Ob Kaplan Chap 6 (Gyn) Gestational Trophoblastic Neoplasia

Front 1

Define GTN

Back 1

GTN is an abnormal proliferation of placental tissue involving both the cytotrophoblast and/or syncytiotrophoblast. It can be either benign or malignant. Malignant GTN can be characterized as either localized or metastatic

Front 2

GTN triad

Back 2

1.Pregnancy <20 weeks
2.HTN and proteinuria
3.No fetal heart tones (FHT)

Front 3

Types of benign GTN

Back 3

1. Benign GTN. This is the classic hydatidiform mole (H-mole).
— Complete mole is the most common benign GTN. It results from fertilization of an empty egg with a single X sperm resulting in paternally derived normal 46,XX karyotype. No fetus, umbilical cord or amniotic fluid is seen. The uterus is filled with grape-like vesicles composed of edematous avascular villi.
— Incomplete mole is the less common benign GTN. It results from fertilization of a normal egg with two sperm resulting in triploid 69,XXY karyotype. A fetus, umbilical cord and amniotic fluid is seen which results ultimately in fetal demise.

Front 4

Types of malignanct GTN

Back 4

1.— Non-metastatic disease is localized only to the uterus.
2.— Good Prognosis metastatic disease has distant metastasis with the most common location being the pelvis or lung.
3.— Poor Prognosis metastatic disease has distant metastasis with the most common location being the brain or the liver. Other poor prognosis factors are: serum b-hCG levels >40,000, >4 months from the antecedent pregnancy, and following a term pregnancy.

Front 5

Risk factors for GTN

Back 5

1. geographically is most common in Taiwan and the Philippines.
2. maternal age extremes (<20 years old, >35 years old)
3. folate deficiency

Front 6

GTN Clinical findings

Back 6

1. (MC) bleeding prior to 16 weeks' gestation and passage of vesicles from the vagina.
2. hypertension
3. hyperthyroidism
4. hyperemesis gravidarum
5. no fetal heart tones
6. (MC) sign is fundus larger than dates
7. bilateral cystic enlargements of the ovary known as theca-lutein cysts.
8. (MC) site of distant metastasis is the lungs.

Front 7

Dx of GTN

Back 7

"Snowstorm" ultrasound. The diagnosis is confirmed with sonogram showing
homogenous intrauterine echoes without a gestational sac or fetal parts.

Front 8

GTN Management

Back 8

1. Obtain a baseline quantitative B-hCG titer.
2. Obtain a chest X-ray to rule out lung metastasis.
3. Perform a suction D&C to evacuate the uterine contents.
4. Place the patient on effective contraception (oral contraceptive pills) for the duration of the follow-up period to ensure no confusion between rising B-hCG titers from recurrent disease and normal pregnancy

Front 9

Tx of GTN

Back 9

1. Benign GTN: Follow weekly serial B-hCG titers until negative for three weeks, then monthly titers until negative for 12 months. Follow-up is for 1 year. If serial B-hCG titers plateau or rise, the patients are diagnosed with persistent gestational trophoblastic disease. They should undergo a metastatic workup (CT scans of the brain, the thorax, the abdomen and the pelvis) and be managed as below.
2. Non-metastatic or Good Prognosis metastatic disease: Administer single agent (metho-trexate or actinomycin D) until weekly B-hCG titers become negative for three weeks, then monthly titers until negative for 12 months. Follow-up is for 1 year.
3. Poor Prognosis metastatic disease: Administer multiple agent chemotherapy (which includes Methotrexate, Actinomycin-D and Cytoxan) until weekly B-hCG titers become negative for three weeks, then monthly titers for 2 years, then every three months for another 3 years. Follow-up is for 5 years.

Front 10

Staging for Gynecological malignancy

Back 10

1. Clinical staging- cervical cancer
2. Surgical staging- endometrial, ovarian, vulvar and trophoblastic cancer