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GESTATIONAL

CHORIOCARCINOMA

BY

DR. D.O. ALLAGOA


INTRODUCTION
INCIDENCE
RISK FACTORS
CLASSIFICATION
PATHOLOGY
STAGING
PROGNOSTIC FACTORS
INTRODUCTION

History of management of trophoblastic dx is


one of the success stories of modern medicine
Majority of women are potentially curable
Ist successful treatment of choriocarcinoma was
in 1956
Success is based on – early diagnosis, ability to
measure HCG and available chemotherapy
Incidence
More common in Orients than Europe or
America
Average incidence- West Africa (Nigeria)
1:30,000 pregnancies- West ( Europe and USA)
1:11,000 pregnancies in Orient communities
In our environment – combined GTD incidences
(Hospital based figures.)
-UPTH -1:707 deliveries (Annual report 2003)
-UCH -1:667 deliveries
-Ile Ife -1:558 deliveries
-Korle-bu -1:1000 deliveries (Ghana)
-LUTH - 1:184 deliveries
-Illorin - 1:344 deliveries
Risk factors
Racial –more commom in Orients, blacks , Caucasians
ABO group
Age: < 20 and >40yrs
Consanguinity
Previous molar pregnancy
Increased number of spontanous abortions
Multiparity
Artificial insemination
normal pregnancy
Diet – low protein, low fat and vitamin A deficiency
Familial cases have been also observed .
Antecedent pregnancies
-60% Hydatidiform mole
-30% previous abortions
-10% normal pregnancies, ectopic or artificial
insemination
CLASSIFICATION
 Subject of intense controversy
-Current staging classification and clinical practice guidelines of
gynecological cancers by FIGO committee on gynecological
oncology NOV 2003
 GTD-
Benign variety
-Hydatidiform mole-Complete/partial

Malignant variety
-Invasive moles ( chorioadenoma destruens)
-placenta site trophoblastic tumour
-Choriocarcinoma
-
 Non gestational trophoblastic dx
- Choriocarcinoma of ovary
-Choriocarcinoma of Testis
Pathology
 Generally tumors arise from the fetal tissues within the
maternal host and composed of syncytiotrophoblast
and cytotrophoblastic cells except PSTT.
-complete- 46xx(90%)/ 46xy(10%)
-partial -69xxy or 69xxx
 Invasive mole
-invades myometrium
- persistent placenta villous structure.
- Does not progress to choriocarcinoma
-regresses spontaneously
 Placenta site trophoblastic dx.
-composed mainly of cytotrophoblastic cells
-Low HCG and High HPL
-Tumor confined to uterus but metastasizes late in its
course
Gestational choriocarcinoma
Arising from trophoblastic epithelium
Malignant
Composed of cytotrophoblastic and syncytiotroblastic
elements
Some cytotrophoblastic choriocarcinoma carcinoma
secrete little HCG while syncytiotroblastic
choriocarcinoma secrete HPL.
Metastases –local sites such as cervix or vagina
- distance sites- lungs brain and liver
-Lymph node metastasis rare
- may suggest a non gestational origin(
Germ cells)
Gestational choriocarcinoma cont.

Trophoblastic metaplasia and HCG


production can be seen in other types of
carcinoma – lungs, bowel, stomach,
pancreas, bladder and kidney.
Excessive stimulation of ovaries with
theca lutein cyst formation and
amenorrhea
Staging
Staging system: international federation of gynaecology and obstetrics
(FIGO) 2002 revised staging.
- Stage 1- Dx confined to the uterus.
- stage II – Dx extending outside the uterus but
limited to the genital structures ( adnexae, vagina, broad
ligament).
-stage IIl - Dx extending to the lungs with or without known
genital tract involvement.
-stage IV - Dx at other metastatic sites.
Sub-staging:
A- No risk factor
B- One risk factor
C- Two risk factors
Risk factors
-HCG > 100,000miu /ml
-Duration of termination of antecedent pregnancy to diagnosis >
6months.
Prognostic scoring systems
 The Bagshaw/ WHO scoring system
 The American National institute of health
(N.I.H ) system

 The modified WHO scoring system


combined FIGO staging. Ratified in June
2002
0 1 2 4

Age <40 >40

Antecedent Hydatidiform abortion Term


pregnancy mole

Interval months <4 4-6 7-12 >12


from index
pregnancy

Pretreatment <103 103-104 104-105 >105


HCG

Largest tumour 3-4cm >5cm


size

Sites of Spleen Gastrointestinal Brain


metastases kidney tract Liver

Number of 1-4 5-8


metastases

Previous failed Single Two or more


chemotherapy drug drugs
-A score of 6 or less – low risk disease treatable by
single agent chemotherapy
-A score of 7 or greater – high risk disease that
requires combination chemotherapy
-Medium risk categorization no more in use

THE AMERICAN NATIONAL INSTITUTE OF


HEALTH (NIH)
Clinical criteria
- Non metastatic
- Metastatic (GTN)- disease outside the uterus
The American national institute of
health clinical criteria. Cont.
A. Good prognosis ( low risk )
-Disease present less than 4 months short
duration
-Pre treatment serum B HCG less than
40,000I.U or urinary excretion of <105
i.u/24 hrs
The American national Institute of health
clinical criteria. Cont.
A. Good prognosis ( low risk )
-Disease present less than 4 months short
duration
-Pre treatment serum B HCG less than
40,000I.U or urinary excretion of <105
i.u/24 hrs.
-No prior chemotherapy
B. Poor prognosis
- Disease of long duration (>4 months )
- Pretreatment serum B HCG > 40,000 i.u or urine B HCG excretion
of >105 i.u./L
-Presence of brain, liver or distant metastases
-Failure of prior chemotherapy
-Disease follows a full term pregnancy
SURVIVAL RATE
-Based on data from the new England
Trophoblastic disease center:
-The overall survival rate for stages I,II & III
is virtually 100%.
-Stage IV dx Survival rate - 70-73%
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