GestationalGestational TrophoblasticTrophoblasticDisease (GTD)Disease (GTD)Disease (GTD)Disease (GTD)Osama M Warda, MDObst...
Types of GTDTypes of GTDBenignBenign•• HydatidiformHydatidiform mole/molar pregnancymole/molar pregnancy(complete or incom...
The termThe term GestationalGestational TrophoblasticTrophoblasticTumorsTumors has been applied the latterhas been applied...
PATHOLOGICPATHOLOGICCLASSIFICATIONCLASSIFICATIONCLINICALCLINICALCLASSIFICATIONCLASSIFICATIONHydatidiformHydatidiform molem...
HydatidiformHydatidiform MoleMole(=vesicular Mole)(=vesicular Mole)(=vesicular Mole)(=vesicular Mole)(=molar pregnancy)(=m...
Definition and EtiologyDefinition and EtiologyHydatidiformHydatidiform mole is a pregnancymole is a pregnancycharacterized...
In aIn a ‘‘complete molecomplete mole’’ the mass ofthe mass oftissue is completely made up oftissue is completely made up ...
In aIn a ‘‘partial molepartial mole’’,, the mass maythe mass maycontain both these abnormal cellscontain both these abnorm...
IncidenceIncidence•• 11 out ofout of 15001500--20002000 pregnancies in thepregnancies in theU.S. and EuropeU.S. and Europe...
Repeat hydatidiform moles occure inRepeat hydatidiform moles occure in00..55--22..66% of patients, and these% of patients,...
ApproximatelyApproximately 1010--1717% of hydatidiform% of hydatidiformmoles will result in invasive molemoles will result...
Clinical risk factors for molar pregnancyClinical risk factors for molar pregnancyAge (extremes of reproductive years)Age ...
CytogeneticsCytogeneticsComplete molar pregnancyComplete molar pregnancyChromosomes are paternal , diploidChromosomes are ...
1919--SepSep--1212 o wardao warda
1919--SepSep--1212 o wardao warda
Comparative Pathologic Features ofComparative Pathologic Features ofComplete and Partial Hydatidiform MoleComplete and Par...
Signs and Symptoms of CompleteSigns and Symptoms of CompleteHydatidiform MoleHydatidiform Mole•• Vaginal bleedingVaginal b...
Signs and Symptoms of PartialSigns and Symptoms of PartialHydatidiform MoleHydatidiform Mole•• Vaginal bleedingVaginal ble...
Diagnosis of hydatidiform moleDiagnosis of hydatidiform moleQuantitative betaQuantitative beta--HCGHCGUltrasound is the cr...
The most common symptom of a mole isThe most common symptom of a mole isvaginal bleeding during the first trimestervaginal...
Complete hydatidiform mole demonstratingenlarged villi of various size1919--SepSep--1212 o wardao warda
Hydatidiform mole: specimen from suctioncurettage1919--SepSep--1212 o wardao warda
A large amount of villi in the uterus.1919--SepSep--1212 o wardao warda
The microscopic appearance of hydatidiform mole:•Hyperplasia of trophobasitc cells•Hydropic swelling of all villi•Vessles ...
A sonographic findings of a molar pregnancy. Thecharacteristic “snowstorm” pattern is evident.1919--SepSep--1212 o wardao ...
Transvaginal sonogram demonstrating the “ snow storm” appearance.1919--SepSep--1212 o wardao warda
Color Dopplor facilitates visualization of the enlarged spiralarteriesclose proximity to the “ snow storm” appearance1919-...
Color Doppler image of a hydatidiform mole and surroundingvessels. The uterine artery is easily identified from its anatom...
1919--SepSep--1212 o wardao warda
Dopplor waveform analysis demonstrates low vascular resistance(RI=0.29) inthe spiral arteries, much lower than that obtain...
1919--SepSep--1212 o wardao warda
Partial hydartidiform mole1919--SepSep--1212 o wardao warda
Microscopic image of partial molar pregnancy.1919--SepSep--1212 o wardao warda
Here is a partial mole in a case of triploidy. Notethe scattered grape-like masses with interveningnormal-appearing placen...
Large bilateral theca lutein cysts resembling ovarian germ celltumors. With resolution of the human chorionic gonadotropin...
Differential diagnosisDifferential diagnosis•• AbortionAbortion•• Multiple pregnancyMultiple pregnancy•• PolyhydramniosPol...
TreatmentTreatmentSuction dilation and curettageSuction dilation and curettage :to remove:to removebenignbenign hydatidifo...
•• Removal of the uterus (hysterectomyRemoval of the uterus (hysterectomy)) ::used rarely to treatused rarely to treat hyd...
Chemotherapy with aChemotherapy with asinglesingle--agent drugagent drugProphylactic (for prevention)Prophylactic (for pre...
HighHigh--risk postmolarrisk postmolartrophoblastic tumortrophoblastic tumor1.1. PrePre--evacuation uterine size larger th...
Patients with hudatidiform mole arePatients with hudatidiform mole arecurative overcurative over 8080% by treatment of% by...
Quantitative serum hCG levels shouldQuantitative serum hCG levels shouldbe obtained everybe obtained every 11--22 weeks un...
Invasive moleInvasive moleInvasive moleInvasive mole1919--SepSep--1212 o wardao warda
DefinitionDefinitionThis term is applied to a molarThis term is applied to a molarpregnancy in which molar villi growpregn...
Invasive mole: the tissue invades into the myometrial layer.No obvious borderline, with obvious bleeding.1919--SepSep--121...
Invasive hydatidiform mole infiltrating the myometrium1919--SepSep--1212 o wardao warda
A case of invasive mole: inside the uterine cavity the typicalA case of invasive mole: inside the uterine cavity the typic...
The same patient owing to the myometrial invasion.The same patient owing to the myometrial invasion.Reduced vascular resis...
Transvaginal color Doppler scan of a patient with invasive mole Followinguterine curettage, Persistent color signals withi...
Doppler image of invasive mole1919--SepSep--1212 o wardao warda
Power Doppler easily detects a vascular echogenicnodule within the myometrium, suggestinginvasive mole1919--SepSep--1212 o...
Doppler image of invasive mole. Doppler waveformanalysis depicts low vascular resistance (RI= 0.35)1919--SepSep--1212 o wa...
Common Sites for MetastaticCommon Sites for MetastaticGestational Trophoblastic TumorsGestational Trophoblastic TumorsSite...
ChoriocarcinomaChoriocarcinomaChoriocarcinomaChoriocarcinoma1919--SepSep--1212 o wardao warda
DefinitionDefinitionA malignant form of GTD whichA malignant form of GTD whichcan develop from a hydatidiform molecan deve...
Characterized by abnormalCharacterized by abnormaltrophoblastic hyperplasia andtrophoblastic hyperplasia andanaplasia , ab...
Gross specimen of choriocarcinoma1919--SepSep--1212 o wardao warda
Microscopic image of choriocarcinomaabsence of chorionic villiabsence of chorionic villi1919--SepSep--1212 o wardao warda
Microscopic image of choriocarcinoma1919--SepSep--1212 o wardao warda
Doppler image of choriocarcinoma1919--SepSep--1212 o wardao warda
Doppler image of choriocarcinoma1919--SepSep--1212 o wardao warda
Symptoms and signsSymptoms and signs•• BleedingBleeding•• InfectionInfection•• Abdominal swellingAbdominal swelling•• Abdo...
WHO Prognostic Scoring SystemWHO Prognostic Scoring SystemScoreScorePrognostic factorPrognostic factor 00 11 22 44Age(year...
FIGO Staging System for GestationalFIGO Staging System for GestationalTrophoblastic TumorsTrophoblastic TumorsStageStage D...
SubstagesSubstages assignedassigned forfor eacheach stagestage asasfollowsfollows::AA:: NoNo riskrisk factorsfactors prese...
1919--SepSep--1212 o wardao warda
IIaIIb1919--SepSep--1212 o wardao warda
IIIa<3cm or locate in half lungIIIb disease beyond IIIa1919--SepSep--1212 o wardao warda
1919--SepSep--1212 o wardao warda
Diagnosis and evaluationDiagnosis and evaluationGestational trophoblastic tumor isGestational trophoblastic tumor isdiagno...
TreatmentTreatmentNonmetastatic GTDNonmetastatic GTDLowLow--Risk Metastatic GTDRisk Metastatic GTDHighHigh--Risk Metastati...
Treatment of Nonmetastatic GTDTreatment of Nonmetastatic GTDHysterectomy is advisable as initial treatment inHysterectomy ...
SingleSingle--agent chemotherapy is the treatment ofagent chemotherapy is the treatment ofchoice for patients wishing to p...
SingleSingle--agent chemotherapy with MTX or actinomycinagent chemotherapy with MTX or actinomycin--D is the treatment for...
Multiagent chemotherapy with or withoutMultiagent chemotherapy with or withoutadjuvant radiotherapy or surgery should bead...
EMAEMA--CO Chemotherapy for poorCO Chemotherapy for poorPrognostic DiseasePrognostic DiseaseEtoposide(VPEtoposide(VP--1616...
PrognosisPrognosisCure rates should approachCure rates should approach 100100% in% innonmetastatic and lownonmetastatic an...
FollowFollow--up After Successfulup After SuccessfulTreatmentTreatmentQuantitative serum hCG levels should beQuantitative ...
Placenta Site TrophoblasticPlacenta Site TrophoblasticTumor (PSTT)Tumor (PSTT)Tumor (PSTT)Tumor (PSTT)1919--SepSep--1212 o...
Placenta Site Trophoblastic Tumor is anPlacenta Site Trophoblastic Tumor is anextremely rare tumor that arised from theext...
1919--SepSep--1212 o wardao warda
Surum hCG levels are relatively lowSurum hCG levels are relatively lowcompared to those seen withcompared to those seen wi...
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  1. 1. GestationalGestational TrophoblasticTrophoblasticDisease (GTD)Disease (GTD)Disease (GTD)Disease (GTD)Osama M Warda, MDObstetrics & Gynecology departmentMansoura Faculty of Medicine
  2. 2. Types of GTDTypes of GTDBenignBenign•• 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 tumortumor1919--SepSep--1212 o wardao warda
  3. 3. The termThe term GestationalGestational TrophoblasticTrophoblasticTumorsTumors has been applied the latterhas been applied the latterthree conditionsthree conditionsAriseArise from thefrom the trophoblastictrophoblastic elementselementsTypes of GTDTypes of GTDAriseArise from thefrom the trophoblastictrophoblastic elementselementsRetainRetain the invasive tendencies of thethe invasive tendencies of thenormal placenta or metastasisnormal placenta or metastasisKeep secretion of the human chorionicKeep secretion of the human chorionicgonadotropingonadotropin ((hCGhCG))1919--SepSep--1212 o wardao warda
  4. 4. PATHOLOGICPATHOLOGICCLASSIFICATIONCLASSIFICATIONCLINICALCLINICALCLASSIFICATIONCLASSIFICATIONHydatidiformHydatidiform molemole*complete*complete*incomplete*incompleteBenign gestationalBenign gestationaltrophoblastic diseasetrophoblastic diseasePathologic and clinical classificationsfor gestational trophoblastic disease*incomplete*incompleteInvasive moleInvasive moleMalignantMalignanttrophoblastic diseasetrophoblastic diseaseNonmetastaticNonmetastaticPlacental sitePlacental sitetrophoblastic tumortrophoblastic tumorMetastaticMetastaticChoriocarcinomaChoriocarcinoma High riskHigh risk Low riskLow risk1919--SepSep--1212 o wardao warda
  5. 5. HydatidiformHydatidiform MoleMole(=vesicular Mole)(=vesicular Mole)(=vesicular Mole)(=vesicular Mole)(=molar pregnancy)(=molar pregnancy)1919--SepSep--1212 o wardao warda
  6. 6. Definition and EtiologyDefinition and EtiologyHydatidiformHydatidiform mole is a pregnancymole is a pregnancycharacterized by vesicular swelling ofcharacterized by vesicular swelling ofplacentalplacental villivilli and usually the absence ofand usually the absence ofan intact fetus.an intact fetus.an intact fetus.an intact fetus.The etiology ofThe etiology of hydatidiformhydatidiform molemoleremains unclear, but it appears to be dueremains unclear, but it appears to be dueto abnormalto abnormal gametogenesisgametogenesis andandfertilizationfertilization1919--SepSep--1212 o wardao warda
  7. 7. In aIn a ‘‘complete molecomplete mole’’ the mass ofthe mass oftissue is completely made up oftissue is completely made up ofabnormal cellsabnormal cellsThereThere is no fetusis no fetus and nothing canand nothing canDefinition and EtiologyDefinition and EtiologyThereThere is no fetusis no fetus and nothing canand nothing canbe found at the time of the firstbe found at the time of the firstscan.scan.1919--SepSep--1212 o wardao warda
  8. 8. In aIn a ‘‘partial molepartial mole’’,, the mass maythe mass maycontain both these abnormal cellscontain both these abnormal cellsand often a fetus that has severeand often a fetus that has severedefects.defects.Definition and EtiologyDefinition and Etiologydefects.defects.In this case the fetus will beIn this case the fetus will beconsumed ( destroyed) by theconsumed ( destroyed) by thegrowing abnormal mass verygrowing abnormal mass veryquickly.quickly. (shrink)(shrink)1919--SepSep--1212 o wardao warda
  9. 9. IncidenceIncidence•• 11 out ofout of 15001500--20002000 pregnancies in thepregnancies in theU.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 > incompleteincomplete1919--SepSep--1212 o wardao warda
  10. 10. Repeat hydatidiform moles occure inRepeat hydatidiform moles occure in00..55--22..66% of patients, and these% of patients, and thesepatiens have a subsequent greater riskpatiens have a subsequent greater riskIncidenceIncidencepatiens have a subsequent greater riskpatiens have a subsequent greater riskof developing invasive mole orof developing invasive mole orchoriocarcinomachoriocarcinomaThere is an increased risk of molarThere is an increased risk of molarpregnancy for women over the agepregnancy for women over the age 40401919--SepSep--1212 o wardao warda
  11. 11. ApproximatelyApproximately 1010--1717% of hydatidiform% of hydatidiformmoles will result in invasive molemoles will result in invasive moleApproximatelyApproximately 22--33% of hydatidiform% of hydatidiformIncidenceIncidenceApproximatelyApproximately 22--33% of hydatidiform% of hydatidiformmoles 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 GTT1919--SepSep--1212 o wardao warda
  12. 12. Clinical risk factors for molar pregnancyClinical risk factors for molar pregnancyAge (extremes of reproductive years)Age (extremes of reproductive years)<<1515>>4040Reproductive historyReproductive historyReproductive historyReproductive historyprior hydatidiform moleprior hydatidiform moleprior spontaneous abortionprior spontaneous abortionDietDietVitamin A deficiencyVitamin A deficiency1919--SepSep--1212 o wardao warda
  13. 13. CytogeneticsCytogeneticsComplete molar pregnancyComplete molar pregnancyChromosomes are paternal , diploidChromosomes are paternal , diploid4646,XX in,XX in 9090% cases% cases4646,XX in,XX in 9090% cases% cases4646,XY in a small part,XY in a small partPartial molar pregnancyPartial molar pregnancyChromosomes 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
  14. 14. 1919--SepSep--1212 o wardao warda
  15. 15. 1919--SepSep--1212 o wardao warda
  16. 16. Comparative Pathologic Features ofComparative Pathologic Features ofComplete and Partial Hydatidiform MoleComplete and Partial Hydatidiform MoleFeatureFeature CompleteComplete MoleMole Partial MolePartial MoleKaryotypeKaryotype Usually diploidUsually diploid 4646XXXX Usually triploidyUsually triploidy 6969XXX mostXXX mostcommon.common.VilliVilli All villi hydropin; noAll villi hydropin; nonormal adjacent villinormal adjacent villiNormal adjacent villi may beNormal adjacent villi may bepresentpresentvesselsvessels present they contain nopresent they contain nofetal blood cellsfetal blood cellsblood cellsblood cellsFetal tissueFetal tissue None presentNone present Usually presentUsually presentTrophoblastTrophoblast Hyperplasia usuallyHyperplasia usuallypresent to variablepresent to variabledegreesdegreesHyperplasia mild and focalHyperplasia mild and focal1919--SepSep--1212 o wardao warda
  17. 17. Signs and Symptoms of CompleteSigns and Symptoms of CompleteHydatidiform MoleHydatidiform Mole•• Vaginal bleedingVaginal bleeding•• HyperemesisHyperemesis ( severe vomit)( severe vomit)•• Size inconsistent with gestationalSize inconsistent with gestational•• Size inconsistent with gestationalSize inconsistent with gestationalage( with no fetal heart beating andage( with no fetal heart beating andfetal movement)fetal movement)•• PreeclampsiaPreeclampsia•• ThecaTheca luteinlutein ovarian cystsovarian cysts1919--SepSep--1212 o wardao warda
  18. 18. Signs and Symptoms of PartialSigns and Symptoms of PartialHydatidiform MoleHydatidiform Mole•• Vaginal bleedingVaginal bleeding•• Absence of fetal heart tonesAbsence of fetal heart tones•• Uterine enlargement andUterine enlargement and•• Uterine enlargement andUterine enlargement andpreeclampsia is reported in onlypreeclampsia is reported in only 33%%of patients.of patients.•• ThecaTheca luteinlutein cysts,cysts, hyperemesishyperemesis isisrarerare..1919--SepSep--1212 o wardao warda
  19. 19. Diagnosis of hydatidiform moleDiagnosis of hydatidiform moleQuantitative betaQuantitative beta--HCGHCGUltrasound is the criterion standard forUltrasound is the criterion standard foridentifying both complete and partialidentifying both complete and partialidentifying both complete and partialidentifying both complete and partialmolar pregnancies. The classic imagemolar pregnancies. The classic imageis of ais of a ““snowstormsnowstorm”” patternpattern1919--SepSep--1212 o wardao warda
  20. 20. The most common symptom of a mole isThe most common symptom of a mole isvaginal bleeding during the first trimestervaginal bleeding during the first trimesterhowever very often no signs of a problemhowever very often no signs of a problemappear and the mole can only be diagnosed byappear and the mole can only be diagnosed byDiagnosisDiagnosisappear and the mole can only be diagnosed byappear and the mole can only be diagnosed byuse 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 thestage 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 alwaysindicate a problem!indicate a problem!1919--SepSep--1212 o wardao warda
  21. 21. Complete hydatidiform mole demonstratingenlarged villi of various size1919--SepSep--1212 o wardao warda
  22. 22. Hydatidiform mole: specimen from suctioncurettage1919--SepSep--1212 o wardao warda
  23. 23. A large amount of villi in the uterus.1919--SepSep--1212 o wardao warda
  24. 24. The microscopic appearance of hydatidiform mole:•Hyperplasia of trophobasitc cells•Hydropic swelling of all villi•Vessles are usually absent1919--SepSep--1212 o wardao warda
  25. 25. A sonographic findings of a molar pregnancy. Thecharacteristic “snowstorm” pattern is evident.1919--SepSep--1212 o wardao warda
  26. 26. Transvaginal sonogram demonstrating the “ snow storm” appearance.1919--SepSep--1212 o wardao warda
  27. 27. Color Dopplor facilitates visualization of the enlarged spiralarteriesclose proximity to the “ snow storm” appearance1919--SepSep--1212 o wardao warda
  28. 28. Color Doppler image of a hydatidiform mole and surroundingvessels. The uterine artery is easily identified from its anatomicallocation.1919--SepSep--1212 o wardao warda
  29. 29. 1919--SepSep--1212 o wardao warda
  30. 30. Dopplor waveform analysis demonstrates low vascular resistance(RI=0.29) inthe spiral arteries, much lower than that obtained in normal early pregnancy1919--SepSep--1212 o wardao warda
  31. 31. 1919--SepSep--1212 o wardao warda
  32. 32. Partial hydartidiform mole1919--SepSep--1212 o wardao warda
  33. 33. Microscopic image of partial molar pregnancy.1919--SepSep--1212 o wardao warda
  34. 34. Here is a partial mole in a case of triploidy. Notethe scattered grape-like masses with interveningnormal-appearing placental tissue.1919--SepSep--1212 o wardao warda
  35. 35. Large bilateral theca lutein cysts resembling ovarian germ celltumors. With resolution of the human chorionic gonadotropin(HCG)stimulation, they return to normal-appearing ovaries.1919--SepSep--1212 o wardao warda
  36. 36. Differential diagnosisDifferential diagnosis•• AbortionAbortion•• Multiple pregnancyMultiple pregnancy•• PolyhydramniosPolyhydramnios•• PolyhydramniosPolyhydramnios1919--SepSep--1212 o wardao warda
  37. 37. TreatmentTreatmentSuction dilation and curettageSuction dilation and curettage :to remove:to removebenignbenign hydatidiformhydatidiform molesmolesWhen the diagnosis ofWhen the diagnosis of hydatidiformhydatidiform mole ismole isestablished, the molar pregnancy should beestablished, the molar pregnancy should beestablished, the molar pregnancy should beestablished, the molar pregnancy should beevacuated.evacuated.AnAn oxytocicoxytocic agent should be infusedagent should be infusedintravenouslyintravenously afterafter the start of evacuationthe start of evacuationand continued for several hours to enhanceand continued for several hours to enhanceuterine contractilityuterine contractility1919--SepSep--1212 o wardao warda
  38. 38. •• Removal of the uterus (hysterectomyRemoval of the uterus (hysterectomy)) ::used rarely to treatused rarely to treat hydatidiformhydatidiform moles ifmoles iffuture pregnancy is no longer desired.future pregnancy is no longer desired.TreatmentTreatment1919--SepSep--1212 o wardao warda
  39. 39. Chemotherapy with aChemotherapy with asinglesingle--agent drugagent drugProphylactic (for prevention)Prophylactic (for prevention)chemotherapy at the time ofchemotherapy at the time ofTreatmentTreatmentchemotherapy at the time ofchemotherapy at the time ofor immediately followingor immediately followingmolar evacuation may bemolar evacuation may beconsidered for the highconsidered for the high--riskriskpatients( to prevent spreadpatients( to prevent spreadof disease )of disease )1919--SepSep--1212 oo wardawarda
  40. 40. HighHigh--risk postmolarrisk postmolartrophoblastic tumortrophoblastic tumor1.1. PrePre--evacuation uterine size larger than expectedevacuation uterine size larger than expectedfor gestational durationfor gestational duration2.2. Bilateral ovarian enlargement (>Bilateral ovarian enlargement (> 99 cm thecacm thecalutein cysts)lutein cysts)lutein cysts)lutein cysts)3.3. Age greater thanAge greater than 4040 yearsyears4.4. 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 astoxemia, hyperthyrodism and trophoblastictoxemia, hyperthyrodism and trophoblasticembolization (villi come out of placenta )embolization (villi come out of placenta )6.6. repeat hydatidiform molerepeat hydatidiform mole1919--SepSep--1212 o wardao warda
  41. 41. Patients with hudatidiform mole arePatients with hudatidiform mole arecurative overcurative over 8080% by treatment of% by treatment ofevacuation.evacuation.FollowFollow--upupevacuation.evacuation.The followThe follow--up after evacuation is keyup after evacuation is keynecessarynecessaryuterine involution, ovarian cystuterine involution, ovarian cystregression and cessation of bleedingregression and cessation of bleeding1919--SepSep--1212 o wardao warda
  42. 42. Quantitative serum hCG levels shouldQuantitative serum hCG levels shouldbe obtained everybe obtained every 11--22 weeks untilweeks untilnegative for three consecutivenegative for three consecutivedeterminations,determinations,FollowFollow--upupdeterminations,determinations,Followed by everyFollowed by every 33 months formonths for 11years.years.Contraception should be practicedContraception should be practicedduring this followduring this follow--up periodup period1919--SepSep--1212 o wardao warda
  43. 43. Invasive moleInvasive moleInvasive moleInvasive mole1919--SepSep--1212 o wardao warda
  44. 44. DefinitionDefinitionThis term is applied to a molarThis term is applied to a molarpregnancy in which molar villi growpregnancy in which molar villi growinto the myometrium or its bloodinto the myometrium or its bloodinto the myometrium or its bloodinto the myometrium or its bloodvessels, and may extend into thevessels, and may extend into thebroad ligament and metastasize to thebroad ligament and metastasize to thelungs, the vagina or the vulva.lungs, the vagina or the vulva.1919--SepSep--1212 o wardao warda
  45. 45. Invasive mole: the tissue invades into the myometrial layer.No obvious borderline, with obvious bleeding.1919--SepSep--1212 o wardao warda
  46. 46. Invasive hydatidiform mole infiltrating the myometrium1919--SepSep--1212 o wardao warda
  47. 47. 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 ofblood flow suggest an invasive mole.blood flow suggest an invasive mole.1919--SepSep--1212 o wardao warda
  48. 48. 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.1919--SepSep--1212 o wardao warda
  49. 49. Transvaginal color Doppler scan of a patient with invasive mole Followinguterine curettage, Persistent color signals within the myometeriun1919--SepSep--1212 o wardao warda
  50. 50. Doppler image of invasive mole1919--SepSep--1212 o wardao warda
  51. 51. Power Doppler easily detects a vascular echogenicnodule within the myometrium, suggestinginvasive mole1919--SepSep--1212 o wardao warda
  52. 52. Doppler image of invasive mole. Doppler waveformanalysis depicts low vascular resistance (RI= 0.35)1919--SepSep--1212 o wardao warda
  53. 53. Common Sites for MetastaticCommon Sites for MetastaticGestational Trophoblastic TumorsGestational Trophoblastic TumorsSiteSite Per centPer centLungLung 6060--9595VaginaVagina 4040--5050Vulva/cervixVulva/cervix 1010--1515Vulva/cervixVulva/cervix 1010--1515BrainBrain 55--1515LiverLiver 55--1515KidneyKidney 00--55SpleenSpleen 00--55GastrointestinalGastrointestinal 00--551919--SepSep--1212 o wardao warda
  54. 54. ChoriocarcinomaChoriocarcinomaChoriocarcinomaChoriocarcinoma1919--SepSep--1212 o wardao warda
  55. 55. DefinitionDefinitionA malignant form of GTD whichA malignant form of GTD whichcan develop from a hydatidiform molecan develop from a hydatidiform moleor from placental trophoblast cellsor from placental trophoblast cellsor from placental trophoblast cellsor from placental trophoblast cellsassociated with a healthy fetus ,anassociated with a healthy fetus ,anabortion or an ectopic pregnancy.abortion or an ectopic pregnancy.1919--SepSep--1212 o wardao warda
  56. 56. Characterized by abnormalCharacterized by abnormaltrophoblastic hyperplasia andtrophoblastic hyperplasia andanaplasia , absence of chorionic villianaplasia , absence of chorionic villiDefinitionDefinitionanaplasia , absence of chorionic villianaplasia , absence of chorionic villi1919--SepSep--1212 o wardao warda
  57. 57. Gross specimen of choriocarcinoma1919--SepSep--1212 o wardao warda
  58. 58. Microscopic image of choriocarcinomaabsence of chorionic villiabsence of chorionic villi1919--SepSep--1212 o wardao warda
  59. 59. Microscopic image of choriocarcinoma1919--SepSep--1212 o wardao warda
  60. 60. Doppler image of choriocarcinoma1919--SepSep--1212 o wardao warda
  61. 61. Doppler image of choriocarcinoma1919--SepSep--1212 o wardao warda
  62. 62. 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 metastases1919--SepSep--1212 o wardao warda
  63. 63. WHO Prognostic Scoring SystemWHO Prognostic Scoring SystemScoreScorePrognostic factorPrognostic factor 00 11 22 44Age(years)Age(years) ≤≤3939 >>3939 —— ——Pregnancy historyPregnancy historyHydatidiformHydatidiformmolemoleAbortion,Abortion,ectopicectopicTermTermpregnancypregnancy——Interval (months) ofInterval (months) oftreatmenttreatment<<44 44--66 77--1212 >>1212treatmenttreatmentInitial hCG(mIU/ml)Initial hCG(mIU/ml) <<101033 101033--101044 101044--101055 >>101055Largest tumor(cm)Largest tumor(cm) <<33 33--55 >>55 ——Sites of metastasisSites of metastasis LungLungSpleen,Spleen,kidneykidneyGI tract, liverGI tract, liver BrainBrainNo. of metastasisNo. of metastasis —— 11--44 44--88 88Previous (treatment)Previous (treatment) —— —— Single drugSingle drug 22 or moreor more0-4 low risk, 5-7 intermediate risk, >8 high risk for death1919--SepSep--1212 o wardao warda
  64. 64. FIGO Staging System for GestationalFIGO Staging System for GestationalTrophoblastic TumorsTrophoblastic TumorsStageStage DescriptionDescriptionⅠⅠ Limited to uterine corpusLimited to uterine corpusⅡⅡExtends to the adnexae, outside the uterus,Extends to the adnexae, outside the uterus,but limited to the genital structuresbut limited to the genital structuresⅢⅢExtends to the lungs with or without genitalExtends to the lungs with or without genitaltracttractⅣⅣ All other metastatic sitesAll other metastatic sites1919--SepSep--1212 o wardao warda
  65. 65. SubstagesSubstages assignedassigned forfor eacheach stagestage asasfollowsfollows::AA:: NoNo riskrisk factorsfactors presentpresentBB:: OneOne riskrisk factorfactorFIGO Staging System for GestationalFIGO Staging System for GestationalTrophoblastic TumorsTrophoblastic TumorsBB:: OneOne riskrisk factorfactorCC:: BothBoth riskrisk factorsfactorsRiskRisk factorsfactors usedused toto assignassign substagessubstages::11.. PretherapyPretherapy serumserum hCGhCG >> 100100,,000000mlU/mlmlU/ml22.. DurationDuration ofof diseasedisease >>66 monthsmonths1919--SepSep--1212 o wardao warda
  66. 66. 1919--SepSep--1212 o wardao warda
  67. 67. IIaIIb1919--SepSep--1212 o wardao warda
  68. 68. IIIa<3cm or locate in half lungIIIb disease beyond IIIa1919--SepSep--1212 o wardao warda
  69. 69. 1919--SepSep--1212 o wardao warda
  70. 70. Diagnosis and evaluationDiagnosis and evaluationGestational trophoblastic tumor isGestational trophoblastic tumor isdiagnosed by rising hCG followingdiagnosed by rising hCG followingevacuation of a molar pregnancy orevacuation of a molar pregnancy orevacuation of a molar pregnancy orevacuation of a molar pregnancy orany pregnancy eventany pregnancy eventOnce the diagnosis established theOnce the diagnosis established thefurther examinations should be donefurther examinations should be doneto determine the extent of disease ( Xto determine the extent of disease ( X--ray, CT, MRI)ray, CT, MRI)1919--SepSep--1212 o wardao warda
  71. 71. TreatmentTreatmentNonmetastatic GTDNonmetastatic GTDLowLow--Risk Metastatic GTDRisk Metastatic GTDHighHigh--Risk Metastatic GTDRisk Metastatic GTDHighHigh--Risk Metastatic GTDRisk Metastatic GTD1919--SepSep--1212 o wardao warda
  72. 72. Treatment of Nonmetastatic GTDTreatment of Nonmetastatic GTDHysterectomy is advisable as initial treatment inHysterectomy is advisable as initial treatment inpatients with nonmetastatic GTD who no longerpatients with nonmetastatic GTD who no longerwish to preserve fertilitywish to preserve fertilityThis 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 courseand shorter duration of chemotherapy.and shorter duration of chemotherapy.Adjusted singleAdjusted single--agent chemotherapy at the timeagent chemotherapy at the timeof operation is indicated to eradicate any occultof operation is indicated to eradicate any occultmetastases and reduce tumor dissemination.metastases and reduce tumor dissemination.1919--SepSep--1212 o wardao warda
  73. 73. SingleSingle--agent chemotherapy is the treatment ofagent chemotherapy is the treatment ofchoice for patients wishing to preserve theirchoice for patients wishing to preserve theirfertility.fertility.Methotrexate(MTX) and ActinomycinMethotrexate(MTX) and Actinomycin--D areD areTreatment of Nonmetastatic GTDTreatment of Nonmetastatic GTDMethotrexate(MTX) and ActinomycinMethotrexate(MTX) and Actinomycin--D areD aregenerally chemotherapy agentsgenerally chemotherapy agentsTreatment is continued until three consecutiveTreatment is continued until three consecutivenormal hCG levels have been obtained and twonormal hCG levels have been obtained and twocourses have been given after the first normalcourses have been given after the first normalhCG level.hCG level.To prevent relapse or metastasisTo prevent relapse or metastasis1919--SepSep--1212 o wardao warda
  74. 74. 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 categoryIf resistance to sequential singleIf resistance to sequential single--agent chemotherapyagent chemotherapydevelops, combination chemotherapy would be takendevelops, combination chemotherapy would be takenTreatment of LowTreatment of Low--RiskRiskMetastatic GTDMetastatic GTDdevelops, combination chemotherapy would be takendevelops, combination chemotherapy would be takenApproximatelyApproximately 1010--1515% of patients treated with single% of patients treated with single--agent chemotherapy will require combinationagent chemotherapy will require combinationchemotherapy with or without surgery to achievechemotherapy with or without surgery to achieveremissionremission1919--SepSep--1212 o wardao warda
  75. 75. Multiagent chemotherapy with or withoutMultiagent chemotherapy with or withoutadjuvant radiotherapy or surgery should beadjuvant radiotherapy or surgery should bethe initial treatment for patients with highthe initial treatment for patients with high--rist metastatic GTDrist metastatic GTDTreatment of HighTreatment of High--RiskRiskMetastatic GTDMetastatic GTDrist metastatic GTDrist metastatic GTDEMAEMA--CO regimen formula is good choice forCO regimen formula is good choice forhighhigh--rist metastatic GTDrist metastatic GTDAdjusted surgeries such as removing foci ofAdjusted surgeries such as removing foci ofchemotherapychemotherapy--resistant disease, controllingresistant disease, controllinghemorrhage may be the one ofhemorrhage may be the one of treatmenttreatmentregimenregimen1919--SepSep--1212 o wardao warda
  76. 76. EMAEMA--CO Chemotherapy for poorCO Chemotherapy for poorPrognostic DiseasePrognostic DiseaseEtoposide(VPEtoposide(VP--1616)) 100100mg/Mmg/M22 IV dailyIV daily××22 daysdays(over(over 3030--4545 minutes)minutes)MethotrexateMethotrexate 100100mg/Mmg/M22IV losding dose,IV losding dose,thenthen 200200mg/Mmg/M22overover 1212 hours dayhours day 11Actinomycin DActinomycin D 00..55mgmg IV dailyIV daily××22 daysdaysFolinic acidFolinic acid1515mg IM or p.o. qmg IM or p.o. q 1212 hourshours××44 startingstarting 2424hours after starting methotrexatehours after starting methotrexateCyclophosphamideCyclophosphamide 600600mg/Mmg/M22 IV on dayIV on day88Oncovin (vincristine)Oncovin (vincristine) 11mg/Mmg/M22 IV on dayIV on day88((Repeat everyRepeat every 1515 days as toxicity permits)days as toxicity permits)1919--SepSep--1212 o wardao warda
  77. 77. PrognosisPrognosisCure rates should approachCure rates should approach 100100% in% innonmetastatic and lownonmetastatic and low--risk metastaticrisk metastaticGTDGTDGTDGTDIntensive multimodality therapy hasIntensive multimodality therapy hasresulted in cure rates ofresulted in cure rates of 8080--9090% in% inpatients with highpatients with high--risk metastatic GTDrisk metastatic GTD1919--SepSep--1212 o wardao warda
  78. 78. FollowFollow--up After Successfulup After SuccessfulTreatmentTreatmentQuantitative serum hCG levels should beQuantitative serum hCG levels should beobtained monthly forobtained monthly for 66 months, every twomonths, every twomonths 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 yearContraception should be maintained for atContraception should be maintained for atleastleast 11 year after the completion ofyear after the completion ofchemotherapy. Condom is the choice.chemotherapy. Condom is the choice.1919--SepSep--1212 o wardao warda
  79. 79. Placenta Site TrophoblasticPlacenta Site TrophoblasticTumor (PSTT)Tumor (PSTT)Tumor (PSTT)Tumor (PSTT)1919--SepSep--1212 o wardao warda
  80. 80. Placenta Site Trophoblastic Tumor is anPlacenta Site Trophoblastic Tumor is anextremely rare tumor that arised from theextremely rare tumor that arised from theplacental implantation siteplacental implantation siteTumor cells infiltrate the myometrium andTumor cells infiltrate the myometrium andDefinitionDefinitionTumor cells infiltrate the myometrium andTumor cells infiltrate the myometrium andgrow between smoothgrow between smooth--muscle cellsmuscle cells1919--SepSep--1212 o wardao warda
  81. 81. 1919--SepSep--1212 o wardao warda
  82. 82. Surum hCG levels are relatively lowSurum hCG levels are relatively lowcompared to those seen withcompared to those seen withchoriocarcinoma.choriocarcinoma.Several reports have noted a benignSeveral reports have noted a benignDignosis and treatmentDignosis and treatmentSeveral reports have noted a benignSeveral reports have noted a benignbehavior of this disease. They are relativelybehavior of this disease. They are relativelychemotherapychemotherapy--resistant, and deaths fromresistant, and deaths frommetastasis have occurred.metastasis have occurred.Surgery has been the mainstay of treatmentSurgery has been the mainstay of treatment1919--SepSep--1212 o wardao warda
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