GTN

Question 1

Describe the genetic pathophysiology and karyotype of the typical complete mole.

Answer 1

Typically 46XX and due to duplication of genetic material from a single sperm within an empty egg

Question 2

Describe the genetic pathophysiology and karyotype of the typical partial mole.

Answer 2

Typically triploid (69XXY, XYY, or XXX) and due to duplication of genetic material from a single sperm within a normal ovum
(Occasionally due to fertilization of a normal ovum with two sperm)

Question 3

What is the most common symptom of molar pregnancy? List three additional possible signs & symptoms.

Answer 3

Most common symptom: vaginal bleeding

Other possible S&S: HTN/preeclampsia, hyperemesis, hyperthyroidism, theca lutein cysts

Question 4

What therapeutic options exist for a partial mole when the fetus is too large for A&C?

Answer 4

D&E
Hysterectomy with pregnancy in situ
Medical termination of pregnancy (associated with increased risk of persistent disease)

Question 5

How long should a woman wait following successful treatment of a molar pregnancy before attempting to conceive again?

Answer 5

6 months after beta = 0 x3

Question 6

List three features which indicated increased risk of post-molar GTN.

Answer 6

Uterine size > dates
hCG > 100 000
Theca-lutein cysts > 6 cm

Question 7

Your patient with GTN has a normal brain MRI, but has symptoms leading you to suspect cerebral metastasis. What follow-up test could you offer?

Answer 7

LP - if CSF:serum hCG > 1:60 this is highly suggestive of brain metastases

Question 8

Describe the staging of GTN.

Answer 8

I - confined to uterus
II - limited to pelvis
III - lung mets present
IV - any other mets present

Question 9

For each of the following features, define the high risk category:
Age
Antecedent pregnancy
Interval from pregnancy
hCG
Largest tumour
Site of metastasis
Number of metastases
Prior failed chemo

Answer 9

Age > 40
Antecedent pregnancy: term pregnancy
Interval > 12 months
hCG > 100 000
Largest tumour > 5 cm
Metastasis to brain or liver
> 8 metastases
Previous failed multiple agent chemo

Question 10

What is the utility of the WHO risk scoring in GTN? For which patients is the risk scoring not useful?

Answer 10

Score > 7 suggests high likelihood of resistance to monotherapy, therefore should start with multiple-agent chemo
Not particularly useful in stage I or IV disease - stage I is always low-risk and stage IV always high-risk
Not useful for PSTT or ETT - in these cases treatment is based on FIGO staging alone

Question 11

What is the value of OCP for a woman undergoing chemo for high-risk GTN?

Answer 11

Other than contraception …
EMA/CO can damage the ovaries, resulting in increased LH
OCP suppresses LH and prevents cross-reactivity with hCG (which would interfere with treatment monitoring)_

Question 12

What options exist for treatment of CNS mets (other than chemo)?

Answer 12

Surgery - craniotomy & excision of met

RT

Question 13

What follow-up test should be done if serum hCG is consistently positive and you suspect phantom beta?

Answer 13

Urine beta

Question 14

You previously treated a woman for a complete mole to good effect. She now has a new partner and they plan to start trying to conceive soon. She wants to know how her new partner affects her risk of recurrent molar pregnancy.

Answer 14

No effect

Rate of recurrence is 1% after a single molar pregnancy, 15-20% after two molar pregnancies

Question 15

Define trophoblastic embolization.

Answer 15

Bilateral pulmonary infiltrates following evacuation of a mole, typically resolve spontaneously within 72 hours

Question 16

How should you treat theca-lutein cysts associated with a complete mole?

Answer 16

No treatment - spontaneous regression typically occurs 2-4 weeks after evacuation of mole
Drain if torted or causing significant symptoms (eg. pelvic pressure)

Question 17

Which contraceptive should not be used in patients who have recently been treated for molar pregnancy?

Answer 17

IUD due to increased risk of bleeding and perforation

Question 18

What is the fertility prognosis for women with familial recurrent hydatidiform mole?

Answer 18

Donor egg typically required for normal pregnancy

Moles in this case are biparental, not androgenetic, so IVF with own ovum is not sufficient treatment

Question 19

Your patient has had multi-agent chemo for treatment of a metastatic GTN. Her beta has normalized and she has received appropriate consolidation chemotherapy. Imaging identifies residual masses in the pelvis. How should these be treated?

Answer 19

No treatment - resection does not impact the risk of relapse

Imaging is done to establish a baseline in the event of future relapse

Question 20

What is the first-line treatment of stage I PSTT or ETT?

Answer 20

Hysterectomy followed by 8 weeks adjuvant chemo (PSTT and ETT are less chemosensitive than choriocarcinoma and invasive mole)

Question 21

What impact does EMA-CO have on later fertility?

Answer 21

Menopause will typically occur about 3 years earlier, but no other impact on fertility - majority of women can become pregnant, no increased rate of congenital anomalies