1.  Classification of gestational trophoplastic diseases (GTD) diseases (GTD)  Incidence of malignant GTD  Pathophysiology  Clinical presentation  How to diagnose malignant GTD  Prognoses of malignant GTD  Treatment of malignant GTD

3. Gestational trophoplastic diseases (GTD) (benign) Non invasive H. mole (malignant) invasive complete partial Non metastatic (invasive mole) Metastatic (choriocarcinoma)

4. 1.Chorio carcinoma will follow complete H.mole in 50% 50% 2. Chorio carcinoma will follow partial H.mole in 0.5% 0.5% 3. Whole HCG assay is used for follow up after H.mole evacuation. H.mole evacuation. 4. Serum progesteron is not used as tumor marker for malignant GTD. 5. Surgery is superior to chemotherapy in the treatment of malignant GTD

5. MALEGNANT GESTATIONAL TROPHOPLASTIC DISEASES Incidence west: 1 in 30000 oriental: 1 in 11000 oriental: 1 in 11000 Geographical area Geographical area Preceding pregnancy Preceding pregnancy H.mole :50% H.mole :50% normal pregnancy: 40% normal pregnancy: 40% abortion or ectopic:5% abortion or ectopic:5% non gestational:5% non gestational:5% Maternal B.group Maternal B.group more with group A, less with group O more with group A, less with group O

6. pathology A villous proliferation Necrosis & hemorrhage

10. Clinical presentation Vaginal bleeding Amenorrhea Abdominal mass Symptoms of distant metastasis (pulmonary, GIT, brain)

11. Diagnosis 1. B hCG follow up after H. mole evacuation A. urinary hCG >30000 iu/24hr or serum hCG >20000 iu/L B. progressive increase of hCG at any time after evacuation of H.mole C. detected hCG 5-6 months after evacuation or platue level for 3 months D. evidence of intracranial, hepatic or GIT metastasis E. persistent vaginal bleeding with raised hCG F. pulmonary metastasis with raised hCG 2. Histopathology 3. U/S,CXR & CT scan

14. Prognosis hCG level: 100000 iu/24 hr in urine 40000 iu/L in blood Interval between preceding pregnancy & diagnosis 4 months Intracranial or hepatic metastasis Size of the tumor : 8 cm Previous chemotherapy Preceding gestation is term pregnancy

15. Treatment 1.Chemotherapy : very sensitive tumor 2.surgery: Sever bleeding Complete family Resistant to chemotherapy Persistent uterine mass or solitary nodule To decrease the duration of chemotherapy 3. radiotherapy: very poor results

21. Low risk group Methotrxate 1mg/kg & folinic acid 6mg im or 15 mg orally after 30 hrs for 8 days & rest for 6 days before starting further course 80% of cases respond to this treatment if resistant to this drug develops then actinomycin D in dose of 10- 13 µgm/kg/day iv for 5 days High risk group Complicated multiple drugs