Gestational Trophoblastic Neoplasia Follow-up

  • Author: Enrique Hernandez, MD, FACOG, FACS; Chief Editor: Warner K Huh, MD   more...
 
Updated: Jan 30, 2012
 

Further Outpatient Care

Patients with gestational trophoblastic neoplasia (GTN) should have follow-up serum hCG levels measured once per week until 4 normal values are obtained. Then, hCG levels should be obtained once per month for 1 year. Patients with stage IV disease are observed with monthly serum hCG level monitoring for 2 years after 3-4 consecutive weekly normal levels. Patients should use a reliable method of contraception.

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Inpatient & Outpatient Medications

During the period of follow-up care, patients with GTN should use a reliable method of contraception, such as oral contraceptives or depot progesterone. The serum hCG levels are critical in monitoring the status of the disease, and a normal intrauterine pregnancy interferes with this critical monitoring tool.

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Transfer

Patients with resistant disease may benefit from consultation at a regional trophoblastic disease center.

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Deterrence/Prevention

  • The early diagnosis of GTN by the close follow-up of serum hCG levels after the evacuation of a hydatidiform mole results in therapeutic intervention prior to the development of high-risk disease.
  • In patients with a history of gestational trophoblastic disease (GTD), measuring serum hCG levels 6 weeks after any subsequent pregnancy should be strongly considered to exclude occult GTN.
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Complications

  • Plateauing or rising serum hCG levels during the period of follow-up care may indicate a normal intrauterine pregnancy or GTN with or without metastasis.
  • Etoposide is associated with an increased risk of developing leukemia. It should be used only in patients with high-risk disease.[65]
  • The rate of abnormal pregnancies (spontaneous abortions, stillbirths, repeat GTD) is higher if a subsequent pregnancy occurs within 6 months of completing chemotherapy, compared with pregnancies that occur after 12 months.[66]
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Prognosis

  • Nonmetastatic GTN has a cure rate of close to 100% with chemotherapy treatment.
  • Metastatic low-risk GTN has a cure rate of close to 100% with chemotherapy treatment.
  • Metastatic high-risk GTN has a cure rate of approximately 75% with chemotherapy treatment.
  • After 12 months of normal hCG levels, less than 1% of patients with GTN have recurrences.
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Patient Education

  • The pregnancy rate after chemotherapy with methotrexate and cyclophosphamide is 80%. Of women treated with EMA-CO, 46% have had at least 1 live birth after chemotherapy.[67, 68]
  • Patients who become pregnant after treatment for GTN should have pelvic ultrasonography early during the pregnancy to confirm that the pregnancy is normal.
  • A serum hCG level should be obtained 6 weeks after delivery of a subsequent pregnancy to exclude repeat GTN.
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Contributor Information and Disclosures
Author

Enrique Hernandez, MD, FACOG, FACS  Chairman, Department of Obstetrics and Gynecology, Director of Gynecologic Oncology, Abraham Roth Professor of Obstetrics, Gynecology and Reproductive Science, Professor of Pathology, Temple University Hospital, Temple University School of Medicine

Enrique Hernandez, MD, FACOG, FACS is a member of the following medical societies: Alpha Omega Alpha, American Cancer Society, American College of Obstetricians and Gynecologists, American College of Surgeons, American Gynecological and Obstetrical Society, American Medical Association, American Society for Colposcopy and Cervical Pathology, Association of Professors of Gynecology and Obstetrics, Johns Hopkins Medical and Surgical Association, Pennsylvania Medical Society, Philadelphia County Medical Society, and Society of Gynecologist Oncologists

Disclosure: GSK Honoraria Speaking and teaching

Specialty Editor Board

Robert C Shepard, MD, FACP  Associate Professor of Medicine in Hematology and Oncology at University of North Carolina at Chapel Hill; Vice President of Scientific Affairs, Therapeutic Expertise, Oncology, at PRA International

Robert C Shepard, MD, FACP is a member of the following medical societies: American Association for Cancer Research, American College of Physician Executives, American College of Physicians, American Federation for Clinical Research, American Federation for Medical Research, American Medical Association, American Medical Informatics Association, American Society of Hematology, Association of Clinical Research Professionals, Eastern Cooperative Oncology Group, European Society for Medical Oncology, Massachusetts Medical Society, and Society for Biological Therapy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Rajalaxmi McKenna, MD, FACP  Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems

Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis

Disclosure: Nothing to disclose.

Chief Editor

Warner K Huh, MD  Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Senior Scientist, Comprehensive Cancer Center, University of Alabama School of Medicine

Warner K Huh, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Society of Clinical Oncology, Massachusetts Medical Society, and Society of Gynecologist Oncologists

Disclosure: MERCK Consulting fee Consulting; ROCHE PHARMA/DIAGNOSTICS Consulting fee Consulting; INTUITIVE SURGICAL Proctor Fee Consulting; Qiagen Consulting fee Consulting

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Histologic section of a complete hydatidiform mole stained with hematoxylin and eosin. Villi of different sizes are present. The large villous in the center exhibits marked edema with a fluid-filled central cavity known as cisterna. Marked proliferation of the trophoblasts is observed. The syncytiotrophoblasts stain purple, while the cytotrophoblasts have a clear cytoplasm and bizarre nuclei. No fetal blood vessels are in the mesenchyme of the villi.
In this microphotograph of a choriocarcinoma metastatic to the brain, the neuropil is seen on the right and the biphasic (2 cell populations) choriocarcinoma is seen to the left with hemorrhage at the left border of the photograph (H&E stain).
Table. Prognostic Scoring Index
Prognostic FactorPoints
Age ≥40 y1
Antecedent pregnancy terminated in abortion1
Antecedent full-term pregnancy2
Interval of 4-7 mo between antecedent pregnancy and start of chemotherapy1
Interval of 7-12 mo between antecedent pregnancy and start of chemotherapy2
Interval of more than 12 mo between antecedent pregnancy and start of chemotherapy4
Beta-hCG level in serum is 1,000 to < 10,000 mIU/mL1
Beta-hCG level in serum is 10,000 to < 100,000 mIU/mL2
Beta-hCG level in serum is ³100,000 mIU/mL4
Largest tumor is 3 cm to < 5 cm1
Largest tumor is ³5 cm2
Site of metastases is spleen or kidney1
Site of metastases is gastrointestinal tract2
Site of metastases is brain or liver4
Number of metastases is 1-41
Number of metastases is 5-82
Number of metastases is >84
Prior chemotherapy with single drug2
Prior chemotherapy with multiple drugs4
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