Gestational trophoblastic neoplasia differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Gestational trophoblastic neoplasia}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Gestational_trophoblastic_neoplasia]]
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Gestational_trophoblastic_neoplasia]]
{{CMG}}{{AE}}{{MD}}
{{CMG}}{{AE}}{{HK}}{{MD}}
 
==Overview==
==Overview==
Choriocarcinoma must be differentiated from non neoplastic diseases, [[neoplastic]] diseases, and other causes of bleeding during [[pregnancy]].
Gestational trophoblastic neoplasia (invasive mole, choriocarcinoma, placental-site trophoblastic tumor [PSTT] and epitheloid trophoblastic tumor [ETT]) should be differentiated from other conditions presenting with similar [[symptoms]] and signs such as increase in [[uterine]] size, [[vaginal bleeding]] and [[amenorrhea]]. The differentials include [[molar pregnancy]] ([[Complete mole|complete]] and [[Molar pregnancy|partial moles]]), [[Ovarian tumor|ovarian tumors]], [[Spontaneous abortions|spontaneous abortion]], [[ectopic pregnancy]] and normal [[Pregnancy|term pregnancy]].  
==Differentiating choriocarcinoma from other diseases==
==Differentiating Choriocarcinoma From Other Diseases==
Choriocarcinoma  must be differentiated from other non-[[neoplastic]] diseases such as:
Gestational trophoblastic neoplasia (invasive mole, choriocarcinoma, placental-site trophoblastic tumor [PSTT] and epitheloid trophoblastic tumor [ETT]) should be differentiated from other conditions presenting with similar [[symptoms]] and signs such as increase in [[uterine]] size, [[vaginal bleeding]] and [[amenorrhea]]. The differentials include the following:
* [[Hydatidiform mole]]
<small><small>
Choriocarcinoma  must be differentiated from other neoplastic diseases such as:
* Invasive hydatidiform mole
* Placental site trophoblastic [[tumor]] (PSTT)
* Mixed germ cell tumor - esp. for testicular and ovarian tumors
Choriocarcinoma  must be differentiated from other causes of bleeding during pregnancy:
* [[Spontaneous abortion]]  
* [[Ectopic pregnancy]]  
* Normal term [[pregnancy]]
{| class="wikitable"
{| class="wikitable"
|+
|+
! rowspan="2" |Differential Diagnosis
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Differential Diagnosis
! colspan="6" |Clinical Features
! colspan="6" align="center" style="background:#4479BA; color: #FFFFFF;" + |Clinical Features
! rowspan="2" |Karyotype
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Karyotype
! colspan="7" |Immunostaining
! colspan="7" align="center" style="background:#4479BA; color: #FFFFFF;" + |Immunostaining
! rowspan="2" |Management
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Management
|-
|-
|'''Presenting Complaints'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Presenting Complaints'''
|'''Potential for Neoplastic Conversion'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Potential for Neoplastic Conversion'''
|'''Beta Human Chorionic Gonadotropin (Beta-hCG) Baseline Levels'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Beta Human Chorionic Gonadotropin (Beta-hCG) Baseline Levels'''
|'''History of Pregnancy'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''History of Pregnancy'''
|'''Theca Leutin Cysts'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + | '''Theca Leutin Cysts'''
|'''Metastatic Route'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Metastatic Route'''
|'''Cytokeratin 18'''  
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Cytokeratin 18'''  
|'''HLA-G'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''HLA-G'''
|'''Human Chorionic Gonadotropin (hCG)'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Human Chorionic Gonadotropin (hCG)'''
|'''Transformation-Related Protein 63 (P63)'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Transformation-Related Protein 63 (P63)'''
|'''Human Placental Lactogen (hPL)'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Human Placental Lactogen (hPL)'''
|'''Melanoma Cell Adhesion Molecule (Mel-CAM)'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Melanoma Cell Adhesion Molecule (Mel-CAM)'''
|'''Ki67'''
| align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Ki67'''
|-
|-
|'''Complete Hydatidiform Mole'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Complete mole|Complete Hydatidiform Mole]]'''<ref name="pmid26421650">{{cite journal |vauthors=Candelier JJ |title=The hydatidiform mole |journal=Cell Adh Migr |volume=10 |issue=1-2 |pages=226–35 |date=March 2016 |pmid=26421650 |pmc=4853053 |doi=10.1080/19336918.2015.1093275 |url=}}</ref><ref name="pmid22439034">{{cite journal |vauthors=Cavaliere A, Ermito S, Dinatale A, Pedata R |title=Management of molar pregnancy |journal=J Prenat Med |volume=3 |issue=1 |pages=15–7 |date=January 2009 |pmid=22439034 |pmc=3279094 |doi= |url=}}</ref><ref name="pmid">{{cite journal |vauthors=Sun SY, Melamed A, Joseph NT, Gockley AA, Goldstein DP, Bernstein MR, Horowitz NS, Berkowitz RS |title=Clinical Presentation of Complete Hydatidiform Mole and Partial Hydatidiform Mole at a Regional Trophoblastic Disease Center in the United States Over the Past 2 Decades |journal=Int. J. Gynecol. Cancer |volume=26 |issue=2 |pages=367–70 |date=February 2016 |pmid= |doi=10.1097/IGC.0000000000000608 |url=}}</ref>
|
|
* [[Vaginal bleeding]]
* [[Vaginal bleeding]]
* Inappropriately large for date [[uterine]] size
* Inappropriately large for date [[uterine]] size
* [[Hyperemesis]]
* [[Hyperemesis]]
* [[Vaginal]] passage of grape-like vescicles
|
|
* High rate of progression (15-20%)
* High rate of progression (15-20%)
|
|
* Extremely high levels ( > 100000 mIU/ml in half of the patients
* Extremely high levels  
** >100000 mIU/ml in half of the patients
|
|
* Not related
* Not related
Line 51: Line 47:
* Present
* Present
|
|
* Benign
* [[Benign]]
|
|
* 46, XX or 46 XY (Paternal dispermy)
* 46, XX or 46 XY (Paternal dispermy)
|
|
* Absent
* Negative
|
|
* Absent
* Negative
|
|
* Extremely elevated
* Extremely elevated
Line 71: Line 67:
* Dilation and curettage (suction)
* Dilation and curettage (suction)
|-
|-
|'''Partial Hydatidiform Mole'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Molar pregnancy|Partial Hydatidiform Mole]]'''<ref name="pmid2">{{cite journal |vauthors=Watson EJ, Hernandez E, Miyazawa K |title=Partial hydatidiform moles: a review |journal= |volume=42 |issue=9 |pages=540–4 |date=September 1987 |pmid= |doi= |url=}}</ref><ref name="pmid8035368">{{cite journal |vauthors=Goldstein DP, Berkowitz RS |title=Current management of complete and partial molar pregnancy |journal=J Reprod Med |volume=39 |issue=3 |pages=139–46 |date=March 1994 |pmid=8035368 |doi= |url=}}</ref><ref name="pmid7070731">{{cite journal |vauthors=Szulman AE, Surti U |title=The clinicopathologic profile of the partial hydatidiform mole |journal=Obstet Gynecol |volume=59 |issue=5 |pages=597–602 |date=May 1982 |pmid=7070731 |doi= |url=}}</ref>
|
|
* [[Vaginal bleeding]]
* [[Vaginal bleeding]]
Line 77: Line 73:
* < 5 % progression rate
* < 5 % progression rate
|
|
* Highly elevated ( > 100000 mIU/ml in one in ten patients)
* Highly elevated  
** >100000 mIU/ml in one in ten patients
|
|
* Not related
* Not related
Line 83: Line 80:
* Absent
* Absent
|
|
* Benign
* [[Benign]]
|
|
* 69,XXY or XXY
* 69,XXY or XYY
|
|
* Absent
* Negative
|
|
* Absent
* Negative
|
|
* Highly elevated
* Highly elevated
Line 103: Line 100:
* Dilation and curettage (suction)
* Dilation and curettage (suction)
|-
|-
|'''Invasive Molar Pregnancy'''  
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Gestational trophoblastic neoplasia|Invasive Molar Pregnancy]]'''  
|
|
* [[Vaginal bleeding]]
* [[Vaginal bleeding]]
Line 112: Line 109:
* High
* High
|
|
* Consequence of molar pregnancy
* Consequence of [[molar pregnancy]]
|
|
* May be present
* May be present
Line 118: Line 115:
* Hematogenous
* Hematogenous
|
|
* 69,XXY or XXY
* 69,XXY or XYY
|
|
* Positive
* Positive
Line 136: Line 133:
* [[Chemotherapy]] ([[Methotrexate]])
* [[Chemotherapy]] ([[Methotrexate]])
|-
|-
|'''Choriocarcinoma'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Choriocarcinoma'''<ref name="pmid16310678">{{cite journal |vauthors=Smith HO, Kohorn E, Cole LA |title=Choriocarcinoma and gestational trophoblastic disease |journal=Obstet. Gynecol. Clin. North Am. |volume=32 |issue=4 |pages=661–84 |date=December 2005 |pmid=16310678 |doi=10.1016/j.ogc.2005.08.001 |url=}}</ref><ref name="pmid9443570">{{cite journal |vauthors=Baergen RN |title=Gestational choriocarcinoma |journal=Gen Diagn Pathol |volume=143 |issue=2-3 |pages=127–41 |date=November 1997 |pmid=9443570 |doi= |url=}}</ref><ref name="pmid26566410">{{cite journal |vauthors=Duffy L, Zhang L, Sheath K, Love DR, George AM |title=The Diagnosis of Choriocarcinoma in Molar Pregnancies: A Revised Approach in Clinical Testing |journal=J Clin Med Res |volume=7 |issue=12 |pages=961–6 |date=December 2015 |pmid=26566410 |pmc=4625817 |doi=10.14740/jocmr2236w |url=}}</ref>
|
|
* [[Vaginal bleeding]]
* [[Vaginal bleeding]]
* [[Weight loss]]
* [[Weight loss]]
|
|
* Neoplastic
* [[Neoplastic]]
|
|
* High
* High
Line 154: Line 151:
|
|
|
|
* Positive
|
|
* Positive
|
|
* Highly elevated
|
|
|
|
|
|
* Positive
|
|
|
|
|-
|-
|'''Placental-site Trophoblastic tumor (PSTT) and Epitheloid Trophoblastic Tumor (ETT)'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Placental-site Trophoblastic tumor (PSTT) and Epitheloid Trophoblastic Tumor (ETT)'''<ref name="pmid27789086">{{cite journal |vauthors=Horowitz NS, Goldstein DP, Berkowitz RS |title=Placental site trophoblastic tumors and epithelioid trophoblastic tumors: Biology, natural history, and treatment modalities |journal=Gynecol. Oncol. |volume=144 |issue=1 |pages=208–214 |date=January 2017 |pmid=27789086 |doi=10.1016/j.ygyno.2016.10.024 |url=}}</ref><ref name="pmid14614893">{{cite journal |vauthors=Kim SJ |title=Placental site trophoblastic tumour |journal=Best Pract Res Clin Obstet Gynaecol |volume=17 |issue=6 |pages=969–84 |date=December 2003 |pmid=14614893 |doi= |url=}}</ref><ref name="pmid27168005">{{cite journal |vauthors=Zhao J, Lv WG, Feng FZ, Wan XR, Liu JH, Yi XF, Qu PP, Xue FX, Wu YM, Zhao X, Ren T, Yang JJ, Xie X, Xiang Y |title=Placental site trophoblastic tumor: A review of 108 cases and their implications for prognosis and treatment |journal=Gynecol. Oncol. |volume=142 |issue=1 |pages=102–108 |date=July 2016 |pmid=27168005 |doi=10.1016/j.ygyno.2016.05.006 |url=}}</ref><ref name="pmid9445130">{{cite journal |vauthors=Shih IM, Kurman RJ |title=Ki-67 labeling index in the differential diagnosis of exaggerated placental site, placental site trophoblastic tumor, and choriocarcinoma: a double immunohistochemical staining technique using Ki-67 and Mel-CAM antibodies |journal=Hum. Pathol. |volume=29 |issue=1 |pages=27–33 |date=January 1998 |pmid=9445130 |doi= |url=}}</ref>
|
|
* [[Vaginal bleeding]]
|
|
* Neoplastic
|
|
* Moderatley elevated
** <1000 mIU/ml in majority of patients
|
|
* About 60% follow term pregnancy
* 40 % follow [[molar pregnancy]] or [[abortion]]
|
|
* Absent
|
|
* [[Lymphatic system|Lymphatic]]
|
|
* 46,XX or XY
|
|
* Positive
|
|
* Positive
|
|
|
|
* Negative (Positive in ETT)
|
|
* Positive (Negative in ETT)
|
|
* Positive (Negative in ETT)
|
|
* Positive ( >1% in PSTT and >10% in ETT)
|
|
* Hysterectomy
|-
|-
|'''Ovarian Tumors'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Ovarian tumor|Ovarian Tumors]]'''<ref name="pmid2050306">{{cite journal |vauthors=Farahmand SM, Marchetti DL, Asirwatham JE, Dewey MR |title=Ovarian endodermal sinus tumor associated with pregnancy: review of the literature |journal=Gynecol. Oncol. |volume=41 |issue=2 |pages=156–60 |date=May 1991 |pmid=2050306 |doi= |url=}}</ref><ref name="pmid3806533">{{cite journal |vauthors=Hopkins MP, Duchon MA |title=Adnexal surgery in pregnancy |journal=J Reprod Med |volume=31 |issue=11 |pages=1035–7 |date=November 1986 |pmid=3806533 |doi= |url=}}</ref><ref name="pmid3532382">{{cite journal |vauthors=Lavery JP, Koontz WL, Layman L, Shaw L, Gumpel U |title=Sonographic evaluation of the adnexa during early pregnancy |journal=Surg Gynecol Obstet |volume=163 |issue=4 |pages=319–23 |date=October 1986 |pmid=3532382 |doi= |url=}}</ref><ref name="pmid2722058">{{cite journal |vauthors=Dgani R, Shoham Z, Atar E, Zosmer A, Lancet M |title=Ovarian carcinoma during pregnancy: a study of 23 cases in Israel between the years 1960 and 1984 |journal=Gynecol. Oncol. |volume=33 |issue=3 |pages=326–31 |date=June 1989 |pmid=2722058 |doi= |url=}}</ref><ref name="pmid20651229">{{cite journal |vauthors=Lengyel E |title=Ovarian cancer development and metastasis |journal=Am. J. Pathol. |volume=177 |issue=3 |pages=1053–64 |date=September 2010 |pmid=20651229 |pmc=2928939 |doi=10.2353/ajpath.2010.100105 |url=}}</ref><ref name="pmid29731792">{{cite journal |vauthors=Goel A, Rao NM, Santhi V, Byna SS, Grandhi B, Conjeevaram J |title=Immunohistochemical Characterization of Normal Ovary and Common Epithelial Ovarian Neoplasm with a Monoclonal Antibody to Cytokeratin and Vimentin |journal=Iran J Pathol |volume=13 |issue=1 |pages=23–29 |date=2018 |pmid=29731792 |pmc=5929385 |doi= |url=}}</ref><ref name="pmid14708717">{{cite journal |vauthors=Rebmann V, Regel J, Stolke D, Grosse-Wilde H |title=Secretion of sHLA-G molecules in malignancies |journal=Semin. Cancer Biol. |volume=13 |issue=5 |pages=371–7 |date=October 2003 |pmid=14708717 |doi= |url=}}</ref><ref name="pmid30675307">{{cite journal |vauthors=Zhou P, Xiong T, Chen J, Li F, Qi T, Yuan J |title=Clinical significance of melanoma cell adhesion molecule CD146 and VEGFA expression in epithelial ovarian cancer |journal=Oncol Lett |volume=17 |issue=2 |pages=2418–2424 |date=February 2019 |pmid=30675307 |pmc=6341705 |doi=10.3892/ol.2018.9840 |url=}}</ref><ref name="pmid15673959">{{cite journal |vauthors=Mita S, Nakai A, Maeda S, Takeshita T |title=Prognostic significance of Ki-67 antigen immunostaining (MIB-1 monoclonal antibody) in ovarian cancer |journal=J Nippon Med Sch |volume=71 |issue=6 |pages=384–91 |date=December 2004 |pmid=15673959 |doi= |url=}}</ref>
|
|
* [[Vaginal bleeding]] or discharge
* [[Weight loss]]
* [[Urinary frequency]]/[[Urinary urgency|urgency]]
* Change in bowel habits
* [[Loss of appetite]]
* [[Pelvic]] pressure/pain
* [[Abdominal pain]]
|
|
* [[Neoplastic]]
|
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* Elevated ([[Dysgerminoma]] and Embryonal carcinoma)
|
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* Overall incidence in pregnancy is  2.4-5.7% (1/300 to 1/556 pregnancies)
* Incidence of malignancy is 1/15,000 to 1/32,000 pregnancies
* [[Germ cell tumor|Germ cell]] and [[Ovarian tumor|epithelial tumors]] are most common
|
|
* Absent
|
|
* Direct extension or seeding
|
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* [[46,XX]]
|
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* Negative (Epithelial tumors may be positive for [[cytokeratin]] AE1/AE3)
|
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* Positive
|
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* Elevated in [[Dysgerminoma|dysgerminomas]] and [[embryonal carcinoma]])
|
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* Positive (especially in epithelial cancers)
|
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* Positive
|
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* Positive
|
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* Positive
|
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* Surgical debulking
* Intravenous/intraperitoneal chemotherapy
|-
|-
|'''Spontaneous Abortion'''  
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Spontaneous abortions|Spontaneous Abortion]]'''<ref name="pmid15516387">{{cite journal |vauthors=Barnhart K, Sammel MD, Chung K, Zhou L, Hummel AC, Guo W |title=Decline of serum human chorionic gonadotropin and spontaneous complete abortion: defining the normal curve |journal=Obstet Gynecol |volume=104 |issue=5 Pt 1 |pages=975–81 |date=November 2004 |pmid=15516387 |doi=10.1097/01.AOG.0000142712.80407.fd |url=}}</ref><ref name="pmid16225027">{{cite journal |vauthors=Griebel CP, Halvorsen J, Golemon TB, Day AA |title=Management of spontaneous abortion |journal=Am Fam Physician |volume=72 |issue=7 |pages=1243–50 |date=October 2005 |pmid=16225027 |doi= |url=}}</ref>
|
|
* [[Vaginal bleeding]]
* [[Lower abdominal pain]]
* [[Lower back pain]]
* [[Vaginal]] passage of [[Fetal|fetal tissue]]
* Reduced [[uterine]] size and regression of [[Symptoms and Signs|signs and symptoms]] of [[pregnancy]]
* Firm [[cervix]]
|
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* Not applicable
|
|
* Decline in levels within 24 hours
|
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* [[Aneuploidy|Aneuploid]] [[pregnancy]]
* History of [[recurrent pregnancy loss]]
*
|
|
* Absent
|
|
* Not applicable
|
|
* [[Down syndrome|47,XX, +21 or 47, XY, +21 (Down's syndrome)]]
* [[Edward's syndrome|47,XX,+18 or 47, XY, +18 (Edward's syndrome)]]
* [[Patau's Syndrome|47,XX, +13 or 47, XY, +13 (Patau syndrome)]]
|
|
* Negative
|
|
* Negative
|
|
* Progressive decline
|
|
* Negative
|
|
* Negative
|
|
* Negative
|
|
* Negative
|
|
* Uterine evacuation if patient has sepsis, hemorrhage and/or intractable pain
* Medical management using prostaglandin analogs
* Expectant management if no complications
|-
|-
|'''Ectopic Pregnancy'''  
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Ectopic pregnancy|Ectopic Pregnancy]]'''<ref name="pmid16217116">{{cite journal |vauthors=Murray H, Baakdah H, Bardell T, Tulandi T |title=Diagnosis and treatment of ectopic pregnancy |journal=CMAJ |volume=173 |issue=8 |pages=905–12 |date=October 2005 |pmid=16217116 |pmc=1247706 |doi=10.1503/cmaj.050222 |url=}}</ref><ref name="pmid1534771">{{cite journal |vauthors=Murphy AA, Nager CW, Wujek JJ, Kettel LM, Torp VA, Chin HG |title=Operative laparoscopy versus laparotomy for the management of ectopic pregnancy: a prospective trial |journal=Fertil. Steril. |volume=57 |issue=6 |pages=1180–5 |date=June 1992 |pmid=1534771 |doi= |url=}}</ref>
|
|
* [[Abdominal]]/[[pelvic pain]]
* [[Vaginal bleeding]]
* [[Amenorrhea]]
* [[Nausea]]
* [[Syncope]]
|
|
* Not applicable
|
|
* Failure of [[Human chorionic gonadotropin|hCG]] doubling (especially during the first 8 weeks)
|
|
* Previous [[ectopic pregnancy]]
* Intrauterine exposure to [[Diethylstilbestrol|diethylstillbestrol]]
* Current use of [[Intrauterine device|intrauterine contraceptive device]]
* Advanced maternal age
|
|
* Absent
|
|
* Not applicable
|
|
* [[46,XX]] or 46, XY
|
|
* Negative
|
|
* Negative
|
|
* A rising [[Beta-human chorionic gonadotrophin|β-hCG]] concentration that fails to reach 50% or plateaus
|
|
* Negative
|
|
* Negative
|
|
* Negative
|
|
* Negative
|
|
* Expectant management (Failure of transvaginal ultrasonography to show the location of the gestational sac and the serum levels of β-hCG and progesterone are low and declining)
* Surgical laproscopy
|-
|-
|'''Normal Term Pregnancy'''  
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Pregnancy|Normal Term Pregnancy]]'''  
|
|
|
|
|
|
|
|
* [[Uterine]] enlargment
* [[Nausea]] with or without [[vomiting]]
* [[Breast]] [[tenderness]]
* [[Amenorrhea]]
* [[Cervix]] is firm, long and closed
* [[Headache]]
* [[Urinary urgency]]
* [[Fatigue]]
|
|
* Not applicable
|
|
* Elevated (>25 mIU/mL)
* Progressive elevation and doubling of levels every 2 days especially during first 8 weeks
|
|
* Not applicable
|
|
* Absent
|
|
* Not applicable
|
|
* [[46,XX]] or [[Males|46, XY]]
|
|
* Negative
|
|
|}
* Negative
{| class="wikitable"
|+
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Clinical Features
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Complete Hydatidiform Mole
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Partial Hydatidiform Mole
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Invasive Molar Pregnancy
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Choriocarcinoma
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Placental-site trophoblastic tumor (PSTT) and Epithelioid trophoblastic tumor (ETT)
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Presenting Complaints'''
|
|
*  
* Progressive elevation and doubling of levels every 2 days especially during first 8 weeks
|
|
*  
* Negative
|
|
*  
* Negative
|
|
* [[Vaginal bleeding]]
* Negative
|
|
* [[Vaginal bleeding]]
* Negative
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Neoplastic Conversion'''
|
*
|
*
|
*
|
* [[Neoplastic disease|Neoplastic]]
|
* [[Neoplastic disease|Neoplastic]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Beta Human Chorionic Gonadotropin (Beta-hCG) baseline levels'''
|
*
|
*
|
* High
|
* High
|
* Moderatley elevated (< 1000 mIU/ml in majority of patients)
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''History of Pregnancies'''
|
*
|
*
|
* Consequence of [[Hydatidiform mole|molar pregnancy]]
|
*
|
* About 60% follow term pregnancy
* 40 % follow [[molar pregnancy]] or [[abortion]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Metastatic Route'''
|
* [[Benign]]
|
* [[Benign]]
|
* [[Blood|Hematogenous]]
|
* [[Blood|Hematogenous]]
|
* [[Lymphatic system|Lymphatic]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Management'''
|
* [[Dilation and curettage (patient information)|Dilation and curettage (suction)]]
|
* [[Dilation and curettage (patient information)|Dilation and curettage (suction)]]
|
*
|
* [[Chemotherapy]] ([[Methotrexate]])
|
|
* [[Hysterectomy]]
* Expectant delivery
* C-section (elective or in cases of breach presentation)
|}
|}
</small></small>
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Latest revision as of 00:09, 3 April 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

Gestational trophoblastic neoplasia (invasive mole, choriocarcinoma, placental-site trophoblastic tumor [PSTT] and epitheloid trophoblastic tumor [ETT]) should be differentiated from other conditions presenting with similar symptoms and signs such as increase in uterine size, vaginal bleeding and amenorrhea. The differentials include molar pregnancy (complete and partial moles), ovarian tumors, spontaneous abortion, ectopic pregnancy and normal term pregnancy.

Differentiating Choriocarcinoma From Other Diseases

Gestational trophoblastic neoplasia (invasive mole, choriocarcinoma, placental-site trophoblastic tumor [PSTT] and epitheloid trophoblastic tumor [ETT]) should be differentiated from other conditions presenting with similar symptoms and signs such as increase in uterine size, vaginal bleeding and amenorrhea. The differentials include the following:

Differential Diagnosis Clinical Features Karyotype Immunostaining Management
Presenting Complaints Potential for Neoplastic Conversion Beta Human Chorionic Gonadotropin (Beta-hCG) Baseline Levels History of Pregnancy Theca Leutin Cysts Metastatic Route Cytokeratin 18 HLA-G Human Chorionic Gonadotropin (hCG) Transformation-Related Protein 63 (P63) Human Placental Lactogen (hPL) Melanoma Cell Adhesion Molecule (Mel-CAM) Ki67
Complete Hydatidiform Mole[1][2][3]
  • High rate of progression (15-20%)
  • Extremely high levels
    • >100000 mIU/ml in half of the patients
  • Not related
  • Present
  • 46, XX or 46 XY (Paternal dispermy)
  • Negative
  • Negative
  • Extremely elevated
  • Absent
  • Absent
  • Absent
  • Absent
  • Dilation and curettage (suction)
Partial Hydatidiform Mole[4][5][6]
  • < 5 % progression rate
  • Highly elevated
    • >100000 mIU/ml in one in ten patients
  • Not related
  • Absent
  • 69,XXY or XYY
  • Negative
  • Negative
  • Highly elevated
  • Absent
  • Absent
  • Absent
  • Absent
  • Dilation and curettage (suction)
Invasive Molar Pregnancy
  • High
  • May be present
  • Hematogenous
  • 69,XXY or XYY
  • Positive
  • Positive
  • Highly elevated
  • Absent
  • Absent
  • Absent
  • Absent
Choriocarcinoma[7][8][9]
  • High
  • Present
  • Hematogenous
  • Positive
  • Positive
  • Highly elevated
  • Positive
Placental-site Trophoblastic tumor (PSTT) and Epitheloid Trophoblastic Tumor (ETT)[10][11][12][13]
  • Neoplastic
  • Moderatley elevated
    • <1000 mIU/ml in majority of patients
  • Absent
  • 46,XX or XY
  • Positive
  • Positive
  • Negative (Positive in ETT)
  • Positive (Negative in ETT)
  • Positive (Negative in ETT)
  • Positive ( >1% in PSTT and >10% in ETT)
  • Hysterectomy
Ovarian Tumors[14][15][16][17][18][19][20][21][22]
  • Overall incidence in pregnancy is 2.4-5.7% (1/300 to 1/556 pregnancies)
  • Incidence of malignancy is 1/15,000 to 1/32,000 pregnancies
  • Germ cell and epithelial tumors are most common
  • Absent
  • Direct extension or seeding
  • Negative (Epithelial tumors may be positive for cytokeratin AE1/AE3)
  • Positive
  • Positive (especially in epithelial cancers)
  • Positive
  • Positive
  • Positive
  • Surgical debulking
  • Intravenous/intraperitoneal chemotherapy
Spontaneous Abortion[23][24]
  • Not applicable
  • Decline in levels within 24 hours
  • Absent
  • Not applicable
  • Negative
  • Negative
  • Progressive decline
  • Negative
  • Negative
  • Negative
  • Negative
  • Uterine evacuation if patient has sepsis, hemorrhage and/or intractable pain
  • Medical management using prostaglandin analogs
  • Expectant management if no complications
Ectopic Pregnancy[25][26]
  • Not applicable
  • Failure of hCG doubling (especially during the first 8 weeks)
  • Absent
  • Not applicable
  • Negative
  • Negative
  • A rising β-hCG concentration that fails to reach 50% or plateaus
  • Negative
  • Negative
  • Negative
  • Negative
  • Expectant management (Failure of transvaginal ultrasonography to show the location of the gestational sac and the serum levels of β-hCG and progesterone are low and declining)
  • Surgical laproscopy
Normal Term Pregnancy
  • Not applicable
  • Elevated (>25 mIU/mL)
  • Progressive elevation and doubling of levels every 2 days especially during first 8 weeks
  • Not applicable
  • Absent
  • Not applicable
  • Negative
  • Negative
  • Progressive elevation and doubling of levels every 2 days especially during first 8 weeks
  • Negative
  • Negative
  • Negative
  • Negative
  • Expectant delivery
  • C-section (elective or in cases of breach presentation)

References

  1. ↑ Candelier JJ (March 2016). "The hydatidiform mole". Cell Adh Migr. 10 (1–2): 226–35. doi:10.1080/19336918.2015.1093275. PMC 4853053. PMID 26421650.
  2. ↑ Cavaliere A, Ermito S, Dinatale A, Pedata R (January 2009). "Management of molar pregnancy". J Prenat Med. 3 (1): 15–7. PMC 3279094. PMID 22439034.
  3. ↑ Sun SY, Melamed A, Joseph NT, Gockley AA, Goldstein DP, Bernstein MR, Horowitz NS, Berkowitz RS (February 2016). "Clinical Presentation of Complete Hydatidiform Mole and Partial Hydatidiform Mole at a Regional Trophoblastic Disease Center in the United States Over the Past 2 Decades". Int. J. Gynecol. Cancer. 26 (2): 367–70. doi:10.1097/IGC.0000000000000608.
  4. ↑ Watson EJ, Hernandez E, Miyazawa K (September 1987). "Partial hydatidiform moles: a review". 42 (9): 540–4.
  5. ↑ Goldstein DP, Berkowitz RS (March 1994). "Current management of complete and partial molar pregnancy". J Reprod Med. 39 (3): 139–46. PMID 8035368.
  6. ↑ Szulman AE, Surti U (May 1982). "The clinicopathologic profile of the partial hydatidiform mole". Obstet Gynecol. 59 (5): 597–602. PMID 7070731.
  7. ↑ Smith HO, Kohorn E, Cole LA (December 2005). "Choriocarcinoma and gestational trophoblastic disease". Obstet. Gynecol. Clin. North Am. 32 (4): 661–84. doi:10.1016/j.ogc.2005.08.001. PMID 16310678.
  8. ↑ Baergen RN (November 1997). "Gestational choriocarcinoma". Gen Diagn Pathol. 143 (2–3): 127–41. PMID 9443570.
  9. ↑ Duffy L, Zhang L, Sheath K, Love DR, George AM (December 2015). "The Diagnosis of Choriocarcinoma in Molar Pregnancies: A Revised Approach in Clinical Testing". J Clin Med Res. 7 (12): 961–6. doi:10.14740/jocmr2236w. PMC 4625817. PMID 26566410.
  10. ↑ Horowitz NS, Goldstein DP, Berkowitz RS (January 2017). "Placental site trophoblastic tumors and epithelioid trophoblastic tumors: Biology, natural history, and treatment modalities". Gynecol. Oncol. 144 (1): 208–214. doi:10.1016/j.ygyno.2016.10.024. PMID 27789086.
  11. ↑ Kim SJ (December 2003). "Placental site trophoblastic tumour". Best Pract Res Clin Obstet Gynaecol. 17 (6): 969–84. PMID 14614893.
  12. ↑ Zhao J, Lv WG, Feng FZ, Wan XR, Liu JH, Yi XF, Qu PP, Xue FX, Wu YM, Zhao X, Ren T, Yang JJ, Xie X, Xiang Y (July 2016). "Placental site trophoblastic tumor: A review of 108 cases and their implications for prognosis and treatment". Gynecol. Oncol. 142 (1): 102–108. doi:10.1016/j.ygyno.2016.05.006. PMID 27168005.
  13. ↑ Shih IM, Kurman RJ (January 1998). "Ki-67 labeling index in the differential diagnosis of exaggerated placental site, placental site trophoblastic tumor, and choriocarcinoma: a double immunohistochemical staining technique using Ki-67 and Mel-CAM antibodies". Hum. Pathol. 29 (1): 27–33. PMID 9445130.
  14. ↑ Farahmand SM, Marchetti DL, Asirwatham JE, Dewey MR (May 1991). "Ovarian endodermal sinus tumor associated with pregnancy: review of the literature". Gynecol. Oncol. 41 (2): 156–60. PMID 2050306.
  15. ↑ Hopkins MP, Duchon MA (November 1986). "Adnexal surgery in pregnancy". J Reprod Med. 31 (11): 1035–7. PMID 3806533.
  16. ↑ Lavery JP, Koontz WL, Layman L, Shaw L, Gumpel U (October 1986). "Sonographic evaluation of the adnexa during early pregnancy". Surg Gynecol Obstet. 163 (4): 319–23. PMID 3532382.
  17. ↑ Dgani R, Shoham Z, Atar E, Zosmer A, Lancet M (June 1989). "Ovarian carcinoma during pregnancy: a study of 23 cases in Israel between the years 1960 and 1984". Gynecol. Oncol. 33 (3): 326–31. PMID 2722058.
  18. ↑ Lengyel E (September 2010). "Ovarian cancer development and metastasis". Am. J. Pathol. 177 (3): 1053–64. doi:10.2353/ajpath.2010.100105. PMC 2928939. PMID 20651229.
  19. ↑ Goel A, Rao NM, Santhi V, Byna SS, Grandhi B, Conjeevaram J (2018). "Immunohistochemical Characterization of Normal Ovary and Common Epithelial Ovarian Neoplasm with a Monoclonal Antibody to Cytokeratin and Vimentin". Iran J Pathol. 13 (1): 23–29. PMC 5929385. PMID 29731792.
  20. ↑ Rebmann V, Regel J, Stolke D, Grosse-Wilde H (October 2003). "Secretion of sHLA-G molecules in malignancies". Semin. Cancer Biol. 13 (5): 371–7. PMID 14708717.
  21. ↑ Zhou P, Xiong T, Chen J, Li F, Qi T, Yuan J (February 2019). "Clinical significance of melanoma cell adhesion molecule CD146 and VEGFA expression in epithelial ovarian cancer". Oncol Lett. 17 (2): 2418–2424. doi:10.3892/ol.2018.9840. PMC 6341705. PMID 30675307.
  22. ↑ Mita S, Nakai A, Maeda S, Takeshita T (December 2004). "Prognostic significance of Ki-67 antigen immunostaining (MIB-1 monoclonal antibody) in ovarian cancer". J Nippon Med Sch. 71 (6): 384–91. PMID 15673959.
  23. ↑ Barnhart K, Sammel MD, Chung K, Zhou L, Hummel AC, Guo W (November 2004). "Decline of serum human chorionic gonadotropin and spontaneous complete abortion: defining the normal curve". Obstet Gynecol. 104 (5 Pt 1): 975–81. doi:10.1097/01.AOG.0000142712.80407.fd. PMID 15516387.
  24. ↑ Griebel CP, Halvorsen J, Golemon TB, Day AA (October 2005). "Management of spontaneous abortion". Am Fam Physician. 72 (7): 1243–50. PMID 16225027.
  25. ↑ Murray H, Baakdah H, Bardell T, Tulandi T (October 2005). "Diagnosis and treatment of ectopic pregnancy". CMAJ. 173 (8): 905–12. doi:10.1503/cmaj.050222. PMC 1247706. PMID 16217116.
  26. ↑ Murphy AA, Nager CW, Wujek JJ, Kettel LM, Torp VA, Chin HG (June 1992). "Operative laparoscopy versus laparotomy for the management of ectopic pregnancy: a prospective trial". Fertil. Steril. 57 (6): 1180–5. PMID 1534771.
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