Gestational trophoblastic diseases arise from the trophoblast and include hydatidiform moles (80%), gestational trophoblastic neoplasia (16%), and choriocarcinoma (4%). Choriocarcinoma is a malignant tumor of the trophoblast that most commonly spreads to the lungs (80%) and vagina (30%). Diagnosis involves symptoms of bleeding, hCG levels, imaging and biopsy. Treatment is usually chemotherapy, with hysterectomy as an option for resistant cases.

1. Gestational trophoblastic diseases

2. They arise from the trophoblast of the balstocyst and are classified as: * hydatidifrom mole (molar pregnancy) (80%) Complete (classic) Incomplete (piratical) * gestational trophoblatic neoplasia Non-metastatic = invasive mole = chorio –adenoma destruens (16%) Metastatic =Choriocarcinoma = chorion epithelioma (4%) Low – risk High – risk

3. Choriocarcinoma

4. Pathology : Incidence : 1: 250-5000 pregnancies in Asia and 1:4000 in the west. Origin: * Choriocarcinoma is a malignant tumour of the trophoblast. 1- About 50% of cases follow molar pregnancy. 2- 25% follow abortion 3- 23% follow normal pregnancy 4- 2% follow ectopic pregnancy. * In rare cases, the tumour arises as a teratoma in the ovary or testicle.

6. Macroscopic appearnce: The tumor arises in the endometrium as a soft friable dark red hemorrhagic mass projecting into the uterine cavity and may from a polyp. Malignant tissue may be buried within the myometrium , inaccessible to the curette, or hidden in a distant metastasis. However, any of these tumor patterns secretes (hCG) which causes cystic changes of the ovaries in about 30% of cases..

7. Microscopic appearance: The tumour consists of cyto-and synecytiotrophoblasts showing malignant characters, invading the myometrium and blood vessels. Chorionic villi are absent this differentiates Choriocarcinoma from invasive mole.

9. Mode of spread: direct spread: to the parametrium, tubes and ovaries. Blood spread: occurs early to distant organs. The commonest sites are lunges (80%), vegina (30%), brain (10%) and liver (10%)

10. FIGO classification : Stage I confined to uterine corpus. Stage II metastases to pelvis and vagina Stage III metastases to lung Stage IV metastases to other organs .

11. multiple single chemotheraby 9 >8 4-8 1-4 n.Of metastis 8 Brain Liver-GIT Spleen -kidney site of metastis 7 >5 3-5 Tuomer d 6 B-AB O-A Abo group 5 >100000 10000-100000 1000- 10000 1000 HCG iu/l 4 >12 7-12 4-6 4 Interval month 3 Full term abo V.M Associated pregnancy 2 <39 ≥ 39 Age (years) 1 S4 S2 S1 S 0 Prognostic factor

12. Bagshwe score Total score ≤ 4 low risk 5-7 moderate risk >8 high risk

13. Diagnosis: A- symptoms: 1- Persistent or irregular vaginal bleeding: it is the commonest symptom occurring after labor, abortion or evacuation of a vesicular mole. Bleeding can occur within days or months but rarely after 2 years. 2- Vaginal discharge: which is blood stained and offensive due to ulceration and infection of the growth . 3- amenorrhea: may be present due to continuous hCG production.

14. 4- Acute abdominal pain: due to intraperitoneal haemorrhage as a result of perforation of the uterus by the growth. 5- Abdominal or vaginal swelling: may develop. 6- Symptoms of metastases: as dysponea, haemoptesis, jaundice and neurological symptoms as headache may be the first manifestation of the tumor.

15. B- signs: (1) cachexia and severe anaemia. (2) fever may be present due to infection and necrosis (3) the uterus may be normal size or enlarged and soft. (4) the ovaries: may be enlarged and eystic. (5) metaststic nodules: in the vulva or vagina

16. C- investigations : (1) uterine curettage: should be done in every case of persistent or irregular uterine bleeding after labour, abortion or molar pregnancy. However, intramural tumour cannot be detected by curettage. (2) serum β- subunite of hCG: persistent or rising titres in absence of pregnancy are indicative of trophoblastic neoplasia . (3) biopsy: from metastatic valvar or vaginal lesions.

17. (4) imaging : a- plain X-ray chest: may show secondaries in the form of &quot; cannon balls&quot; or &quot;snowstorm&quot; appearance. b- ultrasonography: to detect tumour, cystic ovaries and exclude remnants of conception. c- CT scan: for lungs, liver, brain and bone. (5) lumbar puncture : plasma hCG/ CSF hCG ratio less than 60 strongly CNS involvement my metastases (6) blood studies : a- complete blood picture including platelet count b- Renal, liver and thyroid function tests c- Blood group.

20. Treatment: The treatment of choice chemotheraphy

21. Hysterectomy may be indicated in the following conditions: severe uterine bleeding perforation of the uterus with intraperitoneal haemorrhage. Massive haemorrhage from the bowel Torsion of a theca lutein cyst. Durg resistance or toxicity. Persistant localised metastases in the vagina, lung or brain after chemotherapy

22. Chemotherapy: (I) low- risk group score ≤ 4 : Single cytotoxic drug either methotrexate or actinomycin D (II) High-risk group score >8 : Multiple cytotoxic drugs

23. Thank you