Optimal management of low-risk gestational trophoblastic neoplasia

Abstract

Low-risk gestational trophoblastic neoplasia is a highly curable form of gestational trophoblastic neoplasia that arises largely from molar pregnancy and, on rare occasions, from other types of gestations. Risk is defined as the risk of developing drug resistance as determined by the WHO Prognostic Scoring System. All patients with non-metastatic disease and patients with risk scores <7 are considered to have low-risk disease. The sequential use of methotrexate and actinomycin D is associated with a complete remission rate of 80%. The most commonly utilized regimen for the treatment of patients resistant to single-agent chemotherapy is a multiagent regimen consisting of etoposide, methotrexate, actinomycin D, vincristine and cyclophosphamide. The measurement of human chorionic gonadotropin provides an accurate and reliable tumor marker for diagnosis, monitoring the effects of chemotherapy and follow-up to determine recurrence. Pregnancy is allowed after 12 months of normal serum tumor marker. Pregnancy outcomes are similar to those of normal population.

Keywords:

• actinomycin D
• EMACO
• gestational trophoblastic disease
• gestational trophoblastic neoplasia
• methotrexate
• molar pregnancy
• non-metastatic disease
• sequential chemotherapy
• subsequent pregnancy

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Gestational trophoblastic disease is a term that encompasses a wide range of conditions arising from abnormal development of placental tissue including the premalignant complete and partial hydatidiform moles and malignant invasive hydatidiform mole and choriocarcinoma. The malignant forms are collectively known as gestational trophoblastic neoplasia (GTN).

• The quantitative measurement of human chorionic gonadotropin can be used reliably as a serum marker for diagnosis, monitoring the efficacy of treatment and follow-up to determine recurrence.

• Histological confirmation of metastatic disease is not required and biopsy, in some instances, can be dangerous.

• The sequential use of monotherapy with either methotrexate (MTX) or actinomycin D (actD) is considered the standard treatment for low-risk GTN (score <7).

• For women who become resistant to first-line sequential single-agent drug therapy with MTX and actD, multiagent salvage chemotherapy with etoposide, MTX, actD, vincristine and cyclophosphamide is required.

• After achieving gonadotropin remission, consolidation therapy with the last effective agent should be administered to reduce the risk of recurrence.

• Patients are advised to postpone subsequent pregnancy until they have completed 12 months of negative serum marker.

• Subsequent pregnancy outcomes in patients treated for low-risk GTN are similar to outcomes in the normal population.

• Patients treated for GTN may experience psychological disturbances and need assessments and interventions both during treatment and after remission is attained.

Notes

hCG: Human chorionic gonadotropin.