Gestational trophoblastic disease is a heterogeneous group of lesions arising from abnormal placental trophoblast proliferation. It includes premalignant conditions like complete and partial hydatidiform moles, as well as malignant gestational trophoblastic neoplasia (GTN). GTN has varying potential for local invasion and metastasis. While rare, GTN is highly curable even with widespread dissemination. Treatment involves chemotherapy, with single or multi-agent regimens depending on risk factors and disease stage according to the FIGO scoring system. Careful monitoring of beta-hCG levels is important for diagnosis and follow-up.
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
India is the highest TB burden country accounting for more than one-fourth of the global incidence .Genital TB is found in 5-10% of women with infertility problems, with low rates in Australia (1%) and high rates of up to 19% in India (ICMR,2011)
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
India is the highest TB burden country accounting for more than one-fourth of the global incidence .Genital TB is found in 5-10% of women with infertility problems, with low rates in Australia (1%) and high rates of up to 19% in India (ICMR,2011)
what is endometriosis? Theories in endometriosis, sites of endometriosis. types and clinical presentation. signs and symptoms.
Investigations :TVS, CA125
laparoscopic findings
chocolate cyst and extrapelvic endometriosis.
Classification of endometiosis
Diffential diagnosis
Management :of asymptomatic and symptomatic cases
drugs and minimally invasive surgery
surgey and preventive measures in endometiosis.
gestational trophoblastic disease is discussed in its basic knowledge update to enable undergraduate students help understand the disease, diagnose and treat GTD. also enables to follow and detect complications and malignant transformation of molar pregnancy. single drug and multiple dose chemotherapy depending on staging of the disease and related complications & side effects discussed.
what is endometriosis? Theories in endometriosis, sites of endometriosis. types and clinical presentation. signs and symptoms.
Investigations :TVS, CA125
laparoscopic findings
chocolate cyst and extrapelvic endometriosis.
Classification of endometiosis
Diffential diagnosis
Management :of asymptomatic and symptomatic cases
drugs and minimally invasive surgery
surgey and preventive measures in endometiosis.
gestational trophoblastic disease is discussed in its basic knowledge update to enable undergraduate students help understand the disease, diagnose and treat GTD. also enables to follow and detect complications and malignant transformation of molar pregnancy. single drug and multiple dose chemotherapy depending on staging of the disease and related complications & side effects discussed.
Gestational trophoblastic disease (GTD) is a group of pregnancy-related conditions that develop inside a woman's uterus (womb). The abnormal cells start in the tissue that would normally become the placenta. The placenta is the organ that develops during pregnancy to feed the fetus.
16-Aug-2021-"Gestational trophoblastic disease (GTD) is a spectrum of abnormal growth and proliferation of the trophoblasts of the placenta that continue even beyond the end of pregnancy of the placenta".
Gestational trophoblastic disease (GTD) is a group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception. In gestational trophoblastic disease (GTD), a tumor develops inside the uterus from tissue that forms after conception (the joining of sperm and egg).
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
2. Introduction
Gestational Trophoblastic diseases- heterogeneous
group of interrelated lesions that arise from abnormal
proliferation of placental trophoblast.
GTN-subset of malignancies that have varying
propensities for local invasion & mets
GTN-rare human tumors, cured even in the presence
of widespread dissemination
3. WHO Classification
GTD
Premalignant Diseases
Complete Hydatidiform Mole ( C M )
• Partial Hyadatidiform Mole ( P M )
Malignant Diseases (Gestational Trophoblastic Neoplasia)
Nonmetastatic
• Invasive Mole
• Placental site trophoblastic tumor ( PSTT )
• Epitheloid tumour
• Metastatic
• Gestational Choriocarcinoma
4.
5. Epidemiology
It is common in oriental countries- Philippines, China,
Indonesia, Japan, India, Central and Latin America and Africa.
India- 1 in 400 pregnancies
Calculated Incidence of complete mole- 1 in 1945 pregnancies
partial mole- 1 in 695 pregnancies
Age -CMs most common at the extremes of reproductive age
The incidence of CM rises fm I:1000 to 1:76; 1:6.5 in subsequent
pregnancies
CM is the most common antecedent to
Chorio CA. But it can occur after any type of pregnancy 3% after
invasive mole; 16% after CM
6. In the United States,
•1in 600
therapeutic
abortions
•1 in 1,500
pregnancies
In Asian countries,
•The rate is 10 times
higher than in Europe and
North America
In Saudi Arabia;,
•1.48 in 1000 live births
(hospital-based study;
Felemban AA, et al; 1969)
10. GENETICS
P57 cycline dependent kinase inhibitor paternally
imprinted gene which is maternally expressed
P57 kip2 immunostaining is negative in CM in contrast
to PMs Hydropic abortions & normal placenta
Abnormal Methylation
In cases of Familial recurrent molar pregnancy; Defective
locus at 19q 13.4 at single gene NALP7 , it is member of
CATERPILLAR family involved in inflammation &
Apoptosis in genetic CM
Three other genes H19, P57, IGF-2
Chorio CA-specific genes deletion 7p12-q11.2;
Amplification of 7q21-q31 region ; loss of 8p12-p21
11. CLINICAL FEATURES
Complete Mole
Vaginal bleeding
Uterus is larger than POG
Hyperemesis Gravidarum
PET 10-15%
hyperthyroidism 7%
Theca leutin cysts
Beta h CG levels >>
Passage of grapes like vesicle
13. High Risk For Developing Post molar tumor
hCG Levels > 100,000 mIU/L
Excessive Uterine Enlargement
Theca leutin cyst 6cm or larger
14. Clinical features
PARTIALMOLE
Uterus is often not enlarged more than POG
More often presents as Missed or incomplete
abortion
Pre evacuation h CG levels are not more than
100,000IU/ L
Macroscopic : villous swelling is less intense
Embryo is present
15. Management of Molar Pregnancy
Suction Curettage
Cervical preparation with prostaglandins or
misoprostol should be avoided to reduce the risk
of embolisation.
16. Anti-D Prophylaxis (RCOG)
NOT required in Complete Mole: because of poor
vascularisation of the chorionic villi and absence of the
D-antigen.
Required in:
-partial mole: due to presence of RBCs
-complete mole: if diagnosis is not confirmed
histopathologically.
17. Second uterine evacuation
There is NO clinical indication for the routine use
of second uterine evacuation.
It may be useful for symptom control in selected
patients with heavy bleeding or curative if the
recurrent molar tissue is confined to the uterine
cavity
18. FOLLOW UP
HCG:
weekly determination
of B-HCG until these levels
are normal for 3 consecutive
weeks,folld by monthly values
until normal for 6 consecutive
months
Average time for first normal
HCG post evacuation is 9 weeks,
non detectable HCG levels-risk of GTN is 0
19. Contraception
Should NOT conceive until follow up is complete.
Use Barrier method until hCG revert to normal
(?OCPs may act as growth factor for trophoblastic
tissue).
Once hCG has normalised, the combined oral
contraceptive pill may be used.
IUCD should not be used until hCG levels are
normal to reduce the risk of uterine perforation.
20. Role of prophylactic chemotherapy
The long term prognosis for women with a H. Mole is
not improved with prophylactic chemotherapy.
Because toxicity- including death- may be significant,
it is not recommended routinely (ACOG 2004).
It may be useful in the high-risk cases when
follow up are unavailable or unreliable.
HIGH RISK FACTORS:
hCG level >100,000 mIU/ml
Excessive uterine enlargement
Theca lutien cysts 6 cm in diameter
21. Role of hysterectomy
If the patient desires surgical sterilization, a
hysterectomy may be performed with the mole in
situ.
Hysterectomy does not prevent metastasis;
therefore, patients will require follow up with
assessment of hCG levels.
The ovaries may be preserved at the time of
surgery, even in the presence of prominent theca
luiten cysts.
22. Gestational trophoplastic Neoplasia
Nonmetastatic
Invasive Mole:
Clinical features
Clinical diagnosis by persistence or rising titers of Beta h CG in the weeks
after molar evacuation & USG
Persistent bleeding p/v
Lower abdominal pain due to invasion in myometrium, vulva, vagina or
intra abdominal metastasis
It may spread to adjacent pervic structures bladder , rectum; hematuria,
bleeding P/ R
Pulmonary metastasis
Mostly due to initial diagnosis of CM is missed & not on Beta h CG follow
up
23. Invasive H. Mole
Myometrial invasion
Sometimes involving the peritoneum, parametrium, or
vaginal vault. Originate almost always from H. mole
Vesicles
24. Clinical features
Placental Site Trophoblastic Tumor (PSTT):
rare slow growing tumor
menstrual irregularities & lower abdominal pain, galactorrhea due to
hyperprolactinemia increased h PL
Little or no h CG is produced ( Free B hCG fragment )
Rarely presents as nephrotic syndrome, hematuria or DIC
Spread is late local Infiltration & metastasis is through lymphatic
Microscopically: In the normal placenta it is distinct from villous
trophoblast & infiltrates the decidua, myometrium, & spiral arteries.
Mainly from intermediate trophoblast derived fm cytotrophoblast
25. GTN arises when the normal regulatory mechanisms controlling
the proliferation and invasiveness of trophoblastic tissue are
lost.
Diagnosis of the GTN is made on
Clinical presentation
Elevated b-HCG
Evidence of metastasis
Imaging
Tissue for Histology
Metastatic Gestational Trophoblastic
Neoplasia
26. Metastatic Gestational Trophoblastic Neoplasia
CHORIOCARCINOMA:
Clinical features
Occurs mainly following any form of pregnancy, mainly
after CM
Clinical features of bleeding p/v , lower abdominal pain,
or in 1/3 of cases no pelvic symptoms but symptoms of
distant metastasis lungs , brain ,liver, skin, cauda equina &
the heart may present
Highly malignant , appears as soft purple largely
hemorrhagic mass
27. Microscopic: implanting blastocyst with central cores of
mononuclear cytotropho surrounded by rim of
multinucleated syncytiotrophoblast & distinct absence of
chorionic villi extensive areas of necrosis & haemorrage
&frequent evidence of tumor in the sinuses
The hypervascularity & absence of connective tissue
support are the reason for its highly malignant
behaviour
DIAGNOSIS IS BY BETA h CG
28. investigations
Quantitative beta hCG
X Ray Chest
Pelvic Doppler USG
Abdominal doppler USG to rule out liver & renal metastasis
CT chest , abdomen
MRI brain
Beta h CG in cerebrospinal fluid
PET
Genetic studies
29. FIGO REQUIREMENT FOR MAKING DIAGNOSIS
OF GTN
1. Four values or more of plateaue hCG over at
least 3 weeks: days 1, 7, 14 and 21.
2. A rise of hCG of 10% or greater for 3 values or
more over at least 2 weeks: days 1, 7, and 14.
3. Histologic diagnosis of choriocarcinoma.
4. Persistence of hCG beyond 6 months after
mole evacuation.
30. Metastatic disease
Sites: Symptoms:
a. Pulmonary-
80%
Chest pain, dyspnoea
b. Vagina- 30% Vagina bleeding , purulent
discharge and nodule.
c. Liver- 10% Epigastric pain, jaundice,
hepatic rupture leading to
intraperitoneal haemorrhage.
d. Brain- 10% Focal neurological deficit.
31. ANATOMIC FIGO STAGING SYSTEM FOR GTN (2000)
Stage Criteria
I. Disease confined to the uterus
II. Disease outside of uterus but is limited to
the genital structures
III. Disease extends to the lungs with or without
known genital tract involvement
IV. All other metastatic sites
32. FIGO prognostic score (2000)
O 1 2 4
Age (years) <39 >39
Antecedent
pregnancy
Hydatidi form
mole
Abortion Term
pregnancy
Interval from index
pregnancy, months
< 4 4-6 7-12 > 12
Pretreatment hCG
(mlU/ml)
< 103 103-104 > 104-105 > 105
Largest tumour size,
including uterus
3-4 cm 5 cm
Site of metastases Spleen,
kidney
GI tract Brain, liver
Previous failed
chemotherapy
Single Two or more
drugs
Low risk (Score 0-6) and high risk (score> 7)
34. Low Risk GTN
FIGO score 6 or less.
Drugs schedules: single agent chemotherapy
Most commonly used regimen.
Methotrexate: 1 mg/kg 1M on days 1, 3, 5, 7
Folinic acid 0.1 mg/kg 1M on days, 2, 4, 6 and 8.
Side Effects: Stomatitis, conjunctivitis, abdominal and
chest pain.
Actinomycin- D: (primary therapy in case of abnormal
liver function)
35. After the first treatment
Further chemotherapy is withheld as long as the
HCG level is falling progressively
Additional single agent chemotherapy is not
administered at any predetermined or fixed
interval
II course of CT if:
If HCG level plateaus for more than 3 consecutive
weeks or begins to rise again
If HCG level does not decline by 1 log within 18
days of completion of first treatment
If response to first treatment was inadequate,dose of
MTX is increased from 1mg/kg/day to 1.5 mg/kg/day
for each of the 4 treatment days
36. If patient does not wish to preserve fertility
hysterectomy with adjuvant single agent
chemotherapy given.
In case of stage-I PSTT.
Role of adjuvant chemotherapy.
1. Decrease dissemination of viable tumor cells at
surgery.
2. Maintain cytotoxic level of chem.
3. To treat any occult metastasis
Role of hysterectomy in non metastatic
disease i.e. Stage-I
37. Follow up in Low risk GTN
Weekly bhCG titre until normal for 3 consecutive
weeks.
Monthly b HCG level until normal for 12 consecutive
months.
Effective contraception during the follow up
FIGO recommends additional 2 courses of
chemotherapy after initial negative b hCG.
38. High Risk GTN
Stage I, II, III With FIGO score 7 or greater or Stage IV
Primary intensive combination chemotherapy
Regimes given :
MAC.
Modified Bagshawe (CHAMOCA)
EMA-CO
EMA-EP.
39. MAC-III Regime
Mtx 1 mg/kg IM/1V Days 1, 3, 5, 7
Folinic acid 0.1 mg/kg IM Days 2, 4, 6, 8
Actinomycin-D 12 g/kg IV Days 1-5
Cyclophosphamide 3 mg/kg IV Days 1-5
To be repeated every 15 days if toxicity permits.
40. EMA-CO Regime
Etoposide, methotrexate, actinomycin D, alternating weekly with
cyclophosphamide and oncovin.
Day 1 Actinomycin D 500 micrograms IV push
IV. Etoposide 100 mg/m2 over 30-50 min.
Methotrexate 100 mg/m2 IV infusion over 1
hr and then
Methotrexate 200 mg/m2 IV infusion over 12 hrs
Day 2 Actinomycin D 500 micrograms IV push new IV
Etoposide 100 mg/m2 over 30-50 min.
Folinic acid 15 mg IV push Q 6 hrs for 8 doses
beginning 24 hrs after methotrexate bolus.
Day 8 Vincristine (Oncovin) 1 mg/m2 IV
Cyclophosphamide 600 mg/m2 IV
SIDE EFFECT:- Myelosuppresion ,Mucositis , Neuropathy ,Reversible
alopecia
41. EMA-EP
In patient resistant to EMA-CO
On day 8
Etoposide- 10 mg/m2 iv.
Cisplatin- 80 mg/m2 iv
treatment – until 3 consecutive weekly titres
normal.
2-4 cycles given further after initial normal b
H.C.G.
.
42. Follow up OF High risk GTN
Weekly bHCG until normal for 3
consecutive weeks.
Monthly bHCG for 24 consecutive
months.
Contraception in follow up period.
43. Management of sites of metastasis
VAGINAL &PELVIS -30%
Single agent chemotherapy –Low risk
Combination chemotherapy –High risk
If bleeding occurs-
Vaginal packing
Wide local excision
Arteriographic embolisation of hypogastric arteries
45. HEPATIC-10%
Worse prognosis.
Usually associated with widespread metastasis Intraperitoneal
bleeding may occur.
Rx
Chemo & concurrent radiation (2000-3000 cGy).
Hepatic resection to excise resistant foci.
Cerebral-10%
Acute focal neurological deficits.
Combination chemo + WBRT (2000-3000).
Patients with metastasis on initial evaluation respond better
than who develop Lesion during therapy.
During period of WBRT- Mtx in EMA-CO be increased to 1 g/m2
with Folinic.Acid rescue.
.
46. For subsequent pregnancy.
Ist trimester TVS to confirm normal pregnancy.
bHCG 6 wks after termination of pregnancy .
After effective treatment for non-malignant GTN molar
pregnancy occur in 1-2% subsequent pregnancies.
47. CASES REGISTERED IN GTD
CLINIC,GRH
Total no of cases-15
Case 1:
Mrs.Kavitha,28 yr old P2L2A2/MTP with TAT done in
FPAI(8.4.15)/C/O bleeding pv/RPOC with secondary
infection/?invasive partial mole(hcg-1247)-GRH admission-
SE 0n 4.5.15-(hcg-141 on 8.5)
Pt was on weekly b-hcg follow up until 3 normal
values,monthly follow up until 6 normal values,
17.02.16-1.02
16.03.16-120.6
Started on methotrexate
49. Case 2:latha 19 yr unmarried/molar pregnancy/SE @
GRH on 12.08.15 for molar/presented with bleeding pv
I mth later with severe anemia/re evacuation done for
retained tissues
In the post molar evacuation surveillance,weekly b-
hcg rising trend-started on single agent CT
EMACO started
51. Case 3:
Mrs,nambuselvi,42 yr old primi/ms 22 yrs/13 wks
GA/partial molar pregnancy/SE done
Pre evacuation B-HCG-1,14,560
Chest x ray-S/O tiny nodular opacity in left midzone
Pt transferred to med onco in view of invasive mole
Single agent CT-MTX