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Gestational Trophoblastic Neoplasia

Diagnosis

1) Clinico-pathologic Considerations

Two groups of patients can be identified at diagnosis. Low risk patients can be cured by combination chemotherapy. (See chemotherapy protocols). Others must be treated with intensive, multi-agent chemotherapy.

High Risk Group

  • Antecedent term pregnancy    
  • Brain metastasis    
  • Liver metastasis    
  • Metastasized to more than one organ site    
  • Failed prior chemotherapy    
  • βHCG greater than 40,000 (post-evacuation)

Low Risk

  • All others

2) Diagnostic Pathology

  • History/physical, including pelvic examination    
  • Chest X-ray    
  • βHCG    
  • Liver function tests    
  • Lytes, creatinine    
  • CT brain in all, if post term pregnancy    
  • CT liver/or U/S in post molar pregnancy with positive chest X-ray

Management

​ Hydatidiform Mole

The treatment of choice is uterine evacuation followed by weekly HCG. Chest X-ray is mandatory (if positive, chemotherapy is needed see Section 10.5). No other imaging investigations needed unless directed by symptoms. 10%-20% of cases of hydatidiform mole will need treatment.

βHCG is performed weekly until normal for two weeks, then monthly to one year. Pregnancy should be avoided for one year from diagnosis, i.e., whilst on βHCG follow-up. The birth control pill is the recommended method of contraception.

Indications for Chemotherapy

Hydatidiform Mole
Mets to lung or other sites
Plateauing or rising βHCG

Post Non-Molar P​regnancy

Any women in their reproductive years with metastatic tumour and an elevated HCG.

Chemotherapy Protocols  

Role of Surgery

Second evacuation is seldom curative. Complication rate by perforation is up to 15%. Therefore, given the effectiveness and low toxicity, in comparison, of Methotrexate and Actinomycin, repeat evacuation is not recommended.

Emergencies:

  • CNS mets with hemorrhage - neurosurgery
  • Life threatening uterine bleeding - hysterectomy

Hysterectomy as Treatment

Patient in non metastatic group (rising HCG on follow-up, CXR normal) who does not wish chemotherapy.

Estrogen Replacement Therapy - Site Specific Information

Some gynecologic tumours are consiered to be hormone responsive (i.e., some low grade uterine sarcomas). Estrogen replacement in this group of patients should be for symptomatic control. A thorough discussion with the patient of the potential risks and anticipated benefits of such treatment should take place.

Recommendation: continuous estrogen plus progestogen.

Radiotherapy - General Information​ 

Follow-up

Patients should be reminded that it is their responsibility to keep their recommended follow-up appointments. The objectives of the follow-up visits are as follows: 

  1. To determine the patient's immediate response to the treatment employed    
  2. Early recognition and prompt management of treatment related complications    
  3. Early detection of persistent or recurrent disease    
  4. Collection of meaningful data regarding the efficacy of existing treatment policies and their complications so that any appropriate modifications can be instituted

These objectives are best met by having the initial follow-up examination performed by the Agency medical staff. When appropriate, arrangements will be made for follow-up by the referring physician.

Trophoblastic Neoplasia (Other Than Uncomplicated Hydatidirom Moles)​

  • βHCG q 1 week x one month    
  • q 2 weeks x two months    
  • q 1 month x nine months    
  • one year follow-up
SOURCE: Gestational Trophoblastic Neoplasia ( )
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