Gestational Trophoblastic Neoplasia Group 1

GESTATIONAL
TROPHOBLASTIC
NEOPLASIA
GROUP 1
DEFINITION:
Gestational trophoblastic disease (GTD) is a heterogeneous spectrum of diseases with proliferation ranging from benign to malignant state.
Persistent GTD (persistently raised b-hCG) is referred as gestational trophoblastic neoplasia (GTN).
Diagnosis of post molar GTN is made when the hCG level plateaus for 3 or more consecutive weeks or re-elevates. This may occur in 15-20% following hyadatidiform mole.
RISK FACTORS FOR DEVELOPMENT OF GTN
1. Advanced maternal age (> 40 years)

2. B-Hcg > 100,000 IU/L
3. Increased uterine size
4. Bilateral ovarian enlargement (>8 cm)
5. USG – Uterine invasion
6. Increased uterine vascularity (USG Doppler)
Persistent GTN is evidenced by persistence of trophoblastic activity following evacuation of molar pregnancy.
This is clinically diagnosed when the patient presents with
(a) Irregular vaginal bleeding.
(b) Subinvolution of the uterus.
(c) Persistence of theca lutein cysts and
(d) Level of hCG either plateaus or reelevates after an initial fall. After molar evacuation serum β hCG becomes
normal in about 7–9 weeks.
Postmolar GTN of serious nature may be either invasive mole or choriocarcinoma but GTN after non-molar
pregnancy is always a choriocarcinoma.
GTN includes :
• invasive mole/post molar GTN
• Choriocarcinoma
• Placental site trophoblastic tumor (PSTT)
• Epitheloid trophoblastic tumor (ETT)
Incidence
More than 50 percent occur after molar pregnancy, about 25 percent after abortion and/or ectopic
pregnancy and a few after normal pregnancy. Non-metastatic (locally invasive) lesions develop in 15 percent
and metastatic lesions develop in about 4 percent of patients after molar evacuation.
SPREAD OF GTN: Apart from the local spread, vascular erosion takes place early and hence distant
metastases occur rapidly. The common sites of metastases are lungs (80%), anterior vaginal wall (30%), brain
(10%), liver (10%) and others.
CLINICAL FEATURES OF GTN:

The clinical features depend on the location of the primary growth and on its secondary deposits.
Patient profile: There is usually a history of molar pregnancy in recent past. Rarely, its relation with a term
pregnancy, abortion or ectopic pregnancy may be established. GTN after a non-molar pregnancy is always a
choriocarcinoma.
Symptoms: The following are the usual symptoms :
• Persistent ill health.
• Irregular vaginal bleeding, at times brisk.
• Continued amenorrhea.
Other symptoms due to metastatic lesions are:
Lung - Cough, breathlessness, hemoptysis.
Vaginal - Irregular and at times brisk hemorrhage.
Cerebral - Headache, convulsion, paralysis or coma.
Liver - Epigastric pain, jaundice.
Signs:
• Patient looks ill.
• Pallor of varying degrees.
Physical signs are evident according to the organ involved.

Bimanual examination reveals subinvolution of the uterus. There may be a purplish red nodule in the lower-third of
the anterior vaginal wall . Unilateral or bilateral enlarged ovaries may be palpable through lateral fornices.
INVESTIGATIONS
Diagnostic criteria for postmolar GTN (FIGO)
• Levels of serum β-hCG are followed up.

• ≥ Four values of plateaued hCG (±10%) over at least 3 weeks
• time (D:1, 7, 14, 21).
• A rise of hCG of >10% for >3 values over at least 2 weeks time.
• Histologic diagnosis of choriocarcinoma.
• Persistence of hCG beyond 6 months of mole evacuation
• Chest X-Ray – Shows 'cannon ball' or 'snow storm' appearance due to
numerous tumor emboli. Pleural effusion may be present
Cannon ball shadow in the left apical and

mid region of the lung with pleural effusion
in choriocarcinoma
• Pelvic Sonography – Helps not only to localize the lesion but to
differentiate GTN from a normal pregnancy
• Diagnostic uterine curettage – Pre therapy D and C reduces the
intrauterine tumor bulk. It reveals the characteristic histological
pattern. It is emphasized that, the curetted material may not reveal
the diagnosis in all the cases, as the lesion may be deep in the
myometrium or uterus may not be the primary site. One should be
very careful and alert while doing uterine curettage as brisk
hemorrhage may occur
• Histopathology – Choriocarcinoma, on histology show sheets of
anaplastic trophoblastic tissue with cytotrophoblast and
syncytiotrophoblast cells without chorionic villi. Extragonadal germ
cell tumors originate from midline locations such as anterior
mediastinum, retroperitoneum and have no primary tumor in ovaries.

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GESTATIONAL

1. Advanced maternal age (> 40 years)

CLINICAL FEATURES OF GTN:

Physical signs are evident according to the organ involved.

• Levels of serum β-hCG are followed up.

Cannon ball shadow in the left apical and

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