 This term primarily encompasses pathologic entities

that are characterized by aggressive invasion of the

endometrium and myometrium by trophoblast cells.
 Histologic categories include:

1.Invasive mole
2.Gestational choriocarcinoma,
3.Placental-site trophoblastic tumor
4.Epithelioid trophoblastic tumor
 The incidence of choriocarcinoma in USA and
Europe is 1:50.000 pregnancy

 50% of cases follow molar pregnancy

 25% of cases follow abortion
 20% of cases follow term pregnancy
 5% of cases follow ectopic pregnancy
High-risk patients for GTN development are those
with.
 Complete moles
 Age > 40 years,
 Previous history of molar pregnancy,
 An excessively high β-hCG titer prior to evacuation.
 Considerations for Management of Hydatidiform Mole
Preoperative
• Laboratory
• Hemogram; serum β-hCG, creatinine, and hepatic aminotransferase levels
• TSH, free T4 levels
• Type and Rh; group and screen or crossmatch
• Chest radiograph
• Consider hygroscopic dilators
Intraoperative

• Large-bore intravenous catheter(s)

• Regional or general anesthesia
• Oxytocin (Pitocin): 20 units in 1000 mL RL for continuous infusion
• One or more other uterotonic agents may be added as needed:
• Methylergonovine (Methergine): 0.2 mg = 1 mL = 1 ampule IM every 2 hr prn
• Carboprost tromethamine (PGF2α) (Hemabate): 250 μg = 1 mL = 1 ampule IM every 15–90 min prn
• Misoprostol (PGE1) (Cytotec): 200 mg tablets for rectal administration, 800–1000 mg once
• Karman cannula—size 10 or 12
• Consider sonography machine
Postevacuation

• Anti-D immune globulin (Rhogam) if Rh D-negative

• Initiate effective contraceptiona
• Review pathology report
• Serum hCG levels: within 48 hours of evacuation, weekly until undetectable, then monthly for 6 months
• Anti-D immune globulin (Rhogam) if Rh D-negative
• Initiate effective contraceptiona
• Review pathology report
• Serum hCG levels: within 48 hours of evacuation, weekly until undetectable, then monthly for 6 months
1.INVASIVE MOLE:
 This common manifestation o GTN is characterized
by whole chorionic villi that accompany excessive
trophoblastic overgrowth and invasion

 These tissues penetrate deep into the myometrium,

sometimes to involve the peritoneum,adjacent
parametrium, or vaginal vault.

 Such moles are locally invasive but generally lack

the pronounced tendency to develop widespread
metastases typical o choriocarcinoma.
2.Gestational Choriocarcinoma
 This extremely malignant tumor contains sheets of
anaplastic trophoblast

 prominent hemorrhage,necrosis,

 Vascular invasion

 Formed villous structures are characteristically

absent.
 Gestational choriocarcinoma initially invades the
endometrium and myometrium but tends to develop
early blood-borne systemic metastases

1.Lung (80%)
2.Vagina (30%)
3.Pelvis(20%)
4.Liver(10%)
5.Brain(10%)
3.Placental site trophoblastic tumor (PSTT)
 PSTT arises from implantation site intermediate
trophoblast
 It constitutes 1-2% of all GTN
 Most cases are at least locally infiltrative and
myometrial smooth muscle cells are found in
between the clusters of tumor cells
 Serum HCG may be high
 Serum HPL may be raised and can be used as tumor
marker
1.Sympoms
 Irrigular vaginal bleeding
 Purulent vaginal discharge
 Pain
 Mass
 Metastasis
1.lung
2.liver
3.bone
4.Brain
 Cachexia
2.Signs
 General
 Abdominal
 local
 β-hCG level plateau persists in four measurements
during a period of 3 weeks or longer (days 1, 7, 14,
and 21)
 β-hCG level rise in 3 weekly consecutive
measurements or longer, over a period of 2 weeks or
more (days 1, 7, and 14)
 β-hCG level remains elevated for 6 months or more
 Histologic diagnosis of choriocarcinoma
 Laboratory
1.Base line HCG
2.CBC
3.Liver function tests
4.Renal function testd
5.Thyroid function tests
 US or doppler on pelvis
 US or CT abdomen
 Chest X ray or CT
 CT or MRI brain
 Low risk cases :Single agent chemotherapy as
Methotrexate or Actinomycin D

 High risk cases: Multi agent chemotherapy like

EMA-CO

 Surgery, selective arterial embolization and

radiotherapy used in selected cases
 It is antimetabolite agent that inhibits DHF reductase
enzyme required to converts folic acid into folinic acid
 Regimen:
50 mg IM on days 1,3,5,7
CA folinate 7.5-15 mg on days 2,4,6,8
The course is repeated after 2 weaks
 Response rate 72%
 Survival 100%
 Side effects
 Follow up
 Glossitis
 Stomatitis
 Pleurizy
 Peritonitis
 Bone marrow suppression
 Liver toxicity
 Kidney toxicity
Day 1(EMA)
 Etoposide
 Acinomycin D
 Methotrexate
Day 2
 Etoposide
 Acinomycin D
 CA folinate
Day 8( CO)
 Vincristine
 cyclophosphamide
 Success rate 85%
 Survival 90%
 70% in liver metastasis
 27% in brain metastasis
 10% in liver and brain metastasis
 Weekly HCG until negative 3 consecutive measures
 Monthly for 1 year
 Effective contraception
 For high risk cases (stage III and stage IV) extended
follow up for two years is recommended
1.Salpigo-ophorectomy
 Indicated in case of complicated theca lutin cyst by
torsion or rupture
2.Hysterectomy
The incidence of hysterectomy in GTN is one for
every 140 cases
Indications
1.Presence of severe refractory vaginal bleeding or
severe infection
2. Removal of resistant disease in the uterus
3.Decrease tumor load in case of limited or incomplete
response to chemotherapy
 Methotrexate must be given in the periopoerative
period to
1. Treatment of any occult metastasis that may be
present at time of surgery
2. Decrease likelihood of disseminating viable tumor
cells at time of surgery
3. Maintain cytotoxic level of chemotherapy in the
blood stream and tissues in case of disseminated
viable tumor cells
3. Thoracotomy
To remove resistant focus in the lung
4. Craniotomy
To remove resistant metastatic focus in the brain
Role of selective arterial embolization
Selective embolization of internal iliac artery in case
of severe vaginal bleeding
Role of radiotherapy
Brain metastasis can receive radiotherapy in form of
4000 cGY in 10 fractions
 Fertility rate 80%
 70% full term pregnancy
 The rate of congenital malformations is not
increased if pregnancy occurred after 1year
 Adverse pregnancy outcomes if pregnancy occured
less than 1year in the form of
1. Miscarriage
2. Recurrent molar pregnancy
3. Still birth
 27 years G3 with complete molar pregnancy
 HCG 117.000
 Post evacuation HCG 78.000
 1weak after evacuation 18.000
 2weaks 7500
 3weaks 11000
 4weaks 15000
 Us: tumor size 2cm
 Chest Xray, abdominal US free
 43 years G4 delivered vaginal 5 month ago
 Presented with irrigular vaginal bleeding not
responding to treatment
 HCG done and was 300.000
 US: mass inside uterus 7 cm
 Ches Xray and CT abdomen free