Diagnosis and management of gestational trophoblastic disease: 2021 update

Abstract

Gestational trophoblastic disease (GTD) arises from abnormal placenta and is composed of a spectrum of premalignant to malignant disorders. Changes in epidemiology of GTD have been noted in various countries. In addition to histology, molecular genetic studies can help in the diagnostic pathway. Earlier detection of molar pregnancy by ultrasound has resulted in changes in clinical presentation and decreased morbidity from uterine evacuation. Follow‐up with human chorionic gonadotropin (hCG) is essential for early diagnosis of gestational trophoblastic neoplasia (GTN). The duration of hCG monitoring varies depending on histological type and regression rate. Low‐risk GTN (FIGO Stages I–III: score <7) is treated with single‐agent chemotherapy but may require additional agents; although scores 5–6 are associated with more drug resistance, overall survival approaches 100%. High‐risk GTN (FIGO Stages II–III: score ≥7 and Stage IV) is treated with multiagent chemotherapy, with or without adjuvant surgery for excision of resistant foci of disease or radiotherapy for brain metastases, achieving a survival rate of approximately 90%. Gentle induction chemotherapy helps reduce early deaths in patients with extensive tumor burden, but late mortality still occurs from recurrent treatment‐resistant tumors.

Case Report: First-Line Immune Checkpoint Inhibitor Plus Chemotherapy for Oral Metastasis in a Patient with Ultra High-Risk Gestational Choriocarcinoma

“… 27 Notably, for cases at ultra high-risk, it is recommended to begin with gentle induction chemotherapy prior to standard multi-drug combinations, which may result in organ failure and even death. 28 In recent years, the success of PD-1/PD-L1 blockade, a high-efficiency and minimally toxic ICI, in the treatment of multiple cancer types has heralded the beginning of a novel era in tumour therapy. 29 ICIs can induce durable clinical responses that often transform into an overall survival benefit for malignancies.…”

Recurrent Metastatic Choriocarcinoma Responsive to Etoposide and Cisplatin with Etoposide, Methotrexate, and Dactinomycin: A Case Report

“… 6 The choice of chemotherapy treatment is based on the combination of the Federation Internationale de Gynecologie et d'Obstetrique (FIGO) anatomic staging and the World Health Organisation (WHO) prognostic scoring system based on risk factors. 7 According to this scoring system, tumours are classified into two categories: low-risk GTN, if the score is ≤6 and FIGO Stage I-III; and high-risk, if the score is ≥7 regardless of stage and in all cases of FIGO Stage IV disease. The score is associated with the risk of developing chemoresistance to singleagent chemotherapy, and thus guides the choice of first-line chemotherapy.…”

Current Evidence on Immunotherapy for Gestational Trophoblastic Neoplasia (GTN)

“…In Europe, MTX is preferred over ActD because it causes fewer side effects (alopecia, nausea, vomiting and it is less myelosuppressive). There are several different chemotherapy regimens for MTX, but the most commonly used is the MTX eight-day regimen repeated every 14 days: a 50 mg total dose intramuscularly administered on days 1–3–5–7 with 15 mg of FA rescue given 24 h later on (days 2–4–6–8) [ 18 , 19 , 20 ]. Treatment for low-risk disease should be continued for 6 weeks after hCG normalization (three cycles of consolidation) [ 5 ].…”

“…Notably, these treatments are associated with short- and long-term toxicities, affecting quality of life and psychological health [ 28 ]. In addition, about 0.5–5% of patients treated with multiagent chemotherapy for high-risk GTN become chemoresistant [ 18 ]. For patients with high-risk GTN, initiation of polychemotherapy can cause rapid tumor lysis with severe bleeding, metabolic acidosis, myelosuppression and multiorgan failure, leading to death [ 18 ].…”