Gestational Trophoblastic Diseases

Gestational trophoblastic disease encompasses four clinicopathologic forms of growth disturbances of the human placenta: hydatidiform mole (complete and partial), invasive mole, choriocarcinoma, and placental site trophoblastic tumor. The term gestational trophoblastic neoplasia (GTN) has been applied collectively to the latter three conditions. Hydatidiform mole occurs about once in every 1,000-1,500 pregnancies in the United States and Europe, and precedes about one half of all GTN. Hydatidiform moles should be evacuated by either suction curettage or hysterctomy and then followed with serial serum human chorionic gonadotropin (hCG) determinations. Approximately 15-20% of hydatidiform moles will require treatment for GTN. One the diagnosis of GTN is suspected or established following any pregnancy event, evaluation for metastases and risk factors should be undertaken and patients categorized based on anatomic extent of disease and likelihood of response to chemotherapy. GTN should be classified according to the 2002 FIGO stage: WHO prognostic scoring system into nonmetastatic, low-risk metastatic and high-risk metastatic disease categories. Nonmetastatic (FIGO stage I) postmolar GTN can be treated with a variety of single-agent methotrexate or actinomycin D protocols, resulting in the cure of essentially all patients. Metastatic low-risk GTN (FIGO stages II and III: WHO score <7) as well as nonmetastatic (FIGO stage I) choriocarcinoma should be treated with 5-day dosage schedules of methotrexate or actinomycin D, with cure rates approaching 100%. Metastatic high-risk GTN (FIGO stage IV or WHO score ≥7) requires combination chemotherapy with EMA-CO with or without adjuvant radiation therapy and surgery, often with additional salvage chemotherapy employing drug regimens containing platinum agents and etoposide, usually in conjunction with bleomycin (BEP) or ifosfamide (VIP, ICE), to achieve cure rates of 80-90%. Using this approach to management of GTN, the overall cure rate for these tumors should exceed 90%, with reproductive function being preserved in most women.