Gestational Trophoblastic Neoplasia Dr Khalid Sait FRCSCGynecologic OncologistAss

Gestational Trophoblastic Neoplasia Dr Khalid Sait FRCSC/Gynecologic Oncologist/Ass. Prof KAUH/Jeddah / Saudi Arabia khalidsait@yahoo. com

Key Words n n n Group of disease with wide range of neoplastic potential Create a lot of challenge for us in term of diagnosis and treatment Diagnosis and management will depends on the history, HCG level and metastasis work up

Clinical pathology of gestational trophoblastic disease n n 1 - Cytotrophoblast and syncytiotrophoblast cells proliferation Moler pregnancy Invasive mole Choriocarcinoma 2 - Intermediate trophoblastic cells derivative Placental – site tumor

Risk Factors for Moler pregnancy n n n Extremes of reproductive years Prior mole Prior spontaneous abortion Vit A deficiency Race ( Indonesia 1: 85, USA 1: 1500)

Clinical Features n n n Large for date 50 % Hyper emesis 20 % Early PIH 5% Abscent FH ( except in partial mole or twin pregnancy) Hyperthyroidism symptom and sign 5% Rarely presented with metastasis symptom and sign

Management of molar pregnancy Procedure Risk of Persistent GTT Suction Evacuation 20 % Hysterectomy 5%

Follow up of patient with molar pregnancy after evacuation n n HCG weekly serum determination until normal for two values , then monthly for 6 to 12 months Contraception for 1 year Pelvic examination every 2 weeks until normal, then every 3 months Check histopathology

If no proper decrease or BHCG start to increase

Persistent GTD

Indication for initiating treatment during post mole follow up n n n n Serum BHCG values rising more than 10 % for 2 wk ( 3 weekly titre) Serum BHCG values on plateau for 3 wk or decline of less than 10 % Presence of metastasis Significant elevation of serum BHCG values after reaching normal levels Choriocarcinoma or invasive mole on histopathology HCG level still elevated 6 months after molar evacuation HCG > 20000 miu/ml 4 weeks after evacuation

Work up of gestational trophoblastic neoplasia n n n n History and physical examination chest XR ( if neg CT ) Pretreatment HCG titre Hematological survey Serum chemistries CT of brain Ultrasound of pelvis Liver scan ( u/s or CT )

CLASSIFICATION OF GESTATIONAL TROPHOBLASTIC DIS n Benign 1) complete mole 2) Partial mole n Malignant (invasive mole and choriocarcinoma) 1) nonmetastatic 2) metastatic a) low risk b) high risk

Risk factors (malignant GTD) 1. Disease present more that 4 m(long duration) or 2. pretreatment B-HCG greater than 40, 000 mlu/ml or 3. presence of met to sites other than lungs or vagina i, e liver or brain etc. . 4. prior chemo 5 following Term pregnancy

CHEMOTHERAPY FOR GTN NON METASTATIC or GOOD PROGNOSIS METASTATIC *Single agent chemotherapy *survival 90 -100% METASTATIC POOR PROGNOSIS *Combined chemotherapy * survival 50 %