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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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Presentation Transcript
slide3
GTN is divided into three histologic categories :

hydatidiform mole ,

 invasive mole (chorioadenoma destruens)

 choriocarinoma .

Partial hydatidiform moles

 Placental site trophoblastic tumors (PSTT)

slide5
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.
slide6
The initial histologic features of any lesion identified as GTN are less important than the clinical data and hCG level.
slide7
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
slide8
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
clinical finding
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)

partial mole
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

slide11
complete moles : 10% to 30% incidence of malignant
  • partial mole : fewer than 5% of the patients
invasive mole
Invasive mole
  • with invasion into the myometrium without intervening endometrial stroma
  • uterine perforation and hemorrhage
choriocarcinoma
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
slide14
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
slide15
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
risk factors for hydatidiform mole
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

management gtd
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
evacuation
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

follow up
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
slide22
Hysterectomy only if sterillzation desired
  • After completion of 6 months of hCG normal level pregnancy if desired
  • False – positive hCG Test Results
slide23
The heterogeneity of hCG and the variability between different hCG assays may in

False – positive test results .

  • Presence of heterophilic antibodies
slide24
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
higher frequency of post molar malignant gtn
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

slide26
Persistent GTD
  • irregular vaginal bleeding
  • Theca lute in cysts
  • Uterine sub involution
  • Persistently elevated serum hCG level
slide27
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

slide28
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

slide29
Malignant GTN distant metastases
  • Gastrointestinal
  • urologic hemorrhage
  • Hemoptysis
  • Neurological symptoms due to cerebral hemorrhage
  • Clinical hyperthyroidism
slide30
Four principal pulmunary radiologic patterns snowstorm pattern (Alveolar pattern )
  • Discrete rounded densities
  • Plural effusion
  • Embolic pattern
management
Management :
  • Physical and pelvic examinations
  • Baseline hCG level
  • Chest radiograph
  • Pelvic ultrasonography
slide34

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.

slide35
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

slide38
Whole-brain and whole-liver irradiation

in conjunction with chemotherapy

protocol for treatment of gtd
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

slide40
liver
  • 2,000 rd therapy
  • prevent hepatic hemorrhage
  • selective occlusion of the hepatic artery
response during therapy
Response during therapy
  • Weekly intervals during therapy
  • After remission
  • hCG levels in the normal level
  • Every 1 month
  • First year of surveillance .
slide42
Follow up
  • Molar pregnancy 6 month

GTN 1year

  • Met static GTN

Except lung 2 year

slide44
Late complication
  • Slight increase in the incidence of spontaneous abortion
  • Repeat molar 1%
  • ovarian failure as a result of prolonged multi drug chemotherapy
slide45
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