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GESTATIONAL TROPHOBLASTIC DISEASE
---Complete & partial molar pregnancy, invasive
mole, placental site trophoblastic tumor (PSTT), & choriocarcinoma.
---Highly curable, even with widespread metastases.
---Both complete & partial moles are characterized by an excessive amount of paternal chromosomes, which may induce trophoblastic hyperplasia.
---Complete moles usually have a 46,XX karyotype. All molar chromosomes are derived from paternal origin.
---Partial moles generally have a triploid karyotype.
CLINICAL CLASSIFICATION OF MALIGNANT GTD (NIH)
I. NON-METASTATIC GTD: no evidence of disease outside of uterus.
II. GOOD-PROGNOSIS METASTATIC GTD
Short duration (<4months)
Low hCG level (<40,000 mIU/ml serum b-hCG)
No brain or liver mets
No antecedent term pregnancy
No prior chemo
III. POOR-PROGNOSIS METASTATIC GTD
Long duration (>4months)
High pretreatment hCG levels (>40,00 mIU/ml)
Brain or liver mets
Antecedent term pregnancy
Prior chemotherapy
PATIENTS WHO ARE AT HIGH RISK FOR PERSISTENT GTD
1. age > 40
2. Preevacuation hCG>1,000,000 mIU
3. Uterine size >20 weeks
4. Thecaleutein csts
5. Prior mole
Should we use prophylactic chemotherapy?
Prophylactic methotrexate of high-risk patients-
With prophylaxis post-molar tumor incidence is 14%; without MTX, 47%. However, nearly 100% of patients with persistent GTD are successfully treated. Therefore, avoiding the toxic side effects of MTX.
NOTES ON GTD:
---HCG is a very reliable marker for this disease. However it is not reliable for PLACENTAL SITE TROPHOBLASTIC TUMORS (PSTs)
---A majority of patients who received single agent MTX or EMA/CO had subsequent successful live-birth pregnancies. (~83%)
---There is a small but significant risk of second tumors that can be induced by combination chemotherapy. These neoplasms include myeloid leukemia, colon cancer, & breast cancer.
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TREATMENT
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METHTREXATE 5-DAY REGIMEN
METHOTREXATE 0.4 mg/d IM X 5 days
Repeat Q 12-14 days
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METHOTREXATE + FOLINIC ACID
MTX 1 mg/Kg IM DAYS 1,3,5,7
FOLINIC ACID 0.11 mg/kg IM DAYS 2,4,6,8
REPEAT if hCG elevated or plateaued for 3 weeks
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WEEKLY METHOTREXATE
MTX 30 mg/m2 IM weekly
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DACTINOMYCIN 9-13 mg/kg IV X 5 days
Recycle q 14 days
DACTINOMYCIN 40 mg/kg IV Q14 days
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ETOPOSIDE
ETOPOSIDE 200 mg/m2 PO X 5 days
Recycle Q 14 days
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TREATMENT OF HIGH-RISK METASTATIC DISEASE
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EMA-CO REGIMEN (HIGH RISK MET)
Course A
DAY 1
ETOPOSIDE 100 mg/m2 IV over 30 min
METHOTREXATE 100 mg/m2 IV bolus
DAY 2
DACTINOYMCIN 500 ug IV bolus
ETOPOSIDE 100 mg/m2 IV over 30 min
DACTINOMYCIN 500 ug IV bolus
FOLINIC ACID 15 mg IM/PO Q 6 hours X 4 doses. Begin 12 hours after MTX
Course B
DAY 8
VINCRISTINE 1.0 mg/m2 IV bolus
CYCLOPHOSPHAMIDE 600 mg/m2 IV
DAY 15
RECYCLE COURSE A
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EP/EMA (for disease resistant to EMA/CO)
ETOPOSIDE 150 mg/m2 IV
CISPLATIN 75 mg/m2 IV with hydration
Alternate with EMA as described for EMA/CO except on day 2 patients only receive the folinic acid 15 mg BID X 48 hrs
Side effects include myelosuppression, renal impariment etc makes this regimen difficult to administer!
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MTX/DACTINOYCIN/CYCLOPHOSPHAMIDE REGIMEN
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CHAMOMOA (Bagshawe Regimen)
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Cancer Net (PDQ) web site for GTD |
