GTN Flashcards

1
Q

GOG 174

A

-ActD RR 70% vs weekly MTX 53%; criticized due to use of MTX regimen with lowest efficacy and dose 30 mg/m2

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2
Q

Path diagnosis of partial vs. complete mole?

A

Flow to see if diploid or triploid, difference between partial and complete mole. P57 IHC, paternally imprinted, maternally expressed, will see staining in both but complete moles have extravillous staining while partial moles have villous staining.

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3
Q

How do you stage?

A

FIGO vs. WHO score, physical exam, imaging. GTN per GyoEdu lecture actually says for GTN then CXR and CT AP. Small chest mets don’t really change survival so don’t need CT chest if CXR negative. If they do have lung mets then need brain imaging, or if nonmolar GTN. Do not biopsy a vaginal lesion, shit will bleed.

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4
Q

WHO score, what’s it purpose and how done?

A

Prognosis and chemosensitivity. Scoring factors are age, antecedent pregnancy, interval, serum HCG right before chemo, largest tumor size, met sites, met numbers, previous failed chemo (if given something prophylactically, as well). Add up. If patient recurs or fails therapy, new WHO score.

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5
Q

Is a second evacuation an option rather than chemo for postmolar GTN?

A

GOG 242, 60 women. If postmolar (no chorio), not mets, low risk, then yes. 100% alive today, 40% cured with surgery. So these ladies have a 50/50 shot. 3 patients had a pathologic changes, PSTT and chorio. Very few complication.

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6
Q

First line for low-risk GTN?

A

< 7 score for WHO. Lots of ways to do MTX. Weekly MTX is least effective. 8 day is a pain in the butt, have to treat over the weekends. 0.4 mg/kg 5 days IV. Some use Act-D for scores 4-6 because possibly higher cure rates but this is not standard.

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7
Q

Prophylactic chemo after evacuation, should you do?

A

An option for high risk patients, however may increase drug resistance and toxicity, generally not recommended unless your particularly concerned about F/U.

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8
Q

Why do we use OCPs during GTN treatment?

A

There were concerns about OCPs in GTN, worked much better than condoms. Came from GOG 55.

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9
Q

First line for high-risk GTN, AEs, prognosis?

A

Inpatient EMA day 1-2, outpatient CO day 8. Some anemia, some neutropenia, not much thrombocytopenia. Usually don’t start G-CSF but may need. 100% alopecia. Nausea, vomiting, stomatitis but g1, not huge. For what gets lots of points then changes prognosis, liver is a big one, 30% survival 5 years.

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10
Q

What about high-risk GTN score greater than 12?

A

Very high risk. 4% early death due to respiratory complications after their first cycle, florid immune response, hemorrhage and die from respiratory failure. Induction EP, baby. This allows for more gradual reduction in tumor burden and no difference in EMA-CO resistance, very low rates of early death. Repeat weekly 1-2 cycles before EMACO, 100 mg/m2 E and P is 20 mg/m2 both day 1 and 2.

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11
Q

But doctor, what’s my risk of having another mole?

A

After complete mole, risk of 2nd is 1/100, 3rd mole is 1/4. Recurrence after partial only slightly increased. There are familial repetitive hydatiform mole is from missense mutation in NLRP7.

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12
Q

How often getting HCG for posttreatment surveillance after GTN chemo?

A

Treat 1-2 past normal for low-risk, 2-3 past normal for high-risk. Monthly betas x 12 months. Needs effective contraception. 90% of recurrences within 18 months.

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13
Q

What is the role of surgery in GTN?

A

2017 Gyn-Onc paper has nice algorithm, hysterectomies done as primary treatment, for chemoresistant disease, or life threatening hemorrhage. Looking at nonmetastatic…as primary treatment, it’s like 50% effective. Even for chemoresistant disease, for single-agent it was 95% effective and for multi-agent it was 60% effective. For metastatic…not as effective obviously but can be considered, most people will need further treatment.

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14
Q

What are some weird HCG possibilities?

A

Monitor as many forms of HCG as you can. GTN can make many different subunits of bHCG. Hyperglycosylated HCG associated with quiescent GTN. Normal is < 0.8, maybe it hovers 1-2-5, or generally less than 200. Nothing on exam or scan. Normal HCG-H <1% is diagnostic. Also consider pituitary HCG, especially in older patients. For perimenopause the anterior pituitary secretes a big of HCG, often find these before surgery and randomly is positive. If FSH > 20 and HCG 5-100, give them OCPs to suppress, then recheck and should decrease. Also the Hook effect…can get low values of HCG due to excessive serum HCG…all the antibody sites are consumed. Usually happens with HCG > 500k, may have one result come back normal then the next is super low, then back to high again while on treatment.

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15
Q

Chance of secondary malignancies with etoposide?

A

AML related to cumulative dose of etoposide, more than 2 grams/m2. AML for this typically 2-3 years after and has some specific karyotype stuff.

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16
Q

What are some salvage therapies for high-risk GTN?

A

EMA/EP, MAC, TP/TE, BEP, VIP, we don’t know the best. Most people use EMA/EP.

17
Q

Is there a role for immunotherapy?

A

PDL-1 expression is 80-100% in invasive moles and choriocarcinomas. Dose is Pembro 3 mg/kg D1. 2017 four patients with poor response to multiple regimens. Two cured, one progressed.

18
Q

What data is there for pulsed act-D and it’s cost-effectiveness?

A

GOG 069 was main first study, 94% CR for nonmetastatic GTN, low grade toxicities, less missed work for patients, much less costly.

19
Q

What trial looked at Act-D for MTX failure?

A

GOG 176, low risk GTN w/ MTX failure got pulse Act-D, about 75% effective, 2 kept on Act-D despite meeting failure criteria and 8 needed salvage.