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High-Risk Gestational Trophoblastic Neoplasia

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Gestational Trophoblastic Disease

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Abstract

Gestational Trophoblastic Neoplasia (GTN) denotes malignant complications of trophoblasts which include Invasive mole, Choriocarcinoma (CC), Placental Site Trophoblastic Tumor (PSTT), and Epithelioid Trophoblastic Tumor (ETT). The GTN is classified as Low-risk and High-risk GTN according to FIGO 2002 staging system. High-risk GTN is defined when the prognostic score is 7 or greater and Ultrahigh-risk GTN when the score is greater than 12. The management of High-risk GTN is by combination chemotherapy. The cure rate is 80–90% as it is highly sensitive to chemotherapy. However, 10–20% of women with high-risk GTN die subsequently due to drug-resistant disease. Combination chemotherapy with EMA-CO (Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide, Vincristine) regimen is preferred as primary therapy which results in a complete remission rate of 86% and long-term survival of 93%. Resistance to EMA-CO develops when the duration of the disease is longer (>12 months), presence of more than two or three metastatic sites (brain, liver, GI tract), and ineffective prior chemotherapy. Salvage chemotherapy with other regimens can produce remission rates in 70–80% of these patients. Failure of multiple lines can be treated with high-dose chemotherapy with autologous stem cell transplant. Immunotherapy with Pembrolizumab is tried in drug-resistant disease after multiple lines of chemotherapy with success. Ultrahigh-risk GTN needs to be treated with caution as it can result in early deaths which can be prevented by induction low-dose chemotherapy. PSTT arises from intermediate trophoblasts and serum hCG (human Chorionic Gonadotrophin) ranges between 100 and 1000 mIU/ml and surgery is the treatment of choice in localized and metastatic disease. In metastatic disease, chemotherapy can be given even though it is not very chemosensitive. The cure rate is between 80 and 90%. All high-risk GTN patients should be followed for 2 years with monthly hCG. Fertility is rarely affected. However, advancing of menopause by 3 years occurs after combination chemotherapy. Long-term toxicity of combination chemotherapy like second malignancies are known to occur in survivors.

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Authors and Affiliations

  1. Department of Medical Oncology, Madras Medical College, Chennai, Tamil Nadu, India

    K. Kalaichelvi

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  1. K. Kalaichelvi
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Editors and Affiliations

  1. Associate Professor, Department of Gynaecologic Oncology, Acharya Harihar Post Graduate Institute of Cancer, Cuttack, India

    Bhagyalaxmi Nayak

  2. Professor & Head, Department of Obstetrics and Gynecology, King George’s Medical University, Lucknow, India

    Uma Singh

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Kalaichelvi, K. (2021). High-Risk Gestational Trophoblastic Neoplasia. In: Nayak, B., Singh, U. (eds) Gestational Trophoblastic Disease. Springer, Singapore. https://doi.org/10.1007/978-981-33-4878-3_9

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  • DOI: https://doi.org/10.1007/978-981-33-4878-3_9

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  • Publisher Name: Springer, Singapore

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  • Online ISBN: 978-981-33-4878-3

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