GESTATIONAL GESTATIONAL TROPHOBLASTIC TUMORS TROPHOBLASTIC TUMORS

(GTT)(GTT)

** It is a diverse group of tumors It is a diverse group of tumors

80 80 –– 90% Benign 90% Benign

** That includes Benign That includes Benign Hydatidiform mole to Hydatidiform mole to ChoriocarcinomaChoriocarcinoma

Types:Types:

•• Hydatidiform mole 80 – 90%Hydatidiform mole 80 – 90% •• Invasive moleInvasive mole •• Persistent trophoblastic tumorPersistent trophoblastic tumor •• ChoriocarcinomaChoriocarcinoma •• Placental site tumorsPlacental site tumors

Unique about GTTUnique about GTT

•• Cure almost Cure almost 100%100% •• Sensitive marker Sensitive marker ––

Secreted by all typesSecreted by all typesAllow:Allow:- Accurate assessment- Accurate assessment- Follow-up- Follow-up

Epidemiology:Epidemiology:

-- variesvaries-- more in far eastmore in far east

•• diet diet- - more in extreme of more in extreme of reproductive agesreproductive ages-- more in blood group O and Amore in blood group O and A- - risk of having another mole is risk of having another mole is

1 1 –– 3% 3%

Hydatidiform Mole:Hydatidiform Mole:

Types: DifferTypes: Differ

•• HistologicallyHistologically • • CytogeneticallyCytogenetically

I - complete mole I - complete mole2 - partial mole2 - partial mole

Genetic composition:Genetic composition:

>> CompleteComplete •• Chromosomes = 46 xxChromosomes = 46 xx •• Both xBoth xXX are paternally derived are paternally derived

•• Fertilization of abnormal Fertilization of abnormal egg - no egg - no nucleus.nucleus.

>> Haploid sperm 23x → Empty egg → Haploid sperm 23x → Empty egg → Sperm duplicate 46xx diploid or Sperm duplicate 46xx diploid or fertilization by two sperms 15 -25% fertilization by two sperms 15 -25% progress to Gestational progress to Gestational Trophoblastic Trophoblastic TumorTumor

Partial molePartial mole

•• Chromosomes is triploid 69 xxy 80%Chromosomes is triploid 69 xxy 80%

•• Minority triploid 69 xxx 20%Minority triploid 69 xxx 20%

> > Often present with fetal tissueOften present with fetal tissue

-- Fetus may be abnormal.Fetus may be abnormal.

-- Rarely reach to term.Rarely reach to term.

>> 5% Progress to Gestational 5% Progress to Gestational Trophoblastic TumorTrophoblastic Tumor

Hydatidiform Mole:Hydatidiform Mole:-- Confined to the uterine cavityConfined to the uterine cavity-- Occasionally trophoblasticOccasionally trophoblastic––Emboli to Emboli to lunglung

Partial MolePartial Mole• • Some Hydropic villi.Some Hydropic villi.

• • Other villi normal.Other villi normal.

•• Less hyperplasia of Less hyperplasia of trophoblasttrophoblast

•• Some fetal vessels or Some fetal vessels or fetal Rbcfetal Rbc

Complete MoleComplete Mole•• All villi hydropic All villi hydropic

oedematousoedematous

•• All hyperplasia of All hyperplasia of trophoblasttrophoblast

•• Absence of fetal blood Absence of fetal blood vesselsvessels

Hydatidiform Mole:Hydatidiform Mole:Symptoms:Symptoms: Majority > 90% have irregular vaginal Majority > 90% have irregular vaginal ٭٭bleeding 1bleeding 1stst, 2, 2ndnd trimester trimester

•• Bleeding is painlessBleeding is painless •• May expel vesicles May expel vesicles •• Excessive nausea / vomiting Excessive nausea / vomiting Hyperemesis Gravidarum 10-25% Hyperemesis Gravidarum 10-25% •• Pre-eclampsia occurs Pre-eclampsia occurs early < 24 weeks gestation -10-12% early < 24 weeks gestation -10-12%

•• Hyperthyroidism 2 Hyperthyroidism 2 –– 10% 10% if so - test before surgery if so - test before surgery

Signs:Signs:>> Pale Pale>> Tachycardia Tachycardia –– sign of sign of Thyrotoxicosis Thyrotoxicosis> > Tachypnea Tachypnea –– sign of Pulmonary sign of Pulmonary Embolism Embolism>> Uterus: Uterus:

•• Enlarged 50% no fetal heart Enlarged 50% no fetal heart no fetal parts .no fetal parts . > > Theca-luteal cyst(10 Theca-luteal cyst(10 –– 15%) 15%)

Diagnosis:Diagnosis:

•• High index of suspicious from High index of suspicious from clinical dataclinical data •• Ultrasound shows snow storm Ultrasound shows snow storm appearance appearance

••

Laboratory investigations:Laboratory investigations:

•• Full blood count?Full blood count? •• Blood group Blood group –– Rh factor? Rh factor? •• Coagulation Profile ?Coagulation Profile ? •• Liver function test Base Liver function test Base Renal function test line ?Renal function test line ? •• Chest FilmChest Film

Treatment:Treatment:

** Surgery Surgery suction evacuation is the suction evacuation is the standard therapystandard therapy

• • Blood cross match, in theatreBlood cross match, in theatre •• oxytocin infusionoxytocin infusion

** Dilation Dilation –– suction evacuation suction evacuationComplications:Complications:1) __bleeding____________1) __bleeding____________2) ____perforation__________2) ____perforation__________

** Hysterectomy:Hysterectomy:When late reproductive life When late reproductive life

___________ ___________ ___________ ___________

Complication:Complication:

** Uterine perforationUterine perforation

** Uterine HaemorrhageUterine Haemorrhage

Monitoring:Monitoring: ** Serum Serum –– ββ –– Human chorionic Human chorionic GonadotrophinGonadotrophin

What happen to What happen to ββhCG?hCG?- - - it drops post evacuation - it drops post evacuation - 8 weeks post evacuation should - 8 weeks post evacuation should

disapear disapear Follow-up:Follow-up:- Weekly - Weekly ββhCG, until 3 consecutive hCG, until 3 consecutive normal value normal value- Monthly - Monthly ββhCG, until 6 monthshCG, until 6 months

** ContraceptionContraception

Chemotherapy:Chemotherapy:

** Prophylactic not justifiedProphylactic not justified> 79% spontaneous remission> 79% spontaneous remission

When does Chemotherapy is When does Chemotherapy is indicated in Hydatidiform Mole ?indicated in Hydatidiform Mole ?1- When B hCG plataue,or rise1- When B hCG plataue,or rise2- Higher risk of Choriocarcinoma 2- Higher risk of Choriocarcinoma 3-Unreliable for follow-up3-Unreliable for follow-up

Invasive Mole:Invasive Mole:

•• VilliVilli penetrate penetrate MyometriumMyometriumββhCG hCG persistently high after persistently high after

evacuation of evacuation of Hydatidiform MoleHydatidiform Mole

•• Locally invasiveLocally invasive diagnosis at time of Hysterectomy diagnosis at time of Hysterectomy

•• Rarely Rarely MetastasisMetastasis to: to:- Vagina- Vagina- Lung- Lung- Brain- Brain

Placental site Trophoblast TumorPlacental site Trophoblast Tumor

•• Extremely rareExtremely rare •• Occur after non-Molar Occur after non-Molar PregnancyPregnancy •• When Metastasis occur When Metastasis occur –– Fatal Fatal •• ββhCG not extremely highhCG not extremely high • Insensitive to chemotherapy• Insensitive to chemotherapy Surgical resection is the mode of Surgical resection is the mode of treatment.treatment.

Choriocarcinoma:Choriocarcinoma:** MetastasisMetastasis** Non-MetastasisNon-MetastasisHistopathology:Histopathology:- - Avascular Avascular –– - - Invade uterine wallInvade uterine wall- - MetastasisMetastasis- - Sheet of Cytotrophoblast and Sheet of Cytotrophoblast and synchiotrophoblastsynchiotrophoblast

No identifiable villiNo identifiable villi

Choriocarcinoma:Choriocarcinoma:** •• choriocarcinoma followschoriocarcinoma follows Hydatidiform Mole , and carries a better Hydatidiform Mole , and carries a better prognosis THAN prognosis THAN •• Choriocarcinoma that follow:Choriocarcinoma that follow:

- Ectopic- Ectopic- Abortion- Abortion- Normal pregnancy - Normal pregnancy

WHY ? WHY ?

**

Symptoms of metastatic diseaseSymptoms of metastatic diseaseVaginal bleedingVaginal bleeding

Rectal bleedingRectal bleedingHeadacheHeadache

SignsSignsAcute abdomen, rupture liver, cystAcute abdomen, rupture liver, cyst

Neurologic signsNeurologic signsInvestigationInvestigation

CT Scan / MRI of abdomenCT Scan / MRI of abdomenLumber puncture for B hCGLumber puncture for B hCG

Prognostic scoringPrognostic scoring

AgeAgeAntecedent pregnancyAntecedent pregnancy

Interval between end of antecedent Interval between end of antecedent pregnancy and the start of chemotherapypregnancy and the start of chemotherapy

B hCG levelB hCG levelPrior chemotherapyPrior chemotherapy

Site of metastesisSite of metastesisSize of metastasisSize of metastasis

Number of metastasisNumber of metastasis

ChoriocarcinomaChoriocarcinoma

Subdivided into:Subdivided into:Good Good

Prognosis Prognosis Poor Poor

Depending on:Depending on:SiteSite of Metastasis of MetastasisSizeSize

Clinical variablesClinical variables

Good Progostic Factors:Good Progostic Factors:

1) 1) Initial BhCG < 40,000 miu/LInitial BhCG < 40,000 miu/L2) 2) Therapy started within 4 Therapy started within 4 months of antecedent months of antecedent pregnancypregnancy3) 3) Metastasis only to lung or Metastasis only to lung or pelvis.pelvis.

Poor Progostic Factors:Poor Progostic Factors:

** BhCG > 40,000BhCG > 40,000 ** Therapy started > 4 monthsTherapy started > 4 months ** Metastasis to brain or liver Metastasis to brain or liver

failed response to single agent failed response to single agent of chemotherapy.of chemotherapy.

** Choriocarcinoma following Choriocarcinoma following full term pregnancyfull term pregnancy

ChemotherapyChemotherapyMethotrxateMethotrxate

Actinomycin DActinomycin DCyclophosphamideCyclophosphamide

Follow- upFollow- upGood prognosisGood prognosis

Follow up monthly for 1 yearFollow up monthly for 1 yearBad prognosisBad prognosis

Follow-up monthly for 2 years thereafter every 3 Follow-up monthly for 2 years thereafter every 3 months for 5 yearsmonths for 5 years..