GTN<\/span>)<\/h4>\nIn a normal pregnancy the trophoblast (cells that help an embryo attach to the uterus and help form the placenta) invades into and through the lining of the womb. This is necessary to make the placenta and hold it in the womb. Sometimes the trophoblast of a molar pregnancy invades much more deeply into the womb than it should. Rarely it can spread outside.<\/p>\n
Choriocarcinoma<\/h4>\n
A cancerous, fast-growing tumour that develops from trophoblastic cells (cells that help an embryo attach to the uterus and help form the placenta). Almost all choriocarcinomas form in the uterus after fertilization of an egg by a sperm. Choriocarcinomas spread through the blood to other organs, especially the lungs.<\/p>\n
Placental Site Trophoblastic Tumours<\/h4>\n
A very rare type of gestational trophoblastic tumour that starts in the uterus where the placenta was attached.<\/p>\n
[\/et_pb_accordion_item][et_pb_accordion_item _builder_version=”3.0.91″ title=”Risk Factors” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off”]<\/p>\n
The following are risk factors for\u00a0GTD<\/span>:<\/p>\n\n- Extremes of maternal age: The most well established risk factor for\u00a0GTD<\/span>\u00a0is maternal age. Compared to the risk of\u00a0GTD<\/span>\u00a0in the general population of reproductive-age women, the risk is higher in those older than age 35 and slightly increased in those under age 20. Paternal age does not appear to influence the risk of\u00a0GTD<\/span>.<\/li>\n
- History of previous\u00a0GTD<\/span>: Women with a history of one molar pregnancy (partial, complete, or persistent\u00a0GTD<\/span>) have an approximately 1% percent chance of recurrence in subsequent pregnancies (compared to a 0.1% incidence in the general population). The chance of developing\u00a0GTD<\/span>\u00a0is much higher after two molar pregnancies (16 to 28%).<\/li>\n
- Smoking cigarettes.<\/li>\n
- Maternal blood type AB, A, or B.<\/li>\n
- History of infertility.<\/li>\n
- Nulliparity.<\/li>\n
- Use of oral contraceptives (the pill).<\/li>\n<\/ul>\n
Some of the above risk factors have not been demonstrated consistently though.<\/p>\n
[\/et_pb_accordion_item][et_pb_accordion_item _builder_version=”3.0.91″ title=”Diagnosis and Staging” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off”]<\/p>\n
It\u2019s important to let your general practitioner and\/or obstetrician know about any abnormal symptoms you are having during pregnancy. Your doctor may suspect that\u00a0GTD<\/span>\u00a0is present based on a typical pattern of signs and symptoms. Many of these may also be caused by conditions other than\u00a0GTD<\/span>. Still, if you have any of these, it\u2019s important to see your doctor as soon as possible so the problem can be found and treated, if needed.<\/p>\nStaging<\/h3>\n
This is the process of finding out how far a cancer has spread. This information helps me to choose the type of treatment that offers the best possible results.<\/p>\n
Molar pregnancies (complete and partial moles) are usually completely removed during a D&C (Dilatation & curettage), or, rarely, hysterectomy. They don\u2019t need to be surgically \u201cstaged\u201d. Staging is more useful for persistent\u00a0GTD<\/span>s, including invasive moles and choriocarcinomas.<\/p>\nGestational Trophoblastic Disease (GTD<\/span>) Classification<\/h3>\nThe stage of most cancers depends on how large they are and whether they have spread to lymph nodes or distant sites. This is part of staging for\u00a0GTD<\/span>\u00a0as well. But because treatment is usually effective regardless of the extent of the disease, other factors such as a woman\u2019s age, length of time from the pregnancy, and\u00a0HCG<\/span>\u00a0level are more useful in predicting outcomes (prognosis). These factors are taken into account in a scoring system, which will help to guide your treatment.<\/p>\nFIGO<\/span>\u00a0Staging<\/h3>\nThe International Federation of Gynaecology and Obstetrics (FIGO<\/span>) has developed a staging system based on the extent of the\u00a0GTD<\/span>\u00a0as follows:<\/p>\nStage I:<\/strong>\u00a0The tumour is still within the uterus.<\/p>\nStage II:<\/strong>\u00a0The tumour has grown outside of the uterus to involve other genital structures (like the vagina or ovaries). It has not spread outside the pelvis.<\/p>\nStage\u00a0III<\/span>:<\/strong>\u00a0The tumour has spread to the lungs; it may or may not also involve genital structures such as the vagina or vulva.<\/p>\nStage IV:<\/strong>\u00a0The tumour has spread to distant organs such as the brain, liver, kidneys, and\/or gastrointestinal tract.<\/p>\n[\/et_pb_accordion_item][et_pb_accordion_item _builder_version=”3.0.91″ title=”Signs and Symptoms” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off”]<\/p>\n
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Complete Hydatidiform Moles (Molar Pregnancies)<\/h3>\n
Most of these signs and symptoms (except for bleeding), are seen less commonly now than in the past because they tend to occur late in the course of the disease. Most women with\u00a0GTD<\/span>\u00a0are now diagnosed early because of the use of blood tests and ultrasound early in pregnancy.<\/p>\nVaginal Bleeding<\/h4>\n
Almost all women with complete hydatidiform moles have irregular vaginal bleeding during pregnancy. It occurs a little less often with partial moles. Bleeding typically starts during the first trimester (13 weeks) of pregnancy. Women with\u00a0GTD<\/span>\u00a0often pass blood clots or watery brown discharge from the vagina. Sometimes, pieces of the mole resembling a cluster of grapes become dislodged from the uterus and are discharged through the vagina. This bleeding often leads the doctor to order an ultrasound (imaging test), which leads to the diagnosis of a molar pregnancy.<\/p>\nAnaemia<\/h4>\n
In cases of serious or prolonged bleeding, a woman\u2019s body is not able to replace red blood cells as fast as they are lost. This can lead to anaemia (low red blood cell counts). Symptoms can include fatigue and shortness of breath, especially with physical activity.<\/p>\n
Abdominal Swelling<\/h4>\n
The uterus and abdomen can get bigger faster in a complete molar pregnancy than they do in a normal pregnancy. Abnormal uterine enlargement occurs in about 1 out 4 women with complete moles but rarely in women with partial moles.<\/p>\n
Ovarian Cysts<\/h4>\n
Human chorionic gonadotropin (HCG<\/span>), a hormone made by the tumour, may cause fluid-filled cysts to form in the ovaries. These cysts can be large enough to cause abdominal swelling. They only occur with very high levels of\u00a0HCG<\/span>. Even though they can become quite large, they usually go away on their own about 8 weeks after the molar pregnancy is removed. Sometimes they can twist on their blood supply (called torsion). This can cause severe pain and needs to be treated with surgery (to remove the cyst) or a procedure to drain the fluid inside the cyst.<\/p>\nVomiting<\/h4>\n
Many women have nausea and vomiting during the course of a typical pregnancy. With\u00a0GTD<\/span>, however, the vomiting may be more frequent and severe than normal.<\/p>\nPre-Eclampsia<\/h4>\n
Pre-eclampsia (toxaemia of pregnancy) can occur as a complication of a normal pregnancy (usually in the third trimester). When it occurs earlier in pregnancy (like during the first or early second trimester), it can be a sign of a complete molar pregnancy. Pre-eclampsia may cause problems such as high blood pressure, headache, exaggerated reflexes, swelling in the hands or feet, and too much protein leaking into the urine. It affects a small number of women with complete moles but is rare in women with partial moles.<\/p>\n
Hyperthyroidism<\/h4>\n
Hyperthyroidism (overactive thyroid gland) occurs in some women with complete hydatidiform moles. It occurs only in women with very high\u00a0HCG<\/span>blood levels. Symptoms of hyperthyroidism can include rapid heartbeat, warm skin, sweating, problems tolerating heat, and mild tremors (shaking). This occurs in less than 10% of women with complete molar pregnancy.<\/p>\nPartial hydatiform moles<\/h3>\n
The signs and symptoms of partial hydatidiform moles are similar to those of complete moles, but often are less severe. Some symptoms, such as frequent vomiting or an overactive thyroid gland, rarely, if ever, occur with partial moles.<\/p>\n
Partial moles are often diagnosed after what is thought to be a miscarriage. The molar pregnancy is found when the uterus is scraped during a suction dilation and curettage (D&C) and the products of conception are looked at under a microscope.<\/p>\n
Invasive moles and choriocarcinoma<\/h3>\n
These more invasive forms of\u00a0GTD<\/span>\u00a0sometimes develop after a complete mole has been removed. They occur less commonly after a partial mole. Choriocarcinoma can also develop after a normal pregnancy, ectopic pregnancy (where the foetus grows outside of the uterus, such as inside a fallopian tube), or miscarriage. Symptoms can include:<\/p>\nBleeding<\/h4>\n
The most common symptom is vaginal bleeding. Rarely, the tumour grows through the uterine wall, which can cause bleeding into the abdominal cavity along with severe abdominal pain.<\/p>\n
Infection<\/h4>\n
In larger tumours, some of the tumour cells may die, creating an area where bacteria can grow. Infection may develop, which can cause vaginal discharge, crampy pelvic pain, and fever.<\/p>\n
Abdominal Swelling<\/h4>\n
Like hydatidiform moles, more invasive forms of\u00a0GTD<\/span>\u00a0can expand the uterus, causing abdominal swelling. Human chorionic gonadotropin (HCG<\/span>), a hormone made by the tumour, may cause fluid-filled cysts (called theca lutein cysts) to form in the ovaries, which can be large and may also contribute to abdominal swelling.<\/p>\nLung Symptoms<\/h4>\n
The lung is a common site for distant spread of\u00a0GTD<\/span>. Spread to the lungs may cause coughing up of blood, a dry cough, chest pain, or trouble breathing.<\/p>\nVaginal Mass<\/h4>\n
These tumours can sometimes spread to the vagina, which can cause vaginal bleeding or a pus-like discharge. The doctor may also notice a cancerous growth on the vagina during a pelvic exam.<\/p>\n
Other Symptoms of Distant Spread<\/h4>\n
Symptoms depend on where the spread occurs. If\u00a0GTD<\/span>\u00a0has spread to the brain, symptoms can include headache, vomiting, dizziness, seizures, or paralysis on one side of the body. Spread to the liver can cause abdominal pain and a yellowing of the skin or eyes (jaundice).<\/p>\nPlacental Site Trophoblastic Tumours (PSTT<\/span>s)<\/h3>\nPSTT<\/span>s rarely spread to distant sites. More often, they grow into the wall of the uterus.<\/p>\nBleeding<\/h4>\n
As with other forms of\u00a0GTD<\/span>, the most common symptom of\u00a0PSTT<\/span>\u00a0is vaginal bleeding. If the tumour grows all the way through the wall of the uterus, it can cause bleeding into the abdominal cavity with severe abdominal pain.<\/p>\nAbdominal Swelling<\/h4>\n
As they grow within the wall of the uterus,\u00a0PSTT<\/span>s may cause the uterus to enlarge.<\/p>\nLaboratory tests: blood and urine tests<\/h3>\nHuman Chorionic Gonadotropin (HCG<\/span>)<\/h4>\nTrophoblastic cells of both normal placentas and\u00a0GTD<\/span>\u00a0make a hormone called\u00a0HCG<\/span>, which is vital in supporting a pregnancy.\u00a0HCG<\/span>\u00a0is released into the blood, and some of it is excreted in the urine. The sub-unit commonly measured in the blood and urine tests is called beta-HCG<\/span>\u00a0(\u03b2HCG). A complete mole usually releases more\u00a0HCG<\/span>\u00a0than a normal placenta, so finding higher than expected\u00a0HCG<\/span>\u00a0levels in the blood can be a sign that a complete mole is present.<\/p>\nImaging tests<\/h3>\nUltrasound Scan<\/h4>\n
Ultrasound can identify most cases of\u00a0GTD<\/span>\u00a0that are in the uterus, and will likely be the first test you will have if there a suspicion of\u00a0GTD<\/span>. It is a test used to examine the vagina, uterus, fallopian tubes, and bladder. Most ultrasounds are done with the transducer placed on the skin after is first lubricated with gel. For better views an ultrasound transducer (probe) is inserted into the vagina and used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues.<\/p>\nChest X-Ray<\/h4>\n
A chest x-ray may be done in cases of persistent\u00a0GTD<\/span>\u00a0to see if there is any spread to the lungs, which is very unlikely unless the disease is far advanced. I have been using more frequently CT scan of the chest due its higher detection rate of disease.<\/p>\nCT Scan<\/h4>\n
An x-ray machine linked to a computer takes a series of detailed pictures of your organs. A tumour in the liver, lungs, or elsewhere in the body can show up on the CT scan. You may receive contrast material by injection in your arm or hand, by mouth, or by enema. The contrast material makes abnormal areas easier to see.<\/p>\n
MRI<\/span><\/h4>\nA powerful magnet linked to a computer is used to make detailed pictures of your pelvis and abdomen. I can view these pictures on a monitor and can print them on film. An\u00a0MRI<\/span>\u00a0gives excellent details of nearby cancer spread. Sometimes contrast material makes abnormal areas show up more clearly on the picture.<\/p>\nPET<\/span>\u00a0(Positron Emission Tomography) Scan<\/h4>\nYou receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in your body. Cancer cells use sugar faster than normal cells, and areas with cancer look brighter on the pictures. Still,\u00a0PET<\/span>\u00a0scan is rarely used for\u00a0GTD<\/span>.<\/p>\nSome machines are able to perform both a\u00a0PET<\/span>\u00a0and CT scan at the same time (PET<\/span>\u00a0CT scan). This allows the radiologist to compare areas of higher radioactivity on the\u00a0PET<\/span>\u00a0with the appearance of that area on the CT.<\/p>\n<\/div>\n[\/et_pb_accordion_item][et_pb_accordion_item _builder_version=”3.0.91″ title=”Treatment” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off”]<\/p>\n
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After\u00a0GTD<\/span>\u00a0is diagnosed and staged I will discuss treatment options in a multidisciplinary meeting and a recommendation of one or more treatments will be made. No matter what type or stage of\u00a0GTD<\/span>\u00a0a woman has, treatment is available. Your treatment choice depends on many factors. The location and the extent of the disease are very important. Other important factors include the type of\u00a0GTD<\/span>\u00a0present, the level of human chorionic gonadotropin (HCG<\/span>), duration of the disease, sites of spread if any, and the extent of prior treatment. In selecting a treatment plan, I will also consider your age, general state of health, and personal preferences.<\/p>\nIt is important to begin treatment as soon as possible after\u00a0GTD<\/span>\u00a0has been detected. The main methods of treatment are surgery, chemotherapy, and less frequently radiation therapy. Sometimes the best approach uses a combination of 2 or more of these methods.<\/p>\n<\/div>\n[\/et_pb_accordion_item][et_pb_accordion_item _builder_version=”3.0.91″ title=” Follow Up” use_background_color_gradient=”off” background_color_gradient_start=”#2b87da” background_color_gradient_end=”#29c4a9″ background_color_gradient_type=”linear” background_color_gradient_direction=”180deg” background_color_gradient_direction_radial=”center” background_color_gradient_start_position=”0%” background_color_gradient_end_position=”100%” background_color_gradient_overlays_image=”off” parallax=”off” parallax_method=”on” background_size=”cover” background_position=”center” background_repeat=”no-repeat” background_blend=”normal” allow_player_pause=”off”]<\/p>\n\n\n
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Completing treatment can be both stressful and exciting. You may be relieved to finish treatment, but find it hard not to worry about cancer coming back (this is named recurrence). This is a common concern in people who have had cancer. It is a very real concern for some women with\u00a0GTD<\/span>. The risk of\u00a0GTD<\/span>\u00a0returning is very small for molar pregnancies and low-risk\u00a0GTD<\/span>, but may be as high as 10% to 15% in women with high-risk\u00a0GTD<\/span>. For this reason, follow-up is very important.<\/p>\nThe exact steps in the follow-up program depend on the type of\u00a0GTD<\/span>\u00a0you had and the treatment you received.<\/p>\nIn all cases, the most basic test involves measuring levels of\u00a0HCG<\/span>\u00a0in the blood. Rising\u00a0HCG<\/span>\u00a0levels may indicate that the disease is growing again in the uterus (if hysterectomy was not done) or that it has spread to another location and is growing there.<\/p>\nDepending on your situation, you may need to have certain tests or procedures such as chest x-rays or other imaging tests, from time to time.<\/p>\n
If cancer does recur, it will most likely be detected with blood\u00a0HCG<\/span>\u00a0tests before it causes any symptoms. If\u00a0GTD<\/span>\u00a0does come back, in most cases it can be treated successfully.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n