Rise of serum �-hCG levels> 10 percent during three weekly consecutive measurements or longer, during a period of 2 weeks or more-days '1, 7, 14 3.
4.
levels and consideration for diagnostic curettage if levels are elevated. Uterine size is assessed along with careful examination for lower genital tract metastases, which usually appear as bluish vascular masses (Cagayan, 2010). Tissue diagnosis is unnecessary, thus biopsy is not required and may cause significant bleeding.
Once the diagnosis is veriied, in addition to a baseline serum J-hCG level and hemogram, a search for local disease and metastases includes tests of liver and renal function, transvaginal sonography, chest CT scan or radiograph, and brain and abdominopelvic CT scan or MR imaging. Less commonly, positron-emission tomographic (PET) scanning and cerebrospinal luid J-hCG level determination are used to identiy metastases (Lurain, 2011).
GTN is staged clinically using the system of the International Federation of Gynecology and Obstetrics (FIGO) (2009). his includes a modiication of the World Health Organization (WHO) (1983) prognostic index score, with which scores of 0 to 4 are given for each of the categories shown in Table 20-4. Women with WHO scores of 0 to 6 are considered to have low-risk disease, whereas those with a score :::7 are considered in the high-risk group.
Again, it is stressed that the diagnosis of trophoblastic neoplasias is usually made by persistently elevated serum J-hCG levels without conirmation by tissue study. Clinical staging is assigned without regard to histological indings, even if available. Still, there are distinct histological types, described next.
These are the most common trophoblastic neoplasms that follow hydatidiform moles, and almost all invasive moles arise from partial or complete moles. Previously known as chorioadenoma destruens, invasive mole is characterized by extensive tissue invasion by trophoblast and whole villi. There is penetration deep into the myometrium, sometimes with involvement of the peritoneum, adjacent parametrium, or vaginal vault. Although locally aggressive, invasive moles are less prone to metastasize.
his is the most common type of trophoblastic neoplasm to follow a term pregnancy or a miscarriage, and only a third of
TABLE 20-4. International Federation of Gynecology and Obstetrics (FIGO) Staging and Diagnostic Scoring System for Gestational Trophoblastic Neoplasia
Age (years) <40 :::40 Antecedent pregnancy Mole Abortion Term <103 largest tumor size (including uterus) <3 cm 3-4 cm :::5 cm Site of metastases Spleen, kidney GI Liver, brain
Number of metastases
Previous failed chemotherapy drugs :::2 aAdapted by FIGO. blow risk = WHO score of 0 to 6; high risk = WHO score ofs:::7.
J-hCG = beta human chorionic gonadotropin; GI = gastrointestinal; GTN = gestational trophoblastic neoplasia.
Adapted with permission from FIGO Committee on Gynecologic Oncology: Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia, Int J Gynaecol Obstet 2009 Apr;l 05(1 )j3-4.
4-6 7-12 >12 103 to 104 104 to 105 :::105