The lecture has been given on Dec. 13th & 15th, 2010 by Dr. Muhabat Salih Saeid.

1. Gestational Trophoblastic Disease (GTD)

5. Pathologic and clinical classifications for gestational trophoblastic disease Low risk High risk Choriocarcinoma Metastatic Placental site trophoblastic tumor Nonmetastatic Malignant trophoblastic disease Invasive mole Benign gestational trophoblastic disease Hydatidiform mole *complete *incomplete CLINICAL CLASSIFICATION PATHOLOGIC CLASSIFICATION

6. Hydatidiform Mole (molar pregnancy)

13. Clinical risk factors for molar pregnancy Outside North America( occasionally has this disease) Birthplace Vitamin A deficiency Diet prior spontaneous abortion prior hydatidiform mole Reproductive history >40 <15 Age (extremes of reproductive years)

15. Comparative Pathologic Features of Complete and Partial Hydatidiform Mole Hyperplasia mild and focal Hyperplasia usually present to variable degrees Trophoblast Usually present None present Fetal tissue blood cells present they contain no fetal blood cells vessels Normal adjacent villi may be present All villi hydropin; no normal adjacent villi Villi Usually triploidy 69XXX most common. Usually diploid 46XX Karyotype Partial Mole Complete Mole Feature

16. Complete hydatidiform mole demonstrating enlarged villi of various size

17. Hydatidiform mole: specimen from suction curettage

18. A large amount of villi in the uterus.

20. A sonographic findings of a molar pregnancy. The characteristic “snowstorm” pattern is evident.

21. Transvaginal sonogram demonstrating the “ snow storm” appearance.

22. Color Dopplor facilitates visualization of the enlarged spiral arteriesclose proximity to the “ snow storm” appearance

23. Color Doppler image of a hydatidiform mole and surrounding vessels. The uterine artery is easily identified from its anatomical location.

25. Dopplor waveform analysis demonstrates low vascular resistance(RI=0.29) in the spiral arteries, much lower than that obtained in normal early pregnancy

27. Partial hydartidiform mole

28. Microscopic image of partial molar pregnancy.

29. Here is a partial mole in a case of triploidy. Note the scattered grape-like masses with intervening normal-appearing placental tissue.

30. Large bilateral theca lutein cysts resembling ovarian germ cell tumors. With resolution of the human chorionic gonadotropin(HCG) stimulation, they return to normal-appearing ovaries.

42. Invasive mole

44. Invasive mole: the tissue invades into the myometrial layer. No obvious borderline, with obvious bleeding.

45. Invasive hydatidiform mole infiltrating the myometrium

46. A case of invasive mole: inside the uterine cavity the typical “ snow storm” appearance can be detected, The location of blood flow suggest an invasive mole.

47. The same patient owing to the myometrial invasion. Reduced vascular resistance is detected in the uterine artery.

48. Transvaginal color Doppler scan of a patient with invasive mole Following uterine curettage, Persistent color signals within the myometeriun

49. Doppler image of invasive mole

50. Power Doppler easily detects a vascular echogenic nodule within the myometrium, suggesting invasive mole

51. Doppler image of invasive mole. Doppler waveform analysis depicts low vascular resistance (RI= 0.35)

52. Common Sites for Metastatic Gestational Trophoblastic Tumors 0-5 Gastrointestinal 0-5 Spleen 0-5 Kidney 5-15 Liver 5-15 Brain 10-15 Vulva/cervix 40-50 Vagina 60-95 Lung Per cent Site

53. Choriocarcinoma

56. Gross specimen of choriocarcinoma

57. Microscopic image of choriocarcinoma absence of chorionic villi

58. Microscopic image of choriocarcinoma

59. Doppler image of choriocarcinoma

60. Doppler image of choriocarcinoma

62. WHO Prognostic Scoring System 0-4 low risk, 5-7 intermediate risk, >8 high risk for death 2 or more Single drug — — Previous (treatment) 8 4-8 1-4 — No. of metastasis Brain GI tract, liver Spleen, kidney Lung Sites of metastasis — >5 3-5 <3 Largest tumor(cm) >10 5 10 4 -10 5 10 3 -10 4 <10 3 Initial hCG(mIU/ml) >12 7-12 4-6 <4 Interval (months) of treatment — Term pregnancy Abortion, ectopic Hydatidiform mole Pregnancy history — — >39 ≤ 39 Age(years) 4 2 1 0 Prognostic factor Score

63. FIGO Staging System for Gestational Trophoblastic Tumors All other metastatic sites Ⅳ Extends to the lungs with or without genital tract Ⅲ Extends to the adnexae, outside the uterus, but limited to the genital structures Ⅱ Limited to uterine corpus Ⅰ Description Stage

66. IIb IIa

67. IIIa<3cm or locate in half lung IIIb disease beyond IIIa

75. EMA-CO Chemotherapy for poor Prognostic Disease (Repeat every 15 days as toxicity permits) IV on day8 1mg/M 2 Oncovin (vincristine) IV on day8 600mg/M 2 Cyclophosphamide 15mg IM or p.o. q 12 hours×4 starting 24 hours after starting methotrexate Folinic acid IV daily×2 days 0.5mg Actinomycin D IV losding dose, then 200mg/M2 over 12 hours day 1 100mg/M 2 Methotrexate IV daily×2 days (over 30-45 minutes) 100mg/M 2 Etoposide(VP-16)

78. Placenta Site Trophoblastic Tumor (PSTT)