SEMINAR PRESENTED BY DR MONIKA MOURYA AT NSCBMCH JABALPUR

1. SEMINAR ON CHORIOCARCINOMA DEPARTMENT OF OBS & GYNAE N.S.C.B. MEDICAL COLLEGE, JABALPUR (M.P.) Speaker Dr. Monika Mourya

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

5. COMMON SITES FOR METASTATIC GESTATIONAL TROPHOBLASTIC TUMORS Site Per cent Lung 60-95 Vagina 40-50 Vulva/cervix 10-15 Brain 5-15 Liver 5-15 Kidney 0-5 Spleen 0-5 Gastrointestinal 0-5

6. HYDATIDIFORM MOLE (MOLAR PREGNANCY)

10. COMPARATIVE PATHOLOGIC FEATURES OF COMPLETE AND PARTIAL HYDATIDIFORM MOLE Feature Complete Mole Partial Mole Karyotype Usually diploid 46XX Usually triploidy 69XXX most common. Villi All villi hydropin; no normal adjacent villi Normal adjacent villi may be present vessels present they contain no fetal blood cells blood cells Fetal tissue None present Usually present Trophoblast Hyperplasia usually present to variable degrees Hyperplasia mild and focal Uterine size More than date Less than date Theca Lutein cyst 30-60% common Uncommon b HCG High more than 50 thousand Less than 50 thousand Risk of persistent GTN 20% <5% Classical clinical symptoms Common Uncommon

12. Complete hydatidiform mole demonstrating enlarged villi of various size

13. Partial hydartidiform mole

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

16. CLINICAL RISK FACTORS FOR MOLAR PREGNANCY Age (extremes of reproductive years) <15 >40 Reproductive history prior hydatidiform mole prior spontaneous abortion Diet Vitamin A deficiency Birthplace Outside North America( occasionally has this disease)

17. Hydatidiform mole: specimen from suction curettage

18. A large amount of villi in the uterus.

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

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

23. 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.

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

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

32. Invasive mole

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

35. 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.

36. Doppler image of invasive mole

37. CHORIOCARCINOMA

39. Gross specimen of choriocarcinoma

40. Microscopic image of choriocarcinoma absence of chorionic villi

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

58. Placenta Site Trophoblastic Tumor (PSTT)