1. Gestational Trophoblastic Neoplasia
It a group of disease with wide range of neoplastic potential
That creat a lot of chalange for us in term of diagnosis and treatment
Diagnosis and management will depends on the history, HCG level and metatsic workup
It is been allocated to one of the followinng pathological entites;
Dr Khalid Sait
FRCSC/Gynecologic Oncologist/Ass. Prof
KAUH/Jeddah / Saudi Arabia

2. Key Words Group of disease with wide range of neoplastic potential
Create a lot of challenge for us in term of diagnosis and treatment
Diagnosis and management will depends on the history, HCG level and metastasis work up

3. Clinical pathology of gestational trophoblastic disease
1- Cytotrophoblast and syncytiotrophoblast cells proliferation Moler pregnancy Invasive mole Choriocarcinoma
2- Intermediate trophoblastic cells derivative Placental – site tumor
Plac site
Hpl
Little hcg
Can mets
Can invade myometrium
May not respond to ttt
If persist after d and c
Hystrectomy may consider at intial ttt

4. Risk Factors for Moler pregnancy
Extremes of reproductive years
Prior moler mole
Prior spontaneous abortion
Vit A deficiency
Race ( Indonesia 1:85, USA 1:1500)

5. Clinical Features Large for date 50 % Hyper emesis 20 % Early PIH 5%
Abscent FH ( except in partial mole or twin pregnancy)
Hyperthyroidism symptom and sign 5%
Rarely presented with metastasis symptom and sign

6. Management of molar pregnancy
Risk of Persistent GTT
Procedure
20 %
Suction Evacuation 5%
Hysterectomy

7. Follow up of patient with molar pregnancy after evacuation
HCG weekly serum determination until normal for two values ,then monthly for 6 to 12 months
Contraception for 1 year
Pelvic examination every 2 weeks until normal,then every 3 months
Check histopathology

8. If no proper decrease or BHCG start to increase

9. Persistent GTD

10. Indication for initiating treatment during post mole follow up
Serum BHCG values rising more than 10 % for 2 wk ( 3 weekly titre)
Serum BHCG values on plateau for 3 wk or decline of less than 10 %
Presence of metastasis
Significant elevation of serum BHCG values after reaching normal levels
Choriocarcinoma or invasive mole on histopathology
HCG level still elevated 6 months after molar evacuation
HCG > miu/ml 4 weeks after evacuation

11. Work up of gestational trophoblastic neoplasia
History and physical examination
chest XR ( if neg  CT )
Pretreatment HCG titre
Hematological survey
Serum chemistries
CT of brain
Ultrasound of pelvis
Liver scan ( u/s or CT )

12. CLASSIFICATION OF GESTATIONAL TROPHOBLASTIC DIS
Benign
1) complete mole
2) Partial mole
Malignant (invasive mole and choriocarcinoma) ) nonmetastatic
2) metastatic
a) low risk b) high risk

13. Risk factors (malignant GTD)
1.Disease present more that 4m(long duration) or
2.pretreatment B-HCG greater than 40,000mlu/ml or
3.presence of met to sites other than lungs or vagina i,e liver or brain etc..
4. prior chemo
5 following Term pregnancy

14. *Combined chemotherapy
CHEMOTHERAPY FOR GTN
NON METASTATIC or
GOOD PROGNOSIS METASTATIC
*Single agent chemotherapy
*survival %
METASTATIC POOR PROGNOSIS
*Combined chemotherapy
* survival 50 %

15. REMISSION OF GTN DISEASE REMISSION NON METASTATIC 100 %
GOOD PROGNOSIS METASTATIC %
POOR PROGNOSIS METASTATIC %
TOTAL %

16. SUMMARY
GTD IS A RARE ENTITY THAT IS HIGHLY CURABLE , EVEN IN THE PRESENCE OF WIDESPREAD METASTASES

17. Q&A GTN Dr Khalid Sait FRCSC Ass. Prof of Gynecologic Oncology
KAUH,Jeddah Saudi Arabia