Gestational trophoblastic neoplasia

1. Gestational Trophoblastic Disease
:GTD
 Dr Mebanshanbor Garod
 (MS General Surgery, FMAS,
 FEBS Surgical Oncology)

 Surgical Oncology Dept.,
 NEIGRIHMS, Shillong

2. A spectrum of interrelated conditions
originating from placenta:
Pre malignant conditions:
 Complete (CHM) and
 Partial hydatidiform moles moles (PHM)
 Invasive Mole
Malignant conditions:
 Choriocarcinoma
 Placental Site Throphoblastic Tumor (PSTT)
 Epitheloid trophoblastic tumor (ETT)

3. Persistent GTD (aka GTN) rises from
cytotrophoblast and syncitial cells of villous
trphoblast ,produces hCG
PSTT & ETT originates from intermediate
cells of extra villous trophoblast & sparsely
produce hCG

4. 1 in 1500 pregnancy
Very young <16 years; advanced maternal
age >45 years.
20% will develop malignant sequelae.

6. 1. CLINICAL; Usually during the first trimester of
pregnancy
 most common symptom: abnormal bleeding
 hyperemesis gravidarum
 uterine enlargement greater than expected for
gestational age (CHM)
 absent fetal heart sounds
2. USG “snowstorm” appearance, cystic
enlargement of the ovaries in 2nd trimester
(CHM)
3. hCG>I00000 mIU/ml

7. Rule out complictions (preeclampsia,
anemia etc)
Hysterectomy Vs Suction curettage

8. Increasing hCG levels :
• Increase of three values > 10% over 2 weeks or
• Plateau (four values ± 10% over 3 weeks )
• hCG > 20000 IU/l after >4 weeks after evacution
Histologic diagnoses of Choriocarcinoma
or invasive mole from uterine currettage
Clinical or radiographic evidence of
metastases

9. CC occurs in approximately 1 in 20,000–
40,000 pregnancies
 50% after term pregnancies
25% after molar pregnancies
 remainder after other gestational events
PSTT/ETT can develop after any type of
pregnancy

10. CC & PSTT/ETT:
Diagnosis tricky: months to years after
pregnancy as symptoms are non specific
Urine/serum hCG not always elevated

11. 1. hCG
2. HISTOPATH: D&C for hyditaform mole
3. USG Pelvis
4. CT Chest: Persistent GTD or CC
(suspicious CXR findings)
5. MRI Brain: neurological symptoms or
lung mets on CT

14. STaGE I
1. Hysterectomy
2. Single agent Chemotherpy: MTX-F or Act
D

18. Stable hCG for three consecutive weeks
Re-elevated hCG
Not falling at least once within 18 days of
first treatment

20. All patients treated with combination
chemotherapy
Selective use of Radiation therapy and
surgery

22.  three drug doublet regimen TE/TP
Paclitaxel etoposide and cisplatin

24. Little application
Selected patients with cerebral mets
WBI (3000 cGY)

25. Hysterectomy : heavy bleeding, large bulky
intrauterine masses, sigificant pelvic
sepsis
Unresponsive solitary masses in the
liver/spleen/kidneys
Persistent lung nodules: solitary, limited to
one lung, hCG < 1000

27.  Stage I: TAH, Pelvic LN sampling
 Other stages & Metastatic disease: multi
agent CT , EP/EMA

29. FIGO scoring system : determine the risk of
resistance.
FIGO
1. 0-6: single agent MTX/FA or ACT-D
6 weeks maintenance after normalisation of HCG
2. >/ 7 multi agent CT EMA/CO
6 weeks maintenance therapy/8 weeks with poor pgronostic factors
(liver/brain mets)
3. Ultra high risk : EP/EMA or TE/TP

30. • Surgery : isolated foci of chemo-resistant disease
• PSTT/ETT
 Stage I: TAH, Pelvic LN sampling
 Other stages & Metastatic disease: multi agent CT , EP/EMA