Surgery including fertility-sparing treatment of GTD

Abstract

Gestational trophoblastic disease (GTD) consist of a spectrum of diseases, including hydatidiform moles, invasive mole, metastatic mole, choriocarcinoma, placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). GTD are relatively uncommon disease occurring in women of reproductive age, with high cure rates. Primary treatment of hydatidiform moles includes uterine evacuation, followed by close monitoring of serial hCG levels to detect for post-molar gestational trophoblastic neoplasia (GTN). In patients with GTN, the main therapy consists of chemotherapy, although some surgical procedures are important in selected patients in order to achieve cure. Hysterectomy is the mainstay treatment for PSTT or ETT, and may be considered in selected patients for management of hydatidiform mole and malignant GTN especially in chemoresistant disease. Resection of metastatic lesions such as in the lung or brain can be considered in selected patients with isolated chemoresistant tumour. Surgical treatment of GTD will be discussed in this chapter.

Advances in diagnostics and management of gestational trophoblastic disease

“…26 Most common complications are excessive bleeding, uterine perforation, and respiratory distress syndrome. 27 Respiratory distress syndrome may be caused by trophoblastic embolization, high-output congestive heart failure caused by anaemia, hyperthyroidism, preeclampsia, or iatrogenic fluid overload. 7 At the end of suction D&C, the evacuated tissues should be inspected and sent for histological examination.…”

“…7 At the end of suction D&C, the evacuated tissues should be inspected and sent for histological examination. 27 Uterine evacuation by medication only method is not recommended due to high failure rates, risk of haemorrhage, increased risk of post-molar GTN and increased maternal morbidity. 7,23 Hysterectomy with salpingectomy is an alternative method to suction D&C if molar pregnancy is presumed and childbearing is complete.…”

“…Hysterectomy eliminates the possibility of local myometrial invasion as a source of persistent disease and hence reduces the need for subsequent chemotherapy. 7,27,28 Usually the adnexa may be preserved, even if theca lutein cysts are present. Theca lutein cysts usually regress over few months after uterine evacuation as hCG levels decrease.…”

“…Theca lutein cysts usually regress over few months after uterine evacuation as hCG levels decrease. 7,27 Hysterectomy, compared to uterine evacuation, has a significant advantage in preventing post-molar GTN with an approximately 80% reduction in risk. 26,28 Because hysterectomy does not eliminate the possibility of post molar gestational trophoblastic neoplasia these patients should also be monitored postoperatively with serial hCG measurements.…”

“…22 Following evacuation of molar pregnancy, monitoring of hCG levels postoperatively is mandatory to identify and manage post-molar GTN. 27 HCG is used as a marker in post molar monitoring because of the correlation between hCG levels and trophoblastic tumour burden, allowing early diagnosis and treatment of GTN. 29 The mean time to hCG normalization in case of partial HM is 6 weeks and in case of complete HM 7 weeks.…”