18gestational-trophoblas教学讲解课件

GestationalTrophoblasticDisease(GTD)GestationalTrophoblasticDise118gestational-trophoblas教学讲解课件2TypesofGTDBenignHydatidiformmole/molarpregnancy(completeorincomplete)malignantInvasivemoleChoriocarcinoma(chorioepithelioma)PlacentalsitetrophoblastictumorTypesofGTDBenign3ThetermGestationalTrophoblasticTumorshasbeenappliedthelatterthreeconditionsArisefromthetrophoblasticelementsRetaintheinvasivetendenciesofthenormalplacentaormetastasisKeepsecretionofthehumanchorionicgonadotropin(hCG)TypesofGTDThetermGestationalTrophobla4PATHOLOGICCLASSIFICATIONCLINICALCLASSIFICATIONHydatidiformmole*complete*incompleteBenigngestationaltrophoblasticdiseaseInvasivemoleMalignanttrophoblasticdiseaseNonmetastaticPlacentalsitetrophoblastictumorMetastaticChoriocarcinomaHighriskLowriskPathologicandclinicalclassificationsforgestationaltrophoblasticdiseasePATHOLOGICCLASSIFICATIONCLINI5HydatidiformMole

(molarpregnancy)HydatidiformMole

(molarpreg6DefinitionandEtiologyHydatidiformmoleisapregnancycharacterizedbyvesicularswellingofplacentalvilliandusuallytheabsenceofanintactfetus.

Theetiologyofhydatidiformmoleremainsunclear,butitappearstobeduetoabnormalgametogenesisandfertilizationDefinitionandEtiologyHydat7Ina‘completemole’themassoftissueiscompletelymadeupofabnormalcellsThereisnofetusandnothingcanbefoundatthetimeofthefirstscan.DefinitionandEtiologyIna‘completemole’themass8Ina‘partialmole’,themassmaycontainboththeseabnormalcellsandoftenafetusthathasseveredefects.Inthiscasethefetuswillbeconsumed(destroyed)bythegrowingabnormalmassveryquickly.

(shrink)DefinitionandEtiologyIna‘partialmole’,themass9Incidence1outof1500-2000pregnanciesintheU.S.andEurope1outof500-600(anotherreport1%)pregnanciesinsomeAsiancountries.Complete>incompleteIncidence1outof1500-2000p10Repeathydatidiformmolesoccurein0.5-2.6%ofpatients,andthesepatienshaveasubsequentgreaterriskofdevelopinginvasivemoleorchoriocarcinomaThereisanincreasedriskofmolarpregnancyforwomenovertheage40IncidenceRepeathydatidiformmolesoccu11Approximately10-17%ofhydatidiformmoleswillresultininvasivemoleApproximately2-3%ofhydatidiformmolesprogresstochoriocarcinoma(mostofthemarecurable)IncidenceNotdefinitelybenigndisease,hasatightrelationshipwithGTT

Approximately10-17%ofhydati12ClinicalriskfactorsformolarpregnancyAge(extremesofreproductiveyears)

<15

>40Reproductivehistory

priorhydatidiformmole

priorspontaneousabortionDiet

VitaminAdeficiencyBirthplace

OutsideNorthAmerica(occasionallyhasthisdisease)Clinicalriskfactorsformola13Cytogenetics

Completemolarpregnancy

Chromosomesarepaternal,diploid46,XXin90%cases46,XYinasmallpartPartialmolarpregnancy

Chromosomesarepaternalandmaternal,triploid.69,XXY80%69,XXXor69,XYY10-20%Wronglifemessage,socannotdevelopnormallyCytogeneticsCompletemolarpr14ComparativePathologicFeaturesofCompleteandPartialHydatidiformMoleFeatureCompleteMolePartialMoleKaryotypeUsuallydiploid46XXUsuallytriploidy69XXXmostcommon.VilliAllvillihydropin;nonormaladjacentvilliNormaladjacentvillimaybepresentvesselspresenttheycontainnofetalbloodcellsbloodcellsFetaltissueNonepresentUsuallypresentTrophoblastHyperplasiausuallypresenttovariabledegreesHyperplasiamildandfocalComparativePathologicFeature15CompletehydatidiformmoledemonstratingenlargedvilliofvarioussizeCompletehydatidiformmoledem16Hydatidiformmole:specimenfromsuctioncurettageHydatidiformmole:specimenfr17Alargeamountofvilliintheuterus.Alargeamountofvilliinthe18Themicroscopicappearanceofhydatidiformmole:HyperplasiaoftrophobasitccellsHydropicswellingofallvilliVesslesareusuallyabsentThemicroscopicappearanceof19Asonographicfindingsofamolarpregnancy.Thecharacteristic“snowstorm”patternisevident.Asonographicfindingsofamo20Transvaginalsonogramdemonstratingthe“snowstorm”appearance.Transvaginalsonogramdemonst21ColorDopplorfacilitatesvisualizationoftheenlargedspiralarteriescloseproximitytothe“snowstorm”appearanceColorDopplorfacilitatesvisu22ColorDopplerimageofahydatidiformmoleandsurroundingvessels.Theuterinearteryiseasilyidentifiedfromitsanatomicallocation.ColorDopplerimageofahydat2318gestational-trophoblas教学讲解课件24Dopplorwaveformanalysisdemonstrateslowvascularresistance(RI=0.29)inthespiralarteries,muchlowerthanthatobtainedinnormalearlypregnancyDopplorwaveformanalysisdemo2518gestational-trophoblas教学讲解课件26PartialhydartidiformmolePartialhydartidiformmole27Microscopicimageofpartialmolarpregnancy.Microscopicimageofpartialm28Hereisapartialmoleinacaseoftriploidy.Notethescatteredgrape-likemasseswithinterveningnormal-appearingplacentaltissue.Hereisapartialmolein29Largebilateralthecaluteincystsresemblingovariangermcelltumors.Withresolutionofthehumanchorionicgonadotropin(HCG)stimulation,theyreturntonormal-appearingovaries.Largebilateralthecalu30SignsandSymptomsofCompleteHydatidiformMoleVaginalbleedingHyperemesis(severevomit)Sizeinconsistentwithgestationalage(withnofetalheartbeatingandfetalmovement)PreeclampsiaThecaluteinovariancystsSignsandSymptomsofComplete31SignsandSymptomsofPartialHydatidiformMoleVaginalbleedingAbsenceoffetalhearttonesUterineenlargementandpreeclampsiaisreportedinonly3%ofpatients.Thecaluteincysts,hyperemesisisrare.SignsandSymptomsofPartial32DiagnosisofhydatidiformmoleQuantitativebeta-HCGUltrasoundisthecriterionstandardforidentifyingbothcompleteandpartialmolarpregnancies.Theclassicimageisofa“snowstorm”patternDiagnosisofhydatidiformmole33Themostcommonsymptomofamoleisvaginalbleedingduringthefirsttrimesterhoweververyoftennosignsofaproblemappearandthemolecanonlybediagnosedbyuseofultrasoundscanning.(ruttingcheck)Occasionally,auterusthatistoolargeforthestageofthepregnancycanbeanindication.NOTE:Vaginalbleedingdoesnotalwaysindicateaproblem!DiagnosisThemostcommonsymptomofam34DifferentialdiagnosisAbortionMultiplepregnancyPolyhydramniosDifferentialdiagnosisAbortio35TreatmentSuctiondilationandcurettage:toremovebenignhydatidiformmolesWhenthediagnosisofhydatidiformmoleisestablished,themolarpregnancyshouldbeevacuated.AnoxytocicagentshouldbeinfusedintravenouslyafterthestartofevacuationandcontinuedforseveralhourstoenhanceuterinecontractilityTreatmentSuctiondilationan36Removaloftheuterus(hysterectomy):usedrarelytotreathydatidiformmolesiffuturepregnancyisnolongerdesired.

TreatmentRemovaloftheuterus(hystere37Chemotherapywithasingle-agentdrug

Prophylactic(forprevention)chemotherapyatthetimeoforimmediatelyfollowingmolarevacuationmaybeconsideredforthehigh-riskpatients(topreventspreadofdisease)TreatmentChemotherapywithasingle-age38High-riskpostmolartrophoblastictumorPre-evacuationuterinesizelargerthanexpectedforgestationaldurationBilateralovarianenlargement(>9cmthecaluteincysts)Agegreaterthan40yearsVeryhighhCGlevels(>100,000mIU/ml)Medicalcomplicationsofmolarpregnancysuchastoxemia,hyperthyrodismandtrophoblasticembolization(villicomeoutofplacenta)repeathydatidiformmoleHigh-riskpostmolartrophoblas39Patientswithhudatidiformmolearecurativeover80%bytreatmentofevacuation.Thefollow-upafterevacuationiskeynecessaryuterineinvolution,ovariancystregressionandcessationofbleedingFollow-upPatientswithhudatidiformmol40QuantitativeserumhCGlevelsshouldbeobtainedevery1-2weeksuntilnegativeforthreeconsecutivedeterminations,Followedbyevery3monthsfor1years.Contraceptionshouldbepracticedduringthisfollow-upperiodFollow-upQuantitativeserumhCGlevels41InvasivemoleInvasivemole42DefinitionThistermisappliedtoamolarpregnancyinwhichmolarvilligrowintothemyometriumoritsbloodvessels,andmayextendintothebroadligamentandmetastasizetothelungs,thevaginaorthevulva.DefinitionThistermi43Invasivemole:thetissueinvadesintothemyometriallayer.Noobviousborderline,withobviousbleeding.Invasivemole:thetissue44InvasivehydatidiformmoleinfiltratingthemyometriumInvasivehydatidiformmoleinf45Acaseofinvasivemole:insidetheuterinecavitythetypical“snowstorm”appearancecanbedetected,Thelocationofbloodflowsuggestaninvasivemole.Acaseofinvasivemole:insid46Thesamepatientowingtothemyometrialinvasion.Reducedvascularresistanceisdetectedintheuterineartery.Thesamepatientowingtothe47TransvaginalcolorDopplerscanofapatientwithinvasivemoleFollowinguterinecurettage,PersistentcolorsignalswithinthemyometeriunTransvaginalcolorDopplersca48DopplerimageofinvasivemoleDopplerimageofinvasivemole49PowerDopplereasilydetectsavascularechogenicnodulewithinthemyometrium,suggestinginvasivemolePowerDopplereasilydetectsa50Dopplerimageofinvasivemole.Dopplerwaveformanalysisdepictslowvascularresistance(RI=0.35)Dopplerimageofinvasivemol51CommonSitesforMetastatic

GestationalTrophoblasticTumorsSitePercentLung60-95Vagina40-50Vulva/cervix10-15Brain5-15Liver5-15Kidney0-5Spleen0-5Gastrointestinal0-5CommonSitesforMetastatic

G52ChoriocarcinomaChoriocarcinoma53DefinitionAmalignantformofGTDwhichcandevelopfromahydatidiformmoleorfromplacentaltrophoblastcellsassociatedwithahealthyfetus,anabortionoranectopicpregnancy.DefinitionAmalignant54Characterizedbyabnormaltrophoblastichyperplasiaandanaplasia,absenceofchorionicvilliDefinitionCharacterizedbyabnormaltrop55GrossspecimenofchoriocarcinomaGrossspecimenofchoriocarcin56MicroscopicimageofchoriocarcinomaabsenceofchorionicvilliMicroscopicimageofchoriocar57MicroscopicimageofchoriocarcinomaMicroscopicimageofchoriocar58DopplerimageofchoriocarcinomaDopplerimageofchoriocarcino59DopplerimageofchoriocarcinomaDopplerimageofchoriocarcino60SymptomsandsignsBleedingInfectionAbdominalswellingVaginalmassLungsymptomsSymptomsfromothermetastasesSymptomsandsignsBleeding61WHOPrognosticScoringSystemScore

Prognosticfactor0124Age(years)≤39>39——PregnancyhistoryHydatidiformmoleAbortion,ectopicTermpregnancy—Interval(months)oftreatment<44-67-12>12InitialhCG(mIU/ml)<103103-104104-105>105Largesttumor(cm)<33-5>5—SitesofmetastasisLungSpleen,kidneyGItract,liverBrainNo.ofmetastasis—1-44-88Previous(treatment)——Singledrug2ormore0-4lowrisk,5-7intermediaterisk,>8highriskfordeathWHOPrognosticScoringSystemS62FIGOStagingSystemforGestationalTrophoblasticTumorsStageDescriptionⅠLimitedtouterinecorpusⅡExtendstotheadnexae,outsidetheuterus,butlimitedtothegenitalstructuresⅢExtendstothelungswithorwithoutgenitaltractⅣAllothermetastaticsitesFIGOStagingSystemforGestat63Substagesassignedforeachstageasfollows:A:NoriskfactorspresentB:OneriskfactorC:BothriskfactorsRiskfactorsusedtoassignsubstages:1.PretherapyserumhCG>100,000mlU/ml2.Durationofdisease>6monthsFIGOStagingSystemforGestationalTrophoblasticTumorsSubstagesassignedforeachst6418gestational-trophoblas教学讲解课件65IIbIIaIIbIIa66IIIa<3cmorlocateinhalflungIIIbdiseasebeyondIIIaIIIa<3cmorlocateinhalflu6718gestational-trophoblas教学讲解课件68DiagnosisandevaluationGestationaltrophoblastictumorisdiagnosedbyrisinghCGfollowingevacuationofamolarpregnancyoranypregnancyeventOncethediagnosisestablishedthefurtherexaminationsshouldbedonetodeterminetheextentofdisease(X-ray,CT,MRI)DiagnosisandevaluationGestat69TreatmentNonmetastaticGTDLow-RiskMetastaticGTDHigh-RiskMetastaticGTDTreatmentNonmetastaticGTD70TreatmentofNonmetastaticGTD

HysterectomyisadvisableasinitialtreatmentinpatientswithnonmetastaticGTDwhonolongerwishtopreservefertilityThischoicecanreducethenumberofcourseandshorterdurationofchemotherapy.Adjustedsingle-agentchemotherapyatthetimeofoperationisindicatedtoeradicateanyoccultmetastasesandreducetumordissemination.TreatmentofNonmetastaticGTD71Single-agentchemotherapyisthetreatmentofchoiceforpatientswishingtopreservetheirfertility.Methotrexate(MTX)andActinomycin-DaregenerallychemotherapyagentsTreatmentiscontinueduntilthreeconsecutivenormalhCGlevelshavebeenobtainedandtwocourseshavebeengivenafterthefirstnormalhCGlevel.TreatmentofNonmetastaticGTD

TopreventrelapseormetastasisSingle-agentchemotherapyist72Single-agentchemotherapywithMTXoractinomycin-DisthetreatmentforpatientsinthiscategoryIfresistancetosequentialsingle-agentchemotherapydevelops,combinationchemotherapywouldbetakenApproximately10-15%ofpatientstreatedwithsingle-agentchemotherapywillrequirecombinationchemotherapywithorwithoutsurgerytoachieveremissionTreatmentofLow-RiskMetastaticGTD

Single-agentchemotherapywith73Multiagentchemotherapywithorwithoutadjuvantradiotherapyorsurgeryshouldbetheinitialtreatmentforpatientswithhigh-ristmetastaticGTDEMA-COregimenformulaisgoodchoiceforhigh-ristmetastaticGTDAdjustedsurgeriessuchasremovingfociofchemotherapy-resistantdisease,controllinghemorrhagemaybetheoneoftreatment

regimenTreatmentofHigh-RiskMetastaticGTD

Multiagentchemotherapywitho74EMA-COChemotherapyforpoorPrognosticDiseaseEtoposide(VP-16)100mg/M2IVdaily×2days(over30-45minutes)Methotrexate100mg/M2IVlosdingdose,then200mg/M2over12hoursday1ActinomycinD0.5mgIVdaily×2daysFolinicacid15mgIMorp.o.q12hours×4starting24hoursafterstartingmethotrexateCyclophosphamide600mg/M2IVonday8Oncovin(vincristine)1mg/M2IVonday8(Repeatevery15daysastoxicitypermits)EMA-COChemotherapyforpoorP75PrognosisCureratesshouldapproach100%innonmetastaticandlow-riskmetastaticGTDIntensivemultimodalitytherapyhasresultedincureratesof80-90%inpatientswithhigh-riskmetastaticGTDPrognosisCureratesshouldapp76Follow-upAfterSuccessfulTreatmentQuantitativeserumhCGlevelsshouldbeobtainedmonthlyfor6months,everytwomonthsforremainderofthefirstyear,every3monthsduringthesecondyearContraceptionshouldbemaintainedforatleast1yearafterthecompletionofchemotherapy.Condomisthechoice.Follow-upAfterSuccessfulTre77PlacentaSiteTrophoblastic

Tumor(PSTT)PlacentaSiteTrophoblastic

T78PlacentaSiteTrophoblasticTumorisanextremelyraretumorthatarisedfromtheplacentalimplantationsiteTumorcellsinfiltratethemyometriumandgrowbetweensmooth-musclecellsDefinitionPlacentaSiteTrophoblasticTu7918gestational-trophoblas教学讲解课件80SurumhCGlevelsarerelativelylowcomparedtothoseseenwithchoriocarcinoma.Severalreportshavenotedabenignbehaviorofthisdisease.Theyarerelativelychemotherapy-resistant,anddeathsfrommetastasishaveoccurred.SurgeryhasbeenthemainstayoftreatmentDignosisandtreatmentSurumhCGlevelsarerelativel81GestationalTrophoblasticDisease(GTD)GestationalTrophoblasticDise8218gestational-trophoblas教学讲解课件83TypesofGTDBenignHydatidiformmole/molarpregnancy(completeorincomplete)malignantInvasivemoleChoriocarcinoma(chorioepithelioma)PlacentalsitetrophoblastictumorTypesofGTDBenign84ThetermGestationalTrophoblasticTumorshasbeenappliedthelatterthreeconditionsArisefromthetrophoblasticelementsRetaintheinvasivetendenciesofthenormalplacentaormetastasisKeepsecretionofthehumanchorionicgonadotropin(hCG)TypesofGTDThetermGestationalTrophobla85PATHOLOGICCLASSIFICATIONCLINICALCLASSIFICATIONHydatidiformmole*complete*incompleteBenigngestationaltrophoblasticdiseaseInvasivemoleMalignanttrophoblasticdiseaseNonmetastaticPlacentalsitetrophoblastictumorMetastaticChoriocarcinomaHighriskLowriskPathologicandclinicalclassificationsforgestationaltrophoblasticdiseasePATHOLOGICCLASSIFICATIONCLINI86HydatidiformMole

(molarpregnancy)HydatidiformMole

(molarpreg87DefinitionandEtiologyHydatidiformmoleisapregnancycharacterizedbyvesicularswellingofplacentalvilliandusuallytheabsenceofanintactfetus.

Theetiologyofhydatidiformmoleremainsunclear,butitappearstobeduetoabnormalgametogenesisandfertilizationDefinitionandEtiologyHydat88Ina‘completemole’themassoftissueiscompletelymadeupofabnormalcellsThereisnofetusandnothingcanbefoundatthetimeofthefirstscan.DefinitionandEtiologyIna‘completemole’themass89Ina‘partialmole’,themassmaycontainboththeseabnormalcellsandoftenafetusthathasseveredefects.Inthiscasethefetuswillbeconsumed(destroyed)bythegrowingabnormalmassveryquickly.

(shrink)DefinitionandEtiologyIna‘partialmole’,themass90Incidence1outof1500-2000pregnanciesintheU.S.andEurope1outof500-600(anotherreport1%)pregnanciesinsomeAsiancountries.Complete>incompleteIncidence1outof1500-2000p91Repeathydatidiformmolesoccurein0.5-2.6%ofpatients,andthesepatienshaveasubsequentgreaterriskofdevelopinginvasivemoleorchoriocarcinomaThereisanincreasedriskofmolarpregnancyforwomenovertheage40IncidenceRepeathydatidiformmolesoccu92Approximately10-17%ofhydatidiformmoleswillresultininvasivemoleApproximately2-3%ofhydatidiformmolesprogresstochoriocarcinoma(mostofthemarecurable)IncidenceNotdefinitelybenigndisease,hasatightrelationshipwithGTT

Approximately10-17%ofhydati93ClinicalriskfactorsformolarpregnancyAge(extremesofreproductiveyears)

<15

>40Reproductivehistory

priorhydatidiformmole

priorspontaneousabortionDiet

VitaminAdeficiencyBirthplace

OutsideNorthAmerica(occasionallyhasthisdisease)Clinicalriskfactorsformola94Cytogenetics

Completemolarpregnancy

Chromosomesarepaternal,diploid46,XXin90%cases46,XYinasmallpartPartialmolarpregnancy

Chromosomesarepaternalandmaternal,triploid.69,XXY80%69,XXXor69,XYY10-20%Wronglifemessage,socannotdevelopnormallyCytogeneticsCompletemolarpr95ComparativePathologicFeaturesofCompleteandPartialHydatidiformMoleFeatureCompleteMolePartialMoleKaryotypeUsuallydiploid46XXUsuallytriploidy69XXXmostcommon.VilliAllvillihydropin;nonormaladjacentvilliNormaladjacentvillimaybepresentvesselspresenttheycontainnofetalbloodcellsbloodcellsFetaltissueNonepresentUsuallypresentTrophoblastHyperplasiausuallypresenttovariabledegreesHyperplasiamildandfocalComparativePathologicFeature96CompletehydatidiformmoledemonstratingenlargedvilliofvarioussizeCompletehydatidiformmoledem97Hydatidiformmole:specimenfromsuctioncurettageHydatidiformmole:specimenfr98Alargeamountofvilliintheuterus.Alargeamountofvilliinthe99Themicroscopicappearanceofhydatidiformmole:HyperplasiaoftrophobasitccellsHydropicswellingofallvilliVesslesareusuallyabsentThemicroscopicappearanceof100Asonographicfindingsofamolarpregnancy.Thecharacteristic“snowstorm”patternisevident.Asonographicfindingsofamo101Transvaginalsonogramdemonstratingthe“snowstorm”appearance.Transvaginalsonogramdemonst102ColorDopplorfacilitatesvisualizationoftheenlargedspiralarteriescloseproximitytothe“snowstorm”appearanceColorDopplorfacilitatesvisu103ColorDopplerimageofahydatidiformmoleandsurroundingvessels.Theuterinearteryiseasilyidentifiedfromitsanatomicallocation.ColorDopplerimageofahydat10418gestational-trophoblas教学讲解课件105Dopplorwaveformanalysisdemonstrateslowvascularresistance(RI=0.29)inthespiralarteries,muchlowerthanthatobtainedinnormalearlypregnancyDopplorwaveformanalysisdemo10618gestational-trophoblas教学讲解课件107PartialhydartidiformmolePartialhydartidiformmole108Microscopicimageofpartialmolarpregnancy.Microscopicimageofpartialm109Hereisapartialmoleinacaseoftriploidy.Notethescatteredgrape-likemasseswithinterveningnormal-appearingplacentaltissue.Hereisapartialmolein110Largebilateralthecaluteincystsresemblingovariangermcelltumors.Withresolutionofthehumanchorionicgonadotropin(HCG)stimulation,theyreturntonormal-appearingovaries.Largebilateralthecalu111SignsandSymptomsofCompleteHydatidiformMoleVaginalbleedingHyperemesis(severevomit)Sizeinconsistentwithgestationalage(withnofetalheartbeatingandfetalmovement)PreeclampsiaThecaluteinovariancystsSignsandSymptomsofComplete112SignsandSymptomsofPartialHydatidiformMoleVaginalbleedingAbsenceoffetalhearttonesUterineenlargementandpreeclampsiaisreportedinonly3%ofpatients.Thecaluteincysts,hyperemesisisrare.SignsandSymptomsofPartial113DiagnosisofhydatidiformmoleQuantitativebeta-HCGUltrasoundisthecriterionstandardforidentifyingbothcompleteandpartialmolarpregnancies.Theclassicimageisofa“snowstorm”patternDiagnosisofhydatidiformmole114Themostcommonsymptomofamoleisvaginalbleedingduringthefirsttrimesterhoweververyoftennosignsofaproblemappearandthemolecanonlybediagnosedbyuseofultrasoundscanning.(ruttingcheck)Occasionally,auterusthatistoolargeforthestageofthepregnancycanbeanindication.NOTE:Vaginalbleedingdoesnotalwaysindicateaproblem!DiagnosisThemostcommonsymptomofam115DifferentialdiagnosisAbortionMultiplepregnancyPolyhydramniosDifferentialdiagnosisAbortio116TreatmentSuctiondilationandcurettage:toremovebenignhydatidiformmolesWhenthediagnosisofhydatidiformmoleisestablished,themolarpregnancyshouldbeevacuated.AnoxytocicagentshouldbeinfusedintravenouslyafterthestartofevacuationandcontinuedforseveralhourstoenhanceuterinecontractilityTreatmentSuctiondilationan117Removaloftheuterus(hysterectomy):usedrarelytotreathydatidiformmolesiffuturepregnancyisnolongerdesired.

TreatmentRemovaloftheuterus(hystere118Chemotherapywithasingle-agentdrug

Prophylactic(forprevention)chemotherapyatthetimeoforimmediatelyfollowingmolarevacuationmaybeconsideredforthehigh-riskpatients(topreventspreadofdisease)TreatmentChemotherapywithasingle-age119High-riskpostmolartrophoblastictumorPre-evacuationuterinesizelargerthanexpectedforgestationaldurationBilateralovarianenlargement(>9cmthecaluteincysts)Agegreaterthan40yearsVeryhighhCGlevels(>100,000mIU/ml)Medicalcomplicationsofmolarpregnancysuchastoxemia,hyperthyrodismandtrophoblasticembolization(villicomeoutofplacenta)repeathydatidiformmoleHigh-riskpostmolartrophoblas120Patientswithhudatidiformmolearecurativeover80%bytreatmentofevacuation.Thefollow-upafterevacuationiskeynecessaryuterineinvolution,ovariancystregressionandcessationofbleedingFollow-upPatientswithhudatidiformmol121QuantitativeserumhCGlevelsshouldbeobtainedevery1-2weeksuntilnegativeforthreeconsecutivedeterminations,Followedbyevery3monthsfor1years.Contraceptionshouldbepracticedduringthisfollow-upperiodFollow-upQuantitativeserumhCGlevels122InvasivemoleInvasivemole123DefinitionThistermisappliedtoamolarpregnancyinwhichmolarvilligrowintothemyometriumoritsbloodvessels,andmayextendintothebroadligamentandmetastasizetothelungs,thevaginaorthevulva.DefinitionThistermi124Invasivemole:thetissueinvadesintothemyometriallayer.Noobviousborderline,withobviousbleeding.Invasivemole:thetissue125InvasivehydatidiformmoleinfiltratingthemyometriumInvasivehydatidiformmoleinf126Acaseofinvasivemole:insidetheuterinecavitythetypical“snowstorm”appearancecanbedetected,Thelocationofbloodflowsuggestaninvasivemole.Acaseofinvasivemole:insid127Thesamepatientowingtothemyometrialinvasion.Reducedvascularresistanceisdetectedintheuterineartery.Thesamepatientowingtothe128TransvaginalcolorDopplerscanofapatientwithinvasivemoleFollowinguterinecurettage,PersistentcolorsignalswithinthemyometeriunTransvaginalcolorDopplersca129DopplerimageofinvasivemoleDopplerimageofinvasivemole130PowerDopplereasilydetectsavascularechogenicnodulewithinthemyometrium,suggestinginvasivemolePowerDopplereasilydetectsa131Dopplerimageofinvasivemole.Dopplerwaveformanalysisdepictslowvascularresistance(RI=0.35)Dopplerimageofinvasivemol132CommonSitesforMetastatic

GestationalTrophoblasticTumorsSitePercentLung60-95Vagina40-50Vulva/cervix10-15Brain5-15Liver5-15Kidney0-5Spleen0-5Gastrointestinal0-5CommonSitesforMetastatic

G133ChoriocarcinomaChoriocarcinoma134DefinitionAmalignantformofGTDwhichcandevelopfromahydatidiformmoleorfromplacentaltrophoblastcellsassociatedwithahealthyfetus,anabortionoranectopicpregnancy.DefinitionAmalignant135Characterizedbyabnormaltroph