Gestational

Trophoblastic Neoplasia
Divisi Onkologi Ginekologi
Bagian Obstetri & Ginekologi
FK USU / RS H. Adam Malik
Medan
Rare human malignancy that can cure
even in the presence of widespread
metastase.
Including :
Hydatidiform mole (complete or partial)
Invasive mole
Placental site trophoblastic tumor
Choriocarsinoma
Complete hydatidiform mole
Embryonic or fetal tissues (-)
46XX karyotype
Entirely of paternal origin
Ovum nucleus absent or inactivated
Partial hydatidiform mole
Identifiable embryonic ,fetal tissues or villi
Varying size of chorionic villi
Triploid karyotype
Multiple congenital malformation of the fetus
Clinical features :
Vaginal bleeding
Excessive uterine size
Toxemia
Hyper emesis gravidarum
Hyperthyroidism
Trophoblastic embolisation
Theca lutein ovarian cyst
High risk mole
hCG level > 100.000 mIU/ml
Excessive uterine enlargement
Theca lutein > 6 cm in diameter
Diagnosis
Ultrasonography is a reliable and
sensitive technique for the diagnosis
Usually referred as snow storm pattern
Treatment
Suction curettage
Hysterectomy with mole insitu
Prophylactic chemotherapy : controversial
Follow-up : hCG, physical and imaging
Contraception
Malignant Gestational
Trophoblastic Disease
Malignant gestational trophoblastic disease
can named as:
Trophoblastic neoplasia
Trophoblastic tumor
Malignant trophoblastic tumor
Hydatidiform mole and invasive mole are not
malignant
FIGO 2000 staging system
Stage I : disease confined to the uterus
Stage II : disease out side of the uterus but
is limited to the genital structures (adnexa,
vagina, broad ligament)
Stage III : disease extend to the lungs with or
without known genital tract involvement
Stage IV : all other metastatic sites
The scoring system for the FIGO 2000 staging
FIGO score 0 1 2 4
Age 39 > 39 - -
Antecedent pregnancy Hydatidiform
mole
abortion Term
pregnancy
Interval months from index
pregnancy
< 4 4 - 6 7 - 12 > 12
Pretreatment hCG milli
IU/ml
< 10
3
10
3
- 10
4
> 10
4
-10
5
> 10
5

Largest tumor size including
uterus
- 3 - 4 cm 5 cm -
Site of metastases lung Spleen,
kidney
Gastro Inst.
Tract
Brain,
liver
Number of metastases
identified
0 1- 4 4 - 8 > 8
Previous failed
chemotherapy
Single drug Two or
more
drugs
Diagnostic criteria GTN
4 stable hCG level within 3 weeks, on day 1, 7, 14
and 21.
hCG increase 10% for 3 times within 2 weeks,
on day 1, 7 and 14
histological proved choriocarsinoma
hCG still high 6 months post mole evacuation
Low risk : score 6
High risk : score 7
Malignant Gestational Trophoblastic
Neoplasia
Non metastasis disease.
Metastasis disease.
Placental site trophoblastic tumor

Non metastasis disease
15% after hydatidiform mole evacuation
Patient present:
Irregular vaginal bleeding
Theca lutein cyst
Uterine sub involution
Asymmetric uterine enlargement
Persistence elevated hCG level
Metastasis disease
4% after evacuation hydatidiform mole
Sites of metastasis :
Pulmonary
Vaginal
Hepatic
Central nervous system
Placental site trophoblatic tumor
Rare tumor , potential to metastasize and death
After abortion, mole or normal pregnancy
Bleeding accompanied by uterine enlargement
Resemble invasive mole (myometrial invasion)
Characterized: mononuclear invasion
Can be interpreted as sarcoma
Low elevated serum hCG
Mortality rate 15 20%
Diagnostic evaluation
Pretreatment evaluation :
o Complete history taking
o Complete physical examination
o Measurement serum hCG value
o Hepatic, thyroid and renal function test
Diagnostic evaluation
Metastasis work-up :
o Chest radiograph
o USG or CT-scan abdomen & pelvis
o CT or MRI scan of the head
o hCG level from CSF
o Selective angiography
Management
Chemotherapy (single combination)
Hysterectomy plus chemotherapy
Controlled vaginal bleeding
Special treatment for metastatic site

Future Childbearing
After effective treatment, only 1-2% occur at
subsequent pregnancy
No different pregnancy out come
Chemotherapy treatment no association with
congenital malformation at subsequent
pregnancy
Chemotherapy ( single or multiple agent) has
no effects in fertility