Gestational trophoblastic neoplasia (GTN) includes rare gynecological malignancies from abnormal placental cells, highlighting the necessity for early diagnosis and prompt treatment for favorable outcomes. Key symptoms include unusual vaginal bleeding, an enlarged uterus, and elevated β-hCG levels, which require comprehensive monitoring through imaging and therapeutic interventions. A case study illustrating the management of a hydatidiform mole emphasizes the effectiveness of a multidisciplinary approach and individualized chemotherapy in treating invasive moles.

2. Understanding
Gestational
Trophoblastic Neoplasia
Gestational Trophoblastic Neoplasia (GTN) encompasses a suite of rare
but significant gynecological malignancies arising from aberrant
placental trophoblast cells. As medical professionals and researchers,
our comprehension of GTN's complexities is crucial for accurate
diagnosis and effective treatment. This introduction serves to illuminate
the key features, diagnostic procedures, and treatment protocols
associated with GTN, helping to navigate the intricate landscape of this
disease.

3. Incidence and Significance of GTN
0.5 - 2%
1K Pregnancies
(American)
0.5 - 0.6%
1K Pregnancies
(Indian)
100%
Curability
Though rare, GTN is often
treatable when identified
promptly, highlighting the
importance of awareness and
early detection among clinicians.

4. Gestational Trophoblastic Disease
Classification
Pre-Malignant Conditions
• Partial Hydatidiform Moles
• Complete Hydatidiform Moles
Malignant Neoplasia
• Invasive Mole
• Choriocarcinoma
• Placental Site Trophoblastic Tumor
• Epitheloid Trophoblastic Tumor
• Atypical Placental Site Nodule

5. Recognizing GTN Symptoms
1 Vaginal Bleeding
Unusual bleeding may
be indicative of underlying
trophoblastic proliferation,
necessitating further
investigation.
2 Enlarged Uterus
Physical examination may
reveal a uterus that is
larger than expected for
gestational age or
postpartum status.
3 Elevated β-HCG
Critically high serum or
urinary β-HCG levels can
point to the possibility of
invasive mole or
choriocarcinoma.

6. Case Study:
Management of
Hydatidiform Mole
A comprehensive overview of a complex case of hydatidiform mole which
evolves into a gestational trophoblastic neoplasm, exploring the
diagnostic process, treatment regimen, and follow-up protocols — an
invaluable resource for medical practitioners and students delving into the
intricacies of gynecologic oncology.

7. Initial Presentation and Diagnosis
The journey of the patient's medical ordeal begins with 20 years old G2A1 with complaints
of bleeding PV and pain in abdomen for 5 days.
6 months ago patient was apparently alright when she missed her period with UPT positive
status.
USG suggestive of Hydatiform mole.
Suction Evacuation was done in Rajasthan for the same.
B – HCG level was not done.

8. Intervention and Challenges
Upon facing continuous symptoms, the patient undergoes repeat curettage in a private
clinic after 2 months where B – HCG levels were 5000. Persistent bleeding and rising β-
HCG levels not only complicate the patient’s condition but also necessitate more intensive
monitoring and treatment strategies — an ordeal posing substantial risk and requiring
unwavering attention.
Repeat Curettage
Enduring persistent
bleeding, the patient
undergoes a second
curettage, highlighting
the relentless pursuit for
remedial action.
β-HCG Monitoring
The β-HCG levels at
5,000 miu/ml signal an
ongoing concern,
followed by a rise to
14,000 miu/ml, implying
increased risks and
challenges.
Intensified
Surveillance
The development of an
adnexal mass 5*3*2 cm
underscores the need for
vigilant monitoring
through ultrasound, MRI,
and tumor markers,
culminating in a suspect
diagnosis of gestational
trophoblastic neoplasm.

9. Patient came to us with above said reports.
Vital parametrs were normal.
Per Speculum – Minimal bleeding present
Cervix and vagina healthy
Per vaginal – Uterus normal size,
Anteverted,
Cystic swelling of 4*4cm in left adnexa and 2*3cm in right adnexa
DIAGNOSIS – INVASIVE MOLE WITH LEFT ADNEXAL INVOLVEMENT

11. Pathology of Invasive Moles
1 Post-Molar Occurrence
Invasive moles frequently develop following the evacuation of a molar
pregnancy, entailing abnormal trophoblastic growth.
2 Tissue Invasion
The characteristic edematous villi can proliferate and penetrate the
myometrium and nearby structures, indicating potential for significant
complications.
3 Diagnostic Features
Persistent elevated β-HCG levels and distinct ultrasonography findings
help distinguish invasive moles from other conditions.

12. Therapeutic Strategy
Beginning with a multidisciplinary assessment, the patient embarks on a targeted
chemotherapy regimen, reflecting a methodical and precise treatment strategy drawn from
modern oncologic practices.
Medical Oncology
Under the guidance of a
medical oncologist, a
customized plan is
crafted starting with
methotrexate therapy —
a cornerstone of
treatment.
Chemotherapy
The patient receives
meticulously calculated
doses of methotrexate
with careful leucovorin
rescue to strategically
combat the trophoblastic
cells.
Safety Protocols
Monitoring total blood
cell count and organ
function tests ensures
patient safety amidst the
aggressive elimination of
neoplastic tissue.

13. Clinical Response and Follow-Up
The patient's clinical response to the chemotherapy regimen is meticulously documented,
showcasing the dynamism and unpredictability inherent in oncological treatments. Post-
therapy monitoring attests to the therapy's effectiveness and serves as a beacon of hope for
future patient care strategies.
Post-Therapy β-HCG
Following the second
chemotherapy cycle,
the patient's β-HCG
levels drop to
undetectable, marking
a significant milestone
in the recovery journey.
Rigorous Follow-Up
Regular β-HCG
monitoring post-
therapy ensures that
the patient maintains a
non-elevated level, a
critical aspect of
ongoing care.
Long-Term
Surveillance
Continued vigilance in
monitoring β-HCG
levels fortifies against
recurrence,
exemplifying the
thoroughness of follow-
up in oncology.

14. Learning Points
This case provides a rich mosaic of learnings that extend beyond the immediate clinical
aspects, serving to enhance the collective medical knowledge in gynecologic oncology and
patient care protocols.
1 Diagnostic Accuracy
Effective diagnosis relies on
combining clinical presentation with
precise imaging and β-HCG level
monitoring — a balance of art and
science.
2 Multidisciplinary Approach
Successful treatment outcomes
stem from an integrated
multidisciplinary approach, wherein
various specialties converge to offer
comprehensive care.
3 Treatment Individualization
Each patient's treatment journey is unique and must be personalized, as exemplified
by the customized chemotherapy regimen detailed in this case.

15. WHO PROGNOSTIC SCORE

16. Diagnostic Tools for GTN
Ultrasonography
Ultrasonography is central to
identifying suspicious masses
or growths in the uterus
associated with GTN.
β-HCG Monitoring
Tracking β-HCG levels is
instrumental for both diagnosis
and monitoring the response to
treatment for GTN.
MRI Imaging
Magnetic Resonance Imaging
assists in determining the
extent of tumor spread,
crucial in staging and
treatment planning.

17. Understanding GTN Imaging Findings
Heterogeneous Mass
GTN can manifest as a varied
mass with both solid and
cystic components,
characteristic of malignant
growth within the uterus.
Hyperechoic
Appearance
The increased echo signal
suggests the presence of
abnormal tissue that could be
indicative of GTN.
Vascular Spaces
Identification of cystic
vascular spaces within the
mass on Doppler study
supports a GTN diagnosis.

18. Chemotherapy: The Keystone of GTN
Treatment
1
Methotrexate
First-line treatment for non-metastatic and
low-risk GTN cases, with a high success
rate in managing invasive moles. 2 Follow-Up
Continuous β-HCG monitoring post-
treatment verifies the effectiveness of
chemotherapy and the absence of
residual disease.
3
Long-Term Monitoring
Regular checks for a year post-treatment
help ensure complete remission and
detect any recurrence at the earliest
possible stage.

19. TIME TESTED THERAPY -
METHOTREXATe
Methotrexate is an antimetabolite that inhibits the synthesis of DNA, RNA, and proteins. It is administered
both intramuscularly and intravenous, with dose and duration varying depending on the GTN type and
response to treatment. Methotrexate is typically well-tolerated, but patients may experience side effects such
as nausea, vomiting, and hepatotoxicity.
To mitigate the risk of methotrexate-induced hepatotoxicity, regular liver function tests are recommended
during treatment. In severe cases of GTN or those that do not respond to methotrexate, more aggressive
chemotherapy regimens involving drugs such as actinomycin-D or etoposide may be considered. Close
monitoring of blood counts is essential during chemotherapy to manage potential side effects such as anemia
and bleeding.

20. Legacy of Early Detection
Precise Diagnosis
Identifying GTN early
involves recognizing the
nuanced clinical
presentations and decisively
using diagnostic tools.
Timely Intervention
Intervening at the earliest
allows clinicians to employ
chemotherapy effectively,
improving survival outcomes.
Ongoing Research
Advancements in detection
and treatment continue to be
a priority, striving for even
better patient prognoses in
the future.

21. THANK YOU