Gestational Trophoblastic Disease 5

Question 1

What are indications for treatment of postmolar trophoblastic neoplasia?

Answer 1

• Plateauing hCG levels x 4 values over 3 weeks
• Rising hCG levels > 10% x 3 values over 2 weeks
• Persistently elevated hCG levels 6 months after evacuation
• Histopathologic diagnosis of choriocarcinoma
• Detection of metastases

Question 2

What is involved in the treatment of low-risk GTN?

Answer 2

• Methotrexate given 0.4mg/kg (max 25mg)IV push qd x 5 days qo week is an effective regimen as first-line treatment of FIGO low-risk GTN, resulting in a complete response rate of 81% with limited toxicity
• Most patients resistant to initial chemotherapy will be placed into remission with additional single-agent chemotherapy, yielding an overall complete response rate of 94%•
• Presence of metastasis, clinicopathologic diagnosis of choriocarcinoma and increasing FIGO score are associated with resistance to initial single-agent therapy
• Multiagent chemotherapy was required for only 6% of patients who failed sequential single-agent therapy
• Patients with low-risk GTN, if treated appropriately, should have 100% survival rate

Question 3

What is the treatment for high-risk metastatic gestational trophoblastic neoplasia?

Answer 3

• Chemotherapy
  
  • MAC
  • CHAMOCA
  • EMA-CO
  • BEP, VIP, ICE, TP/TE
• Radiotherapy – brain
• Surgery
  
  • Adjuvant
  • Excision of foci of resistant disease
  • Treat infection or bleeding

Question 4

What is the treatment of metastatic gestational trophoblastic neoplasia?

Answer 4

• EMA-CO should be the treatment of choice for patients with high-risk GTN
• 30-40% of high-risk patients will fail first-line therapy or relapse from remission
• Most of these patients with have a clinicopathologic diagnosis of choriocarcinoma, a large tumor burden reflected by a high hCG level, multiple metastases to sites other than the lung and pelvis, and very high FIGO scores
• Salvage chemotherapy with platinum/etoposide-containing drug regimens + bleomycin, ifosfamide or paclitaxel, often combined with surgical resection of sites of persistent tumor (usually in the uterus or lungs), will result in cure rates approaching 90%