A 28-year-old woman, gravida 2 para 2, comes to the office with worsening shortness of breath over the past week. She had a recent episode of hemoptysis. The patient has also had ongoing vaginal bleeding after an uncomplicated vaginal delivery of her son 9 weeks ago. She has no bleeding elsewhere, and she has not resumed sexual intercourse. On physical examination, the patient's uterus is enlarged and the adnexa are normal. Laboratory studies show markedly increased β-hCG levels. Chest radiograph shows multiple bilateral lung nodules. Which of the following would most likely be found on endometrial curettage in this patient?

Question

A 28-year-old woman, gravida 2 para 2, comes to the office with worsening shortness of breath over the past week.  She had a recent episode of hemoptysis.  The patient has also had ongoing vaginal bleeding after an uncomplicated vaginal delivery of her son 9 weeks ago.  She has no bleeding elsewhere, and she has not resumed sexual intercourse.  On physical examination, the patient's uterus is enlarged and the adnexa are normal.  Laboratory studies show markedly increased β-hCG levels.  Chest radiograph shows multiple bilateral lung nodules.  Which of the following would most likely be found on endometrial curettage in this patient?

Quizplus · Accepted Answer

11ec160b_3b1d_2656_9249_43d30eb16adf_MD0001_00 Gestational choriocarcinoma is a malignant tumor that arises from the trophoblast. It is most commonly preceded by a normal pregnancy but can occur following any pregnancy (molar, ectopic, aborted). The tumor causes abnormal vaginal bleeding, uterine enlargement, and significantly increased β-hCG levels. Choriocarcinoma is aggressive and rapidly invades the uterine wall with hematogenous spread thereafter. The lungs are the most common site of distal metastasis, and presenting symptoms can include shortness of breath and hemoptysis. On macroscopic examination, gestational choriocarcinoma is seen as a bulky intrauterine mass that is usually soft and yellow-white, with extensive areas of necrosis and hemorrhage. Histologically, it is composed of abnormal proliferation of mononuclear cytotrophoblasts (red arrows) and multinuclear syncytiotrophoblasts (green arrows). No villi are present. (Choice A) Myomas (eg, uterine fibroids) are common benign tumors of the uterine myometrium characterized by bundles of smooth muscle cells. Common symptoms include menstrual irregularities and pelvic pressure/pain. (Choice B) Cells of the evacuated tissue of a complete mole have a 46,XX (or rarely 46,XY) karyotype containing only paternal DNA. Histologically, no fetal tissue is present, and only edematous (eg, hydropic) villi are seen. (Choice C) Partial hydatidiform moles typically have a triploid karyotype (69,XXX or 69,XXY) containing maternal and paternal DNA, with an extra chromosome set of paternal origin. Evacuated uterine contents contain fetal tissue and other parts (eg, cord, amniotic membrane), some edematous villi with focal trophoblastic proliferation, and normal-appearing villi. (Choice D) The normal endometrium consists of simple columnar epithelial cells. Endometrial hyperplasia characterized by crowded endometrial glands lined by atypical cells (nuclear atypia) is an important risk factor for endometrial cancer. Endometrial hyperplasia is associated with prolonged exposure to high estrogen levels (eg, obesity, nulliparity, tamoxifen use) and can present as abnormal vaginal bleeding in a postmenopausal woman. Educational objective: Choriocarcinoma is a malignant form of gestational trophoblastic disease composed of anaplastic cytotrophoblasts and syncytiotrophoblasts without villi. It often presents as dyspnea/hemoptysis due to pulmonary metastasis from hematogenous spread. __________ References: Gestational trophoblastic disorders: an update in 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26556906) Practice bulletin no. 53--diagnosis and treatment of gestational trophoblastic disease. (http://www.ncbi.nlm.nih.gov/pubmed/15572508)

A 28-Year-Old Woman, Gravida 2 Para 2, Comes to the Office