الفهرس 
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Abstract
Gestational trophoblastic disease (GTD) is a spectrum of interrelated disease processes originating from the trophoblast. This comprises many histological entities including hydatidiform mole, invasive mole, gestational choriocarcinoma, and placental site trophoblastic tumor.
Hydatidiform mole
Vaginal bleeding, excessive uterine size and pelvic discomfort are the most common clinical manifestations. Since pregnancy is by far the most common source of hCG, clinicians generally initially suspect a pregnancy complication (threatened or missed abortion, ectopic pregnancy) rather than GTD in women who present with these complaints in the setting of a positive pregnancy test.
Initial evaluation consists of a quantitative test for hCG and pelvic ultrasound examination. Serum hCG is often much higher in patients with GTD than in those with intrauterine or ectopic pregnancies. In contrast to all other types of GT D. a partial mole contains a fetus and fetal cardiac activity may be detected.
The diagnosis complete or partial mole must be confirmed by histologic examination of tissue. Tissue is obtained by evacuation of the uterine contents by suction curettage.
Suction curettage is the standard method of uterine evacuation. Other alternatives such as medical induction & hystereotomy are no longer accepted. Hysterectomy is a reasonable alternative in women who do not desire preservation of fertility.
Serious complications (eg. respiratory distress from trophoblastic embolization) are more common in women with high human chorionic gonadotropin (hCG) levels and/or uterine size greater than 14 to 16 weeks gestational size. These patients should be managed by clinicians experienced in the treatment of molar pregnancy.
Serum hCG levels should be monitored serially after treatment of complete or partial mo1ar pregnancy to assess for persistent disease. After a new pregnancy is ruled out, persistent disease is diagnosed if the serum hCG concentration plateaus (decline of less than 10 percent for at least four values over three weeks), rises (increase of 10 percent or greater of three or more values over two consecutive weeks), or persists for more than six months after molar evacuation.
A molar pregnancy may coexist with a viable fetus. These pregnancies, if allowed to proceed, often experience complications (eg, hemorrhage, preeclampsia, and preterm delivery) and they are at elevated risk of persistent gestational trophoblastic neoplasia.
Malignant gestational trophoblastic disease
The spectrum of malignant GTD includes; Persistent/invasive gestational trophoblastic neoplasia (GTN), Choriocarcinoma and Placental site trophoblastic tumors (PSTT).
The diagnosis of persistent GTN is typically made in women who have persistently elevated serum levels of beta-human chorionic gonadotropin (beta hCG) following a molar pregnancy.
In addition to serum levels of beta-hCG, pretreatment evaluation includes pelvic ultrasound, and chest imaging. CT or MRI of the brain is recommended only in women who have symptoms suggestive of brain metastases, those with vaginal or lung metastases, and in all patients with choriocarcinoma.
Women with choriocarcinoma who do not desire future fertility. hysterectomy in addition to chemotherapy is recommended. For women with choriocarcinoma who wish to preserve future fertility, chemotherapy alone is administered. Local resection after chemotherapy is suggested only for those women who have evidence of persistent uterine disease after chemotherapy. For women with stage I or Il PSTT, hysterectomy is the treatment of choice, adjuvant chemotherapy (combination rather than single-agent chemotherapy) after hysterectomy is recommended for women who are at high risk for disease recurrence.
For all women with stage I malignant GTD except those with PSTT. one course of single agent chemotherapy (methotrexate rather than dactinomycin) is recommended. For patients who are resistant to single-agent therapy, a second trial of an alternative single agent is recommended before initiating combination cheni0therapy.
Patients with low-risk FIGO stage II and III GTN (WHO prognostic score less than or equal to 6). one course of single-agent chemotherapy is recommended. For women who are resistant to first-line single-agent therapy. combination chemotherapy (MAC then EMA/CO) is recommended rather than a second trial of’ an alternative single agent. For women who are resistant to EMA/CO. a platinum-based regimen such as EMA/EP is recommended. For women with high-risk FIGO stage Il and Ill disease (WHO score of 7 or higher) initial combination chemotherapy (EMA/CO rather than MAC) is recommended. For women who are resistant to EMA/CO. a platinum-based regimen is recommended.
Women with stage IV GTD. initial combination chemotherapy (EMA/CO) is recommended. Resistant disease is treated with a platinum-based regimen. For women who present with cerebral metastases. High dose EMA/CO (with1000mg/m2 of MTX IV ) is recmmended rather than cranial RT or intrathecal MTX. Craniotomy is reserved for life-threating complications and for drug-resistant lesions in patients who have no extracranial disease. Biopsy of metastases should be avoided if at all possible.
All women with GTD should be monitored with weekly serial measurements of serum beta-hCG during therapy. After remission is achieved, serum beta-hCG should be measured monthly until monitoring has shown one year of normal hCG levels.
Patients with GTD can anticipate normal reproduction in the future. Pregnancy should be avoided for at least one year following treatment of molar pregnancies and five years following treatment of malignant GTD.
Recommendations
Early diagnosis by early routine ultrasound, proper treatment and strict follow up of molar pregnancies by serum beta-hCG are important to minimize acute complications, identify malignant sequel promptly and preserve fertility.
Patients with malignant gestational trophoblastic neoplasia should be managed in consultation with an individual experienced in the complex multilnodality treatment of these patients.
We suggest a specialized unit for diagnosis, treatment and follow-up of patients with gestational trophoblastic disease in our department with linkage to nuclear medicine department.