3. Clinical classification :
Benign = 80% (HM)
• Partial HM .
• Complete HM .
Malignant=20% (GTN) include
• Persistant or invasive mole =12-15% of
cases.
• Choriocarcenoma=5-8% of cases .
• Placental site trophoblastic tumor (rare).
4. Epidemiology
• Less than 1 in 1000 pregnancies world
wide
• 2 in 1000 in Asia .
• Risk of recurrence is 1 % (previous one
mole).
• 25% (previous two moles).
5. Risk factors
• Extremes of maternal age
• previous history of molar pregnancy or
spontaneous abortion .
• The incidence is in excess in maternal blood
group A, and deficit in group O.
• Low socioeconomic state
• Using of oral contraceptive pills
7. Comparison of Complete and partial
moles
Feature Complete Mole Partial Mole
Age Greater risk (5-103) Not age related
Karyotype 90% XX, 10% XY
All chromosomes paternally
derived
XXX or XXY
1 Chromosome set maternal:
2 chromosome sets paternal
Fetus Absent Present
hCG Often > 100.000 mIU/mL Rarely elevated above
normal levels for pregnancy
Primary Symptom Bleeding Bleeding
Secondary
Symptoms
Large uterine size for
gestational age
Hyperemesis
Theca Lutein cysts
Preeclampsia
Hyperthyroidism
Un common
Risk of persistence
(GTN)
20% 4%
9. Management of HM :
• In general , the more active trophoblastic
appearance the greater the risk of malignancy.
• Patients with hydatidiform mole are curative over
80% by treatment of evacuation. (suction curettage)
• About 90% of cases ,the trophoblastic tissue die out
completely.
• About 10% of cases the trophoblastic tissue does not
die out completely and may persist or recur as
invasive mole or choriocarcinoma.
10. The follow-up after moler evacuation
:
1-2 wkly hcg levels.
If hcg becomes normal within 56 days then
F/up is for 6 months from date of evacuation.
If hcg does not revert to normal with in 56
days then F/up is for 6 months from the
normalization of of hcg.
11. Indication of chemotherapy after the
evacuation of the hydatidiform mole :
• Serum hCG >20000 i.u/L , at any time after
evacuation of mole.
• Raised hCG at 4 to 6 weeks after evacuation
of mole.
• Evidence of metastases ,hepatic ,brain and
pulmonary.
• Persistent uterine hemorrhage after
evacuation of mole with raised hCG levels.
13. Gestational trophoblastic neoplasia (GT
GTN defines a heterogeneous group of
lesions that represent an aberrant
fertilization event.
The pathogenesis is unique because the
maternal tumor arises from fetal tissue.
It is the most curable gynecologic
malignancy.
Malignant trophoblastic disease can exist
in:
Invasive mole ( = non – metastatic form).
14. Invasive mole
The diagnosis of invasive moles or
“chorioadenoma destruens” is applied to the
moles characterized by :
Abnormal peneterativeness
Extensive local invasion
Excessive trophoblastic proliferation
With preserved villous pattern.
15. Clinical Manifestation
irregular vaginal bleeding.
uterine subinvolution.
theca lutein cyst does not disappear after
emptying uterus.
abdominal pain.
metastatic focus manifestation.
Diagnosis
history and clinical manifestation.
successive measurement of HCG.
ultrasound examination.
17. Choriocarcinoma(metastatic GTN)
Choriocarcinoma subdivide into:
good-prognosis (low risk).
Poor- Prognosis (High risk).
Epidemiology
Incidence West: 1 :10000 and 1 : 70000 pregnancies;
and ,in Asia 1:6000 pregnancies.
The antecedent pregnancy is :
Hydatidiform mole in about 5o% of cases.
Normal pregnancy in about 25% of cases.
Abortion and ectopic pregnancy in about 25 % of cases.
Choriocarcinoma is more likely to occur after
complete mole .
18. Pathological features
Site :
In the uterus 90 % of cases; 10 % of cases in the ,
vagina, lung, liver, and brain.
Macroscopically:
Uterus : It may be localized in the form of hemorrhagic
polyp or multiple hemorrhagic ,necrotic masses in the
cavity.
Some times it is present in the uterine wall ( intramural )
and the cavity is empty.
Microscopically:
Malignant hyperplasia of both cytotrophoblasts ,
and syncytiotrophoblasts.
Extensive hemorrhage.
Absence of villi.
Destruction of the surrounding myomatrum.
19. Spread
Direct : Through the myomatrum and may end
in uterine perforation , internal hemorrhage,
and peritonitis .
Blood : The main method of spread ,and
occurs to;
Genital : Vagina ( 30% ).
Extra genital : Lung ( 80% ) , ( the
commonest site liver , brain (10%) and
bones especially skull and spine.(10%).
20. Causes of death in choriocarcinoma :
• Vaginal bleeding.
• Haemoptysis.
• Intraperitoneal hemorrhage.
• Peritonitis.
• Metastasis to the vaital organs e.g ,brain.
• Pulmonary complications.
21. Clinical feathers
Symptoms :
Expulsion of vesicular mole
Persistent vaginal bleeding is the commonest presentation.
Haemoptysis.
Abdominal pain.
Palpable abdominal mass
neurological symptoms.
Signs:
Marked deterioration of the general condition.
An abdominal swelling may be felt.
The uterus symmetrically enlarged.
Hemorrhagic secondaries may be seen in the vagina.
24. Clinical classification of GTN
According to the FIGO system
score 6 and below receive low-risk
treatment
while patients scoring 7 are given high-risk
treatment (chemotherapy )
25. The international federation of gynaecology and obstetrics(FIGO) prognostic
scoring system employed for assessing the intensity of the initial
chemotherapy treatment.
Score 0 1 2 4
Age ( years ) < 40 ≥ 40 - -
Antecedent pregnancy Mole Abortion Term -
Months from index
pregnancy
< 4 4-6 7-13 ≥13
Pre-treatment hCG
(IU/L)
< 1000 1000-10000 1000-100000 >100000
Largest tumour size < 3cm 3 - 5cm ≥ 5cm -
Site of metastases Lung Spleen, kidny gastrointestin
al
Brain , liver
Number of metastases - 1 - 4 5 - 8 > 8
Previous
chemotherapy
- - Single agent Two or more
drugs
27. Medical (chemotherapy)
I. Non metastatic and good prognosis GTN we
use the
Single agent chemotherapy .
Methotrexate ( antimetabolite ) + folinic
acid .
Actinomycin D ,if there is resistance .
Treatment is 100 % successful.
28. II. Poor Prognosis metastatic trophoblastic
neoplasia and drug resistant tumor we use
Multiple agent chemotherapy is
recommended in this disease.
EMA - CO is considered the regimen of
choice in most high–risk patients (Etoposide
, Methotrexate, Actinomycin D ,
Cyclophosphamide, Vincristin ).
survival rate is 80 – 85 %.
29. Surgery:
• Total abdominal hysterectomy may be done in
patients not desirous of further reproduction ,
and in old age woman.
• Surgical excision of isolated metastases e.g.
pulmonary if resistant to chemotherapy.
• operation is also important in controlling
bleeding , infection, complication.
• in removing remained or drug-resistant foci.
Irradiation
Whole brain irradiation for cerebral
30. Follow-up
• After successful therapy , physical
examination , and chest x-ray follow - up
together with the hCG levels are obtained
for serial interval measurement .
• If at any time hCG levels rises , repeat
the evaluation , staging ,and chemotherapy.
• Women who undergo chemotherapy are
advised not to conceive for one year after
completion of treatment.
31. Placental Site Trophoblastic Tumor .
• Rare tumors ( 0.23% cases of GTD).
• It has a variety of clinical features and
its course is unpredictable.
• Can appear shortly after termination of
pregnancy or years later.
• Hysterectomy is considered optimal therapy
and is usually adequate in most situations.
• It has normal HCG level but high
human placental lactogen level so used as a
32. Future Childbearing
• After treatment of GTN, molar pregnancies
occur in only about 1-2 % of subsequent
pregnancies.
• Fertility rates and pregnancy outcomes
are similar in patients treated for GTD
compared with the general population .
