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WACS > GESTATIONAL TROPHOBLASTIC DISEASE > Flashcards

GESTATIONAL TROPHOBLASTIC DISEASE Flashcards

1
Q

T/F: GTD can therefore occur with both intra-uterine and extra-uterine pregnancies

A

T

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2
Q

Definition of GTD

A

spectrum of proliferative abnormalities of the trophoblast associated with pregnancy.

These diseases are unique in that they secrete hCG which is the tumour marker

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3
Q

2 parts of the spectrum of GTD

A
  1. Hydatidiform mole
  2. Gestational trophoblastic neoplasia
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4
Q

The 2 types of hydatidiform mole

A

Partial and complete

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5
Q

The 4 forms of gestational trophoblastic neoplasia

A
  1. Invasive mole
  2. Placental site trophoblastic tumour
  3. Epitheloid trophoblastic tumour
  4. Choriocarcinoma
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6
Q

Risk factors for GTD

A

Age less than 15 and over 35 years

Previous molar pregnancy

Increased number of spontaneous abortion

Diet – low protein, low fat and vitamin A deficiency

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7
Q

3 morphologic characteristics of hydatidiform mole

A
  1. Mass of vesicles
  2. Loss of fetal blood vessels
  3. Hyperplasia of the trophoblast
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8
Q

T/F: There is fetal or embryonic tissue in complete hydatidiform mole

A

F

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9
Q

T/F: There is fetal or embryonic tissue in partial hydatidiform mole

A

T

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10
Q

Nature of hydatidiform swelling of chorionic villi complete mole

A

Diffuse

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11
Q

Nature of hydatidiform swelling of chorionic villi partial mole

A

Focal

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12
Q

Nature of trophoblastic hyperplasia in complete mole

A

Diffuse

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13
Q

Nature of trophoblastic hyperplasia in partial mole

A

Focal

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14
Q

Scalloping of chorionic villi is found in which type of mole

A

Partial

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15
Q

T/F: Both types of moles have trophoblastic stromal inclusions

A

F. Seen only in partial mole

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16
Q

What is the karyotype of complete mole

A

46XX; 46XY
All chromosomes are paternal in origin

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17
Q

What is the karyotype of partial mole

A

69XXX; 69XXY; 69XYY
Extra set of chromosomes is paternal in origin

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18
Q

Which type of mole is p57 negative

A

Complete mole

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19
Q

Why are the 2 types of hydatidiform mole not p57 positive

A

p57 is expressed only on the maternal allele therefore, the complete mole that is entirely composed of paternal chromosomes are negative for p57

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20
Q

What is the risk of gestational trophoblastic neoplasia with complete mole

A

15 - 20%

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21
Q

What is the risk of gestational trophoblastic neoplasia with partial mole

A

1 - 5%

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22
Q

List 7 clinical presentations of hydatidiform mole

A
  1. Abnormal bleeding in early pregnancy
  2. Hyperemesis gravidarum
  3. Preeclampsia before 20 weeks
  4. Lower abdominal pain
  5. Large-for-dates uterus
  6. Ovarian enlargement
  7. Expulsion of vesicles
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23
Q

With molar pregnancy, the uterus is larger than the period of amenorrhea in –% of cases

A

50%

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24
Q

With molar pregnancy, the uterus corresponds to the period of amenorrhea in –% of cases

A

25%

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25
Q

With molar pregnancy, the uterus is smaller than the period of amenorrhea in –% of cases

A

25% due to inactive or dead mole

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26
Q

2 reasons why the uterus is doughy in consistency in molar pregnancy

A

Absence of amniotic fluid and distension with vesicles

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27
Q

In which of the molar pregnancies are fetal parts seen with fetal heart sounds heard

A

Partial

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28
Q

Snowstorm appearance on USS is seen in which type of molar pregnancy

A

Complete

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29
Q

T/F: MRI can be useful in determining extent of trophoblastic disease

A

T

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30
Q

5 baseline workup in hydatidiform mole

A

hCG levels
Full blood count
Rhesus typing
Chest x-ray; any metastases?
Pelvic scan : Uterine size and ovarian enlargement

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31
Q

2 treatment modalities in molar pregnancy

A
  1. Suction curretage
    2.Hysterectomy with Salpingectomy if patient has completed her family
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32
Q

T/F: Suction curretage is preferably done under USG guidance

A

T

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33
Q

T/F: Suction curretage is aided by oxytocic infusion started before the procedure.

A

F. oxytocin infusion after the start of the evacuation

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34
Q

serum HCG reach normal levels after — weeks post evacuation

A

8 – 12 weeks

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35
Q

T/F: 20% of patients with molar pregnancy will develop malignant sequelae (GTN).

A

T

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36
Q

Patient must be monitored for how long following evacuation or hysterectomy

A

6 months to 1yr

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37
Q

How is hCG monitored post evacuation in molar pregnancy

A

Weekly hCG till normal for 3 consecutive values, then monthly for 6-12 months

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38
Q

Frequency of CXR post evacuation in molar pregnancy

A

Chest x-ray initially and repeat if abnormal or if hCG rises or plateaus

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39
Q

Frequency of pelvic exam post evacuation in molar pregnancy

A

Pelvic exam every 2 weeks till normal then every 3 months

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40
Q

T/F: Normally the serum HCG is undetected after 3 months of evacuation

A

T

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41
Q

When is pregnancy allowed post evacuation in molar pregnancy

A

Pregnancy is allowed if the test remains negative for more than one year

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42
Q

How long should contraception last post evacuation in molar pregnancy

A

At least 1yr

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43
Q

Why is COC the preferred contraceptive post evacuation in molar pregnancy

A

COCs preferred because it suppresses endogenous LH/FSH, which may interfere with hCG measurement at low levels

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44
Q

5 reasons to consider chemotherapy in molar pregnancy

A
  1. Metastatic disease is present
  2. Choriocarcinoma is diagnosed on histology
  3. hCG level still elevated 6 months after molar evacuation
  4. hCG levels rise >10% for 3 values over2 weeks
  5. hCG levels plateaus for 4 consecutive values over 3 weeks
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45
Q

Definition of gestational trophoblastic neoplasia

A

A group of malignant neoplasms that consist of abnormal proliferation of trophoblastic tissue.

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46
Q

GTN may follow hydatidiform mole in –% of cases

A

50%

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47
Q

GTN may follow normal pregnancy in –% of cases

A

25%

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48
Q

GTN may follow ectopic pregnancy or incomplete abortion in –% of cases

A

25%

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49
Q

Pathologic features of invasive mole

A
  • Trophoblastic hyperplasia
  • Swollen villi
  • Myometrial invasion
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50
Q

3 Clinical features of invasive mole

A
  • Irregular postmolar vaginal bleeding
  • Persistent hCG elevation
  • <15% symptoms of lung/vaginal mets
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51
Q

3 Pathologic features of choriocarcinoma

A
  • Mixture of cytotrophoblast and syncytiotrophoblast hyperplasia, no villi
  • Myometrial invasion and metastatic potential
  • Haemorrhage, Necrosis
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52
Q

Clinical features of choriocarcinoma

A
  • Irregular postmolar vaginal bleeding
  • Persistent hCG elevation
  • Metastases and associated symptoms
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53
Q

Pathological features of placental site trophoblastic tumor

A
  • Diploid, No villi, IT hyperplasia
  • Less haemorrhage and necrosis
  • High potential for lymphatic invasion and mets
  • Focal hCG production
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54
Q

Clinical features of placental site trophoblastic tumor

A
  • Low serum hCG
  • Enlarged uterus
  • hCG levels normal to 1,000 mIU/mL
  • Metastases and associated symptoms
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55
Q

Pathological features of Epitheloid trophoblastic tumour

A
  • IT nodules
  • Extensive necrotic tissue,
    Preserved blood vessel structure,
    Hemorrhage and metastases rare
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56
Q

Which of the GTN has swollen villi as a pathologic feature

A

Invasive mole

57
Q

Which GTN has mixture of trophoblast and syncytiotrophoblast hyperplasia as a pathological feature

A

Choriocarcinoma

58
Q

The 2 types of GTN that has myometrial invasion as pathologic features

A

Invasive mole and choriocarcinoma

59
Q

Which type of GTN has high potential for lymphatic invasion and mets

A

Placental site trophoblastic tumor

60
Q

Which type of GTN has focal hCG production

A

Placental site trophoblastic tumor

61
Q

Which type of GTN does not have necrosis as a pathologic feature

A

Invasive mole

62
Q

Which of GTN has extensive necrotic tissue as a pathologic feature

A

Epitheloid trophoblastic tumor

63
Q

Which type of GTN has preserved blood vessel structure as a pathologic feature

A

Epitheloid trophoblastic tumor

64
Q

The two types of GTN that does not have villi as a pathological feature

A

Choriocarcinoma and placental site trophoblastic tumor

65
Q

In which of the GTN is hCG normal to 1000mIU/mL

A

Placental site trophoblastic tumor

66
Q

Which of the GTN has <15% of symptoms of lung/vaginal mets

A

Invasive mole

67
Q

6 risk factors for GTN

A

Maternal age, <20 and >40
Recurrent abortions
Uterus larger than gestational age
hCG levels more than 100,000 IU/L after evacuation
Theca lutein cyst more than 6cm
?? C/S

68
Q

A condition in which hydatidiform mole, with hydropic villi and proliferating trophoblast, has invaded the myometrium through the tissue or veins

A

Invasive mole

69
Q

T/F: With invasive mole, molar villi may be observed on the uterine serosa and extrauterine tubal and ovarian moles can occur

A

T

70
Q

T/F: Invasive moles are less hydropic, and trophoblastic proliferation is easily seen

A

T

71
Q

– % of women with complete moles may develop choriocarcinoma

A

2%

72
Q

Metastasis to the lungs, brain, liver, pelvis, vagina, kidney, intestines, and spleen seen in choriocarcinoma is due to

A

Direct invasion of the myometrium and vasculature

73
Q

4 immunohistochemical markers for confirming histologic diagnosis of CCA

A

hCG, inhibin a, human placental lactogen (hPL) and cytokeratin

74
Q

Staining pattern of immunohistochemical markers in choriocarcinoma

A
  1. hCG and inhibin a in the trophoblast
    2.human placental lactogen (hPL) and inhibin a in intermediate trophoblast
  2. cytokeratin in all trophoblast cells
75
Q

In choricarcinoma histology, intermediate trophoblast stains strongly for – and –

A

human placental lactogen and inhibin A

76
Q

In choriocarcinoma histology, trophoblast stains strongly for – and –

A

hCG and inhibin A

77
Q

The immunhistochemical marker that stains strongly in all trophoblast cells of choriocarcinoma

A

Cytokeratin

78
Q

T/F: PSTT lesions are usually diploid and monomorphic, developing from placental implantation site intermediate trophoblast after a normal or aborted uterine pregnancy

A

T

79
Q

T/F: PSTT lesions contain primarily mononuclear intermediate trophoblast without chorionic villi that infiltrates the uterine wall in sheets or cords between myometrial fibres

A

T

80
Q

PSTT contain –, –, – and – for immunohistochemical diagnosis

A

Cytokeran, hPL, inhibin A and Mel-CAM

81
Q

Rare malignant tumour that arises from neoplastic transformation of chorion-type intermediate trophoblast

A

Epithelioid trophoblastic tumor

82
Q

Lesions appear as nodules of mononuclear intermediate trophoblast, surrounded by hyalinized extracellular matrix within extensive necrotic tissue and with preserved blood vessel structure

A

Epithelioid trophoblastic tumor

83
Q

Intra-tumour haemorrhage and metastases are rarely observed in which GTN

A

Epithelioid trophoblastic tumor

84
Q

FIGO criteria for diagnosis of postmolar GTN

A

When the plateau of hCG lasts for four measurements over a period of 3 weeks or longer; that is, days 1, 7, 14, 21

When there is a rise in hCG for three consecutive weekly measurements over at least a period of 2 weeks or more; days 1, 7, 14

When the hCG level remains elevated for 6 months or more

If there is a histologic diagnosis of choriocarcinoma

85
Q

T/F: hCG monitoring is not recommended for GTN after non molar pregnancy

A

T

86
Q

Clinical presentations of GTN after non molar pregnancy

A

abnormal vaginal bleeding;
bleeding from metastatic sites in the abdomen, lung, or brain;
pulmonary symptoms; and
neurological signs from spine or brain metastasis

87
Q

FIGO stage 1 of GTN

A

Gestational trophoblastic tumours strictly confined to the uterine corpus

88
Q

FIGO stage 2 of GTN

A

Gestational trophoblastic tumours extending to the adnexa or to the vagina, but limited to the genital structures

89
Q

FIGO stage 3 of GTN

A

Gestational trophoblastic tumours extending to the lungs, with or without genital tract involvement

90
Q

FIGO stage 4 of GTN

A

All other metastatic sites

91
Q

Low risk score for FIGO prognostic scoring of GTN

A

7

92
Q

High risk score for FIGO prognostic scoring of GTN

A

> or = 7

93
Q

T/F: Non metastatic and low risk metastatic GTN (Stage I and Stages II–III with scores <7) can be treated with single agent chemotherapy

A

T

94
Q

T/F: High risk metastatic disease (Stage IV and Stages II–III with scores ≥7) should be treated with multi-agent chemotherapy

A

T

95
Q

Patient workup for treatment of GTN

A

FBC including platelet count

Clotting studies

hCG level

Renal and liver function tests

Chest X-ray

96
Q

T/F: Patients with low-risk GTN should be treated with one of the single agent methotrexate or actinomycin D protocols

A

T

97
Q

T/F: The overall complete remission rate is close to 100% for low risk GTN

A

T

98
Q

Chemotherapy should be changed to the alternative single agent in low risk GTN if

A

there has been a good response to the first agent but the hCG level plateaus above normal during treatment

if toxicity precludes an adequate dose or frequency of treatment

99
Q

With low risk GTN multi-agent chemotherapy as for high-risk disease should be initiated
If

A

there is an inadequate response to the initial single agent

If there is significant elevation in hCG level

If there is development of metastasis

if there is resistance to sequential single-agent chemotherapy

99
Q

With low risk GTN multi-agent chemotherapy as for high-risk disease should be initiated
If

A

there is an inadequate response to the initial single agent

If there is significant elevation in hCG level

If there is development of metastasis

if there is resistance to sequential single-agent chemotherapy

100
Q

T/F: After the hCG level has returned to normal,
consolidation with 2–3 more cycles of chemotherapy to decrease the chance of recurrence

A

T

101
Q

The 2 single agent chemotherapy regimen with methothrexate for low risk GTN

A

MTX-FA 8-day regimen (1mg/kg MTX intramuscularly on days 1,3,5,7 with Folinic acid 0.1mg/kg or 15 mg orally 24 h after MTX on days 2,4,6,8); repeat every 2 weeks.

MTX 0.3-0.5 mg/kg (max. 25 mg) intravenously or intramuscularly for 5 days every 2 weeks.

102
Q

The single agent chemotherapy regimen with Actinomycin D for low risk GTN

A

Actinomycin D pulse 1.25 mg/m2 intravenously every 2 weeks.

Actinomycin D 0.5 mg intravenously for 5 days every 2 weeks

103
Q

T/F: Etoposide and 5-fluorouracil can be used as single agents in low risk GTN

A

T

104
Q

T/F: Single agent chemotherapy regimens can be used to treat high-risk GTN

A

F
Multiple agent chemotherapy regimens are used to treat high-risk GTN

105
Q

The most commonly used multiple agent chemotherapy for high risk GTN is

A

EMA-CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine)

106
Q

T/F: Ultra high risk (score greater than or equal to 12 ) as well as patients with liver, brain, or extensive metastases do poorly when treated with first-line multiple agent chemotherapy

A

T

107
Q

For those with massive disease, starting with standard chemotherapy may cause severe marrow suppression leading to
bleeding, septicaemia and multiple organ failure

A

For those with massive disease,
starting with standard chemotherapy may cause severe marrow suppression leading to
bleeding,
Septicaemia
multiple organ failure

108
Q

How do you avoid the severe marrow suppression observed with standard chemotherapy for those with massive disease

A

Start with INDUCTION chemotherapy

This may be avoided by starting with a lower dose and a less intensive regimen, such as etoposide 100 mg/m2 and cisplatin 20 mg/m2 on days 1 and 2, repeated weekly for 1–3 weeks, before starting the usual chemotherapy regimen (INDUCTION)

109
Q

How do you give EMACO

A

Given in two regimens, regimen 1 and regimen 2. The two regimens alternate each week.

110
Q

Regimen 1 for EMACO

A

Day 1
IV Etoposide 100 mg/m2 over 30 minutes
IV bolus Actinomycin-D 0.5 mg
IV bolus Methotrexate 100 mg/m2 followed by IV 200 mg/m2 over 12 hours
Day 2
IV Etoposide 100 mg/m2 over 30 minutes
IV bolus Actinomycin-D 0.5 mg
Folinic acid rescue 15 mg intramuscularly or orally every 12 hours for four doses (starting 24 hours after beginning the methotrexate infusion

111
Q

Regimen 2 for EMACO

A

Day 8
IV bolus Vincristine 1 mg/m2 (maximum 2 mg)
IV Cyclophosphamide 600 mg/m2 over 30 minutes

112
Q

T/F: Combination chemotherapy in high risk GTN should be given every 2 weeks or as often as toxicity permits until the patient achieves three consecutive normal hCG levels

A

T

113
Q

T/F: In the treatment of high risk GTN, after normal hCG levels have been attained, an additional two to four cycles should be administered as consolidation therapy to reduce the risk of relapse.

A

T

114
Q

Salvage/second line chemotherapy for high risk GTN

A

EP-EMA (etoposide, cisplatin, etoposide, methotrexate and actinomycin-D)

TP/TE (paclitaxel, cisplatin/paclitaxel, etoposide)

MBE (methotrexate, bleomycin and etoposide)

ICE (etoposide, ifosfamide, and cisplatin or carboplatin)

BEP (bleomycin, etoposide and cisplatin)

FA (5-fluorouracil, actinomycin-D)

FAEV (floxuridine, actinomycin-D, etoposide and vincristine)

Pembrolizumab (PD 1 inhibitor)

Avelumab(PD-L1 inhibitor)

Gemcitabine

Capecitabine

High-dose chemotherapy with autologous bone marrow or stem cell transplant(still under investigation)

115
Q

T/F: Repeat dilatation and curretage is indicated for high risk GTN

A

Repeat dilatation and curettage is generally avoided to prevent morbidity and mortality caused by uterine perforation, haemorrhage, infection, uterine adhesions, and anaesthetic complications

116
Q

T/F: Radiotherapy has a limited role in GTN

A

T. except in treatment of brain metastasis

117
Q

What is the % of relapse in GTN after treatment

A

3 % of patients will relapse in 1st year, and less than 1 % in subsequent years

118
Q

Duration of contraception after GTN treatment

A

Contraception in cases of GTN should continue for 12 months. (COCs preferred)

119
Q

How is hCG monitored after treatment of GTN

A

In patients with GTN, after hCG is returned to normal, quantitative hCG levels should be evaluated monthly for 12 months.

120
Q

T/F: Both PSTT and ETT are less chemo sensitive than choriocarcinoma.

A

T

121
Q

T/F: Hysterectomy and salpingectomy is the primary mode of treatment in most cases of PSTT and ETT

A

T

122
Q

The most commonly used chemotherapy for PSTT and ETT

A

EP-EMA

123
Q

T/F: Fertility preservation is not suitable in diffuse lesions of PSTT and ETT

A

T

124
Q

The most significant adverse prognostic factor in PSTT and ETT

A

Interval from antecedent pregnancy of more than 48 months

125
Q

T/F: If fertility preservation is desired with PSTT and ETT, especially in a localized lesion, conservative management such as uterine curettage, hysteroscopic resection, and chemotherapy may be considered

A

T

126
Q

Criteria for appropriate patient selection for surgical resection of isolated lung nodule

A

Good surgical candidate,
controlled primary malignancy,
no other evidence of metastatic disease,
pulmonary metastasis confined to one lung,
hCG <1,000.

127
Q

T/F: With brain metastases, Whole brain irradiation performed, 3,000 cGy at 200 cGy fractions can achieve cure rates of 50–80 %

A

T

128
Q

T/F: Cure rates for both low risk and non metastatic disease states approach 100 %.

A

T

129
Q

—% of low risk patients with GTN will develop initial resistance, but will reach 90 % cure rate with single agent chemotherapy

A

20%

130
Q

—% of low risk patients with GTN will require multi-agent chemotherapy.

A

10%

131
Q

T/F: 80–90 % of high risk GTN patients will have curative therapy

A

T

132
Q

—% of high risk GTN patients will relapse or fail first line therapy

A

30%

133
Q

The metastasis in GTN with the lowest survival rate

A

Gastrointestinal tract metastasis has lowest survival rates at 50 %

134
Q

With metastatic disease for PSTT, the curative rate is

A

50–60 %

135
Q

Ideal time for USS in pregnancy after GTN

A

10 weeks

136
Q

When is hCG measured after pregnancy following GTN and why

A

An hCG measurement 6 weeks after completion of the pregnancy to exclude occult trophoblastic neoplasia

137
Q

T/F: Pregnancy during treatment should be monitored with USG at 6weeks and 10weeks

A

T

138
Q

T/F: In pregnancy following GTN if placenta is fine at 10weeks there is little risk for recurrence

A

T

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