General Information
Gestational trophoblastic tumors (GTTs) are rare but highly curable tumors
arising from the products of conception in the uterus. The prognosis for cure
of patients with GTTs is good even when the disease has spread to distant
organs, especially when only the lungs are involved. The probability of cure
depends on the following:
- Histologic type (mole, invasive mole, or choriocarcinoma).
- Extent of spread of the disease.
- Level of the human chorionic gonadotropin
(hCG) titer.
- Duration of disease from the initial pregnancy event to start
of treatment.
- Specific sites of metastases.
- Nature of antecedent
pregnancy.
- Extent of prior treatment.
Selection of treatment depends
on these factors plus the patient’s desire for future pregnancies. The hCG, produced normally during pregnancy, is abnormally
elevated in the blood and urine of patients with this group of diseases and is
a sensitive marker to indicate the presence or absence of disease before,
during, and after treatment.
The most common antecedent pregnancy is that of a hydatidiform mole, usually a
genetic disorder of pregnancy in which only placental-like tissue is present.
The patient will present with abnormal bleeding from onset of pregnancy and may
have a uterus which is much larger than expected. Sonography is the preferred
method of diagnosis, and suction dilation and curettage (D & C) is the preferred method of evacuation.
Of utmost importance is careful follow-up with serum beta hCG (BhCG) weekly
until less than 100 mIU/mL and then every 2 weeks. The patient should have a
careful pelvic examination every other week and a chest x-ray every 4to 6 weeks.
Once the titer of serum BhCG has fallen to normal levels, these two
examinations need no longer be done; however, BhCG titers need to be repeated
every 2 weeks for 3 months, then monthly for 3 months, then every 2 months for
6 months, then every 6 months for 3 years. Each patient should be counseled in
the use of a reliable birth control method. Any patient who develops an
increasing level of serum BhCG, a plateau of the BhCG over 3 weeks, or
persistent elevation of BhCG after 16 weeks of follow-up should be considered
as having gestational trophoblastic neoplasia and should undergo the
appropriate work-up and treatment. Similarly, any patient who develops
metastatic disease during follow-up should be staged and undergo treatment.
Choriocarcinoma most commonly follows a molar pregnancy but can follow a
normal pregnancy, ectopic pregnancy, or abortion, and should always be
considered when a patient has continued vaginal bleeding in the postdelivery
period. Other common signs include bizarre neurologic symptoms in a female
within the reproductive age group and asymptomatic lesions on routine chest
x-ray.
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