Trophoblastic Neoplasms (gestational trophoblastic disease)

Trophoblastic Neoplasms or Gestational Trophoblastic Disease (GTD) encompasses a spectrum of neoplastic disorders that originate from the placental trophoblastic tissue. These diseases range from benign conditions, such as the complete hydatidiform mole and partial hydatidiform mole, to malignant conditions, including invasive mole, choriocarcinoma, and the rare placental-site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT).

Etiology and Pathogenesis

GTD arises from the abnormal proliferation of trophoblasts, which are cells responsible for the development of the placenta during pregnancy. The exact cause of this abnormal proliferation is not fully understood, but genetic and environmental factors are believed to play a role. For instance, complete hydatidiform moles are often characterized by a diploid karyotype that is entirely paternal in origin, while partial moles are typically triploid or tetraploid, with both maternal and paternal contributions.

Classification

GTD is classified into several types based on histological and clinical characteristics:

• Complete Hydatidiform Mole: Characterized by the absence of fetal tissues and a complete takeover of the placenta by cystic villi.
• Partial Hydatidiform Mole: Exhibits some normal placental tissue alongside abnormal trophoblastic proliferation and may contain fetal tissues.
• Invasive Mole: A mole that penetrates the myometrium or beyond, potentially leading to uterine perforation.
• Choriocarcinoma: A highly malignant form that can spread to distant organs.
• Placental-Site Trophoblastic Tumor (PSTT): Arises from the placental site and is characterized by slow growth and late metastasis.
• Epithelioid Trophoblastic Tumor (ETT): A rare form that originates from the chorionic-type intermediate trophoblast.

Clinical Presentation

Symptoms of GTD can vary but often include vaginal bleeding, an unusually large uterus for gestational age, severe nausea and vomiting (hyperemesis gravidarum), and early development of preeclampsia. Elevated levels of the pregnancy hormone, human chorionic gonadotropin (hCG), are also a hallmark of GTD.

Diagnosis

Diagnosis of GTD involves a combination of ultrasound imaging, which may reveal a "snowstorm" pattern in the case of a complete mole, and measurement of hCG levels. Histopathological examination of evacuated uterine contents is definitive for diagnosis.

Treatment

Treatment depends on the type and extent of the disease. Options include suction curettage for molar pregnancies, chemotherapy for malignant forms, and, in some cases, hysterectomy. Monitoring of hCG levels post-treatment is crucial to ensure complete remission and to detect any recurrence early.

Prognosis

The prognosis for benign forms of GTD, such as complete and partial moles, is excellent with appropriate treatment. Malignant forms, including choriocarcinoma, also have a high cure rate with chemotherapy, especially when detected early. However, PSTT and ETT tend to have a poorer prognosis due to their resistance to chemotherapy and potential for late metastasis.

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