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Maladies trophoblastiques

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SAGO 2015 Blida Algerie

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Maladies trophoblastiques

  1. 1. MALADIES TROPHOBLASTIQUES Pr Ag Mourali Mechaal Rt Ben khedija Centre de Maternité de Bizerte Tunisie
  2. 2. INTRODUCTION
  3. 3. MOLE HYDATIFORME
  4. 4. TTG les tumeurs trophoblastiques du site d’implantation (TTSI) et les tumeurs trophoblastiques épithelioides(TTE).
  5. 5. ÉPIDÉMIOLOGIE 12/10000,5-1/1000 0,5-1/1000 1,5-6/1000
  6. 6. FACTEURS DE RISQUES
  7. 7. A
  8. 8. MOLE HYDATIFORME COMPLÈTE Produit de conception diploïde, mais dont les deux lots chromosomiques sont d’origine paternelle: Par dispermie: 20% Par diandrie: 80%
  9. 9. MOLE INCOMPLÈTE Produit de conception triploïde : fécondation d’un ovocyte par deux spermatozoïdes (dispermie) Dysgénie duplication ovocyte ou non expulsion du globule polaire
  10. 10. MOLE HYDATIFORME COMPLÈTE
  11. 11.   CHM PHM Age>40 24.3% 12.5% Age <20 1.9% 4.1% Nulliparity 22.5% 29.2% Multiparity 18% 2% History of Abortion 29% 29% History of mole 3.73% 0% DIU 15.9% 6.3% OP 19.6% 16.7% A+ 29% 39.6% A- 4.7% 0% Mean gestational Age 11.5 11 metrorrhagia 75% 67% Ex sympatic signs 17% 12% Anemia 41.5%   HTA 5% 6% hyperthyroïdy 0.93% 0% Uterine size 41% 37% Ovarian cysts 16% 12% Snowstorm appearance 61% 44% Visible embryo 6.5% 35.5% Mean βHCG 183.5*10³ UI/l 103.1*10³ UI/l
  12. 12. MOLE HYDATIFORME COMPLÈTE ECHOGRAPHIE
  13. 13. ECHOGRAPHIE
  14. 14. ECHOGRAPHIE
  15. 15. ECHOGRAPHIE
  16. 16. CAT DEVANT UNE MH Aspiration utérine échoguidée(risque de rétention) Pas de curetage(perforation, synéchies) Ocytociques Reserve de sang Anti D si RH négatif Adresser le produit à l examen anatomopathologique Récidive (0.6%–2%) Trophoblastic Disease Review for Diagnosis and Management. A Joint Report From the International Society for the Study of Trophoblastic Disease, European Organisation for the Treatment of Trophoblastic Disease, and the Gynecologic Cancer InterGroup. Giorgia Mangili, MD,* Domenica Lorusso, MD,Þ Jubilee Brown, MD. Int J Gynecol Cancer 2014;24: S109YS116)
  17. 17. ÉVOLUTION Suivi β HCG MC: 15-20% vers GTT MP: 0,1-5% vers GTT • Persistent gestational trophoblastic neoplasia after partial hydatidiform mole incidence and outcome. Hancock BW, Nazir K, Everard JE. J Reprod Med 2006;51(10): 764–6. • Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. Lurain JR. Am J Obstet Gynecol 2010;203(6):531–9.
  18. 18. PROPHYLACTIC CHEMOTHERAPY FOR HYDATIDIFORM MOLE TO PREVENT GESTATIONAL TROPHOBLASTIC NEOPLASIA. FU J, FANG F, XIE L, ET AL. COCHRANE DATABASE SYST REV. 2012;10:CD007289. Réduction à 3-8% des GTT post-MHC
  19. 19. ASIAN PAC J CANCER PREV, 16 (6), 2441-244
  20. 20. MOLE INVASIVE • métastases dans 15 %
  21. 21. IMAGERIE
  22. 22. IMAGERIE
  23. 23. CHORIOCARCINOME Le choriocarcinome est souvent d’emblée métastatique : 80% 30% 20% 20% 10%
  24. 24. IMAGERIE
  25. 25. DIAGNOSTIC DES TTG Ngan HY, Bender H, Benedet JL, Jones H, Montruccoli GC, Pecorelli S, et al. Gestational trophoblastic neoplasia, FIGO 2000 staging and classification. Int J Gynecol Obstet 2003;83(Suppl. 1):175–7.
  26. 26. TABLEAU CLINIQUE DES TTG Le diagnostic peut également être suspecté sur des critères cliniques :  Les métrorragies  L’apparition de signes d’hyperthyroidie  Les troubles respiratoires ,troubles neurologiques;  Le syndrome hémorragique aigu sur un site métastatique .
  27. 27. MALADIE DU SITE D’INSERTION PLACENTAIRE  0,2% des GTD  Infiltration trophoblastique de l’endométre et du myométre sur le site d’insertion du placenta.  Cellules trophoblastiques intermédiaires le plus souvent mononuclées, de forme polyédrique  Sécrète peu d’hcg. Plus d’hpl  Importante chimiorésistance.
  28. 28. BILAN D’EXTENSION DES TTG
  29. 29. CLASSIFICATION ET SCORE PRONOSTIQUE Stade anatomique FIGO 2000 I Maladie limitée à l’utérus II TTG étendue en dehors de l’utérus, mais limitée aux structures génitales (annexes, vagin, ligament large) III TTG étendue aux poumons avec ou sans atteinte connue du tractus génital IV Tout autre site métastatique
  30. 30. • Deux groupes de patientes en fonction de leur score pronostique: ≤ 6 : TTG à faible risque d’échec du traitement ≥ 7 : TTG à haut risque d’échec du traitement.
  31. 31. FIRST-LINE CHEMOTHERAPY IN LOW- RISK GESTATIONAL TROPHOBLASTIC NEOPLASIA (REVIEW 2015) ALAZZAM M, TIDY J, HANCOCK BW, OSBORNE R, LAWRIE TA • Methotrexate eight-day regimen (1 mg/kg intramuscular (IM), days one, three, five and seven) with folinic acid rescue (days two, four six and eight), repeated every 14 to 16 days (Bagshawe 1989 • Low-dose (30 to 50 mg/m²) IM methotrexate, repeated weekly (Homesley 1988; Homesley 1990); • Five-day low-dose methotrexate (intravenous (IV) or IM); maximum of 25mg/m² daily for five days, repeated every 14 days(Soper 1994 • Pulsed IV dactinomycin (1.25 mg/m² to a maximum 2 mg single dose), repeated every 14 days (Twiggs 1983; • Five-day dactinomycin (0.5 mg IV), repeated every 14 days (Osathanondh 1975
  32. 32. ROLE OF SURGICAL THERAPY IN THE MANAGEMENT OF GESTATIONAL TROPHOBLASTIC NEOPLASIA. KYUNG JIN EOH, YOUNG SHIN CHUNG, GA WON YIM ET AL. OBSTET GYNECOL SCI 2015;58(4):277-283 L’hysterectomie raccourcie les délais de guérison Haut risque: chimiorésistance Contrôle de l’hémorragie
  33. 33. • After treatment of GTN, frequent monitoring of hCG for at least 12 months with reliable contraception is essential for surveillance of relapse.
  34. 34. TAKE HOME MESSAGES • HCG + echo; diagnostic et surveillance • Chimio prophylaxie discutable • TTG: HCG, choriocarcinome ou métastases • Score OMS • Méthotrexate si faible risque • EMA-CO si risque élevé
  35. 35. MERCI

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