NOTES FOR UNDERGRADUATES AND POSTGRADUATES IN GYNE

1. DR.PRIYA SAXENA

2.  Gestational trophoblastic tumors include:
o Invasive mole
o Choriocarcinoma
o Placental site trophoblastic tumor

3.  H.mole which has invaded the myometrium
 It can progress to choriocarcinoma but may regress spontaneously
 Locally invasive but do not usually metastasize
 If serosa is involved-it may cause intraperitoneal hemorrhage
 It may need hysterectomy as treatment for intractable bleeding.

4.  Special tumor arising from the placental implantation site
 It can be of:
o Low or
o High grade malignancy
 Characteristic histology-composed mainly of cytotrophoblastic elements
arising from intermediate trophoblast of placental bed.
 Bleeding-presenting symptom
 Serum beta HCG-may be only marginally increased
 Immunohistochemistry stains of the tumor tissue-positive for HPL
 Chemotherapy-usually not effective
 It requires hysterectomy for treatment.

5.  Carcinoma of the chorionic epithelium.
 Half the cases follow a hydatiform mole,25% follow an abortion and 25%
follow a normal pregnancy.
 There is absence of villus pattern on histology which differentiates it
from hydatiform mole.
 There is marked elevation of beta-HCG levels.

6.  Abnormal uterine bleeding
 Symptoms due to metastasis like hemoptysis or features suggestive of an
intracranial space occupying lesion. The common sites of metastasis are
the lungs in 75% cases and suburethral vaginal metastasis in 50% cases.
 Theca-lutein cysts of the ovaries are usually seen.
 Rapidly increasing levels of beta-HCG.
 Histopathological diagnosis of choriocarcinoma on curettage for irregular
bleeding.

7. STAGE 1 Tumor confined to the uterine corpus
only
STAGE 2 Tumor extends to the adnexae
outside the uterus but is limited to the
genital structures
STAGE 3 Tumor extends to lungs with or
without genital involvement
STAGE 4 Metastasis to any other
site(eg.liver,brain,etc)

8. Prognostic
factors
Score
0 1 2 4
Age(years) ≤39 >39
Antecedent
pregnancy
Hydatiform mole Abortion Term pregnancy
Interval from
antecedent
pregnancy(month
s)
<4 4-6 7-12 >12
Pre-treatment
HCG(IU/L)
<103 103-104 104-105 >105
Largest tumor
size including
uterus
3-4cm 5cm
Site of metastasis lungs Spleen,kidneys Gastrointestinal
tract
Brain,liver

9. Number of
metastasis
identified
0 1-4 5-8 >8
Previous failed
chemotherapy
- - Single drug Two or more
drugs

10.  A score of 0-6 indicates low risk
 A score ≥7 indicates high risk

11.  Low risk disease:
 Methotrexate is given for low risk disease
 The recommended regimen is Methotrexate alternating with folinic acid
 Methotrexate 1mg/kg body weight is given i.m. on days 1,3,5 and 7 and
folinic acid 0.1 mg/kg body weight on days 2,4,6 and 8
 The courses are repeated at intervals of every 2 weeks.
 Chemotherapy is continued for three courses after the beta-HCG levels
become normal
 Thereafter, levels are checked monthly
 Actinomycin-D in dose of 1.25 mg/m2 every 2 weeks is used for
methotrexate resistance or where methotrexate is contraindicated.

12.  High risk disease:
 The most commonly used regime is the EMACO regime which consists
of Etoposide,Methotrexate,Actinomycin-D, Cyclophosphamide and
Vincristine
 Cycle is repeated every 2 weeks until the beta-HCG is negative,
following which 3 more cycles are given

13.  Invasive mole perforating the serosa causing an intraperitoneal bleeding
 Uncontrollable vaginal bleeding
 Drug resistance
 Placental site trophoblastic tumor

14.  Follow-up and avoidance of pregnancy for atleast 1 year is essential after
chemotherapy
 Women with any form of trophoblastic disease are at increased risk of
developing trophoblastic disease in a subsequent pregnancy.
 It is important to send the placenta for histopathological examination in a
subsequent pregnancy and to do beta-HCG estimations 6 weeks after
delivery to rule out the possibility of developing any gestational
trophoblastic neoplasia.

15. THANK YOU