Cancer of Persistent Gestational Trophoblastic Tumor (GTNs)

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Cancer of Persistent Gestational Trophoblastic Tumor

Persistent GTN tumor include spectrum of disease and are curable malignancies with good prognosis. But, most cases of persistent Gestational trophoblastic tumors are neglected and report for treatment when already tumor has metastasized in different organs like into lung, brain, vagina or pelvic structures. Persistent GTNs are one of the gynecology oncologic emergencies.

Stages of GTN

• Non- metastatic: disease confined to uterus
• Metastatic: Disease spread outside the uterus

Diagnosis: it is based on suggestive clinical history of preceding pregnancy (vesicular mole, abortion or delivery) with persistently high levels of a very sensitive tumor marker in blood, though metastatic work up needs further tests like X Ray chest, CT Scan Brain.

Symptoms of Persistent GTN

1. Persistent vaginal bleeding precede by history of abortion, full term pregnancy or vesicular mole.
2. Persistently raised B HCG after evacuation of vesicular mole.
3. Pulmonary metastasis with breathlessness.
4. Rarely haemo-peritoneum due to involvement of uterine artery.
5. Late neglected cases with brain metastasis may present with epileptic fits, comma or violent behaviour.

Treatment

Role of Surgery

• Stage I : If patient no longer wishes to preserve fertility ,hysterectomy with adjuvant chemotherapy should be performed
• Hysterectomy is done in all cases of placental site trophoblastic tumors
• Surgery is done in form of uterine artery or internal iliac ligation in cases of uncontrolled bleeding, who are desirous to preserve fertility. If facility available uterine artery embolization may also be tried in these cases.
• Thoracotomy rarely required excising persistent lung metastasis even after chemotherapy.

Role of chemotherapy

Low risk GTN(WHO Score<7) are treated with single agent Methotraxate or Actinomycin D, while and high risk GTN ( Score >7)are treated with multi-agent EMA-CO with or without brain radiotherapy and intrathecal methotraxate.

Follow up Follow up is done with serum b HCG levels and clinical examination . with USG whenever it is indicated

In Stage I, II, III: weekly follow up 3 weeks & monthly for 12 months

• Weekly bHCG x3 consecutive weeks
• Monthly BHCG X 12 months
• Effective contraception for period of hormonal follow up

Stage IV : weekly follow up for 3 weeks & monthly for 24 months

Prognosis: GTN is a curable malignancy and has good prognosis with appropriate timely management with surgery and chemotherapy.