Gestational trophoblastic Gestational trophoblastic diseasesdiseases

They arise from the trophoblast of the They arise from the trophoblast of the balstocyst and are classified as:balstocyst and are classified as:

** hydatidifrom mole hydatidifrom mole (molar pregnancy) (80%) (molar pregnancy) (80%)1.1. Complete (classic)Complete (classic)2.2. Incomplete (piratical)Incomplete (piratical) * gestational trophoblatic neoplasia * gestational trophoblatic neoplasia 1.1. Non-metastatic Non-metastatic = invasive mole = chorio –= invasive mole = chorio –

adenoma destruensadenoma destruens (16%) (16%)2.2. MetastaticMetastatic =Choriocarcinoma = chorion =Choriocarcinoma = chorion

epithelioma (4%)epithelioma (4%) Low – riskLow – risk High – risk High – risk

ChoriocarcinomaChoriocarcinoma

PathologyPathology:: IncidenceIncidence: 1: 250-5000 pregnancies in Asia and : 1: 250-5000 pregnancies in Asia and

1:4000 in the west.1:4000 in the west. Origin:Origin: ** Choriocarcinoma is a malignant tumour of the Choriocarcinoma is a malignant tumour of the

trophoblast. trophoblast. 1- About 50% of cases follow molar pregnancy.1- About 50% of cases follow molar pregnancy.2- 25% follow abortion2- 25% follow abortion3- 23% follow normal pregnancy 3- 23% follow normal pregnancy 4- 2% follow ectopic pregnancy.4- 2% follow ectopic pregnancy. ** In rare cases, the tumour arises as a teratoma in In rare cases, the tumour arises as a teratoma in

the ovary or testicle.the ovary or testicle.

Macroscopic appearnce:Macroscopic appearnce:The tumor arises in the endometrium as The tumor arises in the endometrium as 1.1. a soft friable dark red hemorrhagic mass a soft friable dark red hemorrhagic mass

projecting into the uterine cavity and projecting into the uterine cavity and may from a polyp. may from a polyp.

2.2. Malignant tissue may be buried within the Malignant tissue may be buried within the myometrium , inaccessible to the curette, myometrium , inaccessible to the curette, or hidden in a distant metastasis.or hidden in a distant metastasis.

3.3. However, any of these tumor patterns However, any of these tumor patterns secretes (hCG) which causes cystic secretes (hCG) which causes cystic changes of the ovaries in about 30% of changes of the ovaries in about 30% of cases..cases..

Microscopic appearance:Microscopic appearance:

The tumour consists of cyto-and The tumour consists of cyto-and synecytiotrophoblasts showing synecytiotrophoblasts showing malignant characters, invading the malignant characters, invading the myometrium and blood vessels. myometrium and blood vessels.

Chorionic villi are absentChorionic villi are absent this differentiates Choriocarcinoma this differentiates Choriocarcinoma from invasive mole.from invasive mole.

Mode of spread:Mode of spread:

1.1. direct spread: to the parametrium, direct spread: to the parametrium, tubes and ovaries.tubes and ovaries.

2.2. Blood spread: occurs early to Blood spread: occurs early to distant organs. The commonest distant organs. The commonest sites are lunges (80%), vegina sites are lunges (80%), vegina (30%), brain (10%) and liver (10%)(30%), brain (10%) and liver (10%)

FIGO classificationFIGO classification::

Stage I confined to uterine corpus.Stage I confined to uterine corpus. Stage II metastases to pelvis and Stage II metastases to pelvis and

vagina vagina Stage III metastases to lungStage III metastases to lung Stage IV metastases to other Stage IV metastases to other

organs .organs .

Prognostic Prognostic factorfactor

S 0S 0S1S1S2S2S4S4

11Age (years)Age (years)≥≥3939<39<39

22Associated Associated pregnancypregnancy

V.MV.MaboaboFull termFull term

33Interval monthInterval month444-64-67-127-12>12>12

44HCG iu/lHCG iu/l100010001000-1000-

100001000010000-10000-100000100000

>100000>100000

55Abo groupAbo groupO-AO-AB-ABB-AB

66Tuomer dTuomer d3-53-5>5>5

77 site of metastissite of metastisSpleen -Spleen -kidneykidney

Liver-GITLiver-GITBrainBrain

88n.Of metastisn.Of metastis1-41-44-84-8>8>8

99chemotherabychemotherabysinglesinglemultiplemultiple

Bagshwe scoreBagshwe score Total score Total score

≤≤4 low risk4 low risk

5-7 moderate risk5-7 moderate risk

>8 high risk>8 high risk

DiagnosisDiagnosis:: A- symptoms:A- symptoms:1- 1- Persistent or irregular vaginal bleeding: it Persistent or irregular vaginal bleeding: it

is the commonest symptom occurring is the commonest symptom occurring after labor, abortion or evacuation of a after labor, abortion or evacuation of a vesicular mole. Bleeding can occur within vesicular mole. Bleeding can occur within days or months but rarely after 2 years.days or months but rarely after 2 years.

2- Vaginal discharge: which is blood stained 2- Vaginal discharge: which is blood stained and offensive due to ulceration and and offensive due to ulceration and infection of the growth .infection of the growth .

3- amenorrhea: may be present due to 3- amenorrhea: may be present due to continuous hCG production.continuous hCG production.

4- Acute abdominal pain: due to 4- Acute abdominal pain: due to intraperitoneal haemorrhage as a intraperitoneal haemorrhage as a result of perforation of the uterus by result of perforation of the uterus by the growth.the growth.

5- Abdominal or vaginal swelling: may 5- Abdominal or vaginal swelling: may develop.develop.

6- Symptoms of metastases: as 6- Symptoms of metastases: as dysponea, haemoptesis, jaundice dysponea, haemoptesis, jaundice and neurological symptoms as and neurological symptoms as headache may be the first headache may be the first manifestation of the tumor. manifestation of the tumor.

B- signs:B- signs:

(1) cachexia and severe anaemia.(1) cachexia and severe anaemia.

(2) fever may be present due to (2) fever may be present due to infection and necrosis infection and necrosis

(3) the uterus may be normal size or (3) the uterus may be normal size or enlarged and soft.enlarged and soft.

(4) the ovaries: may be enlarged and (4) the ovaries: may be enlarged and eystic.eystic.

(5) metaststic nodules: in the vulva or (5) metaststic nodules: in the vulva or vagina vagina

C- investigationsC- investigations::

(1) uterine curettage: should be done in (1) uterine curettage: should be done in every case of persistent or irregular every case of persistent or irregular uterine bleeding after labour, abortion or uterine bleeding after labour, abortion or molar pregnancy. However, intramural molar pregnancy. However, intramural tumour cannot be detected by curettage.tumour cannot be detected by curettage.

(2) (2) serum β- subunite of hCG: persistent or serum β- subunite of hCG: persistent or rising titres in absence of pregnancy are rising titres in absence of pregnancy are indicative of trophoblastic neoplasiaindicative of trophoblastic neoplasia..

(3) biopsy: from metastatic valvar or vaginal (3) biopsy: from metastatic valvar or vaginal lesions.lesions.

(4) (4) imagingimaging::a- plain X-ray chest: may show secondaries in the a- plain X-ray chest: may show secondaries in the

form of " cannon balls" or "snowstorm" form of " cannon balls" or "snowstorm" appearance.appearance.

b- ultrasonography: to detect tumour, cystic ovaries b- ultrasonography: to detect tumour, cystic ovaries and exclude remnants of conception.and exclude remnants of conception.

c- CT scan: for lungs, liver, brain and bone.c- CT scan: for lungs, liver, brain and bone. (5) lumbar puncture(5) lumbar puncture: plasma hCG/ CSF hCG ratio : plasma hCG/ CSF hCG ratio

less than 60 strongly CNS involvement my less than 60 strongly CNS involvement my metastases metastases

(6) blood studies(6) blood studies::a- complete blood picture including platelet count a- complete blood picture including platelet count b- Renal, liver and thyroid function tests b- Renal, liver and thyroid function tests c- Blood group.c- Blood group.

TreatmentTreatment : :

The treatment of choice The treatment of choice

chemotheraphy chemotheraphy

HysterectomyHysterectomy may be indicated in the may be indicated in the following conditions: following conditions:

severe uterine bleedingsevere uterine bleeding perforation of the uterus with perforation of the uterus with

intraperitoneal haemorrhage. intraperitoneal haemorrhage. Massive haemorrhage from the bowel Massive haemorrhage from the bowel Torsion of a theca lutein cyst.Torsion of a theca lutein cyst. Durg resistance or toxicity.Durg resistance or toxicity. Persistant localised metastases in the Persistant localised metastases in the

vagina, lung or brain after chemotherapy vagina, lung or brain after chemotherapy

ChemotherapyChemotherapy::

(I) (I) low- risk group score ≤ 4low- risk group score ≤ 4::

Single cytotoxic drug either Single cytotoxic drug either methotrexate or actinomycin D methotrexate or actinomycin D

(II) (II) High-risk group score >8 High-risk group score >8 ::

Multiple cytotoxic drugs Multiple cytotoxic drugs

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