Diagnosis and management of gestational trophoblastic disease

Abstract

Gestational trophoblastic disease (GTD) refers to all tumors that arise from the maternal placenta. Gestational trophoblastic neoplasm (GTN) is a subset of GTD and refers to choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. Persistent GTD may develop after treatment of a molar pregnancy and is also referred to as GTN. The treatment of GTN is stratified based on whether the patient is low risk or high risk as determined by the World Health Organization (WHO) score and International Federation of Gynecology and Obstetrics (FIGO) staging system. Low-risk GTN is treated with single-agent chemotherapy, whereas high-risk GTN should be treated with combination regimens. GTN that does not respond to first-line treatment is said to be resistant or refractory. Resistance to a particular chemotherapeutic regimen is evidenced by a plateau or rise in beta-hCG levels. The overall prognosis for GTN is excellent, even in the setting of refractory disease. GTN affects women of reproductive age, and comprehensive counseling must be performed prior to initiation of gonadotoxic treatment. This chapter also discusses the management of GTN with special considerations such as brain and vaginal metastasis, role of secondary curettage, and post-molar prophylactic chemotherapy.