This document summarizes gestational trophoblastic disease (GTD), which includes a spectrum of conditions originating from the placenta, such as complete and partial hydatidiform moles, placental site trophoblastic tumors, and choriocarcinomas. It discusses the signs, symptoms, laboratory tests, staging, management including chemotherapy regimens, follow up care, and risk of recurrence for different types of GTD.

2. Gestational trophoblastic
disease
Spectrum of interrelated conditions originated
from placenta
•Hydatiform mole
- complete :fertilized of an empty egg by
single sperm whose chromosomes replicate
(usually 46 XX)
-partial moles : haploid egg fertilized by
two sperm (69 XXX,69 XXY)
• Placental site trophoblastic tumors
• Choriocarcinomas (malignant often distant
metastasis).
• Invasive moles (local extension into uterus
or vagina)

3. GTD
Premalignant Malignant
. Complete mole . Invasive
mole
.
Choriocarcinomas
. Partial mole
. PSTT

4. Signs and Symptoms
 Hydatiform mole
- Uterine bleeding (6-16 weeks)
- N/V
- Larger than expected uterus
- Enlarged cystic ovaries
 Choriocarcinomas
-continued/recurrent bleeding
. After mole evacuation
. Following delivery , abortion or ectopic
pregnancy
-ulcerative vaginal tumor , pelvic mass ,
evidence of distant metastasis.

5. Lab tests
 Beta-HCG
-range from high normal-millions
-complete mole > partial mole
-can release thyroid hormone with
symptom of hyperthyroidism
 CBC with Plt, clotting function , RFTs,
LFTs, and TFTs
 Imaging :US (TV& TA) and
preoperative chest radiograph

6. Investigations for CC and
PSTT
 For patients admitted for treatment for
presumed choriocarcinomas or PSTT
- As above plus
-CT of the chest and abdomen
-MRI of the brain and pelvis
-Doppler ultrasound of the pelvis
- lumbar puncture to assess the
cerebrospinal fluid to serum
-HCG ratio. The latter if more than 1:60
suggests occult central nervous system
disease

7. True or false ?
 When vaginal metastasis suspected
the biopsy should be done to confirm
diagnosis.
 False.
 Vaginal metastasis are presented in
30% of patient with metastatic disease
, these lesion are highly vascular and
high risk of bleeding.

8. What is the phantom HCG?
 Is a false-positive test result caused
by heterophilic antibodies cross-
reacting with the HCG test.
 This has lead to dramatic
overtreatment and loss of fertility
(hysterectomy ) for some patients.

9. When should be suspected?
 When the HCG values plateau at
relatively low levels and do not
respond to therapeutic maneuvers.
 Heterophilic antibodies are not
excreted in the urine; therefore,
urinary HCG values will not be
detectable.

10. Management of molar
pregnancy
 Dilatation & Curettage
 Following (D& C) patient should
receive anti-Rhesus D prophylaxis in
case of PHM.
 Hysterectomy indicated in:
-patient with age > 35 y
-completed family irrespective of age.
-uncontrolled hemorrhage/ perforation
during suction evacuation.

11. Indications for chemotherapy in
molar pregnancy
1. HCG plateau in 3 consecutive serum
samples (days 1, 7, 14 and 21)
2. Rising HCG in two consecutive serum
samples
3. Heavy vaginal bleeding or evidence of
gastrointestinal or intraperitoneal
hemorrhage
4. Histological evidence of choriocarcinomas
5. Evidence of metastases in the brain, liver or
gastrointestinal tract .

12. 5. Radiological opacities of >2 cm on chest
X-ray
6. Serum HCG of ≥20 000 IU/l >4 weeks
after evacuation, because of the risk of
uterine perforation

13.  If chemotherapy is indicated what kind
chemotherapy I need?
 Single agent? Multiple?
 When I can use aggressive treatment?

14. FIGO 2000 scoring system for
GTN

15. Treatment of low risk patient
(FIGO score 6 or less)

16.  For low risk patients with lung
metastases on their chest X rays, the
policy is to add CNS prophylaxis with
intra-thecal methotrexate (12.5mg)
administration on 3 occasions 2 weeks
apart to minimize the risk of
development of CNS disease.

17. Second line for inadequate
response to methotrexate
therapy
 Single agent Actinomycin D, given at
0.5mg for days 1-5 every two weeks if
the HCG is below 300iu/L
 EMA/CO combination chemotherapy
if the HCG is above 300 iu/L.

18. Treatment of high risk patients
(FIGO score 7 or more)

19. What is adequate response to
chemotherapy?
 A: Means fall in HCG level by 1 log after
a course of chemotherapy.
 How long should patient undergo
chemotherapy?
 A: the patient should be treated 3
courses after HCG levels have
normalized.
 Which type of GTD is less
chemosenstive?
 A: PSTT

20. Treatment of persistent
disease

21. CNS Metastasis
 Approximately 4 % of patients presenting
with cerebral metastases at the time of
diagnosis.
 trophoblast patients with CNS disease can
routinely be cured of their disease.
 Treatment may include :
-Surgical resection if the disease is
superficial
- Modified EMA/CO containing a higher dose
of methotrexate.
- Intra-thecal methotrexate administration,
has produced a cure rate of 86% for patients
with CNS disease.

22. The management of placental
site trophoblast disease
(PSTT) The management depends on careful
staging
 limited to the uterus, curative treatment
can be achieved with hysterectomy alone.
 For patients with disseminated disease
we recommend treatment with EP/EMA
chemotherapy, which is continued for 6-8
weeks after the normalization of the HCG
level Following by hysterectomy.
 The role of CNS prophylaxis in PSTT is
unclear

24. Post Chemotherapy Follow-Up
 Reviewing patients 6 weeks after the
completion of therapy :
 Recheck the sites of original disease
 Doppler US of pelvis
 CXR or CT/MRI if abnormal at presentation
 Advise on the need for contraception for 12
months
 Advise re avoidance of excess sunlight
exposure
 Outline the risk of relapse 5% following
Methotrexate, 3% following EMA-CO or the
chance of a new molar pregnancy (1:75).

25. Post treatment HCG follow-up
Year 1 2-weekly serum and
urine HCG for 1-6 m
2 weekly urine HCG
for
7-12 m
Year 2 4 weekly urine HCG
Year 3 8 weekly urine HCG
Year 4 3-monthly urine HCG
Year 5 4-monthly urine HCG
Year 6-life 6-monthly urine HCG

26. True or false?
 Patients with prior partial or complete
mole have a 10- fold increased risk of
a second Hydatiform mole?
 True

27. True or false ?
 IUD is the encouraged contraceptive
during the entire interval of HCG
follow up?
 False. In fact they have potential risk
for perforation
 Can we use OCPs ?
 A: Yes

28. What type of ovarian cyst can be
clinically evident in 25%-35% of
women with Hydatiform mole?
A: Theca lutein cyst
These are generally detected
preevacuation but can arise within the
first week after evacuation and can take
up to 8 weeks to disappear.