Gestational Trophoblastic disease

Question 1

What is Gestational Trophoblastic Disease (GTD)?

Answer 1

Gestational Trophoblastic Disease (GTD) refers to a group of rare diseases that involve abnormal proliferation of placental trophoblastic cells. It includes conditions like hydatidiform mole (complete or partial), gestational trophoblastic neoplasia (GTN), choriocarcinoma, and placental site trophoblastic tumors.

Question 2

What are the types of diseases included under GTD?

Answer 2

The diseases under GTD include:
Hydatidiform mole (complete or partial)
Gestational Trophoblastic Neoplasia (GTN)
Choriocarcinoma
Placental site trophoblastic tumors

Question 3

What is a Hydatidiform Mole?

Answer 3

A Hydatidiform Mole is a type of GTD characterized by the abnormal growth of trophoblasts, the cells that normally develop into the placenta. It can be complete, where all the placental tissue is abnormal, or partial, where some normal placental tissue is present.

Question 4

What is Gestational Trophoblastic Neoplasia (GTN)?

Answer 4

Gestational Trophoblastic Neoplasia (GTN) is a malignant form of GTD that can develop after any type of pregnancy but is most common following a molar pregnancy. It is characterized by persistent high levels of hCG and can metastasize to other organs.

Question 5

What is the significance of a complete molar pregnancy in GTD?

Answer 5

A complete molar pregnancy is a major risk factor for developing GTN. About 20% of women with a complete molar pregnancy develop malignant disease.

Question 6

What is the most common early sign of Gestational Trophoblastic Neoplasia (GTN)?

Answer 6

The most common early sign of GTN is irregular or heavy vaginal bleeding following a molar pregnancy, miscarriage, or delivery

Question 7

What are common symptoms of GTN related to elevated hCG levels?

Answer 7

Symptoms related to elevated hCG levels in GTN include persistent nausea and vomiting (hyperemesis), excessive tiredness, and signs of hyperthyroidism.

Question 8

What are the potential metastatic symptoms of GTN?

Answer 8

Hemoptysis (coughing up blood) if lung metastases are present
Neurological symptoms like headaches, dizziness, or seizures if brain metastases are involved
Abdominal pain due to liver metastases

Question 9

How can GTN present in terms of uterine size?

Answer 9

GTN can present with an abnormally large uterus for the gestational age, often due to the rapid growth of the abnormal trophoblastic tissue

Question 10

What are some systemic signs of GTN that indicate the disease has progressed?

Answer 10

Systemic signs of advanced GTN include respiratory distress (due to lung involvement), jaundice (from liver involvement), and signs of central nervous system involvement, such as confusion or seizures.

Question 11

What is the first step in managing a patient suspected of having Gestational Trophoblastic Neoplasia (GTN)?

Answer 11

The first step is to perform initial investigations, which include a vaginal ultrasound, chest X-ray, and vaginal examination. If metastatic lesions are found, additional imaging of the liver and brain should be performed.

Question 12

What is the standard treatment approach for low-risk GTN?

Answer 12

Low-risk GTN (FIGO score ≤ 6) is treated with single-agent chemotherapy, typically methotrexate.

Question 13

How is high-risk GTN managed?

Answer 13

High-risk GTN (FIGO score > 6) requires initial multiple-drug chemotherapy. Etoposide
Methotrexate (MTX)
Actinomycin D
Leucovorin calcium
Cyclophosphamide
Vincristine

Question 14

When might a hysterectomy be considered in the management of GTN?

Answer 14

A hysterectomy may be considered for women who have completed childbearing and have disease confined to the uterus, or in cases of Placental Site Trophoblastic Tumor, which is less responsive to chemotherapy.

Question 15

What additional treatment might be necessary for patients with brain metastasis from GTN?

Answer 15

Patients with brain metastasis from GTN may require radiation therapy in addition to chemotherapy.

Question 16

What is the significance of follow-up in the management of GTN?

Answer 16

Follow-up is crucial to ensure the disease does not persist or recur. It includes serial hCG monitoring, clinical examinations, and avoiding pregnancy until hCG levels are undetectable

Question 17

What is Persistent Gestational Trophoblastic Neoplasm (GTN)?

Answer 17

Persistent GTN refers to the condition where the trophoblastic disease continues after initial treatment, usually following a molar pregnancy, and is characterized by continued elevated levels of hCG or the presence of metastatic disease.

Question 18

What are the main signs indicating Persistent GTN?

Answer 18

The main signs of Persistent GTN include persistently elevated or rising hCG levels after the evacuation of a molar pregnancy, abnormal uterine bleeding, and evidence of metastasis.

Question 19

How is Persistent GTN diagnosed?

Answer 19

Persistent GTN is diagnosed through serial hCG measurements that remain elevated or rise after treatment, along with imaging studies such as ultrasound, chest X-ray, and, if necessary, liver and brain imaging

Question 20

What is the treatment approach for Persistent GTN?

Answer 20

Persistent GTN is treated with chemotherapy, and the regimen is based on the FIGO Prognostic Score Index. Low-risk patients receive single-agent chemotherapy (methotrexate), while high-risk patients require multiple-drug chemotherapy

Question 21

What is the role of surgery in managing Persistent GTN?

Answer 21

Surgery, such as a hysterectomy, may be considered for patients with Persistent GTN confined to the uterus, especially if they have completed childbearing. Surgery is required in cases of Placental Site Trophoblastic Tumor, which is less responsive to chemotherapy

Question 22

Why is follow-up important in cases of Persistent GTN?

Answer 22

Follow-up is crucial to monitor the response to treatment and detect any recurrence early. It involves regular hCG measurements, clinical assessments, and avoiding pregnancy until hCG is undetectable

Question 23

What role does a vaginal examination play in the investigation of GTN?

Answer 23

A vaginal examination is performed to assess for metastatic lesions in the vagina and suburethral area, although biopsy of these lesions should be avoided due to the risk of hemorrhage.

Question 24

Why is serial hCG measurement important in GTN?

Answer 24

Serial hCG measurement is crucial for diagnosing and monitoring GTN, as persistently elevated or rising levels after treatment indicate the presence of persistent or metastatic disease.

Question 25

What is Stage I in the FIGO staging for GTN?

Answer 25

Stage I refers to GTN confined to the uterus.

Question 26

What is Stage II in the FIGO staging for GTN?

Answer 26

Stage II indicates GTN that has extended outside the uterus but is confined to the genital structures (e.g., ovaries, fallopian tubes, vagina).

Question 27

What is Stage III in the FIGO staging for GTN?

Answer 27

Stage III GTN involves metastases to the lungs, with or without involvement of the genital tract.

Question 28

What is Stage IV in the FIGO staging for GTN?

Answer 28

Stage IV indicates GTN with metastases to other distant sites, such as the liver or brain.

Question 29

What factors are considered in the FIGO Prognostic Score Index for GTN?

Answer 29

The FIGO Prognostic Score Index considers factors like age, antecedent pregnancy, interval from the end of the antecedent pregnancy, pre-treatment hCG levels, the largest tumor size, the site of metastases, the number of metastases, and prior chemotherapy.

Question 30

How is the FIGO Prognostic Score Index used in GTN management?

Answer 30

The FIGO Prognostic Score Index helps determine the risk level of the GTN, categorizing it into low-risk (score ≤ 6) or high-risk (score > 6), which guides the choice of chemotherapy regimen.

Question 31

What is the significance of a score of ≤ 6 on the FIGO Prognostic Score Index?

Answer 31

A score of ≤ 6 on the FIGO Prognostic Score Index is considered low-risk and typically requires single-agent chemotherapy, such as methotrexate + actinomycin d

Question 32

What does a score of > 6 on the FIGO Prognostic Score Index indicate?

Answer 32

A score of > 6 indicates high-risk GTN, which requires multiple-agent chemotherapy due to the increased likelihood of resistance and metastasis​

Question 33

What is a Complete Mole in Gestational Trophoblastic Disease (GTD)?

Answer 33

A Complete Mole is a type of hydatidiform mole where there is an abnormal fertilization of an egg that has no maternal chromosomes. It typically leads to the proliferation of abnormal trophoblastic tissue without the development of a fetus

Question 34

What is a Partial Mole in Gestational Trophoblastic Disease (GTD)?

Answer 34

A Partial Mole occurs when an egg is fertilized by two sperm, leading to the presence of both normal and abnormal trophoblastic tissue. This type often involves some fetal tissue, but the fetus is usually non-viable

Question 35

How do hCG levels differ between Complete and Partial Moles?

Answer 35

In a Complete Mole, hCG levels are typically much higher than normal for the gestational age. In a Partial Mole, hCG levels are elevated but generally lower compared to a Complete Mole.

Question 36

What are the ultrasound findings for a Complete Mole?

Answer 36

The ultrasound of a Complete Mole typically shows a “snowstorm” pattern or a cluster of grapes appearance, with no identifiable fetal parts.

Question 37

What are the ultrasound findings for a Partial Mole?

Answer 37

In a Partial Mole, ultrasound may show an abnormal placenta with cystic spaces and some abnormal fetal development, but the fetus is typically not viable.

Question 38

What are the genetic differences between a Complete Mole and a Partial Mole?

Answer 38

A Complete Mole is usually diploid and purely paternal in origin (46,XX or 46,XY), while a Partial Mole is typically triploid, with two sets of paternal chromosomes and one set of maternal chromosomes (69,XXX or 69,XXY).

Question 39

What is the risk of progression to Gestational Trophoblastic Neoplasia (GTN) in Complete vs. Partial Moles?

Answer 39

The risk of progression to GTN is higher in Complete Moles (about 15-20%) compared to Partial Moles (about 0.5-5%)

Question 40

What is the characteristic ultrasound finding in a Complete Molar Pregnancy?

Answer 40

The characteristic ultrasound finding in a Complete Molar Pregnancy is a “snowstorm” or “cluster of grapes” appearance, which is due to the presence of multiple small cystic spaces without any identifiable fetal tissue.

Question 41

How does a Partial Molar Pregnancy appear on ultrasound?

Answer 41

In a Partial Molar Pregnancy, the ultrasound may show an abnormal placenta with cystic spaces, along with some fetal tissue that is usually non-viable. The fetus may show signs of growth restriction or anomalies.

Question 42

When is a hysterectomy considered in the management of GTD?

Answer 42

A hysterectomy may be considered in women who have completed childbearing and have disease confined to the uterus, especially in cases of Placental Site Trophoblastic Tumor, which is less responsive to chemotherapy

Question 43

What additional treatment might be required for patients with brain metastasis in GTD?

Answer 43

Patients with brain metastasis may require radiation therapy in addition to chemotherapy to effectively manage the disease