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GESTATIONAL
TROPHOBLASTIC
NEOPLASIA
PRE TREATMENT EVALUATION
History and clinical examination
Serum hCG
Lab evaluation ? RFT, LFT, WBC count, DLC, Platelet count, clotting profile
USG pelvis- excludes pregnancy
Chest X-Ray/CT scan
CT Abdomen and Pelvis
CT/MRI Head ? Brain metastases
Thyroid function test
LOW RISK GTN
METHOTREXATE
? Most common treatment ? single agent Mtx
? Recommended 8 day regimen ? Mtx alternating with Folinic acid
? Mtx 50mg/kg bodyweight I.M - on day 1,3,5,7 and oral folinic acid 7.5 ?15 mg
oral y on days 2,4,6,8
? Treatment repeated every 2 weeks.
Folinic Acid Rescue
Mtx ? Folinic acid antagonist ? inhibit
DNA synthesis
Side effects of Mtx-
o Mild stomatitis
o Pleurisy
o Infrequently pericarditis,peritonitis,pneumonitis
Hence folinic acid- Mtx ALTERNATE regimen :Protect normal mucosal and
serosal cel s.
Before each Mtx course ? CBC, RFT, LFT mandatory.
Courses repeated every 14 days.
Remission ? 3 normal consecutive weekly titers ----- hence weekly serum hCG, done till
normal 3 weeks
One more course ? after normalization of hCG
Pregnancy avoided for atleast one year after cessation of chemotherapy.
Drug Resistance
19 ? 33 % women develop Mtx resistance.
Detection ? increasing or plateauing levels of serum hCG
Second line drug ? Actinomycin D [ Dactinomycin]
Etoposide may also be effective
If still no response ? high risk protocol
DACTINOMYCIN
Superior efficacy as a single agent.
Pulse I.V Dactinomycin 1.25-2 mg /sq.m repeated every
14 days.
Side effects : alopecia, grade 4 toxicity.
Mtx resistant GTN often responds to dactinomycin.
HIGH RISK GTN
q More likely to develop drug resistance to single agent ? hence combination
chemotherapy.
q Highly effective regimen ? ETOPOSIDE + MTX+ DACTINOMYCIN alternating with
CYCLOPHOSPHAMIDE + VINCRISTINE [ONCOVIN] --- EMA-CO REGIMEN
q Cycle repeated every 2 weeks until serum hCG normal ? then 3 more cycles given
q Overal survival ? 86%
1 Quarter patients become refractory to or relapse.
Secondary treatment ?
Platinum based chemotherapy + possible surgical excision of resistance site
? EMA/EP regimen [ etoposide ? cisplatin ]
? paclitaxel + cisplatin alternating with paclitaxel + etoposide
? BEP regimen : bleomycin + etoposide +cisplatin
HYSTERECTOMY
INDICATIONS
? Invasive mole perforating the serosa causing an intraperitoneal bleed
? Uncontrol able vaginal bleeding
? Extensive uterine tumor to reduce burden and limit chemotherapy.
BRAIN METASTASES
Presenting features - seizures /
headaches /hemiparesis
Whole brain irradiation +
combination chemotherapy
Other choice ? intrathecal Mtx,
fortnightly
Moribund circumstances ?IC bleed
? emergency craniotomy + critical
care support
VAGINAL METASTASES
Profuse bleeding ? managed by packing/ wide local excision
Rarely, embolization of hypogastric arteries.
PULMONARY METASTASES
90% - remission with chemotherapy
Rarely ? thoracotomy and excision needed.
LIVER METASTASES
Difficult to treat with chemotherapy
Rarely need hepatic resection and arterial embolisation
POST TREATMENT SURVEILLANCE
Low risk GTN --- weekly hCG ? until titers undetectable for 3 consecutive weeks.
--- then monthly titers until level undetectable for 12 months
High risk GTN --- fol owed for 24 months, since chance of late relapse
Effective contraception during surveillance period.
PROGNOSIS
Overal cure rate for GTN ? 90%
Non and low risk mets ? excel ent prognosis ? 100% survival rate with single agent
therapy
High risk disease ? 86% with multiple agent therapy
POST TREATMENT SEQUELAE
PREMATURE OVARIAN FAILURE
PSYCHOSOCIAL PROBLEMS
RISK OF SECONDARY MALIGNANCY
SUBSEQUENT PREGNANCY
Advised not to become pregnant atleast for 1 year after chemotherapy
Send placenta for histological examination
Do serum hCG test 6 and 10 weeks after delivery
Lifelong fol owup
hCG - H
[Hyperglycosylated Hcg]
Variant of hCG ? produced by invasive
trophoblasts ? has double sized
oligosaccharides
Presence only in implantation phases of
normal pregnancy
Seen mainly in GTN
Action autocrine.
Main action ? promote trophoblast
growth and invasion
Phantom hCG
Due to presence of heterophile Abs in serum
Interfere with immunoassay ? cause false + result
This cause mild elevation of hCG
? clinicians erroneously treat with chemotherapy
Clarification :
? UTP : negative
? Serial dilations of serum sample : phantom hCG unchanged
? Different hCG assay by alternate method : absence of true hCG
DIAGNOSIS OF PSTT
? Presenting symptom ? 90% with bleeding
? Only mild elevation of serum Hcg
- due to predominance of intermediate trophoblast and lack of
syncytiotrophoblast
? Radiological evidence of uterine tumour
? Tumours stain intensively with antibodies to hPL
? However serum hPL not elevated hence hPL not for fol owup.
TREATMENT OF PSTT
Chemoresistant tumors.
Primary modality ? surgery
Simple hysterectomy + pelvic lymphadenectomy + ovary preservation
Lifelong fol ow up
Advanced disease or distant mets ? adjuvant chemotherapy
THANKYOU
This post was last modified on 12 August 2021