Gestational Choriocarcinoma

GESTATIONAL CHORIOCARCINOMA BY DR. D.O. ALLAGOA

INTRODUCTION INCIDENCE RISK FACTORS CLASSIFICATION PATHOLOGY STAGING PROGNOSTIC FACTORS

INTRODUCTION History of management of trophoblastic dx is one of the success stories of modern medicine Majority of women are potentially curable Ist successful treatment of choriocarcinoma was in 1956 Success is based on – early diagnosis, ability to measure HCG and available chemotherapy

Incidence More common in Orients than Europe or America Average incidence- West Africa (Nigeria) 1:30,000 pregnancies- West ( Europe and USA) 1:11,000 pregnancies in Orient communities In our environment – combined GTD incidences (Hospital based figures.) -UPTH -1:707 deliveries (Annual report 2003) -UCH -1:667 deliveries -Ile Ife -1:558 deliveries -Korle-bu -1:1000 deliveries (Ghana) -LUTH - 1:184 deliveries -Illorin - 1:344 deliveries

Risk factors Racial –more commom in Orients, blacks , Caucasians ABO group Age: < 20 and >40yrs Consanguinity Previous molar pregnancy Increased number of spontanous abortions Multiparity Artificial insemination normal pregnancy Diet – low protein, low fat and vitamin A deficiency Familial cases have been also observed . Antecedent pregnancies -60% Hydatidiform mole -30% previous abortions -10% normal pregnancies, ectopic or artificial insemination

CLASSIFICATION  Subject of intense controversy

-Current staging classification and clinical practice guidelines of gynecological cancers by FIGO committee on gynecological oncology NOV 2003  GTDBenign variety -Hydatidiform mole-Complete/partial Malignant variety -Invasive moles ( chorioadenoma destruens) -placenta site trophoblastic tumour -Choriocarcinoma  Non gestational trophoblastic dx - Choriocarcinoma of ovary -Choriocarcinoma of Testis

Pathology  Generally tumors arise from the fetal tissues within the

maternal host and composed of syncytiotrophoblast and cytotrophoblastic cells except PSTT. -complete- 46xx(90%)/ 46xy(10%) -partial -69xxy or 69xxx  Invasive mole -invades myometrium - persistent placenta villous structure. - Does not progress to choriocarcinoma -regresses spontaneously  Placenta site trophoblastic dx. -composed mainly of cytotrophoblastic cells -Low HCG and High HPL -Tumor confined to uterus but metastasizes late in its course

Gestational choriocarcinoma Arising from trophoblastic epithelium Malignant Composed of cytotrophoblastic and syncytiotroblastic elements Some cytotrophoblastic choriocarcinoma carcinoma secrete little HCG while syncytiotroblastic choriocarcinoma secrete HPL. Metastases –local sites such as cervix or vagina - distance sites- lungs brain and liver -Lymph node metastasis rare - may suggest a non gestational origin( Germ cells)

Gestational choriocarcinoma cont. Trophoblastic metaplasia and HCG production can be seen in other types of carcinoma – lungs, bowel, stomach, pancreas, bladder and kidney. Excessive stimulation of ovaries with theca lutein cyst formation and amenorrhea

Staging Staging system: international federation of gynaecology and obstetrics (FIGO) 2002 revised staging. - Stage 1- Dx confined to the uterus. - stage II – Dx extending outside the uterus but limited to the genital structures ( adnexae, vagina, broad ligament). -stage IIl - Dx extending to the lungs with or without known genital tract involvement. -stage IV - Dx at other metastatic sites. Sub-staging: A- No risk factor B- One risk factor C- Two risk factors Risk factors -HCG > 100,000miu /ml -Duration of termination of antecedent pregnancy to diagnosis > 6months.

Prognostic scoring systems  The Bagshaw/ WHO scoring system  The American National institute of health

(N.I.H ) system  The modified WHO scoring system

combined FIGO staging. Ratified in June 2002

0

Age

1

2

<40

>40

4

Antecedent pregnancy

Hydatidiform mole

abortion

Term

Interval months from index pregnancy

<4

4-6

7-12

>12

Pretreatment HCG

<103

103-104

104-105

>105

Largest tumour size

3-4cm

>5cm

Sites of metastases

Spleen kidney

Gastrointestinal tract

Number of metastases

1-4

5-8

Previous failed chemotherapy

Single drug

Two or more drugs

Brain Liver

-A score of 6 or less – low risk disease treatable by single agent chemotherapy -A score of 7 or greater – high risk disease that requires combination chemotherapy -Medium risk categorization no more in use THE AMERICAN NATIONAL INSTITUTE OF HEALTH (NIH) Clinical criteria - Non metastatic - Metastatic (GTN)- disease outside the uterus

The American national institute of health clinical criteria. Cont. A. Good prognosis ( low risk ) -Disease present less than 4 months short duration -Pre treatment serum B HCG less than 40,000I.U or urinary excretion of <105 i.u/24 hrs

The American national Institute of health clinical criteria. Cont. A. Good prognosis ( low risk ) -Disease present less than 4 months short duration -Pre treatment serum B HCG less than 40,000I.U or urinary excretion of <105 i.u/24 hrs. -No prior chemotherapy B. Poor prognosis - Disease of long duration (>4 months ) - Pretreatment serum B HCG > 40,000 i.u or urine B HCG excretion of >105 i.u./L -Presence of brain, liver or distant metastases -Failure of prior chemotherapy -Disease follows a full term pregnancy

SURVIVAL RATE -Based on data from the new England Trophoblastic disease center: -The overall survival rate for stages I,II & III is virtually 100%. -Stage IV dx Survival rate - 70-73%

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