GTD Flashcards
Gestational Trophoblastic Disease is…
A group of placental related disorders derived from a pregnancy
What is the incidence of GTD?
1:200-1000 1:390 for Asian women, 1:750 for non-Asian women Higher at both ends of the reproductive system, < 15 or >45
Gestational trophoblastic neoplasia is…
GTD requiring chemotherapy or excisional treatment because of persistence of HCG or presence of metastasis
What age groups are at higher risk for GTD?
Extremes of maternal age <15 or > 45
Histology diploid. Type of molar?
Complete Paternal duplication / disperm fertilisation
Histology triploid. Type of molar?
Partial 2 paternal sets and 1 maternal haploid set DNA 1 ovum fertilised by 2 sperm
What histological findings suggest a complete molar pregnancy?
Absence of fetal tissue Extensive hydropic change to the villi Excess trophoblast proliferation Absent p57 staining
What histological findings suggest an partial molar pregnancy?
Presence of fetal tissue Focal hydropic change to villi Some excess trophoblast proliferation Positive staining for p57
What percentage of complete molar pregnancies persist / change into malignant disease?
15-25%
What percentage of partial molar pregnancies persist / change into malignant disease?
0.5-4%
If affected by a molar pregnancy, what is the risk of another molar pregnancy?
1% 1:70
What is the most common type of GTN?
Gestational choriocarcinoma
What histological findings are suggestive of a choriocarcinoma?
Absence of chorionic villi Presence of abnormal intermediate trophoblast and cytotrophoblast, rimmed with syncytiotrophoblasts with areas of necrosis and haemorrhage
What guides treatment of gestational choriocarcinoma? What are the two treatment options?
FIGO Score If =6: single-agent therapy with MTX (and folic acid) If 7+: combination therapy with EMA/CO - E: Etoposide - M: Methotrexate - A: Actinomycin / Dactinomycin - C: Cyclophosphamide - O: Ovencin / Vincristine
What are the treatment options for Placental Site Trophoblastic Tumours and Epitheloid Trophoblast Tumour?
Hysterectomy Usually resistant to chemotherapy
What is the fetal consideration in a pregnancy affected by choriocarcinoma?
Tumour crosses the placenta so the newborn of a mother newly diagnosed with choriocarcinoma must be investigated to exclude lung disease
Epithelioid trophoblast tumour is _______ aggressive than choriocarcinoma
Less
What is the risk of cancer with atypical placental site nodules?
10-15%
What are the FIGO criteria for dx of postmolar GTN?
- plateau of HCG lasts for 4 measurements over 3 weeks or longer - rise in HCG for three consecutive weekly measurements over at least 2 weeks - histological diagnosis
What is the recommended management for a twin pregnancy with one viable fetus and one molar pregnancy?
Refer to MFM and GTD centre Counsel regarding risks 40% early fetal loss 36% PTB 20% PET
What is the follow up HCG process for molar pregnancy?
Weekly until normal on three occasions If partial: can then stop If complete: monthly and stop 6 months after normalisation (RANZCOG guideline)
What are the three most common types of GTN?
Gestational Choriocarcinoma Placental Site Trophoblastic Tumours Epitheloid Trophoblast Tumour Other: Atypical Placental Site Nodules
What is the risk of having another molar pregnancy when:
- Had 1 previous molar?
- Had 2 previous molar?
- 1 previous: 1%
- 2 previous: 11-25%
What % of GTN develops from molar pregnancies?
What % of GTN develops from live births?
From molar pregnancy: 60%
From live births: very rare
How would you tell the difference between a hydropic abortus and a partial molar pregnancy on histology?
Partial mole:
- Two types of villi
- Modest trophoblast proliferation
Hydropic abortus:
- Large range of villi
- Minimal trophoblast proliferation
If monitoring of tumour hCG levels is satisfactory and complete following a complete or partial molar pregnancy, what is the risk of GTN following this?
For partial mole: 0%
For complete mole: 0.3%
What is the indication of a second uterine evacuation following a molar pregnancy?
What is the benefit of performing a second evacuation in these circumstances?
Indications: decided by GTN MDM.
- Hydatidiform mole on histology
- Persistently elevated hCG but <5000
- No evidence of metastases
- FIGO 2000 score between 0-4.
Benefit: 40% of patients will avoid chemotherapy.
What advice would you give regarding the prognosis of future pregnancies following treatment for a molar pregnancy?
- Risk of recurrent molar pregnancy 1:80. Higher with increasing numbers of molar pregnancies.
- 1% if one previous
- 11-25% if two previous
- If a molar pregnancy does occur, 68-80% will be of the same histological type
- No affect on future fertility.
Subsequent pregnancy outcomes:
- 70% term live births
- 15% spontaneous miscarriage
- 2-8% preterm birth
- Risk of congenital malformations similar to normal population (0.4-2.5%)
Chemotherapy for GTN:
What are the risks associated with combination chemotherapy EMA-CO?
- Risk of secondary cancers (if survival >25 years after treatment) RR 1.5
- Premature ovarian insufficiency
- Earlier menopause:
- 1 year if single agent chemotherapy
- 3 years if multi-agent chemotherapy
Chemotherapy for GTN:
What is the risk of relapse following chemotherapy for GTN?
What is the median time to relapse?
Relapse risk 3.5%.
Median time to relapse 4 months.
Chemotherapy for GTN:
What is the cure rate for low risk GTN?
What is the cure rate for high risk GTN?
Low risk GTN cure rate: close to 100%
High risk GTN cure rateL 85%
