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GYN
CMECNE

Gestational Trophoblast Disease: Classification and Staging

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. List the differences between partial and complete mole
2. Classify the different types of malignant gestational trophoblastic disease (GTD)

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from July 6 2018 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

WHAT IS IT: 

Gestational trophoblast disease (GTD) describes a set of diseases originating in placental tissue, specifically the chorionic villi and extravillous trophoblast. GTD includes both benign and malignant conditions. Disorders within GTD are considered distinct entities and are classified as follows

Hydatidiform Mole (HN)

Partial: Karyotype 69XXX or 69XXY or 69XYY 

  • Fetus usually present   
  • Usually, a result of diandry (the extra haploid set is from the father) 
    • Ovum retains its maternal nucleus and is fertilized by a single sperm, with subsequent chromosome duplication, or is fertilized by two sperm 
  • Less frequently, may be the result of digyny, which can a occur due to  
    • Failure of one meiotic division during oogenesis leading to a diploid oocyte or 
    • Failure to extrude one polar body from the oocyte 
  • Uterus small for gestation 
  • Complications 
    • 15% to 25% risk of developing into an invasive mole 
    • Theca lutein cysts (rare) |Medical complications (rare) | Postmolar malignant sequelae <5% 

Complete: Karyotype 46 XX (90%) or 46 XY 

  • No fetus 
  • Ovum extrudes its maternal nucleus and is fertilized by either a single sperm, with subsequent chromosome duplication, or two sperm 
  • Diagnosed on ultrasound as diffuse, mixed echogenic pattern 
  • Uterus large for gestational age (50%) 
  • Associated complications that may be present  
    • Theca lutein cysts (15-25%) | Medical complications (<25%) | Postmolar malignant sequelae up to 6-32%

Gestational Trophoblastic Neoplasia (GTN)  

Serum HCG Plateaus or Rises Following Evacuation of the Uterus

  • Invasive mole (IM) 
    • Confined to the uterus, trophoblasts invade into myometrium 
    • Edematous villi with trophoblastic proliferation 
  • Gestational Choriocarcinoma (CCA) 
    • Composed of both syncytiotrophoblasts and cytotrophoblasts  
    • 50% derived from term pregnancies | 25% normal gestations | 25% hydatidiform moles  
  • Placental site trophoblastic tumor (PSTT) 
    • Very rare 
    • Absence of villi, intermediate trophoblast proliferation 
    • Arising from the placental implantation site and resembles an exaggerated form of syncytial endometritis 
    • Much lower growth rates than choriocarcinoma 
    • Presentation after a full-term pregnancy is often delayed by months or years 
    • Resistant to chemotherapy, and therefore hysterectomy is the standard primary treatment if the tumor is confined to the uterus 
  • Epithelioid trophoblastic tumor (ETT) 
    • Extremely rare  
    • May resemble squamous cell cancer of the cervix 
    • Spectrum of benign to malignant

NOTE: Medical complications include the following 

  • Pregnancy-induced hypertension | Hyperthyroidism | Anemia | Hyperemesis gravidarum 

KEY POINTS: 

FIGO Anatomical Staging for malignant GTD  

    • Stage I: Disease confined to the uterus 
    • Stage II: GTN extends outside of the uterus, but is limited to the genital structures (adnexa, vagina, broad ligament) 
    • Stage III: GTN extends to the lungs, with or without known genital tract involvement 
  • Stage IV: All other metastatic sites 

FIGO Modified WHO Prognostic Scoring System as Adapted by FIGO

  • Score 0 to 6
    • Low risk for resistance to single-agent chemotherapy
  • Score ≥7
    • High risk for resistance to single-agent and will require combination chemotherapy

Prognosis   

  • Good prognosis possible even with spread to distant organs (especially if only lung metastases present) unlike most other cancer diagnoses
  • Probability of cure related to the following
    • Histologic type (invasive mole or choriocarcinoma)
    • Extent of spread of the disease/largest tumor size
    • Level of serum beta-hCG
    • Duration of disease from the initial pregnancy event to start of treatment
    • Number and specific sites of metastases
    • Nature of antecedent pregnancy (no prior term pregnancy)
    • Extent of prior treatment (no prior chemotherapy)

Learn More – Primary Sources:

Epidemiology, diagnosis, and treatment of gestational trophoblastic disease: A Society of Gynecologic Oncology evidenced-based review and recommendation

Gestational Trophoblastic Disease Treatment (PDQ®): Health Professional Version

Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia

Understanding and management of gestational trophoblastic disease

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Related ObG Topics:

Prenatal Sonographic Features and Parental Origin of Triploidy
Microarrays and Microdeletions: Key Concepts Summarized

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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