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. ________________________________________________________________ TREATMENT ---------------------------------------------------------------------------------------------------------------- METHTREXATE 5-DAY REGIMEN METHOTREXATE 0.4 mg/d IM X 5 days Repeat Q 12-14 days ---------------------------------------------------------------------------------------------------------------- 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 ---------------------------------------------------------------------------------------------------------------- WEEKLY METHOTREXATE MTX 30 mg/m2 IM weekly ---------------------------------------------------------------------------------------------------------------- DACTINOMYCIN 9-13 mg/kg IV X 5 days Recycle q 14 days DACTINOMYCIN 40 mg/kg IV Q14 days ---------------------------------------------------------------------------------------------------------------- ETOPOSIDE ETOPOSIDE 200 mg/m2 PO X 5 days Recycle Q 14 days ________________________________________________________________ TREATMENT OF HIGH-RISK METASTATIC DISEASE ---------------------------------------------------------------------------------------------------------------- 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 ---------------------------------------------------------------------------------------------------------------- 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! ---------------------------------------------------------------------------------------------------------------- MTX/DACTINOYCIN/CYCLOPHOSPHAMIDE REGIMEN ---------------------------------------------------------------------------------------------------------------- CHAMOMOA (Bagshawe Regimen) ---------------------------------------------------------------------------------------------------------------- ________________________________________________________________
Cancer Net (PDQ) web site for GTD |