This document discusses gestational trophoblastic tumors including invasive mole, choriocarcinoma, and placental site trophoblastic tumor. Invasive mole can progress to choriocarcinoma but may also regress spontaneously. Choriocarcinoma arises from the chorionic epithelium and has markedly elevated beta-HCG levels. Staging and prognostic scoring is described for choriocarcinoma. Low and high risk disease is defined and different chemotherapy regimens are outlined depending on the risk level. Exceptions for chemotherapy include invasive mole perforating the serosa or uncontrollable bleeding.

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.

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