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Chapter 13: Gestational Trophoblastic Neoplasia

John R. Lurain

INTRODUCTION

Epidemiology

Incidence:✫

Hydatidiform mole: 1 in 1000–2000 pregnancies (United States and Europe)

Choriocarcinoma: 1 in 20,000–40,000 pregnancies (United States and Europe)

Gestational trophoblastic neoplasia (GTN) lesions are nearly always disorders of the reproductive years. The incidence is higher in women <20 years and >40 years

 

Pathology

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Gestational Trophoblastic Neoplasia

  • Potential for local invasion and metastases

  • Most commonly develops after a molar pregnancy, but can arise de novo after any gestational experience: spontaneous or induced abortion, ectopic pregnancy, or preterm or term pregnancy

  • The most common sites of metastases are lungs (80%), brain (10%) liver (10%), and vagina (~5%)

 

Hancock BW et al. Gestational Trophoblastic Disease, 3rd ed, 2009

Staging

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Staging

FIGO Anatomic Staging System for GTN
Stage Extent of GTN
I: Confined to the uterus
II: Extends outside the uterus, but is limited to the genital structures (adnexa, vagina, broad ligament)
III: Extends to the lungs, with or without known genital tract involvement
IV: All other metastatic sites
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Staging

FIGO Scoring System✫ (Modified WHO Scoring System)

[Note: This scoring system does not apply to patients with placental-site trophoblastic tumors]
Prognostic Factor 0 1 2 4
Age (years) ≤39 >39 — —
Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy —
Interval from index pregnancy <4 months 4–6 months 7–12 months >12 months
Pretreatment hCG level (IU/L) <1000 1000–10,000 >10,000–100,000 >100,000
Largest tumor size including uterus — 3–4 cm ≥5 cm —
Sites of metastases Lung† Spleen, kidney GI tract Brain, liver
Number of metastases identified† 0 1–4 5–8 >8
Previous ineffective chemotherapy — — Single drug ≥2 drugs

✫FIGO staging system includes a modification of the WHO prognostic index score for risk assessment

†Chest x-ray is used to count the number of metastases for risk score assessment

Note: Total score for a patient is obtained by adding individual scores for each prognostic factor
Total Score Risk
0–6 Low risk
≥7 High risk

Both FIGO Anatomic Staging System and the Modified WHO score should be used. By convention, the FIGO stage is depicted by a Roman numeral and is followed by the Modified WHO Score depicted by an Arabic numeral. The 2 values are separated by a colon (eg, III:9)

 

Kohorn EI:. Int J Gynecol Cancer 2001;11:73–77

Ngan HYS et al. Int J Gynaecol Obstet 2003;83:175–177

Work-up

Once a diagnosis of GTN has been made, it is necessary to determine the extent of disease

Once the initial work-up is completed, patients are categorized (see Staging below)

  1. H&P

  2. Serum hCG

    Note: For staging purposes, the hCG level that is important is that obtained immediately before instituting treatment and not the hCG obtained at the time of the previous molar evacuation

  3. CBC, LFT, serum electrolytes, BUN, creatinine, PTT, and PT

  4. Chest x-ray

  5. CT of chest, abdomen, and ...

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