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GY48 Gynecology
Gynecological Oncology Toronto Notes 2019
With development of hypertension early in pregnancy (i.e. <20 wk), think gestational trophoblastic disease
Treatment
• StageI
■ radiation therapy: for tumours >2 cm diameter or tumour involvement of the mid to lower vagina ■ surgical excision: radical hysterectomy, upper vaginectomy, and bilateral pelvic lymphadenectomy
• StageII-IV:chemoradiation
Fallopian Tube
• leastcommonsiteforcarcinomaoffemalereproductivesystem(0.3%)
• usuallyserousepithelialcarcinoma
• newevidenceshowsthatsomeserousovariancancersoriginateinthefallopiantube • morecommoninfifthandsixthdecade
Clinical Features
• classictriadpresentinminorityofcases,butveryspecific
■ watery discharge (most specific) = “hydrops tubae profluens”
■ vaginal bleeding or discharge in 50% of patients
■ crampy lower abdominal/pelvic pain
■ most patients present with a pelvic mass (see Ovarian Tumours, GY40 for guidelines regarding
diagnosis/investigation)
Treatment
• asformalignantepithelialovariantumours
Gestational Trophoblastic Disease/Neoplasia
• referstoaspectrumofproliferativeabnormalitiesofthetrophoblast
Epidemiology
• 1/1,000pregnancies
• markedgeographicvariation–ashighas1/125inTaiwan • 80%benign,15%locallyinvasive,5%metastatic
• curerate>95%
HYDATIDIFORM MOLE (Benign GTD)
Complete Mole
• mostcommontypeofhydatidiformmole
• diffusetrophoblastichyperplasia,hydropicswellingofchorionicvilli,nofetaltissues,ormembranes
present
• 46XXor46XY,chromosomescompletelyofpaternalorigin(90%)
• 2spermfertilizeemptyeggor1spermwithreduplication
• 15-20%riskofprogressiontomalignantsequelae
• riskfactors
■ geographic (South East Asia most common)
■ others (maternal age >40 yr, β-carotene deficiency, vitamin A deficiency) – not proven
• clinicalfeatures
• oftenpresentduringapparentpregnancywithabnormalsymptoms/findings
■ vaginal bleeding (97%)
■ excessive uterine size for LMP (51%) ■ theca-lutein cysts >6 cm (50%)
■ preeclampsia (27%)
Partial (or Incomplete) Mole
■ hyperemesis gravidarum (26%) ■ hyperthyroidism (7%)
■ β-hCG >100,000 IU/L
■ no fetal heart beat detected
• focaltrophoblastichyperplasiaandhydropicvilliareassociatedwithfetusorfetalparts • oftentriploid(XXY,XYY,XXX)withchromosomecomplementfrombothparents
■ usually related to single ovum fertilized by two sperm
• lowriskofprogressiontomalignantsequelae(<4%)
• associatedwithfetus,whichmaybegrowth-restricted,and/orhavemultiplecongenitalmalformations • clinicalfeatures
■ typically present similar to threatened/spontaneous/missed abortion ■ pathological diagnosis often made after D&C
Investigations
• quantitativeβ-hCGlevels(tumourmarker)abnormallyhighforgestationalage • U/Sfindings
■ if complete: no fetus (classic “snow storm” due to swelling of villi)
■ if partial: molar degeneration of placenta ± fetal anomalies, multiple echogenic regions
corresponding to hydropic villi, and focal intrauterine hemorrhage • CXR(mayshowmetastaticlesions)