Difference between revisions of "Gestational trophoblastic disease"

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(another table)
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==Hydatidiform moles==
==Hydatidiform moles==
===General===
===General===
*Significance: increased risk for choriocarcinoma (in complete moles).
*Non-neoplastic proliferation.
*Non-neoplastic proliferation.
*Significance: increased risk for choriocarcinoma (in complete moles).


Etymology:
Etymology:
Line 89: Line 89:


====Types====
====Types====
*Partial mole.
*Partial mole - see [[partial mole]].
**Triploid.
*Complete mole - see [[complete mole]].
**Choriocarcinoma extremely rare.
*Complete mole.
**Diploid or tetraploid.
**"Empty" egg fertilized, ergo paternal DNA.
**Risk for choriocarcinoma; memory device '''c'''omplete -> '''c'''horiocarcinoma.


===Microscopic===
===Microscopic===
====Partial====
====Mole vs. normal====
Features:
*Moles have large [[chorionic villi]] with edema and abnormal blood vessels.<ref>URL: [http://pathologyoutlines.com/placenta.html#hydatgeneral http://pathologyoutlines.com/placenta.html#hydatgeneral].</ref>
*Scant trophoblastic proliferation.
**May form finger-like projections.
*Fetal tissue.
**Nucleated RBCs common.


====Complete====
Hydropic changes:
Features:
{| class="wikitable"
*Cisterns usu. well-developed.
| '''Entity'''
**Large empty areas within trophoblastic tissue.
| '''Villi (outline)'''
*Rarely nucleated [[RBC]]s.
| '''Blood vessels'''
*Canalicular (thin) blood vessels.
| '''Nucleated RBCs'''
| '''p57 staining'''
| '''Ploidy'''
| '''Image'''
|-
| Complete mole
| bizarre
| canalicular (thin walled) / few (???)
| rare
| -ve
| diploid / tetraploid
| ?
|-
| Partial mole
| jagged
| present
| common
| +ve
| triploid
| ?
|-
| Hydropic abortus
| smooth
| common
| common
| +ve
| diploid
| ?
|}


====Mole vs. normal====
*Moles have large [[chorionic villi]] with edema and abnormal blood vessels.<ref>URL: [http://pathologyoutlines.com/placenta.html#hydatgeneral http://pathologyoutlines.com/placenta.html#hydatgeneral].</ref>


===IHC===
===IHC===
Line 128: Line 145:
*Formal name: ''partial hydatidiform mole''.
*Formal name: ''partial hydatidiform mole''.


===Genetics===
===General===
Genetics:
*Polypoid - usually triploid (e.g. 69XXY).
*Polypoid - usually triploid (e.g. 69XXY).
Images: [http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=12&cat2=86&cat3=795&cat4=3&stype=n]
Images: [http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=12&cat2=86&cat3=795&cat4=3&stype=n]


===Histology===
===Microscopic===
Features:
*Abnormal chorionic villi.
*Abnormal chorionic villi.
**Villi too large (>0.1 mm ?).
**Villi too large (>0.1 mm ?).
Line 151: Line 170:
*Also known as ''classic mole''.
*Also known as ''classic mole''.


===Epidemiology===
===General===
*May precede [[choriocarcinoma]].<ref name=Ref_PBoD1111>{{Ref PBoD|1111}}</ref>
Epidemiology:
*May precede [[choriocarcinoma]]<ref name=Ref_PBoD1111>{{Ref PBoD|1111}}</ref> ~ 1-2% risk.


===Genetics===
Genetics:
*Diploid - most are 46XX.
*Diploid - most are 46XX.
*All male dervived, i.e. arise from DNA in sperm.
*Male derived, i.e. arise from DNA in sperm; empty egg fertilized.  


===Microscopy===
===Radiology===
*"Snowstorm" appearance on ultrasound.<ref>URL:[http://www.jultrasoundmed.org/cgi/content/abstract/18/9/589 http://www.jultrasoundmed.org/cgi/content/abstract/18/9/589]. Accessed on: 27 July 2010.</ref>
 
===Microscopic===
Features:
*No normal villi.
*No normal villi.
*No fetal parts seen.
*No fetal parts seen.
**Very rarely nucleated [[RBC]]s.


Image:  
Image:  
*[http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675(06)70167-X Complete mole (pathconsultddx.com)].
*[http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675(06)70167-X Complete mole (pathconsultddx.com)].
===Radiology===
*"Snowstorm" appearance on ultrasound.<ref>URL:[http://www.jultrasoundmed.org/cgi/content/abstract/18/9/589 http://www.jultrasoundmed.org/cgi/content/abstract/18/9/589]. Accessed on: 27 July 2010.</ref>


==Placental site trophoblastic tumour==
==Placental site trophoblastic tumour==

Revision as of 17:43, 28 May 2011

Gestational trophoblastic disease (GTD) includes choriocarcinoma and hydatidiform moles.

Overview

Most common

Overview of gestational trophoblastic disease:

Gross Nuclear atypia Villi IHC DNA content Images
Complete mole "snowstorm" +/- ? yes, all abnormal [1] p57(KIP2) -ve Paternal, diploid Complete mole (pathconsultddx.com)
Partial mole grape-like
clusters 		+/- large villi, villi with cisterns,
villi with cytotrophoblastic inclusions 		p57(KIP2) +ve Maternal & paternal, tripoid Partial mole (utah.edu)
Choriocarcinoma haemorrahagic, necrotic marked none beta-hCG +ve ? Choriocarcinoma - testicular (webpathology.com)

More comprehensive overview

Benign abnormal looking placenta:

  • Placental site nodule (PSN).
  • Exaggerated placental site (EPS).

Abnormal fertilization:

  • Hydatidiform mole.

Tumours:

  • Invasive mole.
  • Choriocarcinoma.
  • Placental site trophoblastic tumour (PSTT).
  • Epithelioid trophoblastic tumour (ETT).

Choriocarcinoma

General

Clinical/Epidemiology

  • High beta-hCG.
  • May be preceded by a complete hydatidiform mole.[2]
  • More common in the far east.
  • More common at extremes of fertile age (teens and 40-50 years).

Microscopic

Features:

  • Nuclear pleomorphism - usually marked.
  • Often haemorrhage.
  • Syncytiotrophoblast surrounds nests of cytotrophoblast.

Image:

Notes:

  • Its usually NOT choriocarcinoma if there are villi.[3]

IHC

  • beta-hCG +ve.[4]

Hydatidiform moles

General

  • Significance: increased risk for choriocarcinoma (in complete moles).
  • Non-neoplastic proliferation.

Etymology:

  • Hydatid is literally watery vesicle.[5]

Types

Microscopic

Mole vs. normal

Hydropic changes:

Entity Villi (outline) Blood vessels Nucleated RBCs p57 staining Ploidy Image
Complete mole bizarre canalicular (thin walled) / few (???) rare -ve diploid / tetraploid ?
Partial mole jagged present common +ve triploid ?
Hydropic abortus smooth common common +ve diploid ?


IHC

  • p57(KIP2) - the gene is strongly paternally imprinted and the paternal copy is inactived; its expression is from the maternal gene.
    • Complete moles lacks the maternal genome; thus, p57(KIP2) immunostaining is absent.[7]
    • Memory device:
      • p57 is positive in partial moles.
      • 3 Ps - partial moles are triploid.

Molecular

Partial Mole

  • Formal name: partial hydatidiform mole.

General

Genetics:

  • Polypoid - usually triploid (e.g. 69XXY).

Images: [1]

Microscopic

Features:

  • Abnormal chorionic villi.
    • Villi too large (>0.1 mm ?).
    • Villi with cisterns.
      • Contain fluid in the centre, i.e. are "hydropic".
    • Villi with cytotrophoblastic inclusions.
      • Cytotrophoblast in the core of a villus (normally it is only at the surface of the villus).
  • May have fetal parts, such as nucleated RBCs.
  • Trophoblastic proliferation - image - med.utah.edu.
    • Without atypia.[9]

Images:

Complete Mole

  • Formal name: complete hydatidiform mole.
  • Also known as classic mole.

General

Epidemiology:

Genetics:

  • Diploid - most are 46XX.
  • Male derived, i.e. arise from DNA in sperm; empty egg fertilized.

Radiology

  • "Snowstorm" appearance on ultrasound.[11]

Microscopic

Features:

  • No normal villi.
  • No fetal parts seen.
    • Very rarely nucleated RBCs.

Image:

Placental site trophoblastic tumour

  • Abbreviated PSTT.
  • Malignant counterpart of exaggerated placental site or EPS.

Clinical

  • Raised beta-hCG - but usually not has high as in choriocarcinoma.[12]
  • Derived from trophoblast - the stuff that forms the chorionic villi - remember: syncytiotrophoblasts (outer layer) and cytotrophoblasts (inner layer).

Epidemiology

  • Usually follows a normal pregnancy ~ 75% of cases.[12]

Microscopic

Features:

  • Large cells.
  • Nuclear atypia.
  • Cytoplasm - cytoplasmic.
  • NC ratio ~ normal.

EPS vs. PSTT:

  • EPS has a low MIB-1 (Ki-67).

Epithelioid trophoblastic tumour

  • Abbreviated ETT.
  • Often in endocervix.
  • Malignant counterpart of placental site nodule or PSN.

Images:

DDx:

Placental site nodule

General

  • Benign.

Microscopic

Features:

  • Small collection of cells that look similar to decidua (mnemonic NEW):
    • Nucleus, central location.
    • Eosinophilic cytoplasm.
    • Well-defined cell borders.

Images:

DDx:

See also

References

  1. ↑ http://pathologyoutlines.com/placenta.html#completemole
  2. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1110-1111. ISBN 0-7216-0187-1.
  3. ↑ Notebook P.180. 21 September 2009.
  4. ↑ Kalhor N, Ramirez PT, Deavers MT, Malpica A, Silva EG (April 2009). "Immunohistochemical studies of trophoblastic tumors". Am. J. Surg. Pathol. 33 (4): 633–8. doi:10.1097/PAS.0b013e318191f2eb. PMID 19145204.
  5. ↑ URL: http://dictionary.reference.com/browse/hydatid.
  6. ↑ URL: http://pathologyoutlines.com/placenta.html#hydatgeneral.
  7. ↑ Merchant SH, Amin MB, Viswanatha DS, Malhotra RK, Moehlenkamp C, Joste NE (February 2005). "p57KIP2 immunohistochemistry in early molar pregnancies: emphasis on its complementary role in the differential diagnosis of hydropic abortuses". Hum. Pathol. 36 (2): 180–6. doi:10.1016/j.humpath.2004.12.007. PMID 15754295.
  8. ↑ http://jcp.bmjjournals.com/cgi/reprint/51/6/438.pdf
  9. ↑ http://pathologyoutlines.com/placenta.html#incompletemole
  10. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1111. ISBN 0-7216-0187-1.
  11. ↑ URL:http://www.jultrasoundmed.org/cgi/content/abstract/18/9/589. Accessed on: 27 July 2010.
  12. ↑ 12.0 12.1 URL: http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675(06)70463-6. Accessed on: 23 September 2009.
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