Gestational Trophoblastic Tumor

Gestational trophoblastic disease is proliferation of trophoblastic tissue in pregnant or recently pregnant women. Manifestations may include excessive uterine enlargement, vomiting, vaginal bleeding, and preeclampsia, particularly during early pregnancy.

Diagnosis includes measurement of the β subunit of human chorionic gonadotropin, pelvic ultrasonography, and confirmation by biopsy. Tumors are removed by suction curettage. If disease persists after removal, chemotherapy is indicated.
Gestational trophoblastic disease is a tumor originating from the trophoblast, which surrounds the blastocyst and develops into the chorion and amnion. This disease can occur during or after an intrauterine or ectopic pregnancy. If the disease occurs during a pregnancy, spontaneous abortion, eclampsia, or fetal death typically occurs; the fetus rarely survives. Some forms are malignant; others are benign but behave aggressively.

Symptoms and Signs

Initial manifestations of a hydatidiform mole suggest early pregnancy, but the uterus often becomes larger than expected within 10 to 16 wk gestation. Commonly, women test positive for pregnancy, have vaginal bleeding and severe vomiting, and fetal movement and fetal heart sounds are absent. Passage of grapelike tissue strongly suggests the diagnosis. Complications may include uterine infection, sepsis, hemorrhagic shock, and preeclampsia, which may occur during early pregnancy.

Placental site trophoblastic tumors tend to cause bleeding.
Choriocarcinoma usually manifests with symptoms due to metastases.
Gestational trophoblastic disease does not impair fertility or predispose to prenatal or perinatal complications (eg, congenital malformations, spontaneous abortions).

Diagnosis

• Serum β-hCG
• Pelvic ultrasonography

Gestational trophoblastic disease is suspected in women with a positive pregnancy test and any of the following:

• Uterine size much larger than expected for dates
• Symptoms or signs of preeclampsia
• Passage of grapelike tissue
• Suggestive findings (eg, mass containing multiple cysts instead of a fetus) seen during ultrasonography done to evaluate pregnancy
• Unexplained metastases in women of child-bearing age
• Unexpectedly high levels of human chorionic gonadotropin (β-hCG) detected during pregnancy testing
• Unexplained complications of pregnancy

If gestational trophoblastic disease is suspected, testing includes measurement of serum β-hCG and pelvic ultrasonography. Findings (eg, very high β-hCG levels, classic ultrasonographic findings) may suggest the diagnosis, but biopsy is required. Invasive mole and choriocarcinoma are suspected if biopsy findings suggest invasive disease or if β-hCG levels remain higher than expected after treatment for hydatidiform mole

Treatment

• Tumor removal by suction curettage
• Further evaluation for persistent disease and spread of tumor
• Chemotherapy for persistent disease
• Posttreatment contraception for persistent disease

Hydatidiform mole, invasive mole, and placental site trophoblastic tumor are evacuated by suction curettage. Alternatively, if childbearing is not planned, hysterectomy may be done.

After tumor removal, gestational trophoblastic disease is classified clinically to determine whether additional treatment is needed. The clinical classification system does not correspond to the morphologic classification system. Invasive mole and choriocarcinoma are classified clinically as persistent disease. The clinical classification is used because both are treated similarly and because exact histologic diagnosis may require hysterectomy.