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Types of Cancer > Gynecologic Cancers > Gestational Trophoblastic Disease and Choriocarcinoma > NCI Resources
NCI/PDQ® Health professionals: Gestational Trophoblastic Tumors Treatment (PDQ®)
Affiliation:
National Cancer Institute
Last Modified: December 5, 2007
TABLE OF CONTENTS
Purpose of This PDQ® Summary
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This PDQ® cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of gestational trophoblastic tumors. This summary is reviewed regularly and updated as necessary by the PDQ® Adult Treatment Editorial Board.
Information about the following is included in this summary:
- Prognostic factors.
- Cellular classification.
- Staging.
- Treatment options by cancer stage.
This summary is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Some of the reference citations in the summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ® Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations. Based on the strength of the available evidence, treatment options are described as either standard or under clinical evaluation. These classifications should not be used as a basis for reimbursement determinations.
This summary is available in a patient version, written in less technical language, and in Spanish.
Gestational trophoblastic tumors (GTTs) are rare but highly curable tumors arising from the products of conception in the uterus. The prognosis for cure of patients with GTTs is good even when the disease has spread to distant organs, especially when only the lungs are involved. The probability of cure depends on the following:
- Histologic type (mole, invasive mole, or choriocarcinoma).
- Extent of spread of the disease.
- Level of the human chorionic gonadotropin (hCG) titer.
- Duration of disease from the initial pregnancy event to start of treatment.
- Specific sites of metastases.
- Nature of antecedent pregnancy.
- Extent of prior treatment.
Selection of treatment depends on these factors plus the patient's desire for future pregnancies. The hCG, produced normally during pregnancy, is abnormally elevated in the blood and urine of patients with this group of diseases and is a sensitive marker to indicate the presence or absence of disease before, during, and after treatment.
The most common antecedent pregnancy is that of a hydatidiform mole, usually a genetic disorder of pregnancy in which only placental-like tissue is present. The patient will present with abnormal bleeding from onset of pregnancy and may have a uterus which is much larger than expected. Sonography is the preferred method of diagnosis, and suction dilation and curettage (D & C) is the preferred method of evacuation. Of utmost importance is careful follow-up with serum beta hCG (BhCG) weekly until less than 100 mIU/mL and then every 2 weeks. The patient should have a careful pelvic examination every other week and a chest x-ray every 4to 6 weeks. Once the titer of serum BhCG has fallen to normal levels, these two examinations need no longer be done; however, BhCG titers need to be repeated every 2 weeks for 3 months, then monthly for 3 months, then every 2 months for 6 months, then every 6 months for 3 years. Each patient should be counseled in the use of a reliable birth control method. Any patient who develops an increasing level of serum BhCG, a plateau of the BhCG over 3 weeks, or persistent elevation of BhCG after 16 weeks of follow-up should be considered as having gestational trophoblastic neoplasia and should undergo the appropriate work-up and treatment. Similarly, any patient who develops metastatic disease during follow-up should be staged and undergo treatment.
Choriocarcinoma most commonly follows a molar pregnancy but can follow a normal pregnancy, ectopic pregnancy, or abortion, and should always be considered when a patient has continued vaginal bleeding in the postdelivery period. Other common signs include bizarre neurologic symptoms in a female within the reproductive age group and asymptomatic lesions on routine chest x-ray.
Cellular Classification
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Gestational trophoblastic tumors may be classified as follows: 1
- Hydatidiform mole.
- Invasive mole (chorioadenoma destruens).
- Choriocarcinoma.
- Placental-site trophoblastic tumor.
Hydatidiform mole
Hydatidiform mole is defined as products of conception that lack an intact fetus and show gross cyst-like swellings of the chorionic villi caused by an accumulation of fluid. There is disintegration and loss of blood vessels in the villous core.
Invasive mole
Invasive mole (chorioadenoma destruens) is a locally invasive, rarely metastatic lesion characterized microscopically by trophoblastic invasion of the myometrium with identifiable villous structures. Microscopically, this lesion is characterized by hyperplasia of cytotrophoblastic and syncytial elements and persistence of villous structures.
Choriocarcinoma
Choriocarcinoma is a malignant tumor of the trophoblastic epithelium. Uterine muscle and blood vessels are invaded with areas of hemorrhage and necrosis. Columns and sheets of trophoblastic tissue invade normal tissues and spread to distant sites, the most common of which are lungs, brain, liver, pelvis, vagina, spleen, intestines, and kidney.
Placental-site trophoblastic tumor
Placental-site trophoblastic disease is an extremely rare tumor arising from the placental implantation site and resembles an exaggerated form of syncytial endometritis. Trophoblastic cells infiltrate the myometrium, and there is vascular invasion. Human placental lactogen is present in the tumor cells, while immunoperoxidase staining for human chorionic gonadotropin (hCG) is positive in only scattered cells, and serum hCG is relatively low. 1
References:
- Lurain JR: Gestational trophoblastic tumors. Semin Surg Oncol 6 (6): 347-53, 1990. [PUBMED Abstract]
Hydatidiform mole (molar pregnancy) is disease limited to the uterine cavity.
Invasive mole (chorioadenoma destruens) is a locally invasive, rarely metastatic lesion.
The FIGO staging system is as follows: 1
- Stage I: Disease confined to the uterus
- Stage IA: Disease confined to the uterus with no risk factors.
- Stage IB: Disease confined to the uterus with one risk factor.
- Stage IC: Disease confined to the uterus with two risk factors.
- Stage II: Gestational trophoblastic tumor (GTT) extends outside of the uterus but is limited to the genital structures (ovary, tube, vagina, and broad ligament)
- Stage IIA: GTT involving genital structures without risk factors.
- Stage IIB: GTT extends outside of the uterus but is limited to genital structures with one risk factor.
- Stage IIC: GTT extends outside of the uterus but is limited to the genital structures with two risk factors.
- Stage III: GTT extends to the lungs, with or without known genital tract involvement
- Stage IIIA: GTT extends to the lungs, with or without genital tract involvement and with no risk factors.
- Stage IIIB: GTT extends to the lungs, with or without genital tract involvement and with one risk factor.
- Stage IIIC: GTT extends to the lungs, with or without genital tract involvement and with two risk factors.
- Stage IV: All other metastatic sites
- Stage IVA: All other metastatic sites, without risk factors.
- Stage IVB: All other metastatic sites, with one risk factor.
- Stage IVC: All other metastatic sites, with two risk factors.
The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification. 1
- Primary tumor (T)
- TX: Primary tumor cannot be assessed
- T0: No evidence of primary tumor
- T1: Disease limited to uterus
- T2: Disease outside of uterus but is limited to genital structures (ovary, tube, vagina, and broad ligaments)
- Distant metastasis (M)
- M0: No clinical metastasis
- M1a: Lung metastasis
- M1b: All other distant metastasis
Risk factors affecting staging include the following:
- Human chorionic gonadotropin (hCG) greater than 100,000 IU/24-hour urine.
- The detection of disease more than 6 months from termination of the antecedent pregnancy.