• Can also occur with molar pregs

Tx for Molar pregnancies?

• D&C or TAH if done childbearing or risk of hemorrhage

• Serial Quants to make sure it falls to zero

• do not try to get pregnant x 1 year if molar

Describe this US image with GTD

Theca Lutein Cysts and partial mole,

• Transabdominal gray-scale transverse image of the right ovary show marked ovarian enlargement with a multiseptated and multicystic appearance (arrows) consistent with theca lutein cysts.

• Uterus shows partial mole with cystic changes (yellow arrows). U, Uterus.

types of Gestational trophoblastic neoplasia

1. Invasive mole

2. Choriocarcinoma

3. Placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT)

most common Gestational Trophoblastic Neoplasia, characterized by villi and trophoblastic proliferation invading myometrium

Invasive mole

malignant tumor erodes blood vessels and prone to metastasize - is what kind of GT neoplasm?

Choriocarcinoma

This type of GT Neoplasm arises from implantation site of the placenta; rarest and most lethal forms

Placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT)—

What is the US image of? Pt hx - 6mos prior had D&C for complete molar

Choriocarcinoma

Transabdominal gray-scale longitudinal image (A) of the uterus demonstrates a large heterogeneous echogenic mass (white arrows)

with small cystic changes (yellow arrows) in the lower uterine segment extending to the cervix. (B) Transabdominal color Doppler transverse image shows marked vascularity along the periphery of the mass. B, Bladder.

Ultrasound findings for GT Neoplasias

• Focal nodules of varying echogenicity and small anechoic cystic spaces centered in myometrium; variable endometrial component and degrees of vascularity

• Extensive tumors may penetrate beyond the uterus into the parametrium, vagina, or other organs

• Nonspecific gray-scale and Doppler ultrasound appearance of gestational trophoblastic neoplasia makes it challenging to differentiate from other benign uterine entities (myomas, adenomyomas, or retained products of conception

IN GT neoplasia, which has a worse prognosis - small or large mass size? and what do you need to document?

• Larger mass size associated with worse prognosis; document maximum mass diameter

Treatment for Gestational Trophoblastic Neoplasia

• Chemotherapy

• Hysterectomy in PSTT and ETT

  • both tumors are less chemosensitive than choriocarcinoma

• After treatment, surveillance of β-hCG levels for at least 12 months

Mimics of gestational trophoblastic disease

• Hydropic degeneration of the placenta

• Twin pregnancy with single normal-appearing fetus and complete mole may mimic partial mole

Hydropic degeneration of the placenta following pregnancy failure in the first trimester - can be differentiated from molar pregnancies by?

Beta HCG’s will be decreasing in hydropic placenta, vs in molars the HCG will increase