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In the name of GOD

In the name of GOD. Gestational Trophoblastic Neoplasms (GTN) Dr. Yousefi . Z. GTN is divided into three histologic categories :  hydatidiform mole ,  invasive mole (chorioadenoma destruens)  choriocarinoma .  Partial hydatidiform moles

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In the name of GOD

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  1. In the name of GOD

  2. Gestational Trophoblastic Neoplasms (GTN)Dr. Yousefi . Z

  3. GTN is divided into three histologic categories : hydatidiform mole ,  invasive mole (chorioadenoma destruens)  choriocarinoma . Partial hydatidiform moles  Placental site trophoblastic tumors (PSTT)

  4. All derived from the human placental trophoblast and the paternal genome

  5. Human chorionic gonadotropin (hCG) is secreted by these neoplasms and serves as a sensitive tumor marker that correlates well with the clinical course for all GTNs except PSTT.

  6. The initial histologic features of any lesion identified as GTN are less important than the clinical data and hCG level.

  7. Complete Hydatidiform Mole Macroscopically : Edema and swelling of virtually • Villi without identifiable fetal parts or amniotic membranes Microscopically: The chorionic villi are hydropic with marked interstitial edema . fetal vessels are absent • Proliferation of cytotrophoblast and syncytiotrophoblast

  8. Complete moles: completely paternal chromosomal composition . most are 46,XX • An empty egg by a haploid sperm followed by reduplication • Empty ovum + 2323 endoreduplication 46xx Homozy yous

  9. Clinical finding : 1-One third to one half of uterine enlargement 2-Vaginal bleeding 3-Theca lute in cysts 20% 5-pregnancy – induced hypertension 4-pulmonary decompensation 6-hyperthyroidism 7-snowstorm (ultrasonography)

  10. Partial mole • partial moles often are associated with identifiable fetal parts or amniotic membranes • one haploid maternal and two haploid paternal sets of chromosomes diagnosis : until after evacuation of the pregnancy

  11. complete moles : 10% to 30% incidence of malignant • partial mole : fewer than 5% of the patients

  12. Invasive mole • with invasion into the myometrium without intervening endometrial stroma • uterine perforation and hemorrhage

  13. choriocarcinoma • choriocarcinoma rapidly invades the myometrium and uterine vessels , and systemic metastasis • no chorionic villi are identified • hematogenous embolization • (affinity of trophoblast cell for blood vessel) • Most cases have no tissue for pathologic study, hCG level has raise

  14. 50% of cases are preceded by hydatidform mole • Gestational choriocarcinoma has been observed several years after last known pregnancy . • Spontaneous regression of the primary uterine site

  15. Placental site trophoblastic tumor • Locally invasive neoplasms derived from intermediate cells of the placenta • HPL from cytotrophoblast cell • small amounts of hCG • rare systemic metastasis • significantly more resistant to standard chemotherapy than other forms of GTN • hysterectomy is the initial therapy of choice

  16. Risk factors for hydatidiform mole • 1-prevous molar pregnancies • 2-maternal age advanced maternal age , younger women or adolescents • Animal fat • Deficiency of folat –caroten and protein Low socioeconomic state

  17. Management GTD • complete physical and pelvic examinations • complete blood count determination • blood chemistry levels , including renal-liver • baseline serum hCG level • chest radiograph • pelvic ultrasonography

  18. Evacuation: • suction dilation and curettage • hysterectomy • followed closely after hysterectomy • incidence of malignant sequelae: after 20% after suction D&C to less than 5% after hysterectomy

  19. Follow-up • B-hCG levels every 1 to 2 weeks Until hCG level is undetectable • After the first normal level for 2 to 4 weeks • Every then 1 to 2 months for 6 months • Oral contraceptives

  20. Algorithm for diagnosis and treatment of a patient with hydatidiform mole

  21. Hysterectomy only if sterillzation desired • After completion of 6 months of hCG normal level pregnancy if desired • False – positive hCG Test Results

  22. The heterogeneity of hCG and the variability between different hCG assays may in False – positive test results . • Presence of heterophilic antibodies

  23. After evacuation of hydatidiform mole • (9% to 36%) of patients requiring therapy Pattern of hCG regression • If hCG level plateau or raise for 3 or more consecutive weekly levels • appearance of metastatsis

  24. higher frequency of post molar malignant GTN 1-Trophoblastic proliferation 2-Uterine enlargement 3- Theca lute in cysts 4- Respiratory distress syndrome after molar evacuation 5- post evacuation uterine hemorrhage

  25. Persistent GTD • irregular vaginal bleeding • Theca lute in cysts • Uterine sub involution • Persistently elevated serum hCG level

  26. Clinical classification of malignant gestational trophoblastic neoplasia Nonmetastatic GTN A. Not defined in terms of good versus poor prognosis Metastatic GTN Good prognosis (i.e., absence of high-risk factors ) Pretreatment serum B-hCG level < 40,000 mIU/ml Less than 4-month duration of symptoms attributable to disease No evidence of brain or liver metastasis No significant prior chemotherapy No antecedent term pregnancy

  27. Poor pregnosis (i.e., any single high-risk factor ) pretreatment serum B-hCG level >40,000 Iu/ml more than 4-month duration of symptoms attributable to disease brain or liver metastasis or both failed prior chemotherapy antecedent term pregnancy

  28. Malignant GTN distant metastases • Gastrointestinal • urologic hemorrhage • Hemoptysis • Neurological symptoms due to cerebral hemorrhage • Clinical hyperthyroidism

  29. Four principal pulmunary radiologic patterns snowstorm pattern (Alveolar pattern ) • Discrete rounded densities • Plural effusion • Embolic pattern

  30. Management : • Physical and pelvic examinations • Baseline hCG level • Chest radiograph • Pelvic ultrasonography

  31. CT of brain , chest , and abdomen –pelvis • Exclude an uterine pregnancy

  32. Who Orgnaization prognostic scoring system for gestational trophoblastic neoplasia The total score is obtained by adding the individual scores for each prognostic factor . Total score :<4 , low risk ; 5-7 , intermediate risk ;>8 , high risk . Interval :between antecedent pregnancy and start of chemotherapy.

  33. WHO Scoring system Score : <4,low risk 5-7mid risk >8 , high risk • Chemotherapy alone is successful in curing 85% of patients with non metastatic and good-prognosis

  34. Hysterectomy rarely is indicated as Initial therapy for women with malignant GTN

  35. Persistence of a lung nodule after hCG normalization Should not necessarily surgery

  36. Whole-brain and whole-liver irradiation in conjunction with chemotherapy

  37. protocol for treatment of GTD Stage I single agent chemotherapy Resistant combination chemotherapy or hysterectomy with adjuvant chemotherapy Stage II,III low risk single agent chemotherapy high risk combination chemotherapy Resistant second line chemotherapy Stage IV combination chemotherapy radiotherapy Resistant second line chemotherapy

  38. liver • 2,000 rd therapy • prevent hepatic hemorrhage • selective occlusion of the hepatic artery

  39. Response during therapy • Weekly intervals during therapy • After remission • hCG levels in the normal level • Every 1 month • First year of surveillance .

  40. Follow up • Molar pregnancy 6 month GTN 1year • Met static GTN Except lung 2 year

  41. Recurrence rates after therapy for GTN have been 3% to 2.6%

  42. Late complication • Slight increase in the incidence of spontaneous abortion • Repeat molar 1% • ovarian failure as a result of prolonged multi drug chemotherapy

  43. Low incidence of congenital malformations • The incidence of placenta accreta • particular , appears to be increased After first pregnancy • We should be a chest radiography . • Serum BhCG after 6-8 weeks of post partum • Placenta should be undergo pathology

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