Gestational Trophoblastic Disease Flashcards
Define gestational trophoblastic neoplasia. How does it arise?
describes GTD requiring chemotherapy.
- 60% after molar pregnancy
- 30% after miscarriage/abortion
- 10% after normal pregnancy or ectopic
Incidence of GTD?
1: 200-1000 pregnancies
0. 5-0.1%
Risk factors for GTD?
Asian ethnicity
nulliparous
older and younger maternal age (<15yo, >45yo)
What is the chromosomal composition of a complete molar pregnancy?
46XX or 46XY- paternal origin
What symptoms of metastatic disease should be screened for in GTD?
dyspnoea, abnormal neurology
What are the causes/antecedents of gestational choriocarcinoma?
molar pregnancy 25-50%
non-molar abortion 25%
term pregnancy 25-50%
What is the clinical course of placental site trophoblastic tumor?
slow growing tumor, a number of years after a molar pregnancy, miscarriage or term pregnancy. Present with typical gynaecological symptoms, 1/3 with metastases, some with hyperprolactinaemia or nephrotic syndrome.
What is the clinical course of epithelia trophoblastic tumor?
slow growing. long interval from antecedent pregnancy. Commonly follows term pregnancy. may be misdiagnosed as cervical cancer, choriocarcinoma or PSTT. 1/3 present with metastatic disease. hcg low.
recommendations for evacuation of ?molar POC
suction evacuation
preparation of cervix immediately prior is safe
oxytocin can be used after evacuation for haemorrhage
give anti-D if Rh-
What are the indications for second uterine evacuation for molar pregnancy?
- MDT discussion: hydatiform mole on initial histology persistently elevated hcg no evidence of metastatic GTN FIGO score 0-4
40% of patients avoided chemotherapy with a second curettage. 1.6% risk perforation.
Requirements for initial GTD assessment (7)?
Health NZ:
- Full history, LMP date, evacuation date, oral contraceptive intake and symptoms
- information and discussion about the diagnosis and need for regular follow up
- written information
- clinical examination for metastatic disease and pelvic exam
- Chest XE
- tumor hcg test as new baseline
- Offer counselling and psychosocial supports
Women diagnosed with complete mole after ERPOC. Discuss management.
- Specialist centre or clinical lead. CNS specialist for result monitoring.
- tumor hcg FU
- day of diagnosis
- weekly thereafter until 2x normal levels
- monthly for 6 months after normalisation
- Risk of GTN after FU complete is 0.3%. - Repeat clinic review at 8-10 weeks
- symptoms
- contraception - Conception after follow up completed.
- Risk of repeat molar pregnancy 1:70. No affect on fertility.
- no increase in congenital malformations.
- USS: early mid trimester scan
Partial molar monitoring after evacuation?
Weekly t-hcg until three consecutive normal levels, then stop.
Investigations for suspected molar pregnancy at time of suction evacuation?
baseline bhcg
FBC, G+H
If clinically indicated: TFT, LFT, coagulation, CXR
Your patient is diagnosed with a partial mole. What history or serum results would prompt referral to medical oncology?
- plateau of tumor hcg for 4 measurements
- rise of tumor hcg on three consecutive measurements >10%
- serum hcg >20,000 >4w after evacuation
- evidence of metastatic disease
You performed bhcg, FBC, G+H at time of evacuation. Histology demonstrates PSTT. What further investigations are needed?
CT head, chest, abdomen, pelvis
MRI brain if neurological symptoms or pulmonary metastases found.
Follow up after future pregnancies with previous molar pregnancy?
bhcg at 6 weeks
When is repeat evacuation not recommended (RANZCOG)
bhcg >5000
presence of metastases
Avoid inter-surgical interval of less than 6 weeks
What is the serum half life of hcg?
24-36hrs
What investigations should have been completed for diagnosis of PSTT, ETT, choriocarcinoma, or persistent GTD?
FBC, UEC, LFT, G+H, tumor hcg, TFT
CT head, chest, abdomen, pelvis
MRI brain if pulmonary mets or neurological symptoms
What are the components of the WHO risk score for GTN (8)?
Assigned scores 0,1,2 or 4
Age (39 or less = 0), Antecedent pregnancy type (mole, abortion, term pregnancy), interval months from index pregnancy (<4 = 0), pre treatment b-hcg level (<10^3 = 0), largest tumor size(3-4cm = 0), site of metastases, number of metastases, previous failed chemo
What is the low risk protocol for GTN?
MTX/folinic acid alternate days 1-8. Repeated every 2 weeks.
OR
Actinomycin IV
High risk protocol for GTN?
Actinomycin
Etoposide
MTX
Follow up after GTN?
RANZCOG:
monthly bhcg 12 months
NZ GL:
low risk = monthly tHCG 12 months
high risk = monthly tHCG 2 years
PSTT/ETT= follow up minimum of 5 years with hcg and appropriate imaging.
How are PSTT and ETT managed?
They must be treated with surgery as they are not chemo sensitive. High cure rate if present within 48 months.
An interval of more than 48 months has been associated with a 100% death rate. Offer platinum based chemotherapy in this scenario.
When can women who have received chemotherapy for GTN conceive again?
For 1 year after completion of chemotherapy
What is the risk of persistent disease of partial and complete moles after evacuation?
0.5-4% partial mole
15-20% complete mole.
What contraception should be given during chemotherapy for GTN?
barrier methods preferred.
What are the risks of EMA-CO chemotherapy?
RR 1.5 of second malignancy- myeloid leukaemia, Breast and colon cancer, melanoma
cure rates in low risk and high risk GTN?
100% low risk
85% high risk.
GTD- p57 positive on IHC. Diagnosis?
complete molar pregnancy
Complete molar pregnancy. Monitoring weekly with hcg. Has now been negative twice. Recommended management?
one further negative value in 1 week, then testing monthly for 6 months.
Complete molar pregnancy. hcg weekly values:
- 1890
- 1353
- 1256
- 1567
- 1950
what is this?
persistent disease =
>10% risk over 2 weeks OR
<10% fall over 3 weeks OR
elevated levels at 6 months
Complete molar pregnancy. hcg weekly values still + after 5 months. Patient rings concerned. What would you discuss regarding management?
Referral for persistent disease to GONC for management if still positive after 6 months. May require chemotherapy (MDM may consider repeat evacuation). Ensure using contraception.
