12-gestational Trophoblastic Neoplasia

Gestational Trophoblastic Neoplasia WALEED AL-JASSAR FRCSC – GYN ONC

Classification • Hydatidiform Mole ( Molar Pregnancy ) • Invasive Mole • Gestational Choriocarcinoma • Placental Site TrophoblasticTumor ( PSTT ) • •

History • Hippocrates – Dropsy of the uterus • Unhealthy water

Epidemiology of Hydatidiform Mole • The highest incidence is in Asia • Rates in Asia 1 : 500 • Rates in the states 1 : 1500

Risk Factors for Molar Pregnancy • Extremes of Reproductive age – Less than 15 years old and above age 40

• History of previous Molar pregnancy – 10 times more risk

• Dietary factors – Low protein diet 

Factors NOT associated with Molar Pregnancy • • ABO Blood Group • • Cigarette smoking • • Contraceptive history

Hydatidiform Mole 

• Complete Mole  

• Partial Mole

Complete Mole • • • • • • • •

46 XY ( Paternal Genome ) Absent fetus Absent Amnion Diffuse Villous edema Diffuse trophoblastic proliferation Uterine size is 50% large for dates 25-30% Theca Leutein Cysts 10-25% Medical Complications – PIH , Hyperthyroidism , Anemia and Hyperemesis

• 6.8 – 20% Post Molar GTN

Partial Mole • 69 XXX or XXY ( Paternal and Maternal Genome ) • On Pathology Fetal Parts are present • Focal Villous edema • Focal Trophoblastic proliferation • Diagnosed as Missed Abortion • Uterus is small for dates • Rarely there will be a Theca Lutein Cyst or medical Complication • 2.5 – 7.5 % Postmolar GTN

Symptoms • • • • •

Vaginal Bleeding Hyperemesis Pre-eclampsia in the first Trimester Hyperthyroidism ( rarely ) Acute Respiratory Distress – Trophoblastic pulmonary embolization

• Excessive uterine size • Theca lutein cyst  

diagnosis • Passage of Vesicular tissue • Quantitative B hCG • Pelvic U/S •

Management • Blood Work ( CBC , Electrolytes , LFT , RFT , TFT ) • CXR ( Pre Evacuation ) • Suction D & C • Monitor Quatitative hCG every week until Normal • Monthly hCGfor 6 – 12 months • Contraception

Gestational Trophoblastic Neoplasia • Defined by Clinical and Laboratory Criteria 

• GTN is the most curable Gynecologic Malignancy • • GTN after a complete mole 7.5 % 20 % • GTN after a partial Mole 2.5 % - 7.5 %

Risk Factors for Post Molar GTN • High Pre-evacuation hCG • Uterine size larger than expected dates • Theca-lutein Cysts ( More than 6 cm ) • Increasing Maternal age

Diagnosis of Post Molar GTN ( FIGO ) 1.Four Values or more of plateaued hCG ( +/- 10% ) over at least 3 weeks 2.A rise of hCG of 10% or greater for 3 values or more over at least 2 weeks 3.The Histological diagnosis of Choriocarcinoma 4.Persistence of hCG beyond 6 months after mole evacuation

Evaluation of GTN • Complete physical and Pelvic Examination • Baseline Hematologic , renal and Hepatic functions • Base line quantitative hCG • CXR or CT Chest • Brain MRI or CT • CT Abdomen and Pelvis

Clinical Classification system • Non- Metastatic GTN • Metastatic GTN – Good Prognosis • Short Duration ( Less than 4 Months ) • Pretherapy hCG less than 40,000 mIU/ml • No Brain or liver Mets • No antecedent term pregnancy • No prior chemotherapy

– Poor prognosis • Any one risk factor : – Long Duration ( More than 4 Months ) – Pretherapy hCG more than 40,000 mIU/ml – Brain or liver mets – Antecedent term pregnancy – Prior chemotherapy

FIGO 0 SCORING AGE < 40 Antecedent Mole pregnancy Interval from < 4 pregnancy(months

1 ≥ 40 Abortion

2

4

4-<7

7 - < 13

≥ 13

1000 – 10,000 3-5

10,000 – 100,000 >5

> 100,000

Spleen , Kidney 1-4

GI 5-8 Single drug

Brain , Liver >8 2 or more drugs

Term

)

Pre-treatment < 1000 hCG mIU/ml Largest tumorsize (including Site of Mets uterus) (cm) Lung # of Mets Prev. failed chemo

• Low risk – Score of 6 or less –

• High risk – Score of 7 or greater

Treatment • Non Metastatic and low risk GTN – Single Agent chemotherapy • Methotrexate • Actinomycin D

• Metastatic or High risk – EMA-CO – MAC