This document discusses gestational trophoblastic disease (GTD), which includes pre-malignant and malignant conditions originating from the placenta. It covers the spectrum of conditions, risk factors, clinical presentation, diagnosis, staging, and treatment approaches. GTD ranges from complete and partial hydatidiform moles to invasive moles, choriocarcinoma, and other rare types. Diagnosis involves hCG levels, imaging, and pathology. Treatment depends on the stage and includes chemotherapy, surgery, and radiation. The goal is to normalize hCG levels and prevent resistance or recurrence through combination therapies and maintenance protocols.

1. Gestational Trophoblastic Disease
:GTD
 Dr Mebanshanbor Garod
 (MS General Surgery, FMAS,
 FEBS Surgical Oncology)

 Surgical Oncology Dept.,
 NEIGRIHMS, Shillong

2. A spectrum of interrelated conditions
originating from placenta:
Pre malignant conditions:
 Complete (CHM) and
 Partial hydatidiform moles moles (PHM)
 Invasive Mole
Malignant conditions:
 Choriocarcinoma
 Placental Site Throphoblastic Tumor (PSTT)
 Epitheloid trophoblastic tumor (ETT)

3. Persistent GTD (aka GTN) rises from
cytotrophoblast and syncitial cells of villous
trphoblast ,produces hCG
PSTT & ETT originates from intermediate
cells of extra villous trophoblast & sparsely
produce hCG

4. 1 in 1500 pregnancy
Very young <16 years; advanced maternal
age >45 years.
20% will develop malignant sequelae.

6. 1. CLINICAL; Usually during the first trimester of
pregnancy
 most common symptom: abnormal bleeding
 hyperemesis gravidarum
 uterine enlargement greater than expected for
gestational age (CHM)
 absent fetal heart sounds
2. USG “snowstorm” appearance, cystic
enlargement of the ovaries in 2nd trimester
(CHM)
3. hCG>I00000 mIU/ml

7. Rule out complictions (preeclampsia,
anemia etc)
Hysterectomy Vs Suction curettage

8. Increasing hCG levels :
• Increase of three values > 10% over 2 weeks or
• Plateau (four values ± 10% over 3 weeks )
• hCG > 20000 IU/l after >4 weeks after evacution
Histologic diagnoses of Choriocarcinoma
or invasive mole from uterine currettage
Clinical or radiographic evidence of
metastases

9. CC occurs in approximately 1 in 20,000–
40,000 pregnancies
 50% after term pregnancies
25% after molar pregnancies
 remainder after other gestational events
PSTT/ETT can develop after any type of
pregnancy

10. CC & PSTT/ETT:
Diagnosis tricky: months to years after
pregnancy as symptoms are non specific
Urine/serum hCG not always elevated

11. 1. hCG
2. HISTOPATH: D&C for hyditaform mole
3. USG Pelvis
4. CT Chest: Persistent GTD or CC
(suspicious CXR findings)
5. MRI Brain: neurological symptoms or
lung mets on CT

14. STaGE I
1. Hysterectomy
2. Single agent Chemotherpy: MTX-F or Act
D

18. Stable hCG for three consecutive weeks
Re-elevated hCG
Not falling at least once within 18 days of
first treatment

20. All patients treated with combination
chemotherapy
Selective use of Radiation therapy and
surgery

22.  three drug doublet regimen TE/TP
Paclitaxel etoposide and cisplatin

24. Little application
Selected patients with cerebral mets
WBI (3000 cGY)

25. Hysterectomy : heavy bleeding, large bulky
intrauterine masses, sigificant pelvic
sepsis
Unresponsive solitary masses in the
liver/spleen/kidneys
Persistent lung nodules: solitary, limited to
one lung, hCG < 1000

27.  Stage I: TAH, Pelvic LN sampling
 Other stages & Metastatic disease: multi
agent CT , EP/EMA

29. FIGO scoring system : determine the risk of
resistance.
FIGO
1. 0-6: single agent MTX/FA or ACT-D
6 weeks maintenance after normalisation of HCG
2. >/ 7 multi agent CT EMA/CO
6 weeks maintenance therapy/8 weeks with poor pgronostic factors
(liver/brain mets)
3. Ultra high risk : EP/EMA or TE/TP

30. • Surgery : isolated foci of chemo-resistant disease
• PSTT/ETT
 Stage I: TAH, Pelvic LN sampling
 Other stages & Metastatic disease: multi agent CT , EP/EMA