Gestational%20Trophoblastic%20Disease%20(GTD) - PowerPoint PPT Presentation

View by Category
About This Presentation
Title:

Gestational%20Trophoblastic%20Disease%20(GTD)

Description:

Title: Gestational Trophoblastic Disease Author: JKBurzawa Last modified by: s Created Date: 11/28/2010 11:02:39 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

Number of Views:1175
Avg rating:3.0/5.0
Slides: 29
Provided by: JKB9
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Gestational%20Trophoblastic%20Disease%20(GTD)


1
Gestational Trophoblastic Disease (GTD)
  • MAJOR NABILA AMIN
  • ASSISTANT PROFESSOR
  • CONSULTANT GYNAECOLOGIST
  • CMH RAWALPINDI

2
GTD Overview
  • Heterogeneous group of related lesions
  • Arise from abnormal proliferation of trophoblast
    of the placenta
  • Unique because the maternal lesions arise from
    fetal (not maternal) tissue
  • Most GTD lesions produce the beta subunit of
    human chorionic gonadotropin (B-hCG)

3
Overview
  • Hydatidiform Mole
  • Complete
  • Partial
  • Benign
  • Gestational Trophoblastic Neoplasia (GTN)
  • Persistent/Invasive Mole
  • Choriocarcinoma
  • Placental-Site Trophoblastic Tumor (PSTT)
  • Malignant

4
Hydatidiform Mole
  • North America 0.6-1.1 per 1000 pregnancies
  • Asia 2-10 per 1000 (3x Western countries)
  • Difference possibly related low dietary intake of
    carotene (vitamin A deficiency) and animal fat
  • More common at reproductive extremes in age (gt35y
    or lt20y)

5
Hydatidiform Mole
  • Risk Factors
  • History of previous GTD
  • If one previous mole, 1 chance of recurrence
    (vs. 0.1 in general population)
  • If 2 previous moles, risk of recurrence increases
    to 16-28
  • Smoking
  • Vitamin A deficiency

6
Hydatidiform Mole
  • Clinical Manifestations
  • Vaginal bleeding/anemia
  • Enlarged uterus (size gt dates)
  • Pelvic pain
  • Theca lutein cysts
  • Hyperemesis gravidarum
  • Hyperthyroidism
  • Preeclampsia lt20 weeks gestation
  • Vaginal passage of hydropic vesicles

7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
Hydatidiform Mole Treatment
  • Evaluate for coexisting conditions
  • - History and physical
  • - CBC, coagulation profile, serum chemistry
  • - thyroid function
  • - blood type and crossmatch
  • - chest radiography
  • - pelvic ultrasonography
  • Evacuation of mole
  • - Suction curettage
  • - Hysterectomy if completed childbearing
  • If Rh negative, give rhogham

11
(No Transcript)
12
Follow-Up Care Molar Pregnancy
  • 80 of patients cured by evacuation
  • Follow B-hCG levels every two weeks until 3
    consecutive tests negative
  • Then monthly B-hCG every month for 6-12 months
  • Avoid pregnancy for at least 6 months after first
    normal B-hCG
  • Birth control during follow-up period
  • Subsequent Pregnancies
  • Send placenta for pathology
  • Check B- hCG 6 weeks postpartum

13
Gestational Trophoblastic Neoplasia (GTN)
  • Persistent/Invasive Mole
  • Choriocarcinoma
  • Placental-Site Trophoblastic Tumor (PSTT)
  • Malignant

14
Risk Factors for GTN After Mole
  • Preevacuation uterine size greater than
    gestationl age or larger than 20 weeks gestation
  • Theca-lutein cysts larger than 6 cm
  • Age gt 40 years
  • Serum hCG levels gt 100,000 mIU/mL
  • Medical complications of molar pregnancy
  • Previous hydatidiform mole

15
Invasive Mole
  • Myometrial invasion by hydatidiform mole
  • 1 in 15,000 pregnancies
  • 10-17 of hydatidiform moles will progress to
    invasive moles

16
Persistent Mole
  • Definition of persistent molar disease and need
    for chemotherapy (at least one of the following)
  • B-hCG plateau for 4 values for 3 weeks
  • B-hCG increase of 10 for 3 values for 2
    weeks
  • B-hCG persistence 6 months after molar evacuation
  • Histopathologic diagnosis of choriocarcinoma
  • Presence of metastatic disease

17
Choriocarcinoma
  • Most aggressive type of GTN
  • Abnormal trophoblastic hyperplasia
  • Absence of chorionic villi
  • Direct invasion of myometrium
  • Vascular spread to distant sites
  • Lungs
  • Brain
  • Liver
  • Pelvis and vagina
  • Spleen, intestines, and kidney

18
Choriocarcinoma
  • May come from any type of pregnancy
  • - 25 follow abortion or tubal pregnancy
  • - 25 with term gestation
  • - 50 from hydatidiform moles
  • 2-3 of moles progress to choriocarcinoma
  • Incidence 1 in 40,000 pregnancies

19
Placental-Site Trophoblastic Tumor (PSTT)
  • Originate from intermediate cytotrophoblast cells
  • Secrete human placental lactogen (hPL)
  • B-hCG often normal
  • Less vascular invasion, necrosis and hemorrhage
    than choriocarcinoma
  • Lymphatic spread
  • Arise months to years after term pregnancy but
    can occur after spontaneous abortion or molar
    pregnancy

20
Placental-Site Trophoblastic Tumor (PSTT)
  • Most common symptom is vaginal bleeding
  • Tend to
  • - Remain in uterus
  • - Disseminate late
  • - Produce low levels of B-hCG compared to other
    GTN
  • - Be resistant to chemotherapy (treat with
    surgery)

21
Signs Symptoms GTN
  • Continued uterine bleeding, uterine perforation,
    enlarged irregular uterus, persistent bilateral
    ovarian enlargement
  • From metastatic lesions abdominal pain,
    hemoptysis, melena, increased intracranial
    pressure (headaches, seizures, hemiplegia),
    dyspnea, cough, chest pain

22
Diagnosis of GTN
  • Increase or plateau in B-hCG after molar
    pregnancy
  • Pathologic diagnosis by DC or biopsy of
    metastatic lesions
  • WARNING biopsy of metastatic lesions can result
    in massive hemorrhage
  • Metastatic workup CXR (or CT chest), CT
    abdomen/pelvis /- CT/MR of brain

23
Classification Staging of GTD
  • FIGO Staging
  • Describes anatomic distribution of disease
  • World Health Organization (WHO) Scoring Index
  • Describes prognosis

24
FIGO Staging
Stage Description
I Disease confined to the uterus
II Disease extends outside the uterus but limited to genital structures (adnexa, vagina, and broad ligament)
III Disease extends to the lungs with or without genital tract involvement
IV Disease involves any other metastatic sites
25
WHO Prognostic Score Index
Score Score Score Score
Characteristic 0 1 2 4
Age lt40 40 - -
Antecedent preg Mole Abortion Term -
Interval from index pregnancy lt4 months 4-6 months 7-12 months gt12 months
Pretreatment hCG lt103 103- 104 104-105 gt105
Largest tumor size (including uterus) lt 3cm 3-4 cm 5cm -
Site of metastases Lung Spleen, kidney GI tract Liver, brain
Number of metastases - 1-4 5-8 gt8
Previous failed chemotherapy - - Single drug 2 drugs
26
Therapy for GTN
  • Low-risk score 6
  • High-risk score 7
  • Single agent therapy for nonmetastatic (stage I)
    or low-risk metastatic (stage II and III) with
    score lt7 ? survival rates 100
  • Combination chemotherapy /- adjuvant radiation
    and/or surgery for high-risk metastatic disease
    or score 7

27
Therapy Nonmetastatic GTN
  • Single-agent with either methotrexate or
    dactinomycin
  • Chemotherapy continued until hCG values normal
    and then 2-3 cycles beyond
  • Change to alternative single-agent for hCG
    plateaus above normal or toxicities
  • If significant elevation of hCG or new
    metastases, switch to multiagent
  • 85-90 cured with initial regimen, lt5 will
    require hysterectomy for cure

28
Therapy Low-risk Metastatic GTN
  • Low-risk metastatic disease can be treated with
    single-agent therapy with 5-day regimens
  • Cure rates 100 but 30-50 will be develop
    resistance to first agent
  • If resistance to sequential single-agent
    chemotherapy (5-10 of patients), switch to
    multiagent chemotherapy

29
Therapy High-risk Metastatic GTN
  • Stage IV
  • Stage II/III with score gt 7
  • Disease refractory to single-agent chemotherapy
  • Combination Chemotherapy
  • EMACO
  • Day 1 Etoposide, Methotrexate and Dactinomycin
  • Day 8 Cyclophosphamide and Vincristine
    (Oncovorin)
  • Repeat q2 weeks until remission
  • Continue for at least 2-3 cycles beyond first
    normal hCG
  • MAC (Methotrexate, Dactinomycin,
    Cyclophosphamide)
  • EMA/EP EMA Etoposide and Cisplatin

30
Therapy High-risk Metastatic GTN
  • Cure rates 80-90
  • Hysterectomy and/or thoracotomy may be useful in
    resistant setting or symptomatic management
  • Poorer prognosis with choriocarcinoma, metastases
    to places other than lung and/or vagina, number
    of metastases, and failure of previous
    chemotherapy

31
PSTT Therapy
  • Hysterectomy
  • Chemotherapy for metastatic disease or
    nonmetastatic disease with poor prognosis
  • - Interval from index pregnancy gt 2 years
  • - Deep myometrial invasion
  • - Tumor necrosis
  • - Mitotic count gt 6 per 10 high-power fields
  • Survival rates
  • 100 for nonmetastatic disease
  • 50-60 for metastatic disease

32
Follow-up Care
  • After completion of chemotherapy, follow serial
    hCG every 2 weeks for three months, then monthly
    for one year
  • Physical examinations every 6-12 months and
    imaging as indicated

33
Reproductive Performance
  • Most women resume normal ovarian function
  • No increase risk of stillbirths, abortions,
    congenital anomalies, prematurity, or major
    obstetric complications
  • No evidence of reactivation
  • At increased risk for development of second
    episode

34
False Positive Serum hCG
  • Phantom hCG syndrome/ phantom choriocarcinoma
  • 3-4 of healthy individuals have human-antimouse
    antibodies that can mimic hCG immunoreactivity
  • To verify
  • Urine hCG should be negative
  • Should not show parallel decrease with serial
    dilutions
  • Test at national B-hCG reference lab

35
Summary
  • Hydatidiform mole is a benign condition, 80
    cured with suction DC
  • Malignant GTN
  • Persistent or invasive mole
  • Choriocarcinoma
  • PSTT
  • WHO score gt 7 represents high-risk disease
  • GTN very sensitive to chemotherapy
About PowerShow.com