1. GESTATIONAL TROPHOBLASTIC TUMORS (GTT)

2. *It is a diverse group of tumors 80 – 90% Benign * That includes Benign Hydatidiform mole to Choriocarcinoma *It is a diverse group of tumors 80 – 90% Benign * That includes Benign Hydatidiform mole to Choriocarcinoma

3. Types: Hydatidiform mole 80 – 90% Invasive mole Persistent trophoblastic tumor Choriocarcinoma Placental site tumors

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

5. Epidemiology: -varies -more in far east diet - more in extreme of reproductive ages -more in blood group O and A - risk of having another mole is 1 – 3%

6. Hydatidiform Mole: Types: Differ Histologically Cytogenetically I - complete mole 2 - partial mole

7. Genetic composition: >Complete Chromosomes = 46 xx Both x X are paternally derived Fertilization of abnormal egg - no nucleus. >Haploid sperm 23x → Empty egg → Sperm duplicate 46xx diploid or fertilization by two sperms 15 -25% progress to Gestational Trophoblastic Tumor

8. Partial mole Chromosomes is triploid 69 xxy 80% Minority triploid 69 xxx 20% > Often present with fetal tissue - Fetus may be abnormal. - Rarely reach to term. >5% Progress to Gestational Trophoblastic Tumor Partial mole Chromosomes is triploid 69 xxy 80% Minority triploid 69 xxx 20% > Often present with fetal tissue - Fetus may be abnormal. - Rarely reach to term. >5% Progress to Gestational Trophoblastic Tumor

9. Hydatidiform Mole: -Confined to the uterine cavity -Occasionally trophoblastic – Emboli to lung Hydatidiform Mole: -Confined to the uterine cavity -Occasionally trophoblastic – Emboli to lung Partial Mole Some Hydropic villi. Some Hydropic villi. Other villi normal. Other villi normal. Less hyperplasia of trophoblast Less hyperplasia of trophoblast Some fetal vessels or fetal RbcSome fetal vessels or fetal Rbc Complete Mole All villi hydropic oedematous All villi hydropic oedematous All hyperplasia of trophoblast All hyperplasia of trophoblast Absence of fetal blood vessels Absence of fetal blood vessels

10. Hydatidiform Mole: Symptoms: ٭ Majority > 90% have irregular vaginal bleeding 1 st, 2 nd trimester Bleeding is painless May expel vesicles Excessive nausea / vomiting Hyperemesis Gravidarum 10-25% Pre-eclampsia occurs early 90% have irregular vaginal bleeding 1 st, 2 nd trimester Bleeding is painless May expel vesicles Excessive nausea / vomiting Hyperemesis Gravidarum 10-25% Pre-eclampsia occurs early < 24 weeks gestation -10-12% Hyperthyroidism 2 – 10% if so - test before surgery

11. Signs: > Pale > Tachycardia – sign of Thyrotoxicosis > Tachypnea – sign of Pulmonary Embolism > Uterus: Enlarged 50% no fetal heart no fetal parts. > Theca-luteal cyst(10 – 15%) Signs: > Pale > Tachycardia – sign of Thyrotoxicosis > Tachypnea – sign of Pulmonary Embolism > Uterus: Enlarged 50% no fetal heart no fetal parts. > Theca-luteal cyst(10 – 15%)

12. Diagnosis: High index of suspicious from clinical data Ultrasound shows snow storm appearance Diagnosis: High index of suspicious from clinical data Ultrasound shows snow storm appearance

13. Laboratory investigations: Full blood count? Blood group – Rh factor? Coagulation Profile ? Liver function test Base Renal function test line ? Chest Film

14. Treatment: * Surgery suction evacuation is the standard therapy

15. Blood cross match, in theatre oxytocin infusion * Dilation – suction evacuation Complications: 1) __bleeding____________ 2) ____perforation__________ * Hysterectomy: When late reproductive life ___________ ___________ Blood cross match, in theatre oxytocin infusion * Dilation – suction evacuation Complications: 1) __bleeding____________ 2) ____perforation__________ * Hysterectomy: When late reproductive life ___________ ___________

16. Complication: * Uterine perforation * Uterine Haemorrhage

17. Monitoring: * Serum – β – Human chorionic Gonadotrophin What happen to βhCG? - - it drops post evacuation - 8 weeks post evacuation should disapear Follow-up: - Weekly βhCG, until 3 consecutive normal value - Monthly βhCG, until 6 months * Contraception

18. Chemotherapy: * Prophylactic not justified > 79% spontaneous remission When does Chemotherapy is indicated in Hydatidiform Mole ? 1- When B hCG plataue,or rise 2- Higher risk of Choriocarcinoma 3-Unreliable for follow-up

19. Invasive Mole: Villi penetrate Myometrium βhCG persistently high after evacuation of Hydatidiform Mole Locally invasive diagnosis at time of Hysterectomy Rarely Metastasis to: - Vagina - Lung - Brain

20. Placental site Trophoblast Tumor Extremely rare Occur after non-Molar Pregnancy When Metastasis occur – Fatal βhCG not extremely high Insensitive to chemotherapy Surgical resection is the mode of treatment.

21. Choriocarcinoma: *Metastasis * Non-Metastasis Histopathology: - Avascular – - Invade uterine wall - Metastasis - Sheet of Cytotrophoblast and synchiotrophoblast No identifiable villi

22. Choriocarcinoma: *choriocarcinoma follows Hydatidiform Mole, and carries a better prognosis THAN Choriocarcinoma that follow: - Ectopic - Abortion - Normal pregnancy WHY ? *

23. Symptoms of metastatic disease Symptoms of metastatic disease Vaginal bleeding Vaginal bleeding Rectal bleeding Rectal bleeding Headache Headache Signs Signs Acute abdomen, rupture liver, cyst Acute abdomen, rupture liver, cyst Neurologic signs Neurologic signs Investigation Investigation CT Scan / MRI of abdomen CT Scan / MRI of abdomen Lumber puncture for B hCG Lumber puncture for B hCG

24. Prognostic scoring Prognostic scoring Age Age Antecedent pregnancy Antecedent pregnancy Interval between end of antecedent pregnancy and the start of chemotherapy Interval between end of antecedent pregnancy and the start of chemotherapy B hCG level B hCG level Prior chemotherapy Prior chemotherapy Site of metastesis Site of metastesis Size of metastasis Size of metastasis Number of metastasis Number of metastasis

25. Choriocarcinoma Subdivided into: Good Prognosis Poor Depending on: Site of Metastasis Size Clinical variables

26. Good Progostic Factors: 1) Initial BhCG < 40,000 miu/L 2) Therapy started within 4 months of antecedent pregnancy 3) Metastasis only to lung or pelvis.

27. Poor Progostic Factors: * BhCG > 40,000 * Therapy started > 4 months * Metastasis to brain or liver failed response to single agent of chemotherapy. * Choriocarcinoma following full term pregnancy

28. Chemotherapy Chemotherapy Methotrxate Methotrxate Actinomycin D Actinomycin D Cyclophosphamide Cyclophosphamide Follow- up Follow- up Good prognosis Good prognosis Follow up monthly for 1 year Follow up monthly for 1 year Bad prognosis Bad prognosis Follow-up monthly for 2 years thereafter every 3 months for 5 years. Follow-up monthly for 2 years thereafter every 3 months for 5 years.