Gestational trophoblastic disease is a spectrum of interrelated disease processes originating from the placenta. GTD is a spectrum of tumours with a wide range of biologic behaviour and potential for metastases They are characterised by an abnormally high amount of HcG levels in the blood

1. Tanga regional refferal hospital
Thursday clinical presentation
DEPARTMENT:obs/ gyn
TOPIC: Gestational trophoblastic diseases
PRESENTER:
Dr.Hamisi Mkindi,MD
FACILITATOR:
Dr.Joseph Mberesero,MD,Mmed
Obs/Gyn

2. CONTENTS
1. Introduction
2. Classification
3. Epidemiology
4. Risk factors
5. Pathogenesis
6. Clinical features
7. Work up
8. Treatment

3. Introduction
 Dfn
 Gestational trophoblastic disease is a
spectrum of interrelated disease processes
originating from the placenta.
 GTD is a spectrum of tumours with a wide
range of biologic behaviour and potential for
metastases
 They are characterised by an abnormally high
amount of HcG levels in the blood

4. Modified WHO Classification
1. Molar lesions
a. Hydatidiform mole
• complete
• partial
a. Invasive mole (Chorioadenoma destruens)
2. Nonmolar lesions
a. Choriocarcinoma
b. Placental site trophoblastic tumor

5. EPIDEMIOLOGY
Hydatidiform moles
 The most common GTDs
 Incidence:
 Varies worldwide from 1:125 deliveries in
Mexico and Taiwan to 1:1500 in USA
 Common in under 20 and above 40 women
 10% to 17% of cases, can progress to become
an invasive mole or persistent GTDs.

6. EPIDEMIOLOGY
Choriocarcinoma
 A malignant form of GTDs
 Incidence:
 More common in many Asian and African
countries, where it affects up to 1 pregnancy in
2,500.
 1% to 3% of hydatidiform moles progress to
become choriocarcinoma.
 50% develop from moles.
 25% follows abortions, tubal pregnancy
 25% follows normal term pregnancy.

7. RISK FACTORS
• Age.
– The incidence of molar pregnancy highest in
women aged 15 years or younger, and those aged
45 years or older. In the latter group, the relative
frequency of the lesion is at least 10 times greater
than that at ages 20 to 40 years
• Previous Mole
– Women with molar pregnancies are at increased
risk of developing either a complete or a partial
mole in a future pregnancy

8.  Diet
 In women whose diets are deficient in protein,
folic acid, animal fat and carotene
 Genetic factors
 There is an increased association with the AB
blood group which possesses no ABO antibodies
 Other risk factors are alcoholism, smoking
and the use of contraceptives

9. PATHOGENESIS
 Complete mole
 Partial mole
 Invasive mole
 Choriocarcinoma

10. +
+
Complete Mole: Pathogenesis
Two sperm
(XX or XY)
Duplication of
Sperm DNA
X sperm
46 XX
or
46 XY
Empty egg
or

11. +
+
Partial Mole: Pathogenesis
One diploid sperm
Two haploid sperm
or
23Y
23X 23X
23X
46XY
69XXY
or
69XXX

12. Differences btn complete vs partial mole:
pathologic features and behavior
Feature Complete mole Partial mole
1. Karyotype
2. Embryo/fetus
3. Hydropic
swelling
46,XX(46,XY)
Absent
Marked, cisterns
present,
all villi involved
Triploid
Present
Less pronounced, focal
Cisterns less prominen
4. Trophoblastic
proliferation
Variable, may be
marked
Focal, minimal
5. Behavior 10-30% develop GTN 0.5-4%

13. Invasive mole
 Hydatidiform mole in which hydropic villi
invade the myometrium or blood vessels or
more rarely, are deported to extrauterine sites.
 Lack the tendency to widespread metastasize
 Can regress spontaneously unlike
choriocarcinoma
 Can be distiguished from choriocarcinoma by
the presence of villi

14. Choriocarcinoma
 Highly malignant epithelial tumor.
 Arises from the trophoblast of any type of
gestational event, most often hydatidiform
mole.
 Consists of dimorphic (trophoblasts and
syncytiotrophoblasts) without chorionic villi
 Rapid proliferation with vessel invasion–
hemorrhagic mass

15. CLINICAL FEATURES;
 Uterine bleeding in first trimester
 Absence of fetal heart beats
 Rapid enlargement of the uterus than
expected GA
 hCG titers greater than expected for
GA
 Expulsion of grapes like vesicles
 Hyperemesis

16. CLINICAL FEATURES Cont
 Theca luteal cysts
 Onset of pre-eclampsia in first trimester
 Pathognomonic for hydatidiform mole
 Other features
 Hyperthyroidism
 Tachycardia

17. WORK UP
 History and physical examination
 USS
 Snow stom appearance
 Visible vesicles
 Can also detect luteal cyst
 B hcg
 May be of value in diagnosing molar
pregnancies

18. WORK UP CONT…
 Chest film
 R/O lung metastasis - cannon ball opacities
 Haematologic survey-WBC, platelet counts
 Brain CT/MRI - R/O Brain metastasis
 Abdominal and pelvic ultrasound, R/O
 Liver metastasis
 Luteal cysts
 LFTs
 RFTs
 Histology-Exam of POC-defn dx is made

19. TREATMENT
Molar pregnancy
i. Suction curettage
– Set an IV line for oxytocic infusion only
commenced once evacuation has been
completed.
i. Blood transfusion
Note: The procedure may be accompanied
with severe haemorrhage
iii. Monitor output

20. Treatment cont
Choriodenoma destruens
a. Chemotherapy
b. Elective Hysterectomy
Prognosis
a. Good with treatment
b. 75 – 85% > 5 years

21. Metastatic Gestational Trophoblastic
Disease
 Rx in metastatic disease uses either single-
agent chemotherapy/multiple-agent
chemotherapy
 Several classification systems have been
developed.
- National Cancer Institute
- World Health Organization (WHO)
- Revised FIGO (International Federation on
Gynecology and Obstetrics)

22. NCI class
*Determines if pt will have a good or poor prognosis in response to single-agent chemo.
I. Low risk choriocarcinoma: Characteristics
1. Presents before 4 months postabortion
2. Follows abortion or molar abortion
3. hCG is < 100,000IU/24 hours
4. Mets to the lungs or no mets

23. NCI class cont…
II: High risk choriocarcinoma: Characteristics
1. Follows term pregnancy
2. Size > 5cm diameter
3. Mets to the brain
4. Blood group AB highest risk
5. Presents > 4 months post delivery

24. WHO class
 Scoring system based on an individual's risk
factors.
 A total score of 0–6 is considered low-risk
and a total score 7 is categorized as high-risk

26. Revised FIGO (International Federation on
Gynecology and Obstetrics)
 A patient is assigned a stage based on the
anatomic location of disease and given a risk
factor score based on the WHO prognostic
scoring system.
 The goal of the revised FIGO staging is to
improve the assessment and clinical
management of patients.

28. Rx
1. Low risk choriocarcinoma(good
prognosis)
 Methotraxate alone
 5-day treatment cycle is given
 Once negative titers have been achieved, an
additional course is administered

29. Rx continuation
2. High risk choriocarcinoma(poor
prognosis)
These patients require prolonged
hospitalization
Combined chemotherapy
a. MAC –(Methotraxate, Actinomycin D, chrolambucil)
b. EMA/CO (Etoposide, Methotraxate,
Actinomycin, Oncovin (Vincristine),
The cycle is repeated every 2 weeks

30. Rx: Placental-Site Trophoblastic Tumor
 Generally is resistant to chemotherapy,
hysterectomy is the recommended route of
treatment.
 Partial uterine resection involving the tumor
is possible if the patient desires to retain
fertility.
 EP-EMA is the preferred regimen over
EMACO.
 Good prog if loc to uterus n antecedent
pregnancy <2 years

31. Follow up
 Clinical
 Laboratory

32. FOLLOW UP: Moles
 Duration = 1 – 2 years
 Schedule visits plus measure serum hCG in the
following order
 Weekly during treatment until 3 normal levels (3 weeks)
 Monthly for 3 months, then 3 monthly for 9 months.
 Then after every 6 months for one year
 Patient should not conceive
 Contraception
 Preferably barrier method otherwise COC
 Why COC, - because rarely cause abnormal vaginal
bleeding that may be difficult to distinguish from the
complication of GTDs

33. FOLLOW UP: CHORIOCARCINOMA
 Duration – 2 years
 During follow up period
1. Measure serum hCG
a. Once weekly during treatment until 3 normal
levels (3 weeks)
b. Then every month for 3 months
c. Then after every 3 months for 9 months.
d. Followed by after every 6 monthly for one year

34. FOLLOW UP cont
2. During follow up clinic visit the following
should be done
Take history R/O
 Abnormal vaginal bleeding, cough, chest pain
Do pelvic assessment: R/O ovarian cysts
Investigate;
 CXR R/O lung mets – cannon balls
 Pelvic USS
3. Patient should not conceive: contraception

35. Cont…
 SUMMARY GTD’s

36. Summary
 Gestational trophoblastic disease is a
spectrum.
 Molar and Non molar. Invasive and non
invasive.
 The two main risk factors: extremes of
maternal age and previous GTD
 Elevated serum hCG concentration. Pv
bleeding,enlarged uterus and pelvic
discomfort

37. Summary
 Initial evaluation consists of a quantitative
test for hCG and pelvic ultrasound
examination.
 Dx of complete or partial mole must be
confirmed by histologic examination of
tissue.
 Rx:SE,Hysterectomy,Chemotherapy

39. References
 http://www.ncbi.nlm.nih.gov/pubmed/
 http://emedicine.medscape.com/article/
 http://www.cancer.gov/types/gestational-
trophoblastic/hp/gtd-treatment-pdq
 Berkowitz RS, Goldstein DP. Chorionic
tumors. N Engl J Med 1996; 335:1740.
 DC dutta text book of obstetrics 7th
edition
 Current diagnosis and treatment in ostetrics
and gynaecology 10th
edition