MALIGNANT GESTATIONAL TROPHOBLASTIC DISEASE 1

Question 1

What is the classification of malignant gestational trophoblastic neoplasia (GTN)?

Answer 1

Choriocarcinoma, persistent hydatidiform mole, invasive mole, and placental-site trophoblastic tumor (PSTT).

Question 2

List the risk factors for malignant GTD requiring chemotherapy.

Answer 2

Older age (≥40 years), preceding molar pregnancy, large tumor size (>5cm), high hCG levels (>10^5 miu/L), previous chemotherapy, and metastases.

Question 3

What is the role of the WHO prognostic scoring system in GTD?

Answer 3

It classifies GTD into low-risk (score 0-7) and high-risk (score >7) groups.

Question 4

Define choriocarcinoma.

Answer 4

A rapidly growing, invasive pregnancy-related tumor originating from trophoblast cells.

Question 5

What are the histopathological findings in choriocarcinoma?

Answer 5

Dimorphic cytotrophoblast and syncytiotrophoblast populations, myometrial invasion, prominent necrosis, and hemorrhage.

Question 6

Describe the FIGO anatomic staging for choriocarcinoma.

Answer 6

Stage 1: Uterine involvement; Stage 2: Vaginal metastases; Stage 3: Lung metastases; Stage 4: Distant metastases.

Question 7

What are the common clinical presentations of choriocarcinoma?

Answer 7

Irregular vaginal bleeding, metastatic symptoms (e.g., breathlessness, CNS disturbances, epigastric pain).

Question 8

How is choriocarcinoma diagnosed?

Answer 8

High β-hCG levels and persistent bleeding after pregnancy.

Question 9

What is the normal timeline for hCG to return to baseline after different pregnancy outcomes?

Answer 9

H. Mole: 84-100 days; Artificial abortion: 30 days; Spontaneous abortion: 19 days; Normal delivery: 12 days; Ectopic pregnancy: 8-9 days.

Question 10

List the investigations necessary for GTN diagnosis and management.

Answer 10

FBC, RFT, LFT, HIV, CXR, USS, CT/MRI, brain imaging, and serial β-hCG levels.

Question 11

What is the mainstay of treatment for GTN?

Answer 11

Chemotherapy is the primary treatment.

Question 12

Name commonly used chemotherapy drugs for GTN.

Answer 12

Methotrexate, Actinomycin D, 5-Fluorouracil, Vincristine, Cyclophosphamide, Etoposide.

Question 13

What distinguishes low-risk from high-risk GTN?

Answer 13

Low-risk: Single-agent therapy; High-risk: Multi-agent therapy (EMA-CO regimen).

Question 14

What are the principles of chemotherapy for GTN?

Answer 14

Low-risk patients receive single-agent; high-risk patients receive multi-agent therapy.

Question 15

What is the role of follow-up monitoring in GTN treatment?

Answer 15

Regular β-hCG monitoring and additional chemotherapy courses after normalization.

Question 16

Why is hCG follow-up critical after hysterectomy for GTN?

Answer 16

To detect and manage potential metastases.

Question 17

What are the surgical options for GTN management?

Answer 17

Hysterectomy, arterial ligation, embolization, and metastatic lesion removal.

Question 18

Define an invasive mole.

Answer 18

A hydatidiform mole with villi penetrating deeply into the myometrium or blood vessels.

Question 19

What are the clinical features of an invasive mole?

Answer 19

Vaginal bleeding, intraperitoneal bleeding, uterine subinvolution, pelvic pain.

Question 20

How is an invasive mole diagnosed?

Answer 20

Persistent high β-hCG levels and imaging findings.

Question 21

What distinguishes an invasive mole from a choriocarcinoma?

Answer 21

Presence of villi distinguishes invasive mole from choriocarcinoma.

Question 22

What is the treatment for invasive moles?

Answer 22

Chemotherapy ± hysterectomy.

Question 23

Define placental-site trophoblastic tumor (PSTT).

Answer 23

A rare trophoblastic tumor predominantly composed of intermediate trophoblasts.

Question 24

How is PSTT diagnosed?

Answer 24

Persistent vaginal bleeding, low serum β-hCG (<10,000), histology.

Question 25

What is the treatment for PSTT?

Answer 25

Hysterectomy.

Question 26

What are the risk factors for developing an invasive mole?

Answer 26

History of complete hydatidiform mole, older age, high β-hCG levels.

Question 27

What is the significance of syncytiotrophoblast cells in GTD histology?

Answer 27

Their absence in PSTT histology.

Question 28

What are the metastatic symptoms associated with choriocarcinoma?

Answer 28

Hemoptysis, neurological symptoms, epigastric pain, jaundice.

Question 29

What is the survival rate for low-risk GTN treated with single-agent therapy?

Answer 29

Nearly 100%.

Question 30

Describe the EMA-CO regimen for high-risk GTN.

Answer 30

A multi-agent regimen combining etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine.

Question 31

How is hCG monitored during GTN treatment?

Answer 31

Monitored every 1-2 weeks until normalization and monthly for 1 year post-treatment.

Question 32

What is the role of hysterectomy in older patients with GTN?

Answer 32

To manage localized disease or excessive bleeding.

Question 33

What are the complications of untreated invasive moles?

Answer 33

Persistent hemorrhage, uterine perforation, distant metastases.

Question 34

What is the pathology of invasive moles?

Answer 34

Excessive trophoblastic proliferation with preserved villous pattern.

Question 35

How is PSTT different from other forms of GTD?

Answer 35

PSTT is locally invasive, indolent, and resistant to chemotherapy.

Question 36

What are the signs of metastasis in GTN?

Answer 36

Bluish vaginal nodules, CNS disturbances, lung symptoms.

Question 37

What is the importance of staging in GTN management?

Answer 37

Guides treatment and prognosis.

Question 38

How does age affect the prognosis of GTN?

Answer 38

Older age is associated with worse outcomes.

Question 39

Why is chemotherapy less effective in PSTT?

Answer 39

Due to its indolent nature and lower hCG production.

Question 40

What are the indications for selective arterial embolization in GTN?

Answer 40

To control localized bleeding.

Question 41

What are the adverse effects of GTN chemotherapy?

Answer 41

Bone marrow suppression, GI ulceration, liver/renal dysfunction.

Question 42

How is bleeding managed in patients with GTN?

Answer 42

Uterine artery embolization or hysterectomy.

Question 43

Why should conception be avoided for one year post-GTN treatment?

Answer 43

To allow for complete recovery and minimize recurrence risk.

Question 44

What are the features of chorioadenoma destruens?

Answer 44

Abnormal penetrativeness and extensive invasion by trophoblastic cells.

Question 45

How is persistent low-level hCG in PSTT managed?

Answer 45

Monitoring and hysterectomy if needed.

Question 46

What imaging techniques are used in GTN diagnosis?

Answer 46

Ultrasound, CT, MRI, and brain imaging.

Question 47

What is the role of β-hCG in GTN diagnosis and monitoring?

Answer 47

Essential for diagnosis, staging, treatment response, and follow-up.

Question 48

What percentage of complete hydatidiform moles become invasive?

Answer 48

Approximately 16%.

Question 49

Describe the presentation of metastatic nodules in GTN.

Answer 49

Bluish nodules filled with dark red blood.

Question 50

How is uterine subinvolution related to invasive moles?

Answer 50

It indicates incomplete uterine recovery, often linked to invasive mole.