GTD/GTN

Question 1

what is the ddx for size greater than dates in 1st/2nd tri?

Answer 1

• incorrect dating
• multiple gestation
• fibroid
• molar pregnancy

Question 2

partial vs complete mole

• karyotype
• fetus present?
• uterine size
• theca lutein cyst

Answer 2

partial

• 69 XXY or 69XXX
• present
• SGA
• rare theca lutein cyst

complete

• 46XY or 46 XX
• fetus absent
• LGA
• common theca lutein

Question 3

risk of molar pregnancies in future?

Answer 3

2% or 10-fold

Question 4

risk of development of post-molar GTN: complete vs partial?

Answer 4

complete: 15-20%
partial: 1-5%

Question 5

what are the types of GTN?

Answer 5

• invasive mole
• choriocarcinoma
• placental site trophoblastic tumor
• epitheloid site trophoblastic tumor

Question 6

FIGO staging system?

Answer 6

Stage I - uterine disease
Stage II - direct extension/mets to genital structures
Stage III - lung mets
Stage IV - non lung distant mets

Question 7

What score denotes low risk vs high risk with FIGO classification?

Answer 7

Low risk is less than 7

High risk is 7 or greater

Question 8

what goes into FIGO prognostic score?

Answer 8

Age
Tumor size
Chemo hx (failed chemo prior?)
Prior pregnancy (time since, and time - Ab vs full term)
Pre-treatment HCG
Metastasis (# and site)

Question 9

what evaluation and management with suspected molar pregnancy?

Answer 9

• CBC, T/S, renal fxn, LFTs, TFTs, CXR
• rhogam in necessary
• D&C (under US guidance ideally); have uterotonics ready

Question 10

what is follow-up protocol after evacuation of molar pregnancy?

Answer 10

• HCG q1-2 week until three consecutive normals

- Then two more normal HCG q3 months

Question 11

What are follow-up criteria for post-molar GTN?

Answer 11

• Plateu of HCG x 4 measures over 3 weeks
• Increase in 10% or higher x 3 measures over 2 weeks
• Persistent HCG 6 months after evacuation

Question 12

Management of post-molar GTN/malignant GTD/invasive mole

Answer 12

Need to “stage”: H&P, US, CXR -> then WHO risk score

If no evidence of extrauterine disease/low risk disease, either: repeat D&C (40% wont need D&C) or Hysterectomy.

If so - follow-up q2wk HCG until 3 x negative. Then q month x 6 months of negative HCG

Question 13

If persistent disease after evacuation of invasive mole, then how to stage?

Answer 13

repeat H&P, US, CBC, LFTs, BMP, TFTs

CT chest/abd/pelvis. If + lung mets, then MRI brain

Question 14

Low risk invasive mole chemotherapy?

Answer 14

MTX or actinomycin-D (higher complete response rate, more toxic).
If one fails, try the other – bc high cure rates

Question 15

High risk invasive mole?

Answer 15

EMA-CO
etoposide
MTX
actinomycin D
cyclophosphomide
Vincristine

Question 16

choriocarcinoma - unique elements

Answer 16

• quick to metastasize
• chemoresponsive
• VASCULAR - do not biopsy

Question 17

management of PSTT or ESTT

Answer 17

• refer to GYN onc immediately

- general surgical management bc chemo unresponsive

Question 18

“false positive” serum beta + but uHCG negative

Answer 18

• phantom HCG (heterophile antibodies)

- pituitary postmenopausal HCG production-> check LH

Question 19

most common sites of metastatic invasion for GTN?

Answer 19

• lung (80%)
• vagina (30%)
• brain (10%)
• liver (10%)