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Gestational Trophoblastic

Neoplasia
WALEED AL-JASSAR
FRCSC – GYN ONC
Classification
• Hydatidiform Mole ( Molar
Pregnancy )
• Invasive Mole
• Gestational Choriocarcinoma
• Placental Site TrophoblasticTumor
( PSTT )


History
• Hippocrates
– Dropsy of the uterus
• Unhealthy water
Epidemiology of Hydatidiform
Mole
• The highest incidence is in Asia
• Rates in Asia 1 : 500
• Rates in the states 1 : 1500
Risk Factors for Molar
Pregnancy
• Extremes of Reproductive age
– Less than 15 years old and above age
40
• History of previous Molar pregnancy
– 10 times more risk
• Dietary factors
– Low protein diet

Factors NOT associated with
Molar Pregnancy

• ABO Blood Group

• Cigarette smoking

• Contraceptive history
Hydatidiform Mole

• Complete Mole

• Partial Mole
Complete Mole
• 46 XY ( Paternal Genome )
• Absent fetus
• Absent Amnion
• Diffuse Villous edema
• Diffuse trophoblastic proliferation
• Uterine size is 50% large for dates
• 25-30% Theca Leutein Cysts
• 10-25% Medical Complications
– PIH , Hyperthyroidism , Anemia and
Hyperemesis
• 6.8 – 20% Post Molar GTN
Partial Mole
• 69 XXX or XXY ( Paternal and Maternal
Genome )
• On Pathology Fetal Parts are present
• Focal Villous edema
• Focal Trophoblastic proliferation
• Diagnosed as Missed Abortion
• Uterus is small for dates
• Rarely there will be a Theca Lutein Cyst
or medical Complication
• 2.5 – 7.5 % Postmolar GTN
Symptoms
• Vaginal Bleeding
• Hyperemesis
• Pre-eclampsia in the first Trimester
• Hyperthyroidism ( rarely )
• Acute Respiratory Distress
– Trophoblastic pulmonary embolization
• Excessive uterine size
• Theca lutein cyst


diagnosis
• Passage of Vesicular tissue
• Quantitative B hCG
• Pelvic U/S

Management
• Blood Work ( CBC , Electrolytes , LFT ,
RFT , TFT )
• CXR ( Pre Evacuation )
• Suction D & C
• Monitor Quatitative hCG every week
until Normal
• Monthly hCGfor 6 – 12 months
• Contraception
Gestational Trophoblastic
Neoplasia
• Defined by Clinical and Laboratory
Criteria

• GTN is the most curable Gynecologic


Malignancy

• GTN after a complete mole 7.5 % -
20 %
• GTN after a partial Mole 2.5 % - 7.5
%
Risk Factors for Post Molar
GTN
• High Pre-evacuation hCG
• Uterine size larger than expected
dates
• Theca-lutein Cysts ( More than 6 cm )
• Increasing Maternal age
Diagnosis of Post Molar GTN
( FIGO )
1.Four Values or more of plateaued
hCG ( +/- 10% ) over at least 3
weeks
2.A rise of hCG of 10% or greater for 3
values or more over at least 2
weeks
3.The Histological diagnosis of
Choriocarcinoma
4.Persistence of hCG beyond 6 months
after mole evacuation
Evaluation of GTN
• Complete physical and Pelvic
Examination
• Baseline Hematologic , renal and
Hepatic functions
• Base line quantitative hCG
• CXR or CT Chest
• Brain MRI or CT
• CT Abdomen and Pelvis
Clinical Classification
system
• Non- Metastatic GTN
• Metastatic GTN
– Good Prognosis
• Short Duration ( Less than 4 Months )
• Pretherapy hCG less than 40,000
mIU/ml
• No Brain or liver Mets
• No antecedent term pregnancy
• No prior chemotherapy
– Poor prognosis
• Any one risk factor :
– Long Duration ( More than 4 Months )
– Pretherapy hCG more than 40,000
mIU/ml
– Brain or liver mets
– Antecedent term pregnancy
– Prior chemotherapy
FIGO 0 1 2 4
SCORING
AGE < 40 ≥ 40
Antecedent Mole Abortion Term
pregnancy
Interval from < 4 4-<7 7 - < 13 ≥ 13
pregnancy(months
)

Pre-treatment < 1000 1000 – 10,000 – > 100,000


hCG mIU/ml 10,000 100,000
Largest 3-5 >5
tumorsize
(including
Site of Mets
uterus) (cm) Lung Spleen , GI Brain , Liver
# of Mets Kidney
1-4 5-8 >8
Prev. failed Single drug 2 or more
chemo drugs
• Low risk
– Score of 6 or less

• High risk
– Score of 7 or greater
Treatment
• Non Metastatic and low risk GTN
– Single Agent chemotherapy
• Methotrexate
• Actinomycin D
• Metastatic or High risk
– EMA-CO
– MAC