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  1. 1. Gestational trophoblastic diseases
  2. 2. <ul><li>They arise from the trophoblast of the balstocyst and are classified as: </li></ul><ul><li>* hydatidifrom mole (molar pregnancy) (80%) </li></ul><ul><li>Complete (classic) </li></ul><ul><li>Incomplete (piratical) </li></ul><ul><li>* gestational trophoblatic neoplasia </li></ul><ul><li>Non-metastatic = invasive mole = chorio –adenoma destruens (16%) </li></ul><ul><li>Metastatic =Choriocarcinoma = chorion epithelioma (4%) </li></ul><ul><li>Low – risk </li></ul><ul><li>High – risk </li></ul>
  3. 3. Choriocarcinoma
  4. 4. Pathology : <ul><li>Incidence : 1: 250-5000 pregnancies in Asia and 1:4000 in the west. </li></ul><ul><li>Origin: </li></ul><ul><li>* Choriocarcinoma is a malignant tumour of the trophoblast. </li></ul><ul><li>1- About 50% of cases follow molar pregnancy. </li></ul><ul><li>2- 25% follow abortion </li></ul><ul><li>3- 23% follow normal pregnancy </li></ul><ul><li>4- 2% follow ectopic pregnancy. </li></ul><ul><li>* In rare cases, the tumour arises as a teratoma in the ovary or testicle. </li></ul>
  5. 6. <ul><li>Macroscopic appearnce: </li></ul><ul><li>The tumor arises in the endometrium as </li></ul><ul><li>a soft friable dark red hemorrhagic mass projecting into the uterine cavity and may from a polyp. </li></ul><ul><li>Malignant tissue may be buried within the myometrium , inaccessible to the curette, or hidden in a distant metastasis. </li></ul><ul><li>However, any of these tumor patterns secretes (hCG) which causes cystic changes of the ovaries in about 30% of cases.. </li></ul>
  6. 7. <ul><li>Microscopic appearance: </li></ul><ul><li>The tumour consists of cyto-and synecytiotrophoblasts showing malignant characters, invading the myometrium and blood vessels. Chorionic villi are absent this differentiates Choriocarcinoma from invasive mole. </li></ul>
  7. 9. <ul><li>Mode of spread: </li></ul><ul><li>direct spread: to the parametrium, tubes and ovaries. </li></ul><ul><li>Blood spread: occurs early to distant organs. The commonest sites are lunges (80%), vegina (30%), brain (10%) and liver (10%) </li></ul>
  8. 10. FIGO classification : <ul><li>Stage I confined to uterine corpus. </li></ul><ul><li>Stage II metastases to pelvis and vagina </li></ul><ul><li>Stage III metastases to lung </li></ul><ul><li>Stage IV metastases to other organs . </li></ul>
  9. 11. multiple single chemotheraby 9 >8 4-8 1-4 n.Of metastis 8 Brain Liver-GIT Spleen -kidney site of metastis 7 >5 3-5 Tuomer d 6 B-AB O-A Abo group 5 >100000 10000-100000 1000- 10000 1000 HCG iu/l 4 >12 7-12 4-6 4 Interval month 3 Full term abo V.M Associated pregnancy 2 <39 ≥ 39 Age (years) 1 S4 S2 S1 S 0 Prognostic factor
  10. 12. <ul><li>Bagshwe score </li></ul><ul><li>Total score </li></ul><ul><li>≤ 4 low risk </li></ul><ul><li>5-7 moderate risk </li></ul><ul><li>>8 high risk </li></ul>
  11. 13. Diagnosis: <ul><li>A- symptoms: </li></ul><ul><li>1- Persistent or irregular vaginal bleeding: it is the commonest symptom occurring after labor, abortion or evacuation of a vesicular mole. Bleeding can occur within days or months but rarely after 2 years. </li></ul><ul><li>2- Vaginal discharge: which is blood stained and offensive due to ulceration and infection of the growth . </li></ul><ul><li>3- amenorrhea: may be present due to continuous hCG production. </li></ul>
  12. 14. <ul><li>4- Acute abdominal pain: due to intraperitoneal haemorrhage as a result of perforation of the uterus by the growth. </li></ul><ul><li>5- Abdominal or vaginal swelling: may develop. </li></ul><ul><li>6- Symptoms of metastases: as dysponea, haemoptesis, jaundice and neurological symptoms as headache may be the first manifestation of the tumor. </li></ul>
  13. 15. <ul><li>B- signs: </li></ul><ul><li>(1) cachexia and severe anaemia. </li></ul><ul><li>(2) fever may be present due to infection and necrosis </li></ul><ul><li>(3) the uterus may be normal size or enlarged and soft. </li></ul><ul><li>(4) the ovaries: may be enlarged and eystic. </li></ul><ul><li>(5) metaststic nodules: in the vulva or vagina </li></ul>
  14. 16. C- investigations : <ul><li>(1) uterine curettage: should be done in every case of persistent or irregular uterine bleeding after labour, abortion or molar pregnancy. However, intramural tumour cannot be detected by curettage. </li></ul><ul><li>(2) serum β- subunite of hCG: persistent or rising titres in absence of pregnancy are indicative of trophoblastic neoplasia . </li></ul><ul><li>(3) biopsy: from metastatic valvar or vaginal lesions. </li></ul>
  15. 17. <ul><li>(4) imaging : </li></ul><ul><li>a- plain X-ray chest: may show secondaries in the form of &quot; cannon balls&quot; or &quot;snowstorm&quot; appearance. </li></ul><ul><li>b- ultrasonography: to detect tumour, cystic ovaries and exclude remnants of conception. </li></ul><ul><li>c- CT scan: for lungs, liver, brain and bone. </li></ul><ul><li>(5) lumbar puncture : plasma hCG/ CSF hCG ratio less than 60 strongly CNS involvement my metastases </li></ul><ul><li>(6) blood studies : </li></ul><ul><li>a- complete blood picture including platelet count </li></ul><ul><li>b- Renal, liver and thyroid function tests </li></ul><ul><li>c- Blood group. </li></ul>
  16. 20. Treatment: <ul><li>The treatment of choice </li></ul><ul><li>chemotheraphy </li></ul>
  17. 21. <ul><li>Hysterectomy may be indicated in the following conditions: </li></ul><ul><li>severe uterine bleeding </li></ul><ul><li>perforation of the uterus with intraperitoneal haemorrhage. </li></ul><ul><li>Massive haemorrhage from the bowel </li></ul><ul><li>Torsion of a theca lutein cyst. </li></ul><ul><li>Durg resistance or toxicity. </li></ul><ul><li>Persistant localised metastases in the vagina, lung or brain after chemotherapy </li></ul>
  18. 22. Chemotherapy: <ul><li>(I) low- risk group score ≤ 4 : </li></ul><ul><li>Single cytotoxic drug either methotrexate or actinomycin D </li></ul><ul><li>(II) High-risk group score >8 : </li></ul><ul><li>Multiple cytotoxic drugs </li></ul>
  19. 23. Thank you