New Guideline for Gestational Trophoblastic Disease

September 25, 2013

By Will Boggs, MD

NEW YORK (Reuters Health) Sep 25 - The European Society of Medical Oncology says women with malignant forms of gestational trophoblastic disease need centralized care.

That advice comes in a baker's dozen of recommendations the group issued this month for diagnosing and managing gestational trophoblastic disease (GTD).

As the writers noted in the Annals of Oncology online September 1, GTD includes a spectrum of disorders.

They range from the premalignant conditions of complete (CHM) and partial (PHM) hydatidiform moles through to the malignant invasive mole, choriocarcinoma, and the very rare placental site trophoblastic tumor/epithelioid trophoblastic tumor (PSTT/ETT).

The recommendations, developed by Dr. M. J. Seckl from Imperial College London and colleagues in the ESMO Guidelines Working Group, have also been endorsed by the Japanese Society of Medical Oncology.

Based on detailed reviews of published work, they begin by asserting that the optimal management of the malignant forms of GTD, known collectively as gestational trophoblastic neoplasia (GTN), requires centralization of care, pathology review, and monitoring of hCG (human chorionic gonadotropin).

Diagnosis usually proceeds from sonographic examination to histological examination of the products of conception from nonviable pregnancies.

For women with singleton molar pregnancies, termination should proceed by suction dilatation and curettage, but recurrences generally require chemotherapy.

After staging of GTN with the FIGO scoring system, treatment can be with either single-agent methotrexate or single-agent actinomycin D (for low-risk disease, FIGO scores 0-6) or with multiagent chemotherapy (for patients with FIGO scores of 7 and above).

The duration of chemotherapy also differs according to the disease. Low-risk disease requires six weeks of maintenance treatment after hCG normalizes, whereas high-risk disease requires maintenance therapy for eight weeks when there are liver or brain metastases.

In ultra-high-risk GTN, induction with low-dose etoposide and cisplatin can reduce the risk of early death, and even high-risk failures can often be salvaged with further chemotherapy.

Surgery alone can salvage some patients with isolated foci of chemoresistant disease, but residual lung or uterine masses following chemotherapy do not require excision.

Management of PSTT/ETT depends on the disease stage and risk factors for poor outcome, most important of which is the interval from last known pregnancy. Presentation within four years of the last known pregnancy may require hysterectomy with pelvic node sampling, whereas disease presenting later may benefit from multi-agent and subsequent high-dose chemotherapy.

Dr. Benedict B. Benigno, director of Gynecologic Oncology at Northside Hospital, Atlanta, Georgia and founder and CEO of The Ovarian Cancer Institute, told Reuters Health by email, "This is the best review article on gestational trophoblastic disease that I have ever encountered. I spent three years as a civilian surgeon in South Vietnam during the war and encountered seven to ten such cases each week and for this reason I have maintained an interest in this unusual disease."

"The guidelines are very good and I would expect physicians to use them as indicated in the text," said Dr. Benigno. "Only brief mention is made of the use of high-dose chemotherapy with autologous stem cell rescue in the management of cases of GTD refractory to standard therapy, which is unfortunate since I believe that many more such patients could be cured by the use of this form of treatment."

The authors and the ESMO Head Office did not respond to a request for comments on this report.

SOURCE: http://bit.ly/15tSLRt

Ann Oncol 2013.

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