Surgical Procedures: Surgery and Staging for Gestational Trophoblastic Neoplasia (GTN)
What is Gestational Trophoblastic Neoplasia?
At times, pregnancies result in a tumor being made rather than a fetus being made. This rare condition is called gestational trophoblastic disease or GTD. Often, it is not cancerous, yet there are some forms of the condition in which cancer can develop (gestational trophoblastic neoplasia).
Cells have certain functions and jobs. During conception the sperm and the egg are responsible for fertilization. The trophoblastic cells are responsible for implanting the embryo into the uterine wall and forming the placenta. In rare cases, there are problems during conception, leading to an abnormal pregnancy and ultimately tumor formation. These gestational tumors are classified by type and include:
- Complete and partial hydatidiform moles (molar pregnancies).
- Invasive moles.
- Placental-site trophoblastic tumors.
- Epithelioid trophoblastic tumors.
In these cases, the pregnancy is abnormal and not viable or able to grow and survive. On ultrasound, the image looks like a grape like cluster of fluid filled villi, without the presence of a fetus. In some very rare instances, a woman can have a molar and normal pregnancy at the same time.
When an egg without any maternal DNA is fertilized by sperm, this is called a complete molar pregnancy, as there is only the presence of paternal DNA. In cases where 2 sperm fertilize a normal egg, this is called a partial molar pregnancy. Neither pregnancy results in normal fetal development of the fertilized egg.
While these molar pregnancies are typically not cancer, some may continue to grow and become a cancerous condition. Some molar pregnancies grow through the innermost uterine layer into the muscle and can spread to other parts of the body, however, these are not considered a cancer.
As stated, some of these molar pregnancies are cancerous, including choriocarcinoma, placental-site trophoblastic tumors, and epithelioid trophoblastic tumors.
Gestational choriocarcinoma is a fast growing tumor which has the potential to spread to other parts of the body including the brain, lungs, liver, kidney, spleen, intestines, pelvis and/or vagina. The cells that were to become the placenta, start to invade through the muscular layer of the uterine wall and into the blood vessels that surround the uterus. While most cases of choriocarcinoma develop from complete molar pregnancies, there are some women who experience the condition following delivery, after a miscarriage, ectopic pregnancy, abortion or other tumors of the genital tract.
Placental-site tumors are rare and can develop months to years following a pregnancy at the site where the placenta attached to the uterine wall. As in choriocarcinoma, these tumors invade through the muscular wall of the uterus and into the blood vessels surrounding the uterus. When the cancer spreads (not typical), it can be found in other areas of the body including the lungs, pelvis and lymph nodes.
Epithelioid trophoblastic tumors can also be seen following delivery. This is a slow growing cancer which can take several years to diagnose. It can, at times, grow into the cervix and spread to the lungs.
Staging of GTD
Once a diagnosis of malignant gestational trophoblastic disease or neoplasia has been made or if there is suspicion that the disease is present, your healthcare provider will order testing to determine the stage of cancer, which may include:
Physical Exam: This is a general physical exam, including a pelvic exam and Pap smear. Your medical history and symptoms will also be reviewed and evaluated.
Imaging: Radiology tests can look inside your body to look at the cancer and determine if it has spread. These tests can include:
Serum Blood Work: Blood samples may be taken to check chemistry studies and beta human chorionic gonadotropin (β-hCG).
Other Tests: You may be asked to provide a urine sample to evaluate for certain abnormalities, as well as the presence of beta human chorionic gonadotropin (β-hCG). You may also need a lumbar puncture to obtain a sample of your cerebrospinal fluid to check for cancer.
Gestational trophoblastic neoplasia (the malignant form of gestational trophoblastic disease) spreads to other parts of the body through the tissue, lymph and blood systems. The stages of gestational trophoblastic neoplasia range from stage 1 through stage 4.
Most often, it may be recommended that those with gestational trophoblastic neoplasia undergo surgery. The surgical procedure recommended will depend on several factors and your surgeon will discuss with you in detail the recommended procedure based on your unique situation.
Surgical Procedures Used to Treat GTD
Common surgical procedures to treat gestational neoplasia include:
- Dilation and curettage with suction evacuation: This surgical method is often used for women with a molar pregnancy. Also called a D&C, this will remove the tissue lining the uterus. The surgeon will scrape the inner wall of the uterus and use a vacuum suction to remove any abnormal tissue within the uterus.
- Hysterectomy: During this procedure, the uterus and cervix are removed and in some cases one or both ovaries and fallopian tubes.
What are the risks associated with surgery for Gestational Trophoblastic Neoplasia?
There are risks with surgery used to treat gestational trophoblastic neoplasia. Some of the risks and side effects may include:
- Reaction to anesthesia.
- Blood clots.
- Wound breakdown.
- Damage to surrounding organs such as the urinary tract, bladder, rectum or other.
- Menopause with ovary removal.
D&C specific risks include:
- Uterine perforation.
- Damage to the cervix.
- Uterine scarring (Asherman’s Syndrome) which can cause painful menses, cessation of menses, miscarriages and infertility.
What is recovery like?
Recovery and hospital stay after the surgery will depend on the surgical procedure you have had.
You will be told how to care for your surgical incisions and will be given any other instructions before leaving the hospital.
Your medical team will discuss with you the medications you will be taking, such as those for pain, blood clot, infection, constipation prevention and/or other conditions.
Your healthcare provider will discuss your particular activity restrictions and nutritional needs you may have depending on the surgery you have had.
How can I care for myself?
You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.
Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.
There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation.
Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.
- Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.
This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.
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Mt. Sinai. Choriocarcinoma. Retrieved from http://www.mountsinai.org/health-library/diseases-conditions/choriocarcinoma on January 17, 2017
ACS. Treatment of gestational trophoblastic disease by type and stage. 2017. Retrieved from http://www.cancer.org/cancer/gestationaltrophoblasticdisease/detailedguide/gestational-trophoblastic-disease-treating-by-stage
Mayo Clinic Staff. Abdominal Hysterectomy. 2019. Retrieved from http://www.mayoclinic.org/tests-procedures/abdominal-hysterectomy/details/risks/cmc-20178861