Gestational Trophoblastic DIsease

Question 1

What is GTD?

Answer 1

Trophoblastic tissue proliferates in a more aggressive way than normal. (overgrowth of placental tissue) ->Higher HCG levels.

Question 2

What are the types of GTD?

Answer 2

Premalignant:
-Complete mole
-Partial mole

Malignant
-Locally invasive: invasive mole
- Choriocarcinoma

Placental site trophoblastic tumour

Epithelioid trophoblastic tumour

Question 3

What is the epidemiology of GTD?

Answer 3

1 in 500-1,000 pregnancies
(recurrence 1: 100)

In Ireland in 2021 138 cases of women with suspected GTD were registered with the national GTD registry, monitoring and advisory centre

More common
< 20, > 35

Previous molar pregnancy

Asians and Africans

Question 4

What is a Hydatidiform Mole?

Answer 4

Question 5

What are invasive moles?

Answer 5

invasion within the uterus (into the myometrium)

Question 6

What are Choriocarcinoma?

Answer 6

metastases to other parts of the body.

Question 7

What is gestational trophoblastic neoplasia?

Answer 7

persistent elevation in HCG after primary treatment for gestational trophoblastic disease is referred to as gestational trophoblastic neoplasia

Question 8

Note placental site trophoblastic tumour: secretes HPL. BHCG levels can be lower making diagnosis difficult. Presents later – an average of 3.4 years after the index pregnancy

Question 9

What are possible symptoms of GTD?

Answer 9

• Vaginal bleeding 6-12 wks. often painless (may be
  heavy with vesicles)
  
  • Hyperemesis
  • Hyperthyroidism (high HCG stimulates TSH receptor)
  • Early PET (first or early second trimester)

Question 10

What are signs of GTD?

Answer 10

-Large uterus (confused with multiple pregnancies)
-Ovarian enlargement due to theca lutein cysts (1/3) due to high BHCG

Can be picked up on routine ultrasound

Question 11

What investigations would you do for suspected GTD?

Answer 11

Serum HCG (higher in complete mole)

Ultrasound: snow storm appearance in CM

Question 12

What is the management of GTD?

Answer 12

ERPC to remove trophoblastic tissue (->histology)

Monitor hCG (urine or serum) – see next slide

Question 13

When can people get pregnant after GTD?

Answer 13

-Next pregnancy: not until follow-up complete.
(or not until 1 yr later if chemotherapy uses).
Need regular early scans in pregnancy (8/14wks)
No longer need to have HCG measured after a subsequent pregnancy event.

Question 14

When can the OCP be used after GTD?

Answer 14

OCP: can be used after ERPC whilst HCG levels are being monitored.

Question 15

What are the follow-up GTD HSE guidelines for complete mole?

Answer 15

check serum HCG weekly until 3 normal results. Then monthly.
If hCG has reverted to normal within 8 weeks of the pregnancy event then follow up will be for 6 months from the date of uterine evacuation.
If hCG has not reverted to normal within 8weeks of the pregnancy event then follow-up will be for 6months from normalisation of the hCG level.

Question 16

What are the follow-up GTD HSE guidelines for partial mole?

Answer 16

Check serum HCG weekly until normalisation then one further check 4 weeks later

Question 17

When do people with GTN need chemo?

Answer 17

hCG rises or plateau after evacuation

Bleeding: heavy vaginal or GI/intraperitoneal

Histological evidence of choriocarcinoma

Evidence of mets (brain, liver, GI, resp)

Question 18

When do GTN need to be sent for registry/monitoring/advisory centre in cork?

Answer 18

HCG> 20,000>4 wks post ERPC
HCG abnormal 6/12 post ERPC

Question 19

What is choriocarcinoma?

Answer 19

Malignant neoplasm of trophoblastic cell

Question 20

What are the causes of choriocarcinoma?

Answer 20

50 %: Molar pregnancy
40% Normal pregnancy
5% miscarrage/ectopic
5% non-gestational (germ cell ovarian)

Question 21

What are the clinical features of choriocarcinoma?

Answer 21

As detailed for GTD
After normal pregnancy:
Malaise/amenorrhoea (due to raised hCG)
Invades uterine muscle: irreg vaginal bleeding months/years after childbirth
Mets via blood vessels Lung (cough, dysp, haemoptysis), Brain (headache, dizziness, faint), GIT (rectal bleeding), Liver

Cannonball mets

Question 22

How is choriocarcinoma treated?

Answer 22

ERPC

Chemotherapy
Low risk (Score </= 6): methotrexate +/- folic acid
or Actinomycin D

High risk (score >/=7) combination chemotherapy EMA/CO

Question 23

What is the survival rate of choriocarcinoma?

Answer 23

5 yr survival approaches 100%

Question 24

What are scoring indicators for choriocarcinoma?

Answer 24

Age
Nature of proceeding pregnancy
Time from pregnancy to treatment
Pretreatment HCG
Largest tumour size
Site of mets
Number of mets
Previous failed chemo

Question 25

What investigations do staging include?

Answer 25

Investigations include serum HCG, pelvic u/s, CT TAP+/-MRI brain

Question 26

What are the stages of choriocarcinoma?

Answer 26

•Stage I: Disease confined to the uterus
•Stage II: GTN extends outside of the uterus, but is limited to the genital structures (i.e., adnexa, vagina, broad ligament)
•Stage III: GTN extends to the lungs, with or without known genital tract involvement
•Stage IV: All other metastatic sites

Question 27

What follow up after chemotherapy is needed for choriocarcinoma?

Answer 27

HCG
Fortnightly for 6 months
Monthly for 1 yr after treatment
Every 2 months for 2yrs

Follow-up for at lease 5 years may be considered in those at highest risk

Question 28

Which of the following is correct in relation to molar pregnancy

1. Partial hydatidiform moles are more likely to require chemotx than complete moles
2. The COCP and HRT are safe to use once HCG levels have normalised
3. Following molar pregnancy women are at increased risk of future congenital foetal malformation and infertility
4. Complete molar pregnancies are associated with foetal parts
5. All partial moles are diploid (contain 46 pairs of chromosomes).