Gestational Trophoblastic Neoplasia (KBK)

8/11/2019 Gestational Trophoblastic Neoplasia (KBK)

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GestationalTrophoblastic Neoplasia

Divisi Onkologi Ginekologi

Bagian Obstetri & Ginekologi

FKUSU / RS H. Adam Malik

Medan


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Rare human malignancy that can cure

even in the presence of widespreadmetastase.

Including : Hydatidiform mole (complete or partial)

Invasive mole

Placental site trophoblastic tumor Choriocarsinoma


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Complete hydatidiform mole

Embryonic or fetal tissues (-)

46XX karyotype

Entirely of paternal origin

Ovum nucleus absent or inactivated


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Partial hydatidiform mole

Identifiable embryonic ,fetal tissues or villi Varying size of chorionic villi

Triploid karyotype

Multiple congenital malformation of the fetus


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Clinical features :

Vaginal bleeding

Excessive uterine size

Toxemia Hyper emesis gravidarum

Hyperthyroidism

Trophoblastic embolisation Theca lutein ovarian cyst


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High risk mole

hCG level > 100.000 mIU/ml

Excessive uterine enlargement

Theca lutein > 6 cm in diameter


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Diagnosis

Ultrasonography is a reliable and

sensitive technique for the diagnosis

Usually referred as snow storm pattern


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Treatment

Suction curettage

Hysterectomy with mole insitu

Prophylactic chemotherapy : controversial

Follow-up :hCG, physical and imaging Contraception


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Malignant Gestational

Trophoblastic Disease

Malignant gestational trophoblastic diseasecan named as:

Trophoblastic neoplasia

Trophoblastic tumor

Malignant trophoblastic tumor

Hydatidiform mole and invasive mole are notmalignant


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FIGO 2000 staging system

Stage I : disease confined to the uterus

Stage II : disease out side of the uterus but

is limited to the genital structures (adnexa,

vagina, broad ligament)

Stage III : disease extend to the lungs with or

without known genital tract involvement

Stage IV : all other metastatic sites


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The scoring system for the FIGO 2000 staging

FIGO score 0 1 2 4

Age 39 > 39 - -

Antecedent pregnancy Hydatidiform

mole

abortion Term

pregnancy

Interval months from index

pregnancy

< 4 4 - 6 7 - 12 > 12

Pretreatment hCG milli

IU/ml

< 103 103- 104 > 104-105 > 105

Largest tumor size including

uterus

- 3 - 4 cm 5 cm -

Site of metastases lung Spleen,

kidney

Gastro Inst.

Tract

Brain,

liver

Number of metastases

identified

0 1- 4 4 - 8 > 8

Previous failed

chemotherapy

Single drug Two or

more

drugs


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Diagnostic criteria GTN

4 stable hCG level within 3 weeks, on day 1, 7, 14

and 21.

hCG increase 10% for 3 times within 2 weeks,on day 1, 7 and 14

histological proved choriocarsinoma

hCG still high 6 months post mole evacuation

Low risk : score 6

High risk : score 7


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Malignant Gestational TrophoblasticNeoplasia

Non metastasis disease.

Metastasis disease.

Placental site trophoblastic tumor


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Non metastasis disease

15% after hydatidiform mole evacuation

Patient present:

Irregular vaginal bleeding

Theca lutein cyst

Uterine sub involution

Asymmetric uterine enlargement

Persistence elevated hCG level


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Metastasis disease

4% after evacuation hydatidiform mole

Sites of metastasis : Pulmonary

Vaginal

Hepatic Central nervous system


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Placental site trophoblatic tumor

Rare tumor , potential to metastasize and death

After abortion, mole or normal pregnancy

Bleeding accompanied by uterine enlargement

Resemble invasive mole (myometrial invasion)

Characterized: mononuclear invasion

Can be interpreted as sarcoma

Low elevated serum hCG

Mortality rate 1520%


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Diagnostic evaluation

Pretreatment evaluation :o Complete history taking

o Complete physical examination

o Measurement serum hCG value

o Hepatic, thyroid and renal function test


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Diagnostic evaluation

Metastasis work-up :

o Chest radiographo USG or CT-scan abdomen & pelvis

o CT or MRI scan of the head

o hCG level from CSF

o Selective angiography


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Management

Chemotherapy (singlecombination)

Hysterectomy plus chemotherapy

Controlled vaginal bleeding

Special treatment for metastatic site


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Future Childbearing

After effective treatment, only 1-2% occur at

subsequent pregnancy

No different pregnancy out come

Chemotherapy treatment no association with

congenital malformation at subsequent

pregnancy

Chemotherapy ( single or multiple agent) has

no effects in fertility


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Documents

Gestational Trophoblastic Neoplasia (KBK)