1. GESTATIONAL TROPHOBLASTIC TUMORS
GESTATIONAL TROPHOBLASTIC Disease (GTD)
(GTT)

2. Learning Objective
At the end of this session, I would like you to be able to:
Have an idea about GTT
Diagnose GTT
Know how to manage GTT
Know how to monitor GTT

3. Abnormalities of trophoblasts
It is a diverse group of tumors 80%- 90% benign.
Abnormalities of trophoblasts
Resulting from abnormal events occurring at or shortly after fertilization
GTT follow normal or abnormal pregnancy
Contains paternal genes

4. Types: Benign Hydatidiform mole 80%-90% Malignant Invasive mole
Persistent trophoblastic tumor
Choriocarcinoma
Placental site tumors (Rare)

5. Unique about GTT
Cure almost 100%
Sensitive marker- secreted by all types
Allow:
Accurate assessment
Follow-up

6. Epidemiology:
Varies
More in far east
Diet
More in extreme of reproductive ages
Risk of having another mole is 1- 3%

7. Hydatidiform mole:
Results from abnormal events occur at or shortly after fertilization, ? Abnormal gametogensis
Types:
Histoligically
Cytogenically
Complete mole
Partial mole

8. Genetic composition Complete (diploid karyotype &paternal in origin
• Chromosomes = 46 xx
• Both xx, are paternally derived
Fertilization of abnormal egg- no nucleus
Haploid sperm 23x empty egg sperm duplicate 46xx diploid(>90%)
< 20% empty ovum fertilized by 2 sperm resulting in 46xy
% progress to Gestational Trophoblastic Tumor

9. Partial mole
Chromosomes, triploid 69 xxy (80%)
Minority triploid 69 xxx 20%(dispermic)
Maternal& paternal genes
Often present with fetal tissue
Fetus may be abnormal
Rarely reach term
5% progress to persistent gestational trophoblastic tumor

10. Hydatidiform mole: Confined to the uterine cavity
Occasionally trophoblastic-Embolic to lungs
Partial mole
• some hydropic villi.
• other villi normal.
• less hyperplasia of trophoblast.
• some fetal vessels or fetal Rbc.
Complete mole
• all villi hydropic oedematous
•all trophoblast are hyperplasia
• absence of fetal blood vessels
Greater risk of becoming malignant

11. Hydatidiform mole:
Symptoms:
• majority >90% have irregular vaginal bleeding 1st, 2nd trimester (does not indicate a problem)
• bleeding is painless
• may expel vesicles
• 1/3 excessive nausea/ vomiting, Why??
hyperemesis gravidarum 25%
• pre-eclampsia occurs Early <24 weeks gestation 3-12%
What other conditions in pregnancy, when PET occurs early???
•hyperthyroidism 2- 10%, test before surgery
Theca luteal cysts, bilateral

12. Signs:
Pale complexion
Tachycardia sign of thyrotoxicosis
Tachypnea- sign of pulmonary Embolism
Uterus: Enlarged 50%
Theca luteal cyst, 10-15%
Secondary post partum bleeding (PPH)
Persistent bleeding , should always think GTT/GTD
What should you do??

13. Partial Mole More common May be undetected
May not appear abnormal on Ultrasound (USS)
USS ordered for ??
Histopathology of Retained product of conception (RPOC) partial or complete.

15. SNOWSTORM APPEARANCE OF MOLAR PREGNANCY

16. Requirement for chemotherapy
H mole may not regress spontaneously and require chemotherapy, more common with??
10-17% of H. mole result in invasive mole
3% of mole progress to choriocarcinoma

17. Diagnosis: High index of suspicious from clinical data
Quantatative beta-hCG
Ultrasound shows _______ appearance
Differential diagnosis:
________________
Chest x-ray ??

18. Laboratory investigations:
Full blood count?
Blood group – Rh________?
Coagulation profile?
Liver function test
Renal function test base line?
Chest film

19. Treatment:
Pre-requisites
____________
Surgery

20. Blood cross match in theatre
Syntocinon infusion
Dilation – suction evacuation
Complication
___________?
Hysterectomy:
When _________?
_________?

21. Complication:
Uterine perforation
Uterine haemorrhage

22. Monitoring: Follow-up Serum- β human chronic gonadotrophin
What happens to βhCG ?
Initially
Post evacuation – immediate
6-8 weeks post evacuation
Follow-up
Weekly βhCG, until 3 consecutive normal values
Monthly βhCG , until 6 months
Contraception??
History of molar pregnancy, Postpartum check βhCG at delivery, 6 and 10 weeks
Repeat H> mole occur in 1-3 %, have greater risk of invasive or choriocarcinoma

23. Chemotherapy: Prophylactic not justified >79% spontaneous remission
When does chemotherapy is indicated in hydatidiform mole?

24. Invasive mole: Villi penetrate myometrium
5 – 10 % preceded by hydatidiform mole
βhCG persistently high after evacuation of hydatidiform mole
Locally invasive
Rarely metastases to:
Vagina
Lung
Brain

25. Placental site trophoblast tumor
Extremely rare
Occur after non-molar pregnancy
Sheets of cytotrophoblasts only
When melastasis occur – fatal
βhCG levels are relatively low
Relatively chemotherapy-resistant
Surgery has been the main stay of treatment

26. Choriocarcinoma: Metastastatic Non-metastatatic Histopathology:
Invade uterine wall
Metastasis
Sheet of cytotrophoblast and synchiotriphoblast
No identifiable villi

27. Choriocarcinoma:
50% of choriocarcinoma have preceding hydatidiform mole
50% of choriocarcinoma follow:
Ectopic
Abortion
Normal pregnancy
• Trophoblast after normal pregnancy almost always choriocarcioma

28. Choriocarcinoma Subdivided into: Good Poor prognosis
Low risk and high risk
Depending on:
Site
Size of metastasis
Clinical variables

29. Good Prognostic Factor:
Initial βhCG < 40,000 miu/L
Therapy started within 4 months of antecedent pregnancy
Metastasis only to lung or pelvis
No prior chemotherapy.

30. Poor Prognostic Factor :
βhCG > 40,000 miu/L (initial)
Therapy > 4 months from the pregnancy
Metastasis to brain or liver
failed response to a single agent of chemotherapy
Choriocarcinoma following full term pregnancy.

31. FIGO Staging for GTT
Description
Stage

32. Chemotherapy Methotrexate Etoposide Actinomycin D Cyclophosphomide
Oncovin
Folinic acid IM

33. Further Reading www.hmole-chorio.org.uk www.swot.org.uk

34. Questions time Molar pregnancy Never include a fetus
Commonly present with vaginal bleeding in early pregnancy
If complete contains only paternal genes
HCG levels will lower than normal in early pregnancy
May result in a need for chemotherapy

35. GTT There is a decreased incidence with increasing age
It gives typical USS appearance
It is monitored post evacuation by urinary oestriol
It can be treated with trimthoprate

36. Following a diagnosis of a molar pregnancy
Serum hCG level should fall to within normal range in the first 4 weeks
Pregnancy should be avoided by inserting IUCD
Hysterectomy reduces the necessity for hCG monitoring

37. Clinical case scenario
Mrs. F is a 22 years old ward clerk. She is 8 weeks pregnant, and is complaining of severe nausea and vomiting, the uterus is compatible with 14 weeks. What is the differential diagnosis??