gestational trophoblastic disease GTD

Types of GTDTypes of GTD
BenignBenign
•• HydatidiformHydatidiform mole/molar pregnancymole/molar pregnancy
(complete or incomplete)(complete or incomplete)(complete or incomplete)(complete or incomplete)
malignantmalignant
•• Invasive moleInvasive mole
•• ChoriocarcinomaChoriocarcinoma ((chorioepitheliomachorioepithelioma))
•• Placental sitePlacental site trophoblastictrophoblastic tumortumor
1919--SepSep--1212 o wardao warda

The termThe term GestationalGestational TrophoblasticTrophoblastic
TumorsTumors has been applied the latterhas been applied the latter
three conditionsthree conditions
AriseArise from thefrom the trophoblastictrophoblastic elementselements
Types of GTDTypes of GTD
AriseArise from thefrom the trophoblastictrophoblastic elementselements
RetainRetain the invasive tendencies of thethe invasive tendencies of the
normal placenta or metastasisnormal placenta or metastasis
Keep secretion of the human chorionicKeep secretion of the human chorionic
gonadotropingonadotropin ((hCGhCG))

PATHOLOGICPATHOLOGIC
CLASSIFICATIONCLASSIFICATION
CLINICALCLINICAL
CLASSIFICATIONCLASSIFICATION
HydatidiformHydatidiform molemole
*complete*complete
*incomplete*incomplete
Benign gestationalBenign gestational
trophoblastic diseasetrophoblastic disease
Pathologic and clinical classifications
for gestational trophoblastic disease
*incomplete*incomplete
Invasive moleInvasive mole
MalignantMalignant
trophoblastic diseasetrophoblastic disease
NonmetastaticNonmetastatic
Placental sitePlacental site
trophoblastic tumortrophoblastic tumor
MetastaticMetastatic
ChoriocarcinomaChoriocarcinoma High riskHigh risk Low riskLow risk

HydatidiformHydatidiform MoleMole
(=vesicular Mole)(=vesicular Mole)(=vesicular Mole)(=vesicular Mole)
(=molar pregnancy)(=molar pregnancy)

Definition and EtiologyDefinition and Etiology
HydatidiformHydatidiform mole is a pregnancymole is a pregnancy
characterized by vesicular swelling ofcharacterized by vesicular swelling of
placentalplacental villivilli and usually the absence ofand usually the absence of
an intact fetus.an intact fetus.an intact fetus.an intact fetus.
The etiology ofThe etiology of hydatidiformhydatidiform molemole
remains unclear, but it appears to be dueremains unclear, but it appears to be due
to abnormalto abnormal gametogenesisgametogenesis andand
fertilizationfertilization

In aIn a ‘‘complete molecomplete mole’’ the mass ofthe mass of
tissue is completely made up oftissue is completely made up of
abnormal cellsabnormal cells
ThereThere is no fetusis no fetus and nothing canand nothing can
ThereThere is no fetusis no fetus and nothing canand nothing can
be found at the time of the firstbe found at the time of the first
scan.scan.

In aIn a ‘‘partial molepartial mole’’,, the mass maythe mass may
contain both these abnormal cellscontain both these abnormal cells
and often a fetus that has severeand often a fetus that has severe
defects.defects.
defects.defects.
In this case the fetus will beIn this case the fetus will be
consumed ( destroyed) by theconsumed ( destroyed) by the
growing abnormal mass verygrowing abnormal mass very
quickly.quickly. (shrink)(shrink)

IncidenceIncidence
•• 11 out ofout of 15001500--20002000 pregnancies in thepregnancies in the
U.S. and EuropeU.S. and Europe
•• 11 out ofout of 500500--600600 (another report(another report 11%%))•• 11 out ofout of 500500--600600 (another report(another report 11%%))
pregnancies in some Asian countries.pregnancies in some Asian countries.
•• Complete >Complete > incompleteincomplete

Repeat hydatidiform moles occure inRepeat hydatidiform moles occure in
00..55--22..66% of patients, and these% of patients, and these
patiens have a subsequent greater riskpatiens have a subsequent greater risk
IncidenceIncidence
patiens have a subsequent greater riskpatiens have a subsequent greater risk
of developing invasive mole orof developing invasive mole or
choriocarcinomachoriocarcinoma
There is an increased risk of molarThere is an increased risk of molar
pregnancy for women over the agepregnancy for women over the age 4040

ApproximatelyApproximately 1010--1717% of hydatidiform% of hydatidiform
moles will result in invasive molemoles will result in invasive mole
IncidenceIncidence
moles progress to choriocarcinomamoles progress to choriocarcinoma
( most of them are curable)( most of them are curable)
Not definitely benign disease ,Not definitely benign disease ,
has a tight relationship with GTThas a tight relationship with GTT

Clinical risk factors for molar pregnancyClinical risk factors for molar pregnancy
Age (extremes of reproductive years)Age (extremes of reproductive years)
<<1515
>>4040
Reproductive historyReproductive historyReproductive historyReproductive history
prior hydatidiform moleprior hydatidiform mole
prior spontaneous abortionprior spontaneous abortion
DietDiet
Vitamin A deficiencyVitamin A deficiency

CytogeneticsCytogenetics
Complete molar pregnancyComplete molar pregnancy
Chromosomes are paternal , diploidChromosomes are paternal , diploid
4646,XX in,XX in 9090% cases% cases4646,XX in,XX in 9090% cases% cases
4646,XY in a small part,XY in a small part
Partial molar pregnancyPartial molar pregnancy
Chromosomes are paternal and maternal, triploid.Chromosomes are paternal and maternal, triploid.
6969,XXY,XXY 8080%%
6969,XXX or,XXX or 6969,XYY,XYY 1010--2020%%
Wrong life message , so can not develop normally1919--SepSep--1212 o wardao warda

Comparative Pathologic Features ofComparative Pathologic Features of
Complete and Partial Hydatidiform MoleComplete and Partial Hydatidiform Mole
FeatureFeature CompleteComplete MoleMole Partial MolePartial Mole
KaryotypeKaryotype Usually diploidUsually diploid 4646XXXX Usually triploidyUsually triploidy 6969XXX mostXXX most
common.common.
VilliVilli All villi hydropin; noAll villi hydropin; no
normal adjacent villinormal adjacent villi
Normal adjacent villi may beNormal adjacent villi may be
presentpresent
vesselsvessels present they contain nopresent they contain no
fetal blood cellsfetal blood cells
blood cellsblood cells
Fetal tissueFetal tissue None presentNone present Usually presentUsually present
TrophoblastTrophoblast Hyperplasia usuallyHyperplasia usually
present to variablepresent to variable
degreesdegrees
Hyperplasia mild and focalHyperplasia mild and focal

Signs and Symptoms of CompleteSigns and Symptoms of Complete
Hydatidiform MoleHydatidiform Mole
•• Vaginal bleedingVaginal bleeding
•• HyperemesisHyperemesis ( severe vomit)( severe vomit)
•• Size inconsistent with gestationalSize inconsistent with gestational•• Size inconsistent with gestationalSize inconsistent with gestational
age( with no fetal heart beating andage( with no fetal heart beating and
fetal movement)fetal movement)
•• PreeclampsiaPreeclampsia
•• ThecaTheca luteinlutein ovarian cystsovarian cysts

Signs and Symptoms of PartialSigns and Symptoms of Partial
Hydatidiform MoleHydatidiform Mole
•• Vaginal bleedingVaginal bleeding
•• Absence of fetal heart tonesAbsence of fetal heart tones
•• Uterine enlargement andUterine enlargement and•• Uterine enlargement andUterine enlargement and
preeclampsia is reported in onlypreeclampsia is reported in only 33%%
of patients.of patients.
•• ThecaTheca luteinlutein cysts,cysts, hyperemesishyperemesis isis
rarerare..

Diagnosis of hydatidiform moleDiagnosis of hydatidiform mole
Quantitative betaQuantitative beta--HCGHCG
Ultrasound is the criterion standard forUltrasound is the criterion standard for
identifying both complete and partialidentifying both complete and partialidentifying both complete and partialidentifying both complete and partial
molar pregnancies. The classic imagemolar pregnancies. The classic image
is of ais of a ““snowstormsnowstorm”” patternpattern

The most common symptom of a mole isThe most common symptom of a mole is
vaginal bleeding during the first trimestervaginal bleeding during the first trimester
however very often no signs of a problemhowever very often no signs of a problem
appear and the mole can only be diagnosed byappear and the mole can only be diagnosed by
DiagnosisDiagnosis
appear and the mole can only be diagnosed byappear and the mole can only be diagnosed by
use of ultrasound scanning. (rutting check)use of ultrasound scanning. (rutting check)
Occasionally, a uterus that is too large for theOccasionally, a uterus that is too large for the
stage of the pregnancy can be an indication.stage of the pregnancy can be an indication.
NOTE: Vaginal bleeding does not alwaysNOTE: Vaginal bleeding does not always
indicate a problem!indicate a problem!

Complete hydatidiform mole demonstrating
enlarged villi of various size1919--SepSep--1212 o wardao warda

Hydatidiform mole: specimen from suction
curettage

A large amount of villi in the uterus.

The microscopic appearance of hydatidiform mole:
•Hyperplasia of trophobasitc cells
•Hydropic swelling of all villi
•Vessles are usually absent

A sonographic findings of a molar pregnancy. The
characteristic “snowstorm” pattern is evident.

Transvaginal sonogram demonstrating the “ snow storm” appearance.1919--SepSep--1212 o wardao warda

Color Dopplor facilitates visualization of the enlarged spiral
arteriesclose proximity to the “ snow storm” appearance

Color Doppler image of a hydatidiform mole and surrounding
vessels. The uterine artery is easily identified from its anatomical
location.1919--SepSep--1212 o wardao warda

Dopplor waveform analysis demonstrates low vascular resistance(RI=0.29) in
the spiral arteries, much lower than that obtained in normal early pregnancy

Partial hydartidiform mole

Microscopic image of partial molar pregnancy.

Here is a partial mole in a case of triploidy. Note
the scattered grape-like masses with intervening
normal-appearing placental tissue.1919--SepSep--1212 o wardao warda

Large bilateral theca lutein cysts resembling ovarian germ cell
tumors. With resolution of the human chorionic gonadotropin(HCG)
stimulation, they return to normal-appearing ovaries.

Differential diagnosisDifferential diagnosis
•• AbortionAbortion
•• Multiple pregnancyMultiple pregnancy
•• PolyhydramniosPolyhydramnios•• PolyhydramniosPolyhydramnios

TreatmentTreatment
Suction dilation and curettageSuction dilation and curettage :to remove:to remove
benignbenign hydatidiformhydatidiform molesmoles
When the diagnosis ofWhen the diagnosis of hydatidiformhydatidiform mole ismole is
established, the molar pregnancy should beestablished, the molar pregnancy should beestablished, the molar pregnancy should beestablished, the molar pregnancy should be
evacuated.evacuated.
AnAn oxytocicoxytocic agent should be infusedagent should be infused
intravenouslyintravenously afterafter the start of evacuationthe start of evacuation
and continued for several hours to enhanceand continued for several hours to enhance
uterine contractilityuterine contractility

•• Removal of the uterus (hysterectomyRemoval of the uterus (hysterectomy)) ::
used rarely to treatused rarely to treat hydatidiformhydatidiform moles ifmoles if
future pregnancy is no longer desired.future pregnancy is no longer desired.
TreatmentTreatment

Chemotherapy with aChemotherapy with a
singlesingle--agent drugagent drug
Prophylactic (for prevention)Prophylactic (for prevention)
chemotherapy at the time ofchemotherapy at the time of
TreatmentTreatment
chemotherapy at the time ofchemotherapy at the time of
or immediately followingor immediately following
molar evacuation may bemolar evacuation may be
considered for the highconsidered for the high--riskrisk
patients( to prevent spreadpatients( to prevent spread
of disease )of disease )
1919--SepSep--1212 oo wardawarda

HighHigh--risk postmolarrisk postmolar
trophoblastic tumortrophoblastic tumor
1.1. PrePre--evacuation uterine size larger than expectedevacuation uterine size larger than expected
for gestational durationfor gestational duration
2.2. Bilateral ovarian enlargement (>Bilateral ovarian enlargement (> 99 cm thecacm theca
lutein cysts)lutein cysts)lutein cysts)lutein cysts)
3.3. Age greater thanAge greater than 4040 yearsyears
4.4. Very high hCG levels(>Very high hCG levels(>100100,,000000 m IU/ml)m IU/ml)
5.5. Medical complications of molar pregnancy such asMedical complications of molar pregnancy such as
toxemia, hyperthyrodism and trophoblastictoxemia, hyperthyrodism and trophoblastic
embolization (villi come out of placenta )embolization (villi come out of placenta )
6.6. repeat hydatidiform molerepeat hydatidiform mole

Patients with hudatidiform mole arePatients with hudatidiform mole are
curative overcurative over 8080% by treatment of% by treatment of
evacuation.evacuation.
FollowFollow--upup
evacuation.evacuation.
The followThe follow--up after evacuation is keyup after evacuation is key
necessarynecessary
uterine involution, ovarian cystuterine involution, ovarian cyst
regression and cessation of bleedingregression and cessation of bleeding

Quantitative serum hCG levels shouldQuantitative serum hCG levels should
be obtained everybe obtained every 11--22 weeks untilweeks until
negative for three consecutivenegative for three consecutive
determinations,determinations,
FollowFollow--upup
determinations,determinations,
Followed by everyFollowed by every 33 months formonths for 11
years.years.
Contraception should be practicedContraception should be practiced
during this followduring this follow--up periodup period

Invasive moleInvasive moleInvasive moleInvasive mole

DefinitionDefinition
This term is applied to a molarThis term is applied to a molar
pregnancy in which molar villi growpregnancy in which molar villi grow
into the myometrium or its bloodinto the myometrium or its bloodinto the myometrium or its bloodinto the myometrium or its blood
vessels, and may extend into thevessels, and may extend into the
broad ligament and metastasize to thebroad ligament and metastasize to the
lungs, the vagina or the vulva.lungs, the vagina or the vulva.

Invasive mole: the tissue invades into the myometrial layer.
No obvious borderline, with obvious bleeding.

Invasive hydatidiform mole infiltrating the myometrium

A case of invasive mole: inside the uterine cavity the typicalA case of invasive mole: inside the uterine cavity the typical
““snow stormsnow storm”” appearance can be detected, The location ofappearance can be detected, The location of
blood flow suggest an invasive mole.blood flow suggest an invasive mole.

The same patient owing to the myometrial invasion.The same patient owing to the myometrial invasion.
Reduced vascular resistance is detected in the uterine artery.Reduced vascular resistance is detected in the uterine artery.

Transvaginal color Doppler scan of a patient with invasive mole Following
uterine curettage, Persistent color signals within the myometeriun

Doppler image of invasive mole1919--SepSep--1212 o wardao warda

Power Doppler easily detects a vascular echogenic
nodule within the myometrium, suggesting
invasive mole1919--SepSep--1212 o wardao warda

Doppler image of invasive mole. Doppler waveform
analysis depicts low vascular resistance (RI= 0.35)

Common Sites for MetastaticCommon Sites for Metastatic
Gestational Trophoblastic TumorsGestational Trophoblastic Tumors
SiteSite Per centPer cent
LungLung 6060--9595
VaginaVagina 4040--5050
Vulva/cervixVulva/cervix 1010--1515Vulva/cervixVulva/cervix 1010--1515
BrainBrain 55--1515
LiverLiver 55--1515
KidneyKidney 00--55
SpleenSpleen 00--55
GastrointestinalGastrointestinal 00--55

ChoriocarcinomaChoriocarcinomaChoriocarcinomaChoriocarcinoma

A malignant form of GTD whichA malignant form of GTD which
can develop from a hydatidiform molecan develop from a hydatidiform mole
or from placental trophoblast cellsor from placental trophoblast cellsor from placental trophoblast cellsor from placental trophoblast cells
associated with a healthy fetus ,anassociated with a healthy fetus ,an
abortion or an ectopic pregnancy.abortion or an ectopic pregnancy.

Characterized by abnormalCharacterized by abnormal
trophoblastic hyperplasia andtrophoblastic hyperplasia and
anaplasia , absence of chorionic villianaplasia , absence of chorionic villi
anaplasia , absence of chorionic villianaplasia , absence of chorionic villi

Gross specimen of choriocarcinoma

Microscopic image of choriocarcinoma
absence of chorionic villiabsence of chorionic villi

Microscopic image of choriocarcinoma

Doppler image of choriocarcinoma

Symptoms and signsSymptoms and signs
•• BleedingBleeding
•• InfectionInfection
•• Abdominal swellingAbdominal swelling•• Abdominal swellingAbdominal swelling
•• Vaginal massVaginal mass
•• Lung symptomsLung symptoms
•• Symptoms from other metastasesSymptoms from other metastases

WHO Prognostic Scoring SystemWHO Prognostic Scoring System
ScoreScore
Prognostic factorPrognostic factor 00 11 22 44
Age(years)Age(years) ≤≤3939 >>3939 —— ——
Pregnancy historyPregnancy history
HydatidiformHydatidiform
molemole
Abortion,Abortion,
ectopicectopic
TermTerm
pregnancypregnancy
——
Interval (months) ofInterval (months) of
treatmenttreatment
<<44 44--66 77--1212 >>1212
treatmenttreatment
Initial hCG(mIU/ml)Initial hCG(mIU/ml) <<101033 101033--101044 101044--101055 >>101055
Largest tumor(cm)Largest tumor(cm) <<33 33--55 >>55 ——
Sites of metastasisSites of metastasis LungLung
Spleen,Spleen,
kidneykidney
GI tract, liverGI tract, liver BrainBrain
No. of metastasisNo. of metastasis —— 11--44 44--88 88
Previous (treatment)Previous (treatment) —— —— Single drugSingle drug 22 or moreor more
0-4 low risk, 5-7 intermediate risk, >8 high risk for death1919--SepSep--1212 o wardao warda

FIGO Staging System for GestationalFIGO Staging System for Gestational
Trophoblastic TumorsTrophoblastic Tumors
StageStage DescriptionDescription
ⅠⅠ Limited to uterine corpusLimited to uterine corpus
ⅡⅡ
Extends to the adnexae, outside the uterus,Extends to the adnexae, outside the uterus,
but limited to the genital structuresbut limited to the genital structures
ⅢⅢ
Extends to the lungs with or without genitalExtends to the lungs with or without genital
tracttract
ⅣⅣ All other metastatic sitesAll other metastatic sites

SubstagesSubstages assignedassigned forfor eacheach stagestage asas
followsfollows::
AA:: NoNo riskrisk factorsfactors presentpresent
BB:: OneOne riskrisk factorfactor
FIGO Staging System for GestationalFIGO Staging System for Gestational
Trophoblastic TumorsTrophoblastic Tumors
BB:: OneOne riskrisk factorfactor
CC:: BothBoth riskrisk factorsfactors
RiskRisk factorsfactors usedused toto assignassign substagessubstages::
11.. PretherapyPretherapy serumserum hCGhCG >> 100100,,000000
mlU/mlmlU/ml
22.. DurationDuration ofof diseasedisease >>66 monthsmonths

IIa
IIb

IIIa<3cm or locate in half lung
IIIb disease beyond IIIa

Diagnosis and evaluationDiagnosis and evaluation
Gestational trophoblastic tumor isGestational trophoblastic tumor is
diagnosed by rising hCG followingdiagnosed by rising hCG following
evacuation of a molar pregnancy orevacuation of a molar pregnancy orevacuation of a molar pregnancy orevacuation of a molar pregnancy or
any pregnancy eventany pregnancy event
Once the diagnosis established theOnce the diagnosis established the
further examinations should be donefurther examinations should be done
to determine the extent of disease ( Xto determine the extent of disease ( X--
ray, CT, MRI)ray, CT, MRI)

TreatmentTreatment
Nonmetastatic GTDNonmetastatic GTD
LowLow--Risk Metastatic GTDRisk Metastatic GTD
HighHigh--Risk Metastatic GTDRisk Metastatic GTDHighHigh--Risk Metastatic GTDRisk Metastatic GTD

Treatment of Nonmetastatic GTDTreatment of Nonmetastatic GTD
Hysterectomy is advisable as initial treatment inHysterectomy is advisable as initial treatment in
patients with nonmetastatic GTD who no longerpatients with nonmetastatic GTD who no longer
wish to preserve fertilitywish to preserve fertility
This choice can reduce the number of courseThis choice can reduce the number of courseThis choice can reduce the number of courseThis choice can reduce the number of course
and shorter duration of chemotherapy.and shorter duration of chemotherapy.
Adjusted singleAdjusted single--agent chemotherapy at the timeagent chemotherapy at the time
of operation is indicated to eradicate any occultof operation is indicated to eradicate any occult
metastases and reduce tumor dissemination.metastases and reduce tumor dissemination.

SingleSingle--agent chemotherapy is the treatment ofagent chemotherapy is the treatment of
choice for patients wishing to preserve theirchoice for patients wishing to preserve their
fertility.fertility.
Methotrexate(MTX) and ActinomycinMethotrexate(MTX) and Actinomycin--D areD are
Treatment of Nonmetastatic GTDTreatment of Nonmetastatic GTD
Methotrexate(MTX) and ActinomycinMethotrexate(MTX) and Actinomycin--D areD are
generally chemotherapy agentsgenerally chemotherapy agents
Treatment is continued until three consecutiveTreatment is continued until three consecutive
normal hCG levels have been obtained and twonormal hCG levels have been obtained and two
courses have been given after the first normalcourses have been given after the first normal
hCG level.hCG level.
To prevent relapse or metastasisTo prevent relapse or metastasis1919--SepSep--1212 o wardao warda

SingleSingle--agent chemotherapy with MTX or actinomycinagent chemotherapy with MTX or actinomycin--
D is the treatment for patients in this categoryD is the treatment for patients in this category
If resistance to sequential singleIf resistance to sequential single--agent chemotherapyagent chemotherapy
develops, combination chemotherapy would be takendevelops, combination chemotherapy would be taken
Treatment of LowTreatment of Low--RiskRisk
Metastatic GTDMetastatic GTD
develops, combination chemotherapy would be takendevelops, combination chemotherapy would be taken
ApproximatelyApproximately 1010--1515% of patients treated with single% of patients treated with single--
agent chemotherapy will require combinationagent chemotherapy will require combination
chemotherapy with or without surgery to achievechemotherapy with or without surgery to achieve
remissionremission

Multiagent chemotherapy with or withoutMultiagent chemotherapy with or without
adjuvant radiotherapy or surgery should beadjuvant radiotherapy or surgery should be
the initial treatment for patients with highthe initial treatment for patients with high--
rist metastatic GTDrist metastatic GTD
Treatment of HighTreatment of High--RiskRisk
Metastatic GTDMetastatic GTD
rist metastatic GTDrist metastatic GTD
EMAEMA--CO regimen formula is good choice forCO regimen formula is good choice for
highhigh--rist metastatic GTDrist metastatic GTD
Adjusted surgeries such as removing foci ofAdjusted surgeries such as removing foci of
chemotherapychemotherapy--resistant disease, controllingresistant disease, controlling
hemorrhage may be the one ofhemorrhage may be the one of treatmenttreatment
regimenregimen

EMAEMA--CO Chemotherapy for poorCO Chemotherapy for poor
Prognostic DiseasePrognostic Disease
Etoposide(VPEtoposide(VP--1616)) 100100mg/Mmg/M22 IV dailyIV daily××22 daysdays
(over(over 3030--4545 minutes)minutes)
MethotrexateMethotrexate 100100mg/Mmg/M22
IV losding dose,IV losding dose,
thenthen 200200mg/Mmg/M22
overover 1212 hours dayhours day 11
Actinomycin DActinomycin D 00..55mgmg IV dailyIV daily××22 daysdays
Folinic acidFolinic acid
1515mg IM or p.o. qmg IM or p.o. q 1212 hourshours××44 startingstarting 2424
hours after starting methotrexatehours after starting methotrexate
CyclophosphamideCyclophosphamide 600600mg/Mmg/M22 IV on dayIV on day88
Oncovin (vincristine)Oncovin (vincristine) 11mg/Mmg/M22 IV on dayIV on day88
((Repeat everyRepeat every 1515 days as toxicity permits)days as toxicity permits)

PrognosisPrognosis
Cure rates should approachCure rates should approach 100100% in% in
nonmetastatic and lownonmetastatic and low--risk metastaticrisk metastatic
GTDGTDGTDGTD
Intensive multimodality therapy hasIntensive multimodality therapy has
resulted in cure rates ofresulted in cure rates of 8080--9090% in% in
patients with highpatients with high--risk metastatic GTDrisk metastatic GTD

FollowFollow--up After Successfulup After Successful
TreatmentTreatment
Quantitative serum hCG levels should beQuantitative serum hCG levels should be
obtained monthly forobtained monthly for 66 months, every twomonths, every two
months for remainder of the first year,months for remainder of the first year,months for remainder of the first year,months for remainder of the first year,
everyevery 33 months during the second yearmonths during the second year
Contraception should be maintained for atContraception should be maintained for at
leastleast 11 year after the completion ofyear after the completion of
chemotherapy. Condom is the choice.chemotherapy. Condom is the choice.

Placenta Site TrophoblasticPlacenta Site Trophoblastic
Tumor (PSTT)Tumor (PSTT)Tumor (PSTT)Tumor (PSTT)

Placenta Site Trophoblastic Tumor is anPlacenta Site Trophoblastic Tumor is an
extremely rare tumor that arised from theextremely rare tumor that arised from the
placental implantation siteplacental implantation site
Tumor cells infiltrate the myometrium andTumor cells infiltrate the myometrium and
Tumor cells infiltrate the myometrium andTumor cells infiltrate the myometrium and
grow between smoothgrow between smooth--muscle cellsmuscle cells

Surum hCG levels are relatively lowSurum hCG levels are relatively low
compared to those seen withcompared to those seen with
choriocarcinoma.choriocarcinoma.
Several reports have noted a benignSeveral reports have noted a benign
Dignosis and treatmentDignosis and treatment
Several reports have noted a benignSeveral reports have noted a benign
behavior of this disease. They are relativelybehavior of this disease. They are relatively
chemotherapychemotherapy--resistant, and deaths fromresistant, and deaths from
metastasis have occurred.metastasis have occurred.
Surgery has been the mainstay of treatmentSurgery has been the mainstay of treatment

gestational trophoblastic disease GTD

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