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Dr. Mohamed El Sherbiny
MD Ob.& Gyn. Senior Consultant
Damietta, Egypt

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Rt is a spectrum of trophoblastic diseases
that includes:
Complete molar pregnancy
Partial molar pregnancies
Rnvasive mole
Choriocarcinoma
Placental site trophoblastic tumour
 
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Rt is a spectrum of trophoblastic diseases
that develops malignant sequelae. GTN
includes:
Persistent post molar GTD
Rnvasive mole
Choriocarcinoma
Placental site trophoblastic tumour
 
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Classifications
Gestational Trophoblastic Disease (GTD)

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Geature Partial mole Complete mole
Most commonly Most commonly
69, XXX or - XXY 46, XX or -,XY
Karyotype
Pathology
Getus Often present Absent
Amnion, fetal RBC Usually present Absent
Villous edema Variable, focal Diffuse
Trophoblastic proliferation Gocal, slight-moderate Diffuse, slight-severe
Clinical presentation
Diagnosis Missed abortion Molar gestation
Uterine size Small for dates 50% large for dates
Theca lutein cysts Rare 25-30%
Medical complications Rare 10-25%
Postmolar CTN 2.5-7.5% 6.8-20%

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 hich omen Should Be
Rnvestigated Gor Persistent GTN
After A Non-molar Pregnancy?
Any woman who develops persistent
vaginal bleeding after a pregnancy event.
A urine pregnancy test should be
performed in all cases of persistent or
irregular vaginal bleeding after a
pregnancy event.
Symptoms from metastatic disease, such
as dyspnoea or abnormal neurology, can
occur very rarely.
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Case Scenario 1
A 32-year-old Gravida 3 ,Para 2 woman. She
has 2*
History of suction evacuation of molar
pregnancy 5 weeks ago.
Her post evacuation level of hCG level was
120,550 mRU/mL and the weekly follow up
has a rapid decline.
She is very worried about malignant GTD
(GTN), as at the last follow up, her hCG
levels was unexpectedly raised from 10,900
to 12,100 mRU/mL (11%)
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 The Case Scenario1

The case has only one rise level of

hCG ,so the treatment that should be
initiated is:

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GRGO SCORRNG 0 1 2 4

Age (years) <40 >40

Antecedent pregnancy Mole Abortion Term --

Pregnancy to treatment <4 4to <7 7to <13 13

Rnterval (months)

Pretreatment serum <1000 1000-10,000 10,000-100,000 > 100,000

hCG (iu/l)
Largest tumour size, <3 3 to<5 5 --
including uterus (cm)

Site of metastases Lung Spleen & Gastro- Liver &

Kidney intestinal brain
Number of metastases -- 1-4 5-8 >8

Previous failed -- -- Single drug 2 Drugs

chemotherapy


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GRGO SCORRNG 0 1 2 4

Age (years) <40 >40

Antecedent pregnancy Mole Abortion Term --

Pregnancy to treatment <4 4to <7 7to <13 13

Rnterval (months)

Pretreatment serum <1000 1000-10,000 10,000-100,000 > 100,000

hCG (iu/l)
Largest tumour size, <3 3 to<5 5 --
including uterus (cm)

Site of metastases Lung Spleen Gastro- Liver

&Kidney intestinal &brain
Number of metastases -- 1-4 5-8 >8

Previous failed -- -- Single drug 2 Drugs

chemotherapy

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Stage R Disease confined to the uterus

Stage RR GTN extends outside of the uterus but

is limited to the genital structures
(adnexa, vagina, broad ligament)
Stage RRR GTN extends to the lungs, with or
without known genital tract
involvement
Stage RV All other metastatic sites (brain, liver)

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GRGO SCORRNG 0 1 2 4

Age (years) <40 >40

Antecedent pregnancy Mole Abortion Term --

Pregnancy to treatment <4 4to <7 7to <13 13

Rnterval (months)

Pretreatment serum <1000 1000-10,000 10,000-100,000 > 100,000

hCG (iu/l)
Largest tumour size, <3 3 to<5 5 --
including uterus (cm)

Site of metastases Lung Spleen Gastro- Liver

&Kidney intestinal &brain
Number of metastases -- 1-4 5-8 >8

Previous failed -- -- Single drug 2 Drugs

chemotherapy
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The patient responds to the MTX
At the last dose of chemotherapy,
the patient asked:

1-hen am R allowed to conceive?

2- ill chemotherapy lead to
premature menopause?
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hat Rs The Survival of GTN By
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 Case
Scenario 2
The family of a 31-year-old P3+1 woman brings her
to the emergency room with altered mental
status. Gynecologist is called as there was
blood spots at here under wear.

Upon further history taking, she is noted as:

' Underwent D&C 4 months ago for secondary
postpartum hemorrhage 10 weeks postnatally
' Received cough expectorants at the last 3 weeks
and had bloody sputum in the last 2 days
' No history of recent trauma, infections or past
history of chronic medical disorders
' She is lactating and the husband is using
contraceptive condom
' P:110/70, pulse 95/m, RR 24/m
' Chest: Mild wheeze
' Examination of breasts, abdomen and rectum
were normal.
' Pelvic examination: Small brown vascular
nodule at the postero-lateral wall of the vagina
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Metastatic Vaginal Tumors

Probably Choriocarcinoma
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Vaginal metastases from adenocarcinoma of other
pelvic and abdominal organs are more
common than primary vaginal cancers.
These primary malignancy usually metastasize via
direct or lymphatic spread.
On the contrary, GTN metastasizes mainly
hematogenously to the Lung 80%, Vagina 30%,
Liver 10%, CNS 10%, spleen and kidney.


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The history of:
' D&C 4 months ago for secondary postpartum
hemorrhage 10 weeks postnatal may be
suggestive of persistent trophoblastic disease
' Receiving cough expectorants at the last 3
weeks and had bloody sputum in the last 2
days, are suggestive of lung metastasis
The presentation at the emergency room with
altered mental status also may suggest brain
metastasis
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GRGO SCORRNG 0 1 2 4

Age (years) <40 >40

Antecedent pregnancy Mole Abortion Term --

Pregnancy to treatment <4 4to <7 7to <13 13

Rnterval (months)

Pretreatment serum <1000 1000-10,000 10,000-100,000 > 100,000

hCG (iu/l)
Largest tumour size, <3 3 to<5 5 --
including uterus (cm)

Site of metastases Lung Spleen Gastro- Liver

&Kidney intestinal &brain
Number of metastases -- 1-4 5-8 >8

Previous failed -- -- Single drug 2 Drugs

chemotherapy
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Stage R Disease confined to the uterus

Stage RR GTN extends outside of the uterus

but is limited to the genital structures
(adnexa, vagina, broad ligament)
Stage RRR GTN extends to the lungs, with or
without known genital tract
involvement
Stage RV All other metastatic sites (brain, liver)

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Stage Disease confined to the uterus Single Agent
R Chemotherapy
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Stage GTN extends outside of the uterus
Low Risk
RR but is limited to the genital
structures (adnexa, vagina, broad (score 6)
ligament)
Stage GTN extends to the lungs, with or High Risk
10
RRR without known genital tract (Score 7)
involvement

Stage All other metastatic sites (brain, Multi-agent

RV liver) Chemotherapy

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Chemotherapy Should Not
Be Repeated Unless
BC > 3000/cu mm
Polymorph > 1500 cu mm
Platelets > 100,000 cu mm
BUN, SGOT, SGPT are normal

No febrile course
No oral or GRT ulceration
 
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