GTD

Question 1

All forms of GTD are characterized by a distinct tumor marker

Answer 1

the beta subunit of human chorionic gonadotropin (hCG

Question 2

types of GTD

Answer 2

Hydatidiform mole (complete or partial) 
Persistent/invasive gestational trophoblastic neoplasia (GTN) 
Choriocarcinoma 
Placental site trophoblastic tumors 
.

Question 3

Complete and partial hydatidiform moles result of

Answer 3

of an aberrant fertilization event that leads to a proliferative process.

Question 4

Malignant GTD can develop from

Answer 4

molar pregnancy or can arise after any gestational experience: spontaneous or induced abortion, ectopic pregnancy, or preterm and term pregnancy

Question 5

RISK FACTORS

Answer 5

Extremes of age
older than age 35 and slightly increased in those under age 20
Assisted reproductive technology
History of previous GTD
Current smoking (>15 cigarettes per day)
Maternal blood type AB, A, or B.
History of infertility, nulliparity.
use of oral contraceptives (however, oral contraceptives do not increase the risk of developing postmolar GTD )

Question 6

CLINICAL MANIFESTATIONS in general

Answer 6

Vaginal bleeding 
Enlarged uterus 
Pelvic pressure or pain 
Theca lutein cysts 
Anemia 
Hyperemesis gravidarum 
Hyperthyroidism 
Preeclampsia before 20 weeks of gestation 
Vaginal passage of hydropic vesicles

Question 7

Complete hydatidiform mole result of

Answer 7

a result of fertilization of an empty ovum by two sperms or a single sperm that duplicates, resulting in a 46 XX or 46 XY karyotype.

Question 8

Complete hydatidiform mole s & s hcg level

Answer 8

The presence of a complete mole (which lacks a fetus) often leads to excessive uterine size for the expected “gestational age
The marked elevation in serum hCG associated with a complete mole can lead to complications. These include ovarian enlargement due to theca lutein cysts; hyperemesis gravidarum; early development of preeclampsia (before 20 weeks of gestation); and hyperthyroidism, which is most often subclinical]. These complications occur in approximately 25 percent of .
more than 100,000 hcghyd

Question 9

Partial hydatidiform mole result of

Answer 9

A partial mole is the result of fertilization of a haploid ovum by two sperm or duplication of one sperm, resulting in a triploid karyotype (69 XXY, 69 XXX, 69 XYY

Question 10

partial hydatidiform s & s and hcg level

Answer 10

Partial moles are the only type of GTD that are associated with the presence of a fetus, and fetal cardiac activity may be detected. However, there is a high rate of intrauterine death related to triploidy.
Thus, a partial mole is often misdiagnosed as an incomplete or missed abortion and the correct diagnosis of GTD is made only after histologic review of the surgical specimen.
These pregnancies are infrequently associated with excessive uterine size, ovarian enlargement, preeclampsia, hyperemesis, or hyperthyroidism because hCG levels are generally lower than those observed with a complete mole

Question 11

hydatidiform evaluation tests

Answer 11

Human chorionic gonadotropin
Ultrasound
blood tests
Radiographic evaluation includes pelvic ultrasound
Chest imaging
CT scan or magnetic resonance imaging (MRI) of the brain
. Cerebral involvement can also be assessed by measuring beta-hCG levels in the cerebrospinal fluid (CSF)

Question 12

us findings in hydatidiform

Answer 12

Complete mole
The absence of an embryo or fetus
No amniotic fluid
Central heterogeneous mass with numerous discrete anechoic spaces, which correspond to diffuse hydatidiform swelling of the hydropic chorionic villi. This has classically been described as a “snowstorm pattern” on older ultrasounds
Theca lutein cysts
Partial mole
A fetus is present, may be viable, and is often growth restricted
Amniotic fluid is present, but may be reduced
Focal anechoic spaces and/or increased echogenicity of chorionic villi (swiss cheese pattern)
Increased transverse diameter of the gestational sac
Theca lutein cysts are usually absent

Question 13

Management of hydatidiform mole

Answer 13

suction curettage

Patients who have no desire for future fertility may opt for hysterectom

Question 14

suction curettage procedure

Answer 14

Under adequate anesthesia, oxytocin is administered and the cervix is dilated to allow passage of the suction cannula.
During dilation of the cervix, brisk uterine bleeding is often encountered, which generally slows significantly once suction evacuation has commenced. Heavy bleeding is nearly always self-limited, and inappropriate transfusion should be avoided.
A suction catheter of 12 mm is usually sufficient to evacuate a complete molar pregnancy since there is no fetus. A larger catheter may be needed to evacuate a partial mole with a coexistent fetus greater than 12 weeks of gestation.
The suction curette is not advanced to the fundus; instead, it is placed just inside the internal os.
Vacuum pressures of 50 to 60 cm Hg are then applied and the hydropic placental tissue is drawn
As additional tissue is evacuated, the uterus will contract and the suction curette may then be advanced to the fundus.
Suction curettage can be performed under ultrasound guidance if needed to facilitate the procedure and confirm complete evacuation of uterine contents.
Intravenous oxytocin is administered, and for uteri over 14-weeks size, we suggest fundal massage to stimulate myometrial contraction

Question 15

Malignant GTD symptom

Answer 15

The most common symptom is vaginal bleeding. Uterine rupture resulting in hemoperitoneum is rare, but may occur in patients who do not comply with recommended follow-up.

Question 16

Characteristics that increase the likelihood of GTN after molar evacuation include

Answer 16

Large theca lutein cysts (≥6 cm), 
Excessively enlarged uterus for dates, 
Age over 40, previous GTD, 
Initial hCG >100,000 mIU/mL, 
The presence of hyperplasia or atypia on histology. 
Heterozygosity (dispermic moles

Question 17

after molar vs non after molar GTD

Answer 17

after molar usually persistent GTN

non molar all most always choriocarcinoma

Question 18

Choriocarcinoma symptoms

Answer 18

. The typical clinical presentation is late postpartum bleeding, which persists beyond the usual six to eight weeks. Primary or secondary postpartum hemorrhage are other common presentations. However, abnormal vaginal bleeding may develop a year or more after an antecedent pregnancy. Hemorrhage can be severe if the tumor erodes through the myometrium or uterine vessels. 
Respiratory symptoms (eg, cough, chest pain, hemoptysis) or signs of gastrointestinal, urologic, and intracerebral bleeding are indicative of metastatic disease. Hepatic involvement from advanced disease may cause epigastric or right upper quadrant pain. 
Physical examination often reveals an enlarged uterus and bilateral ovarian cysts. Vaginal metastases are present in about 30 percent of cases; these lesions are very vascular and prone to bleeding; they may also become infected

Question 19

DIAGNOSIS OF MALIGNANT DISEASE

Answer 19

hCG levels should be monitored serially after treatment of a molar pregnancy. In a representative study, the average times to normalization of serum hCG after a complete or partial mole were 99 and 59 days, respectively
According to FIGO criteria, the presence of persistent (malignant) GTD after evacuation of a complete or partial molar pregnancy should be suspected if any of the following is present :
A serum hCG concentration that plateaus (decline of less than 10 percent for at least four values over three weeks)
A serum hCG concentration that rises (increase more than 10 percent of three values over two consecutive weeks eg, day 1, 7, 14)
Persistence of detectable serum hCG for more than six months after molar evacuation
The histologic identification of choriocarcinoma
The presence of metastatic disease usually implies the presence of choriocarcinoma rather than invasive mole.
Approximately 90 percent of these cases represent invasive mole, and <10 percent are choriocarcinomas; PSTTs are rare.

Question 20

ROLE OF U/S IN MALIGNANT DISEASE

Answer 20

Invasive mole typically appears as one or more poorly defined masses in the uterus with anechoic areas. Color Doppler of the anechoic areas reveals high vascular flow. Invasion into the myometrium may be visualized.
Choriocarcinoma and PSTT — Choriocarcinoma appears as a mass enlarging the uterus, with a heterogeneous appearance that correlates with areas of necrosis and hemorrhage. The tumor is usually markedly hypervascular on color Doppler . The tumor may extend into the parametrium

Question 21

Staging and prognostic stratification

Answer 21

Stage I — All patients with persistently elevated beta-hCG levels and tumor confined to the uterus.
Stage II — The presence of tumor outside of the uterus, but limited to the vagina and/or pelvis.
Stage III — Pulmonary metastases with or without uterine, vaginal, or pelvic involvement.
Stage IV — All other metastatic sites (eg, brain, liver, kidneys, gastrointestinal tract).
All stages were further stratified as A, B or C depending on the presence or absence of one or both of two risk factors for recurrence (beta-hCG ≥100,000 mIU/mL, or the detection of disease more than six months followed termination of an antecedent pregnancy).

Question 22

Single-agent chemotherapy

Answer 22

Methotrexate with and without leucovorin

Dactinomycin

Question 23

Multiagent chemotherapy

Answer 23

(EMA/CO
Etoposide — 100 mg/m 2 IV over 30 minutes on days 1 and 2
Methotrexate — 100 mg/m 2 IV push followed by 200 mg/m 2 IV over 12 hours on day 1
Dactinomycin — 0.5 mg IV bolus on days 1 and 2
Leucovorin calcium — 15 mg orally every 12 hours for four doses, starting 24 hours after start of MTX
Cyclophosphamide — 600 mg/m 2 IV on day 8
Vincristine Oncovin®) — 1.0 mg/m 2 IV on day 8

Question 24

when to stop Chemotherapy

Answer 24

Assessment of response —All women with GTD should be monitored with weekly serial measurements of serum beta-hCG during therapy. Remission is defined as three consecutive normal hCG values (less than 5 milli-international units/mL) over 14 to 21 days.
When weekly or biweekly single agent chemotherapy regimens are used, the regimen is continued until the third negative result is obtained. When infusional MTX is given as a one-time dose, hCG levels are followed weekly, with additional therapy given only if an inadequate response is observed.
When combination chemotherapy with EMA/CO is used, the regimen is repeated every two weeks until normalization of beta-hCG, and then generally continued for an additional three cycles (six weeks). After remission is achieved, serum beta-hCG should be measured monthly until monitoring has shown one year of normal hCG levels