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Published by: api-3703352 on Dec 02, 2009
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1-Hydatidiform Mole (V.M): Complete and partial 2-Invasive Mole 3-Placental site trophoplastic tumor 4-Gestational choriocarcinoma

•Complete hydatidiform Mole:
-Trophoblastic hyperplasia (Both cytotrophoblast, syncytial) -Hydropic changes of villi -No fetus

•Partial hydatidiform Mole:
-Focal trophoblastic hyperplasia (usually only syncytial) -hydropic changes of villi -There is embryo which usually die early

•Invasive Mole (chorioadenoma destruens):
-Invading the myometrium ( complete or partial) -Does not progress to choriocarcinoma -It may metastasize but does not progress like true cancer. -It may regress spontaneously -distinguished from choriocarcinoma by the presence of chorionic villi.

Gestational Choriocarcinoma:
-Carcinoma arising from trophoblastic epithelium both cyto and syncytio elements. -Can follow conception give rise to live birth, stillbirth, abortion, ectopic or hydatidiform mole. -lack of villous structures distinguish choriocarcinoma from invasive mole ->50% of choriocarcinoma are preceded by hydatidiform mole. -25% after abortion , 22.5% after delivery ( even 5 yrs, most serious). -Principal risk is uterine perforation or severe uterine bleeding

•Placental site trophoblastic tumor:
-Composed mainly of cytotrophoblastic cells -relatively low hCG -less common than invasive mole and choriocarcinoma -Complete surgical excision is preferred as the tumor is not chemo sensitive as choriocarcinoma -Produce abundant amount of human placental lactogen (HPL) -Slow growth and may present years after term, nonmolar abortion or complete H.M Usually no distant metastases

GESTATIONAL TROPHOBLASTIC TUMORS: 1-Invasive Mole 2-Choriocarcinoma 3-Placental site tumor

-Overall incidence: 1-10 per 1000 ( in U.K: 1 in 1000) -less frequent in blacks -Racial differences: higher incidence of hydatidiform mole in Asia -Age: hydatidiform mole is more common : 40-45 (3xfolds),45-49 (26xfols), >50(400xfolds), below 15 (6Xfolds) -previous hydatidiform mole increase risk 20-fold -Partial mole is less frequent than complete H.M -3% of H.M will finally develop choriocarcinoma -Blood group: AB , B

Complete hydatidiform mole : Maternal nucleus lost with sperm duplication of haploid sperm or two different sperms( fertilization of empty egg)

Partial hydatidiform mole : one maternal and two paternal chromosome sets


> 90%: 46xx: single sperm

4-8%: 46xx : Dispermy

Loss of Maternal Genetic material


23 x

23 x


23 x

23 x

Two paternal genetic contribution

23 x

23 x

Loss of Maternal Genetic material

Duplication of haploid sperm

23 23 x x



23x 23x

23x 23x


Maternal genetic contribution is retained Two paternal genetic contribution

69xxx: Triploid Conceptus

Partial mole is l less frequently followed by malignant sequele than complete mole

Presentation of VM
-Amenorrhea -Bleeding -Brownish discharge -Complications (esp. HG) -Pain (comp. ovarian cyst, expulsion)

-Choriocarcinoma is 1500 times more common after a molar pregnancy than after a term delivery -It is usually suspected after molar pregnancy if hCG failed normalized after 6 months of evacuation. -Choriocarcinoma and placental site tumor are the only G.T.T originating from a term delivery or a non-molar pregnancy. -Majority of choriocarcinoma present within a year of an apparently normal pregnancy or non-molar abortion. However, the presentation may be delayed for several years. -Vaginal bleeding, bloodstained discharge, abdominal pain.. -Extra uterine and ovarian masses are frequent. -In about 30%, the presenting features are non-gynecological: pulmonary, cerebral, and hepatic (dyspnea,haemoptysis…..

Complications of GTD

gravidarum -Thyrotoxicosis -DIC -AF EMBOLISM -Local He -Invasive Mole: perforation -Choriocarcinoma:2-5% -complication of cyst (TRH)


-hCG estimation: secreted by syncytiotrophoblasts -Ultrasound: snowstorm appearance, ±fetus, theca-lutein cysts -Chest x-ray -CBC (anaemia) ,coag. profile -T3,T4

-Polypeptide excreted in the urine with a half-life of 2436 hours -Measurement is using RIA with sensitivity 1 i.u/l in serum and 20 i.u/l in the urine -hCG assay does not discriminate between G.T.D and normal pregnancy though very high levels may lead to suspicion. -Significance of hCG measurement:
a) indication of tumor volume b) determine prognosis c) monitoring the treatment (detection of drug resistance, treatment period till hCG undetectable)

-Snow storm appearance , not entirely specific. -Theca lutein cysts -Hepatic, renal metastases


-C.T, MRI: Pulmonary, intraperitoneal and cerebral metastases

-Suction evacuation of hydatidiform mole -Hysterectomy: old age , GMP -Factors increasing the risk of persistent trophoblastic disease: a) uterine size > date b) Bilateral cystic ovarian enlargement c) Pre-evacuation serum hCG> 100,000 i.u/l d) Methods of evacuation (medical induction, hysterectomy….) e) Age: more than 40 years


-: measurement of hCG * every 2 weeks till limit of detection then *monthly during first year then *3-monthly during second year and after all further pregnancy (bec. Risk of recurrence and risk of choriocarcinoma arising even following normal pregnancy) -Further pregnancy should not be attempted till hCG is normal for at least 6 months

Indications for chemotherapy of G.T.T:
hCG monitoring: -Rising hCG after evacuation -hCG is not falling (plateau) 4 months after evacuation -hCG > 20,000 mIU/L Metastases: -pulmonary, vulval or vaginal metastasis -Any other metastases Presentation: -Heavy vaginal bleeding or intraperitoneal bleeding Histopathological diagnosis of choriocarcinoma

Prognostic Factors:
Prognostic factor Age Antecedent pregnancy Interval (months) hCG level ABO group(♀,♂) Largest tumor Site No. of metastases Prior chemotherapy 0 <39 H.M 4 10³ 1 >39 abortion 4-6 10³-10* O×A A×O 3-5 Spleen,kidney 1-4 Term 7-12 10*-10** B AB >5cm GI,liver 4-8 Single drug >8 >10** 2 4

If Score: •<4:low-risk •5-7:Midlle •>8:High risk

2 or more

Chemotherapy Strategy:
Group Regime Side -effect Others


Methotrexate Ca folinate

Alopecia, oral ulceration, photosensitivity, myelosuppression As above Drug resistance

75% will be cured 20% need to change drug 5% intolerant to Rx 96% complete response 4% relapse


Etoposide Actinomycin D


EMA/CO Etoposide Methotrexate Actinomycin D Cyclophosphamon covine

93% complete remission (no prior chemo…) 76% (those had prior chemo)


-100% in low-risk group -98% in medium-risk group -93% in high-risk group with no prior chemtherapy 74% in high-risk group with prior chemotherapy


-For H.M for 2 years -For persistant trophoblastic diseases for life -Patients usually advised to avoid pregnancy for a year after completion of chemotherapy.


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