Gestational trophoblastic neoplasia differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Monalisa Dmello, M.B,B.S., M.D. [2]

Overview

Choriocarcinoma must be differentiated from non neoplastic diseases, neoplastic diseases, and other causes of bleeding during pregnancy.

Differentiating choriocarcinoma from other diseases

Choriocarcinoma must be differentiated from other non-neoplastic diseases such as:

• Hydatidiform mole

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

Differential Diagnosis	Clinical Features					Karyotype	Immunostaining							Management
	Presenting Complaints	Potential for Neoplastic Conversion	Beta Human Chorionic Gonadotropin (Beta-hCG) Baseline Levels	History of Pregnancy	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
Partial Hydatidiform Mole
Invasive Molar Pregnancy
Choriocarcinoma
Placental-site Trophoblastic tumor (PSTT) and Epitheloid Trophoblastic Tumor (ETT)
Ovarian Tumors
Spontaneous Abortion
Ectopic Pregnancy
Normal Term Pregnancy

Clinical Features	Complete Hydatidiform Mole	Partial Hydatidiform Mole	Invasive Molar Pregnancy	Choriocarcinoma	Placental-site trophoblastic tumor (PSTT) and Epithelioid trophoblastic tumor (ETT)
Presenting Complaints	Vaginal bleeding Inappropriately large for date uterine size Hyperemesis	Vaginal bleeding	Vaginal bleeding Elevated beta-hCG	Vaginal bleeding	Vaginal bleeding
Neoplastic Conversion	High rate of progression (15-20%)	< 5 % progression rate	Neoplastic	Neoplastic	Neoplastic
Beta Human Chorionic Gonadotropin (Beta-hCG) baseline levels	Extremely high levels ( > 100000 mIU/ml in half of the patients	Highly elevated ( > 100000 mIU/ml in one in ten patients)	High	High	Moderatley elevated (< 1000 mIU/ml in majority of patients)
History of Pregnancies	Not related	Not related	Consequence of molar pregnancy	Approximately half of the cases occur as a consequence of molar pregnancy Quarter of the cases follow abortion or tubal pregnancy Rest follow term or pre-term pregnancy	About 60% follow term pregnancy 40 % follow molar pregnancy or abortion
Metastatic Route	Benign	Benign	Hematogenous	Hematogenous	Lymphatic
Management	Dilation and curettage (suction)	Dilation and curettage (suction)	Chemotherapy (Methotrexate)	Chemotherapy (Methotrexate)	Hysterectomy