1. Gestational Trophoblastic Disease GTD GTD : a group of diseases related to pregnancy, including several types of tumors ranging from benign to malignant.

2. GTD benignmalignant complete partialtransitional mole invasive Chorio- carcinoma PSTT GTT 1. Definition

3. 2. Characteristic features GTD Derived from fetal tissue Accurate Tumor marker H chorionic gonadotropin Sensitive to chemotherapy Genetic makeup

4. 3. Etiology unknown Incidence varies among Nation and ethnic Patient agePrevious history Genetic factorBlood group,etal

5. 4. Type of GTD completepartial transitional 23X 46XX 23X23X 23Y 69XXX69XXY 69xxx 69xxy 47xxx 47xxy trisome tripleidy Mole pregnancy choromosome Blighted ovum sperm haploid reduplicate karyotype

6. keryotype diagnosis embryo HCG titer Uterus Malignant potential Complete mole Mostly 46xx 1 st trimester No embryo high 33% large for date 15-25% partial mole triploid 2 nd trimester abnormal fetus moderate 10% 5-10% transtional mole trisomy, triploid 1 st trimester no embryo low never rarely GTT (invading uterus) invasive mole placental site trophoblastic tumor choriocarcinoma Metastasis possible rarely metastasis widespread metastasis

7. 5. pathology Uterus: large for gestational date fill with typical vesicles no embryo Ovary: theca lutein cysts : high HCG values Under Microscopy Hyperplasia of trophoblast （ cyto~&. Syncytial) villi swollen no vessels /fetal blood cell

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10. 7. symptoms Amenorrhea (2-4M after LMP, average 12W ) bleeding (irregular /spot ) pain: light /cramping (uterus enlarger / abortion) uterua date/size discrepany (too large/too smal lfor gestational age, usually larger) Hyperemesis severe nausea and vomiting PIH hyperthyroidism theca lutein cysts Similar to abortion High HCG

11. 8. diagnosis Clinical presentation esp: typical vesicles expelled very high HCG values 200,000IU/ml Ultrasonography absence of gestational sac/ fetal fill with multiple diffuse echo --- snowstorm appearence

12. 9. Treatment Evacuation risk for bleeding injure of uterus pulmonary complication caution: blood transfusion available, oxytocin drip dilatation hysterctomy: prophylactic chemo-therapy not necessary for follow-up difficult elder than 40y desire sterilization suction curettage

13. 10. Follow-up During regression After remission Indication for treatment Weekly HCG Pelvic exam 1w after evacuation and every 2-4 w until negative HCG HCG weekly for 4W HCG monthly for 6-12 mo HCG if patient symptomatic HCG 6w after any subsequent pregnancy Rising HCG (3weekly values) plateau(10% for 3w ) metastasis biopsy with chorioca, pSTT

14. 11. Sequelae Invasive molechoriocarcinoma PSTT Pathology Villi Trophoblast Invade deepth Antecedent pregnancy Interval Site of metastases presence Marked proliferation /atypical ~ Uterine muscle and blood vessel Hydatidiform mole (mole) <6M Local invasion vagina, lung No Tissue necro lysis and bleeding, mass ~ Uterine muscle and blood vessel Marked All types pregnancy 6-12M Lung, brain etal No Inter- trophoblast Remaining localized All types pregnancy 12M/more rare

15. 12. diagnosis of GTT presentation Local tumor damage: bleeding Metastatic tumor damage : HCG Plateaued/rising titer after evacaution Titer not return to normal >12W post eva Reelevated after a normal level Other exam. Utrasonography : rule out normal pregnancy / uterus muscle change Chest radiography Abdominal and heat CT scan : histopathology

16. 13. Staging FIGO staging for GTD (international federation of Gynecology & obstetrics) Confined to uterus corpus Limited to genital structure Extends to lungs All other site Stage I Stage II Stage III Stage IV

17. 14. Treatment for GTT hysterectomy Unnecessary Only for large bleeding/infection/desire sterilization Chemo-therapy Sigle agent: MTX methotrexate (15-25mg im/iv,daily ×5d ) Act-D dactiniomycin(0.015mg/kg iv daily ×5d) 5-FU (28-30mg/kg/iv daily ×10d ) Triple therapy MTX 20mg+Act-D0.5mg+CTX250mg /iv/d ×15d repeated as toxicity allow untill HCG normal 3times then 2cycles Side effects: gastrointestinal smptem, liver injury, born morrow suppression,alopecia Radiation therapy Unnecessary, only for central nevous

18. 15. Follow-up for GTT General physical pelvic examination baseline chest X-ray Utrasonography HCG CT Every 2week---HCG normal every month----1year Every 3monthes-----3year Every 1 year-----5year

19. 16. summary 1.GTD is a group of diseases with special characters 2.Profound hormonal change (HCG) with proliferation of trophoblastic tissue 3. Rapidly progressive and very curable with chemotherapy 4. Follow-up after treatment is very important