Przewlekła choroba trofoblastyczna i choriokarcynoma
Zapobieganie i profilaktyka
Przewlekła choroba trofoblastyczna (GTD) oraz choriokarcinoma to złośliwe formy choroby trofoblastycznej ciąży, które mogą rozwinąć się po zaśniadzie groniastym, poronieniu, ciąży donoszonej lub ektopowej. Ryzyko rozwoju GTD jest wyższe u pacjentek poniżej 20. i powyżej 35. roku życia, z historią zaśniadu groniastego lub silnym wywiadem rodzinnym. Profilaktyczna chemioterapia, głównie metotreksatem (MTX) w dawce około 70 mg doustnie przez 3 tygodnie, może zmniejszyć ryzyko rozwoju GTN o 38% u pacjentek z całkowitym zaśniadem groniastym (CHM) wysokiego ryzyka, jednak jej rutynowe stosowanie budzi kontrowersje ze względu na potencjalne działania niepożądane, ryzyko oporności oraz koszty leczenia. Wczesne rozpoznanie GTN dzięki ścisłemu monitorowaniu poziomów hCG w surowicy po ewakuacji zaśniadu pozostaje najskuteczniejszą metodą prewencji wtórnej.
- Przewlekła choroba trofoblastyczna i choriokarcynoma – Profilaktyka i Prewencja
- Profilaktyka pierwotna
- Chemioprofilaktyka po zaśniadzie groniastym
- Profilaktyka Metotreksatem
- Kontrowersje dotyczące chemioprofilaktyki
- Aktualne wytyczne dotyczące chemioprofilaktyki
- Profilaktyka wtórna i monitorowanie
- Regularne monitorowanie i kontrola
- Antykoncepcja i planowanie kolejnych ciąż
- Monitorowanie poziomów hCG
- Opcje leczenia w prewencji progresji choroby
- Specjalistyczna opieka w ośrodkach GTD
- Rokowanie i przeżywalność
- Wnioski i zalecenia
Przewlekła choroba trofoblastyczna i choriokarcynoma – Profilaktyka i Prewencja
Przewlekła choroba trofoblastyczna i choriokarcynoma stanowią złośliwe formy choroby trofoblastycznej ciąży (GTD – Gestational Trophoblastic Disease). Choriokarcynoma jest rzadkim, ale agresywnym nowotworem trofoblastycznym, który może rozwinąć się po ciąży zaśniadowej, poronieniu, ciąży donoszonej lub ciąży ektopowej. Przewlekła choroba trofoblastyczna obejmuje utrzymujące się zmiany po usunięciu zaśniadu groniastego. Oba schorzenia wymagają ścisłego monitorowania i odpowiedniego postępowania profilaktycznego.123
Profilaktyka pierwotna
Obecnie nie ma możliwości całkowitego zapobiegania przewlekłej chorobie trofoblastycznej ani choriokarcynomie. Jedyną metodą pełnej prewencji GTD byłoby unikanie ciąży, co oczywiście nie jest praktycznym rozwiązaniem dla większości kobiet planujących potomstwo.12
Pacjentki z czynnikami ryzyka rozwoju choroby trofoblastycznej powinny być świadome zwiększonego zagrożenia i omówić tę kwestię z lekarzem prowadzącym. Do czynników ryzyka rozwoju GTD i jej złośliwych form należą:3
- Wiek – osoby powyżej 35 lub poniżej 20 roku życia mogą być w grupie podwyższonego ryzyka
- Wcześniejsze ciąże zaśniadowe – znacznie zwiększają ryzyko kolejnych
- Silny wywiad rodzinny ciąż zaśniadowych
Chemioprofilaktyka po zaśniadzie groniastym
Profilaktyka Metotreksatem
Profilaktyczna chemioterapia (P-chem) została wprowadzona w latach 60. XX wieku jako potencjalna metoda zapobiegania transformacji nowotworowej zaśniadu groniastego wysokiego ryzyka. Badania wykazały, że pojedynczy kurs profilaktyczny daktynomycyny lub metotreksatu może zmniejszyć ryzyko rozwoju przetrwałej choroby trofoblastycznej po usunięciu zaśniadu.12
Metotreksat (MTX) był jednym z pierwszych leków stosowanych w prewencji choriokarcynoma po przetrwałej chorobie trofoblastycznej. Badania przeprowadzone na Uniwersytecie Kyushu w Japonii wykazały, że podanie MTX w dawce około 70 mg doustnie w ciągu 3 tygodni po usunięciu zaśniadu może zmniejszyć ryzyko rozwoju choriokarcynoma. W badaniu obejmującym 107 przypadków leczonych MTX nie wystąpił żaden przypadek choriokarcynoma po zastosowanej terapii.12
Aktualizacja przeglądu Cochrane z 2017 roku wskazała, że chemioterapia profilaktyczna może zmniejszyć ryzyko rozwoju nowotworowej postaci choroby trofoblastycznej (GTN) o 38% u kobiet z całkowitym zaśniadem groniastym (CHM), które są w grupie wysokiego ryzyka transformacji złośliwej.3
Kontrowersje dotyczące chemioprofilaktyki
Pomimo potencjalnych korzyści, rutynowe stosowanie chemioprofilaktyki budzi kontrowersje w środowisku medycznym. Istnieją obawy, że chemioterapia profilaktyczna może:12
- Zwiększać oporność nowotworu na standardową terapię u kobiet, u których następnie rozwinie się choroba trofoblastyczna
- Opóźniać czas do diagnozy GTN
- Zwiększać ryzyko późniejszej lekooporności
- Narażać niepotrzebnie na chemioterapię pacjentki, u których choroba i tak by się nie rozwinęła (tylko około 16% pacjentek z grupy wysokiego ryzyka rozwija GTN)
- Zwiększać koszty leczenia
Z tego powodu praktyka chemioprofilaktyki jest zwykle ograniczona do krajów, w których znaczna liczba kobiet nie wraca na zalecane wizyty kontrolne.5
Aktualne wytyczne dotyczące chemioprofilaktyki
Międzynarodowa Federacja Ginekologii i Położnictwa (FIGO) oraz National Comprehensive Cancer Network (NCCN) podają, że chemioprofilaktyka może być stosowana w przypadku zaśniadu groniastego w określonych okolicznościach, gdy:1
- Ryzyko rozwoju GTN po zaśniadzie jest znacznie większe niż standardowe
- Niemożliwe jest wiarygodne monitorowanie pacjentki w okresie poresekcyjnym
Niektóre badania wykazały korzystny efekt profilaktycznej chemioterapii. W jednym z badań w grupie pacjentek otrzymujących chemioprofilaktykę nie rozwinęła się choroba trofoblastyczna u żadnej z nich (0%), podczas gdy w grupie kontrolnej u 15,3% pacjentek wystąpiło przetrwałe krwawienie z pochwy, a u 7% rozwinęło się choriokarcynoma z przerzutami do mózgu.12
Wyniki badań wskazują, że chemioprofilaktyka nie powinna być zalecana rutynowo, ponieważ podobne efekty terapeutyczne uzyskuje się w obu grupach (z i bez profilaktyki), a co najmniej jeden kurs monoterapii może powodować działania niepożądane u pacjentek, u których choroba mogłaby się nie rozwinąć bez stosowania profilaktyki.12
Profilaktyka wtórna i monitorowanie
Regularne monitorowanie i kontrola
Wczesne rozpoznanie GTN dzięki ścisłemu monitorowaniu poziomów hCG w surowicy po ewakuacji zaśniadu groniastego umożliwia interwencję terapeutyczną przed rozwinięciem się choroby wysokiego ryzyka. Jest to obecnie najskuteczniejsza metoda prewencji wtórnej.1
Po potwierdzeniu całkowitego lub częściowego zaśniadu groniastego kluczowe jest poinformowanie pacjentki o:1
- Znaczeniu regularnych kontroli
- Ryzyku przetrwałej choroby
- Konieczności unikania kolejnej ciąży do momentu uzyskania zgody od lekarza
Zaśniad groniasty całkowity (CHM) ma potencjał złośliwy sięgający 20% i 5% szans na odległe przerzuty nowotworowe. Choć wskaźniki nawrotów GTN są niskie (około 0,62%), ryzyko nawrotu znacznie wzrasta bez długoterminowej obserwacji, co podkreśla potrzebę ciągłej opieki.2
Antykoncepcja i planowanie kolejnych ciąż
Pacjentki powinny być poinformowane o konieczności unikania ciąży przez co najmniej rok po jakimkolwiek rodzaju choroby trofoblastycznej i leczeniu. Należy zapewnić wsparcie w wyborze odpowiedniej metody antykoncepcji.1
Kobietę można zapewnić, że ryzyko nawrotu choroby trofoblastycznej wynosi tylko 1% w kolejnej ciąży po pojedynczym zaśniadzie, ale wzrasta do około 25% w przypadku przebycia dwóch całkowitych zaśniadów groniastych.23
Zaleca się, aby po przebyciu zaśniadu groniastego kobieta odczekała od 6 miesięcy do roku przed próbą zajścia w kolejną ciążę. W przypadku kolejnych ciąż zaleca się wykonanie wczesnego badania USG w celu potwierdzenia, że ciąża jest prawidłowa i nie ma cech zaśniadu.12
Monitorowanie poziomów hCG
U pacjentek z historią choroby trofoblastycznej ciąży (GTD) należy rozważyć pomiar poziomów hCG w surowicy 6 tygodni po każdej kolejnej ciąży, aby wykluczyć utajoną GTN.1
hCG jest czułym markerem chorób trofoblastycznych, gdyż może pochodzić z trofoblastów pozostałych w organizmie pacjentki po zaśniadzie wodnym. Badania bioptatu endometrium ujawniły pozostałości trofoblastów u pacjentek z podwyższonym poziomem hCG.1
Opcje leczenia w prewencji progresji choroby
Terapia Metotreksatem
Metotreksat (MTX) pozostaje kluczowym lekiem w leczeniu przetrwałej choroby trofoblastycznej, co pozwala zapobiec rozwojowi choriokarcynoma. Najważniejszym aspektem zapobiegania choriokarcynoma ciążowemu jest leczenie metotreksatem przetrwałej choroby trofoblastycznej po zaśniadzie groniastym.12
W przypadku niedoboru metotreksatu, powinien on być zarezerwowany dla leczenia z intencją wyleczenia u pacjentek z GTN wysokiego ryzyka (np. wynik WHO 7 lub wynik WHO 5-6 z dodatkowymi cechami wysokiego ryzyka) lub do leczenia pacjentek z GTN niskiego ryzyka, które nie zareagowały na monoterapię daktynomycyną, doszło u nich do nawrotu lub wystąpiła reakcja alergiczna.1
Daktynomycyna
Badania wykazały skuteczność pojedynczej dawki daktynomycyny w profilaktyce poresekcyjnej GTN u nastolatek z zaśniadem groniastym wysokiego ryzyka. Kolejne prace naukowe potwierdziły, że profilaktyczna jednorazowa dawka daktynomycyny u pacjentek wysokiego ryzyka może być prostym, skutecznym, bezpiecznym i tanim podejściem bez niekorzystnego wpływu na zgodność z ogólną obserwacją lub późniejszym leczeniem.1
Powtórny zabieg łyżeczkowania
Badania retrospektywne oceniały leczniczy efekt drugiego łyżeczkowania w przetrwałej chorobie trofoblastycznej. Ta metoda może być rozważana w określonych przypadkach jako sposób na zmniejszenie konieczności stosowania chemioterapii, jednak wymaga dalszych badań nad jej skutecznością.1
Histerektomia
Usunięcie macicy (histerektomia) jest jedną z możliwości leczenia przetrwałej choroby trofoblastycznej, szczególnie u kobiet, które nie planują już ciąży. Może być rozważana jako alternatywa dla chemioterapii lub w przypadkach opornych na leczenie farmakologiczne.1
Specjalistyczna opieka w ośrodkach GTD
Wyniki leczenia kobiet z GTN i GTD są lepsze przy ciągłej opiece w specjalistycznych ośrodkach zajmujących się chorobami trofoblastycznymi. Rejestracja pacjentek w takim ośrodku stanowi minimalny standard opieki.1
Rokowanie i przeżywalność
Rokowanie w przypadku choriokarcynoma we wczesnym stadium jest dobre. Wskaźnik przeżycia dla osób z ciążowym choriokarcynoma niskiego ryzyka wynosi prawie 100%. Wskaźnik przeżycia dla osób z ciążowym choriokarcynoma wysokiego ryzyka wynosi 94%.1
Wnioski i zalecenia
Na podstawie dostępnych danych można sformułować następujące zalecenia dotyczące profilaktyki przewlekłej choroby trofoblastycznej i choriokarcynoma:12
- Dokładna ultrasonograficzna diagnostyka ciąży zaśniadowej jest kluczowa dla wczesnego wykrycia i zapobiegania rozwojowi choriokarcynoma
- Ścisłe monitorowanie poziomów hCG po ewakuacji zaśniadu groniastego pozostaje złotym standardem postępowania
- Chemioprofilaktyka nie jest zalecana rutynowo dla wszystkich pacjentek po zaśniadzie groniastym
- Chemioprofilaktyka może być rozważana w wybranych przypadkach wysokiego ryzyka lub gdy regularne kontrole nie są możliwe
- Pacjentki powinny unikać ciąży przez co najmniej 6-12 miesięcy po przebyciu zaśniadu groniastego
- Każda kolejna ciąża powinna być monitorowana wczesnym USG, a poziom hCG powinien być sprawdzony 6 tygodni po jej zakończeniu
- Opieka w specjalistycznym ośrodku zajmującym się chorobami trofoblastycznymi zwiększa szanse na pomyślne wyniki leczenia
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Materiały źródłowe
- #1 Gestational Trophoblastic Disease: Symptoms & Treatmenthttps://my.clevelandclinic.org/health/diseases/6130-gestational-trophoblastic-disease
There isnt a way to prevent gestational trophoblastic disease. […] Gestational trophoblastic disease is rare, but certain factors beyond your control may increase your risk. These factors include: Your age. People older than 35 or younger than 20 may be at higher risk for GTD. Having prior molar pregnancies. Strong family history of molar pregnancies.
- #1 Choriocarcinoma: Causes, Symptoms, Treatment & Preventionhttps://my.clevelandclinic.org/health/diseases/24863-choriocarcinoma
No, you cant prevent choriocarcinoma. If youve had a molar pregnancy, talk to your healthcare provider about your risk for choriocarcinoma. […] The outlook for choriocarcinoma in its early stages is good. The survival rate for people with low-risk gestational choriocarcinoma is almost 100%. The survival rate for people with high-risk gestational choriocarcinoma is 94%.
- #1 Gestational Trophoblastic Disease Treatment (PDQ®) – NCIhttps://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq
Studies have shown that a single course of prophylactic dactinomycin or methotrexate can decrease the risk of a postmolar gestational trophoblastic disease (GTD). […] However, there is concern that chemoprophylaxis increases tumor resistance to standard therapy in the women who subsequently develop GTD. […] Therefore, this practice is generally limited to countries in which a large number of women do not return for follow-up.
- #1 Prevention of Choriocarcinoma after Postmolar Persistent Trophoblastic Disease | Auctoreshttps://auctoresonline.org/article/prevention-of-choriocarcinoma-after-postmolar-persistent-trophoblastic-disease
Prevention of Choriocarcinoma after Postmolar Persistent Trophoblastic Disease […] Also Chemotherapy was progresses in choriocarcinoma after Methotrexate, still its prevention with the treatment of persistent trophoblastic disease is needed after molar treatment. The prevention was achieved with particular MTX treatment of persistent trophoblastic disease. […] The author intended to prevent choriocarcinoma with MTX therapy in postmolar women. […] Thus, the most important point to prevent gestational choriocarcinoma is MTX treatment of persistent trophoblastic disease after the hydatidiform mole, namely it is important to treat the cases of positive pregnancy test after the mole should be firstly treated with MTX in the prevention of malignant choriocarcinoma. […] Molar pregnancy is correctly diagnosed 2 weeks after the doubtful ultrasound examination. Let us diagnose hydatidiform mole correctly with ultrasound to get the chance to prevent choriocarcinoma after the mole.
- #1 The effect of prophylactic chemotherapy on treatment outcome of postmolar gestational trophoblastic neoplasia | BMC Women’s Health | Full Texthttps://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-02134-w
P-chem was considered as an effective method to prevent malignant transformation of high-risk HM, after it was first introduced in 1966. […] An updated Cochrane Review in 2017 concluded that P-chem might reduce the risk of post-molar GTN to 38% in women with CHM who are at high risk of malignant transformation. […] However, P-chem cannot be recommended routinely for high risk HM nowadays, since it has been reported that P-chem might exert adverse effects on subsequent follow-up and treatment of postmolar GTN. […] As previous studies stated, P-chem might delay the time to diagnosis of GTN and increase the risk of subsequent drug resistance, but these effects were very uncertain due to the small samples and limited evidences. […] Nevertheless, the International Federation of Gynecology and Obstetrics (FIGO) and National Comprehensive Cancer Network (NCCN) still stated that P-Chem could be administered for HM under certain circumstances, in which the risk of postmolar GTN is much greater than normal or where reliable follow-up is not possible.
- #1https://pjmhsonline.com/index.php/pjmhs/article/view/4043
Prophylactic chemotherapy reduces the risk of development of gestational trophoblastic neoplasia as concluded by this study. […] No patient (0%) in group A developed gestational trophoblastic neoplasia while two patients (15.3%) in group B developed persistent vaginal bleeding and 1 patient (7%) developed choriocarcinoma involving the brain. […] However, only 16% of patients in high-risk molar category develop gestational trophoblastic neoplasia which means this will expose 84% patients to unnecessary chemotherapy. This will increase the cost of treatment also.
- #1 The effect of prophylactic chemotherapy on treatment outcome of postmolar gestational trophoblastic neoplasia | BMC Women’s Health | Full Texthttps://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-02134-w
Due to limited contributing data, drug resistance following P-chem was inadequately evaluated in previous study. […] Combined previous studies with our data, P-chem is not recommended because the similar therapeutic effects were obtained in both group and even at least one course of single agent would give adverse effect to patients who might not develop to GTN without P-chem. […] But, for patients who had already received P-chem, our results also indicated that P-chem dont contribute to drug resistance for postomar GTN treatment. […] In summary, we found that P-chem delayed the time to GTN diagnosis, but did not increase risk score or lead to subsequent drug resistance of postmolar GTN. […] But, P-Chem should be adopted in caution since it might have the potency to increase the severity of postmolar GTN.
- #1 Gestational Trophoblastic Neoplasia Treatment & Management: Medical Care, Surgical Care, Preventionhttps://emedicine.medscape.com/article/279116-treatment
The early diagnosis of GTN by the close follow-up of serum hCG levels after the evacuation of a hydatidiform mole results in therapeutic intervention prior to the development of high-risk disease. […] In patients with a history of gestational trophoblastic disease (GTD), measuring serum hCG levels 6 weeks after any subsequent pregnancy should be strongly considered to exclude occult GTN.
- #1 Update on gestational trophoblastic disease – O&G Magazinehttps://www.ogmagazine.org.au/24/3-24/update-on-gestational-trophoblastic-disease/
Gestational trophoblastic neoplasia (GTN) includes the malignant gestational trophoblastic disease conditions of persistent trophoblastic disease, invasive mole, choriocarcinoma, placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). Overall, GTN affects fewer than 1/40,000 pregnancies and the latter two conditions are extremely rare, affecting at most 1/50,000 pregnancies. […] CHM have a malignant potential of 20% and a 5% chance of distant metastatic spread. […] gestational trophoblastic disease management must therefore be timely and according to evidence-based guidelines. While recurrence rates for GTN are low at 0.62%, the risk of recurrence significantly increases without long-term follow up, supporting the need for ongoing care. […] Following confirmation of a CHM or PHM, it is essential that the patient is informed and advised of the importance of follow up, risk of persistent disease and the need to avoid further pregnancy until advised otherwise.
- #1 Update on gestational trophoblastic disease – O&G Magazinehttps://www.ogmagazine.org.au/24/3-24/update-on-gestational-trophoblastic-disease/
Patients should be counselled to avoid pregnancy for at least one year following any kind of GTN and treatment and support should be given to facilitate contraception choices. […] A woman can be reassured that the risk of gestational trophoblastic disease recurrence is only 1% in her subsequent pregnancy after a single molar pregnancy, but is closer to 25% if she has had two complete molar pregnancies. […] Women are therefore recommended to have an early ultrasound scan in any subsequent pregnancy to confirm a viable, non-molar pregnancy.
- #1 Molar pregnancy – Symptoms and causes – Mayo Clinichttps://www.mayoclinic.org/diseases-conditions/molar-pregnancy/symptoms-causes/syc-20375175
Persistent GTN is usually treated with chemotherapy. Another treatment possibility is removal of the uterus, also known as hysterectomy. […] If you’ve had a molar pregnancy, talk to your pregnancy care provider before trying to get pregnant again. You might want to wait six months to one year. The risk of having another molar pregnancy is low, but it’s higher once you’ve had a molar pregnancy. […] During future pregnancies, a care provider may do early ultrasounds to check your condition and make sure the baby is developing.
- #1https://irispublishers.com/accs/fulltext/chemotherapeutic-prevention-of-choriocarcinoma-developed-in-persistent-trophoblastic-disease-after-hydatidiform-mole.ID.000513.php
The author intended to prevent choriocarcinoma (Ch-C) with MTX chemotherapy. […] Ch-C prevention was tried in 1960s in Kyushu University Department of Obstetrics and Gynecology, by the administration of MTX generally for 70mg per-oral in post molar cases within 3 weeks after the mole. […] The hCG might be originated from trophoblasts remained in patients body after hydatid mole, because an endometrial specimen revealed remained trophoblasts, namely, hCG was sensitive marker of trophoblastic diseases. […] Malignant trophoblastic disease was prevented by the MTX therapy, actually, no choriocarcinoma developed after the MTX course in 107 cases of MTX treatment in this study. […] The most important point to prevent gestational choriocarcinoma is MTX treatment of persistent trophoblastic disease after the hydatidiform mole. […] Molar pregnancy is correctly diagnosed 2 weeks after the doubtful ultrasound examination. Let us diagnose hydatidiform mole correctly with ultrasound to get the chance to prevent choriocarcinoma after the mole.
- #1 SGO, FWC, and GOG-F* Communique: Considerations When Treating Gestational Trophoblastic Neoplasia in the Setting of a Methotrexate Shortage | Society of Gynecologic Oncologyhttps://www.sgo.org/news/drugshortage3/
Gestational trophoblastic neoplasia (GTN) comprises the following subtypes: invasive mole, choriocarcinoma, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT). […] GTN is stratified as low-risk or high-risk disease by the World Health Organization (WHO) scoring system based on the risk of disease progression and resistance to single-agent chemotherapy. […] When methotrexate is in short supply, it should be preserved for curative intent treatment in patients with high-risk GTN (e.g. WHO score 7 or WHO score of 5-6 with additional high-risk features) or for the treatment of patients with low-risk GTN who did not respond to, relapsed from, or had an allergic reaction to single-agent treatment with dactinomycin. […] Cure is possible with this regimen; therefore, methotrexate should be preserved for curative intent treatment in patients with high-risk GTN.
- #1 Diagnosis and Management of Gestational Trophoblastic Disease | SpringerLinkhttps://link.springer.com/10.1007/978-3-031-14881-1_11
Ayhan A, Ergeneli MH, Yce K, Yapar EG, Kisnisci AH. Effects of prophylactic chemotherapy for postmolar trophoblastic disease in patients with complete hydatidiform mole. Int J Gynaecol Obstet. 1990;32:3941. […] Uberti EM, Diestel MC, Guimares FE, De Npoli G, Schmid H. Single-dose actinomycin D: efficacy in the prophylaxis of post-molar gestational trophoblastic neoplasia in adolescents with high-risk hydatidiform mole. Gynecol Oncol. 2006;102:32532. […] Uberti EM, Fajardo MC, da Cunha AG, Rosa MW, Ayub AC, Graudenz MS, Schmid H. Prevention of postmolar gestational trophoblastic neoplasia using prophylactic single bolus dose of actinomycin D in high-risk hydatidiform mole: a simple, effective, secure and low-cost approach without adverse effects on compliance to general follow-up or subsequent treatment. Gynecol Oncol. 2009;114:299305. […] van Trommel NE, Massuger LF, Verheijen RH, Sweep FC, Thomas CM. The curative effect of a second curettage in persistent trophoblastic disease: a retrospective cohort survey. Gynecol Oncol. 2005;99:613.
- #1 Gestational Trophoblastic Disease | Doctorhttps://patient.info/doctor/gestational-trophoblastic-disease
Prophylactic chemotherapy may reduce the risk of progression to GTN in women with complete moles who are at a high risk of malignant transformation. However, current evidence in favour of prophylactic chemotherapy is limited. […] Outcomes for women with GTN and GTD are better with ongoing management from GTD centres. The registration of affected women with a GTD centre represents a minimum standard of care.
- #2 SGO, FWC, and GOG-F* Communique: Considerations When Treating Gestational Trophoblastic Neoplasia in the Setting of a Methotrexate Shortage | Society of Gynecologic Oncologyhttps://www.sgo.org/news/drugshortage3/
Gestational trophoblastic neoplasia (GTN) comprises the following subtypes: invasive mole, choriocarcinoma, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT). […] GTN is stratified as low-risk or high-risk disease by the World Health Organization (WHO) scoring system based on the risk of disease progression and resistance to single-agent chemotherapy. […] When methotrexate is in short supply, it should be preserved for curative intent treatment in patients with high-risk GTN (e.g. WHO score 7 or WHO score of 5-6 with additional high-risk features) or for the treatment of patients with low-risk GTN who did not respond to, relapsed from, or had an allergic reaction to single-agent treatment with dactinomycin. […] Cure is possible with this regimen; therefore, methotrexate should be preserved for curative intent treatment in patients with high-risk GTN.
- #2 Gestational Trophoblastic Disease | MD Anderson Cancer Centerhttps://www.mdanderson.org/cancer-types/gestational-trophoblastic-disease.html
Gestational trophoblastic disease (GTD) is a group of rare tumors that develop from placental tissue. […] The only way to prevent GTD is not to become pregnant. […] However, if a woman does have risk factors its a good idea to discuss them with a health care provider. This may lead to more frequent monitoring during early pregnancy.
- #2 The effect of prophylactic chemotherapy on treatment outcome of postmolar gestational trophoblastic neoplasia | BMC Women’s Health | Full Texthttps://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-02134-w
P-chem was considered as an effective method to prevent malignant transformation of high-risk HM, after it was first introduced in 1966. […] An updated Cochrane Review in 2017 concluded that P-chem might reduce the risk of post-molar GTN to 38% in women with CHM who are at high risk of malignant transformation. […] However, P-chem cannot be recommended routinely for high risk HM nowadays, since it has been reported that P-chem might exert adverse effects on subsequent follow-up and treatment of postmolar GTN. […] As previous studies stated, P-chem might delay the time to diagnosis of GTN and increase the risk of subsequent drug resistance, but these effects were very uncertain due to the small samples and limited evidences. […] Nevertheless, the International Federation of Gynecology and Obstetrics (FIGO) and National Comprehensive Cancer Network (NCCN) still stated that P-Chem could be administered for HM under certain circumstances, in which the risk of postmolar GTN is much greater than normal or where reliable follow-up is not possible.
- #2https://irispublishers.com/accs/fulltext/chemotherapeutic-prevention-of-choriocarcinoma-developed-in-persistent-trophoblastic-disease-after-hydatidiform-mole.ID.000513.php
The author intended to prevent choriocarcinoma (Ch-C) with MTX chemotherapy. […] Ch-C prevention was tried in 1960s in Kyushu University Department of Obstetrics and Gynecology, by the administration of MTX generally for 70mg per-oral in post molar cases within 3 weeks after the mole. […] The hCG might be originated from trophoblasts remained in patients body after hydatid mole, because an endometrial specimen revealed remained trophoblasts, namely, hCG was sensitive marker of trophoblastic diseases. […] Malignant trophoblastic disease was prevented by the MTX therapy, actually, no choriocarcinoma developed after the MTX course in 107 cases of MTX treatment in this study. […] The most important point to prevent gestational choriocarcinoma is MTX treatment of persistent trophoblastic disease after the hydatidiform mole. […] Molar pregnancy is correctly diagnosed 2 weeks after the doubtful ultrasound examination. Let us diagnose hydatidiform mole correctly with ultrasound to get the chance to prevent choriocarcinoma after the mole.
- #2https://www.pjmhsonline.com/index.php/pjmhs/article/view/4043
Prophylactic chemotherapy reduces the risk of development of gestational trophoblastic neoplasia as concluded by this study. […] No patient (0%) in group A developed gestational trophoblastic neoplasia while two patients (15.3%) in group B developed persistent vaginal bleeding and 1 patient (7%) developed choriocarcinoma involving the brain. […] This will increase the cost of treatment also.
- #2 Gestational Trophoblastic Disease | Doctorhttps://patient.info/doctor/gestational-trophoblastic-disease
Prophylactic chemotherapy may reduce the risk of progression to GTN in women with complete moles who are at a high risk of malignant transformation. However, current evidence in favour of prophylactic chemotherapy is limited. […] Outcomes for women with GTN and GTD are better with ongoing management from GTD centres. The registration of affected women with a GTD centre represents a minimum standard of care.
- #2 Update on gestational trophoblastic disease – O&G Magazinehttps://www.ogmagazine.org.au/24/3-24/update-on-gestational-trophoblastic-disease/
Gestational trophoblastic neoplasia (GTN) includes the malignant gestational trophoblastic disease conditions of persistent trophoblastic disease, invasive mole, choriocarcinoma, placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). Overall, GTN affects fewer than 1/40,000 pregnancies and the latter two conditions are extremely rare, affecting at most 1/50,000 pregnancies. […] CHM have a malignant potential of 20% and a 5% chance of distant metastatic spread. […] gestational trophoblastic disease management must therefore be timely and according to evidence-based guidelines. While recurrence rates for GTN are low at 0.62%, the risk of recurrence significantly increases without long-term follow up, supporting the need for ongoing care. […] Following confirmation of a CHM or PHM, it is essential that the patient is informed and advised of the importance of follow up, risk of persistent disease and the need to avoid further pregnancy until advised otherwise.
- #2 Update on gestational trophoblastic disease – O&G Magazinehttps://www.ogmagazine.org.au/24/3-24/update-on-gestational-trophoblastic-disease/
Patients should be counselled to avoid pregnancy for at least one year following any kind of GTN and treatment and support should be given to facilitate contraception choices. […] A woman can be reassured that the risk of gestational trophoblastic disease recurrence is only 1% in her subsequent pregnancy after a single molar pregnancy, but is closer to 25% if she has had two complete molar pregnancies. […] Women are therefore recommended to have an early ultrasound scan in any subsequent pregnancy to confirm a viable, non-molar pregnancy.
- #2 Gestational Trophoblastic Neoplasia Treatment & Management: Medical Care, Surgical Care, Preventionhttps://emedicine.medscape.com/article/279116-treatment
The early diagnosis of GTN by the close follow-up of serum hCG levels after the evacuation of a hydatidiform mole results in therapeutic intervention prior to the development of high-risk disease. […] In patients with a history of gestational trophoblastic disease (GTD), measuring serum hCG levels 6 weeks after any subsequent pregnancy should be strongly considered to exclude occult GTN.
- #3 Update on gestational trophoblastic disease – O&G Magazinehttps://www.ogmagazine.org.au/24/3-24/update-on-gestational-trophoblastic-disease/
Gestational trophoblastic neoplasia (GTN) includes the malignant gestational trophoblastic disease conditions of persistent trophoblastic disease, invasive mole, choriocarcinoma, placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). Overall, GTN affects fewer than 1/40,000 pregnancies and the latter two conditions are extremely rare, affecting at most 1/50,000 pregnancies. […] CHM have a malignant potential of 20% and a 5% chance of distant metastatic spread. […] gestational trophoblastic disease management must therefore be timely and according to evidence-based guidelines. While recurrence rates for GTN are low at 0.62%, the risk of recurrence significantly increases without long-term follow up, supporting the need for ongoing care. […] Following confirmation of a CHM or PHM, it is essential that the patient is informed and advised of the importance of follow up, risk of persistent disease and the need to avoid further pregnancy until advised otherwise.
- #3 Gestational Trophoblastic Disease: Symptoms & Treatmenthttps://my.clevelandclinic.org/health/diseases/6130-gestational-trophoblastic-disease
There isnt a way to prevent gestational trophoblastic disease. […] Gestational trophoblastic disease is rare, but certain factors beyond your control may increase your risk. These factors include: Your age. People older than 35 or younger than 20 may be at higher risk for GTD. Having prior molar pregnancies. Strong family history of molar pregnancies.
- #3 The effect of prophylactic chemotherapy on treatment outcome of postmolar gestational trophoblastic neoplasia | BMC Women’s Health | Full Texthttps://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-02134-w
P-chem was considered as an effective method to prevent malignant transformation of high-risk HM, after it was first introduced in 1966. […] An updated Cochrane Review in 2017 concluded that P-chem might reduce the risk of post-molar GTN to 38% in women with CHM who are at high risk of malignant transformation. […] However, P-chem cannot be recommended routinely for high risk HM nowadays, since it has been reported that P-chem might exert adverse effects on subsequent follow-up and treatment of postmolar GTN. […] As previous studies stated, P-chem might delay the time to diagnosis of GTN and increase the risk of subsequent drug resistance, but these effects were very uncertain due to the small samples and limited evidences. […] Nevertheless, the International Federation of Gynecology and Obstetrics (FIGO) and National Comprehensive Cancer Network (NCCN) still stated that P-Chem could be administered for HM under certain circumstances, in which the risk of postmolar GTN is much greater than normal or where reliable follow-up is not possible.
- #3 Molar pregnancy – Symptoms and causes – Mayo Clinichttps://www.mayoclinic.org/diseases-conditions/molar-pregnancy/symptoms-causes/syc-20375175
Persistent GTN is usually treated with chemotherapy. Another treatment possibility is removal of the uterus, also known as hysterectomy. […] If you’ve had a molar pregnancy, talk to your pregnancy care provider before trying to get pregnant again. You might want to wait six months to one year. The risk of having another molar pregnancy is low, but it’s higher once you’ve had a molar pregnancy. […] During future pregnancies, a care provider may do early ultrasounds to check your condition and make sure the baby is developing.
- #3 The effect of prophylactic chemotherapy on treatment outcome of postmolar gestational trophoblastic neoplasia | BMC Women’s Health | Full Texthttps://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-02134-w
Due to limited contributing data, drug resistance following P-chem was inadequately evaluated in previous study. […] Combined previous studies with our data, P-chem is not recommended because the similar therapeutic effects were obtained in both group and even at least one course of single agent would give adverse effect to patients who might not develop to GTN without P-chem. […] But, for patients who had already received P-chem, our results also indicated that P-chem dont contribute to drug resistance for postomar GTN treatment. […] In summary, we found that P-chem delayed the time to GTN diagnosis, but did not increase risk score or lead to subsequent drug resistance of postmolar GTN. […] But, P-Chem should be adopted in caution since it might have the potency to increase the severity of postmolar GTN.
- #4https://www.pjmhsonline.com/index.php/pjmhs/article/view/4043
Prophylactic chemotherapy reduces the risk of development of gestational trophoblastic neoplasia as concluded by this study. […] No patient (0%) in group A developed gestational trophoblastic neoplasia while two patients (15.3%) in group B developed persistent vaginal bleeding and 1 patient (7%) developed choriocarcinoma involving the brain. […] This will increase the cost of treatment also.
- #4 Molar pregnancy – Symptoms and causes – Mayo Clinichttps://www.mayoclinic.org/diseases-conditions/molar-pregnancy/symptoms-causes/syc-20375175
Persistent GTN is usually treated with chemotherapy. Another treatment possibility is removal of the uterus, also known as hysterectomy. […] If you’ve had a molar pregnancy, talk to your pregnancy care provider before trying to get pregnant again. You might want to wait six months to one year. The risk of having another molar pregnancy is low, but it’s higher once you’ve had a molar pregnancy. […] During future pregnancies, a care provider may do early ultrasounds to check your condition and make sure the baby is developing.
- #5 Gestational Trophoblastic Disease Treatment (PDQ®) – NCIhttps://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq
Studies have shown that a single course of prophylactic dactinomycin or methotrexate can decrease the risk of a postmolar gestational trophoblastic disease (GTD). […] However, there is concern that chemoprophylaxis increases tumor resistance to standard therapy in the women who subsequently develop GTD. […] Therefore, this practice is generally limited to countries in which a large number of women do not return for follow-up.
- #5 Update on gestational trophoblastic disease – O&G Magazinehttps://www.ogmagazine.org.au/24/3-24/update-on-gestational-trophoblastic-disease/
Patients should be counselled to avoid pregnancy for at least one year following any kind of GTN and treatment and support should be given to facilitate contraception choices. […] A woman can be reassured that the risk of gestational trophoblastic disease recurrence is only 1% in her subsequent pregnancy after a single molar pregnancy, but is closer to 25% if she has had two complete molar pregnancies. […] Women are therefore recommended to have an early ultrasound scan in any subsequent pregnancy to confirm a viable, non-molar pregnancy.