Gynecology - Moles

Gynecology

[MOLES]

Benign Moles (aka Gestational Trophoblastic Disease) Moles aren’t cancerous, but they are potentially premalignant as choriocarcinoma may arise from Moles. Let’s discuss the  precancer before getting to the c ancer. A complete mole is “complete.” It’s a product of normal fertilization , has a “completely” normal number of chromosomes (46), and is “completely” molar; there are no fetal parts. It’s a  product of a broken egg. One single sperm gets inside one single egg, but that egg has no nucleus, so the sperm spontaneously doubles its chromosomes. Though normal in the number of chromosomes, it isn’t normal in chromosome complement; all the genetic material is of the sperm. An incomplete mole is “incompletely molar” in that it contains some fetal parts, doesn’t have the normal number of chromosomes (69), and is a product of two separate sperm fertilizing one normal egg. Aside from the differences in fertilization, genetic content, and presence of fetal parts, all moles  present the same way.

Complete Mole

Incomplete Mole

 Each letter represen ts 23 chromosome, S: Sperm, E: Egg

A mole grows faster, produces more B-HCG, and looks different than a normal pregnancy on exam and ultrasound. That being said, there are a couple of ways it can present. If the B-HCG is super high or there’s a size-date discrepancy (it’s growing too fast), there’s a chance there is a molar pregnancy. Because the BHCG is elevated so high and B-HCG “looks like” TSH, the  patient may present with hyperthyroidism . But B-HCG also causes “morning sickness,” presenting with nausea and vomiting in the first trimester. Too much B-HCG (levels can be > 100,000 ) causes Hyperemesis Gravidarum - a severe, dehydrating morning sickness or one that lasts beyond the first trimester. A  pelvic exam may demonstrate a grape-like mass expelled into the vagina through the cervix. A pelvic ultrasound will reveal a snowstorm appearance of the mass in the uterus. A suction curettage will reveal the grape-like mass. Track the HCG weekly to assure it was all gotten. It should decline linearly. Put her on OCPs  to prevent pregnancy; if she gets pregnant it’s impossible to be sure if it’s an invasive mole or a regular pregnancy!

Invasive Moles and Choriocarcinoma Any pregnancy - molar or regular - can result in a cancer: Choriocarcinoma. It’s a cancer of gestational contents. After a miscarriage , normal delivery, or molar pregnancy, if there’s elevation of the B-HCG or its symptoms (listed above), suspect chorio. Diagnose it with an ultrasound  first, cut it out with a curettage , and stage it with a CT scan. For localized disease (Stage I) use Methotrexate followed by Actinomycin D (fertility sparing) or TAH (fertility complete). For resistant disease, use MAC. For advanced stage disease, more aggressive chemo is required: Etoposide, Methotrexate, Actinomycin D, and Carboplatin.

Persistence of B-HCG suggests chorio

 Normal return to basel ine

 Stage I

Concept Uterus

II

Genitals

III

Mets to Lungs only Mets to anywhere else

IV

Treatment Methotrexate then Actinomycin D Or TAH Etoposide, Methotrexate, Actinomycin D, and Carboplatin +/- Surgery SAA

Beyond Scope

All disease gets contraception for a minimum of 12 months with serial B-HCG monitoring.  MAC is Methotrexate , Actinomycin D, and Cyclophosphamide; it’s only used in refractory disease.

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