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Query: UMLS:C0027627 (metastases)
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The estimated incidence of twin pregnancy consisting of hydatidiform mole and a coexisting fetus is 1 per 22,000-100,000 pregnancies. Since 1965, nine patients with this entity have been treated at the New England Trophoblastic Disease Center (NETDC), Boston. One patient had a partial hydatidiform mole coexisting with a normal placenta and fetus. The other eight patients had twin pregnancies with a complete hydatidiform mole (CHM) and coexisting fetus. We compared the clinical outcomes in these 8 patients and 14 additional published case reports of multiple gestations composed of CHM and coexisting fetuses with a group of 71 patients with singleton CHM treated at NETDC. Twelve of the 22 patients (55%) with CHM and coexisting fetuses developed persistent gestational trophoblastic tumor, requiring chemotherapy. Five of these patients developed metastases requiring multiple cycles of chemotherapy to achieve remission. The presenting symptoms of multiple conception with CHM and coexisting fetuses were similar to those in patients with a singleton conception and complete mole. However, as compared to singleton CHM, patients having a multiple conception with CHM and coexisting fetuses were diagnosed at a later gestational age, had higher preevacuation beta-human chorionic gonadotropin levels and had a greater propensity to develop persistent tumor. These data indicate that patients with multiple conceptions consisting of CHM and coexisting fetuses are at high risk of developing persistent gestational trophoblastic tumor.
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PMID:Clinical features of multiple conception with partial or complete molar pregnancy and coexisting fetuses. 803 69

Gestational trophoblastic disease is a term that describes a group of tumors that share several characteristics as follows: (1) they arise in fetal chorion, (2) they produce human chorionic gonadotropin (hCG), and (3) they respond extremely well to chemotherapy. Although rare, they have received a disproportionate amount of attention because they were the first metastatic solid tumor to be cured using chemotherapy. Also, hCG was the first reliable tumor marker. Finally, because they arise in fetal tissue, they have the potential for a strong immune response against paternal antigens in the tumor. This potential for immunologic rejection was thought initially to explain the success of chemotherapy in this disease. The early detection of gestational trophoblastic disease is successful in patients who have had a hydatidiform mole as the pregnancy event that begins the process but unsuccessful in the early detection of the development of choriocarcinoma after a normal term delivery, abortion (spontaneous or elective), or ectopic pregnancy. Surveillance after evacuation of a molar pregnancy (whether complete or a partial mole) consists of regular evaluation of hCG production and the detection of metastatic disease. However, the development of gestational choriocarcinoma after term pregnancy or an abortion (no molar tissue can develop as a consequence of these pregnancies) is detectable only by signs or symptoms of metastatic disease in any of the many organs to which this tissue can spread. Unlike most staging classifications in gynecologic cancers, which are based on histologic findings and tumor location, the classification used in gestational trophoblastic disease stresses other features that are more useful for treatment selection. Both the National Institutes of Health and the World Health Organization classifications emphasize the importance of recognizing factors that predict the likelihood of a tumor responding to chemotherapy. Currently available treatment can cure all patients except those who are in the very high-risk group, which usually is characterized by metastasis to the brain or liver or a history of prior chemotherapy. Even in this category, approximately 80% of patients are curable.
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PMID:Diagnosis and management of gestational trophoblastic disease. 838 9

A 28-year-old Caucasian woman who had a missed abortion was subsequently found to have a partial hydatidiform mole. Despite twice repeated suction and evacuation of the uterus, her serum beta-human chorionic gonadotropin levels remained persistently elevated. Angiography demonstrated a large vascular uterine tumour and two small metastases in the liver. The patients was classified as having gestational trophoblastic disease stage IV. She responded well to multiagent chemotherapy. The role of imaging in the section of gestational trophoblastic disease is discussed.
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PMID:Clinics in diagnostic imaging (9). Gestational trophoblastic disease with liver metastases. 878 25

Choriocarcinoma most commonly follows a molar pregnancy, but it may develop after any gestational event. If choriocarcinoma follows a term pregnancy, it is associated with an unfavorable outcome and a 60% survival rate. A 33 year female who had delivered a normal girl 4 months before, presented with a nodule on the scalp behind the right ear. The pathologic diagnosis was compatible with metastatic choriocarcinoma. This tumor did not respond to chemotherapy, and she died a year later of multiple liver and pulmonary metastases. The development of a choriocarcinoma following a full term pregnancy is associated with a poor prognosis. We suggest that patients who do not achieve a clinical or serological remission after EMA-CO treatment be considered for high dose chemotherapy such as transplant.
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PMID:Unusual presentation of a metastatic choriocarcinoma following a full term pregnancy: a case report. 885 2

Choriocarcinoma usually occurs following molar pregnancy and is uncommon following normal pregnancy. This report describes a case of choriocarcinoma in a Congolese woman 2 months after normal full-term birth of her first child. Diagnosis was suspected based on ultrasonographic findings and massive elevation of plasma beta HCG and confirmed by histologic study of placental specimens. The disease progressed rapidly despite chemotherapy and death occurred 7 months after confirmed diagnosis with multiple metastases. The incidence of choriocarcinoma after normal pregnancy is estimated to be only 0.18 cases per 1000 pregnancies in Black Africa. This low incidence increases the likelihood of late diagnosis and increases the severity of prognosis. The poor availability of antitumor drugs is a major handicap for management of these patients in developing countries. Under these conditions, the authors recommend immediate hysterectomy if metastasis has not occurred.
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PMID:[Choriocarcinoma after a normal pregnancy. A case report observed in Brazzaville]. 892 80

Gestational trophoblastic disease is a common gynaecological problem in Malaysia. The incidence of molar pregnancy is 2.8 per 1000 deliveries, being more common amongst the Chinese. The preferred method of evacuation is suction curettage; complete evacuation of the uterus was not achieved at the first attempt in 25 per cent of cases. Partial moles in our centre comprised 30 per cent of all moles. This is potentially malignant and needs follow-up for a complete mole. In the management of an invasive mole, chemotherapy should not be withheld in the presence of metastases and failure of regression of hCG. The role of prophylactic hysterectomy and prophylactic chemotherapy in the management of molar pregnancy is discussed "Selective preventive chemotherapy" in patients at "risk" appears appropriate. Chemotherapy remains the main modality of treatment for gestational trophoblastic tumours (GTT). We categorised our patients into low, medium and high-risk groups; survivals were 100, 98, and 61.7 percent respectively. These patients when categorised according to FIGO staging had survivals of 100, 80, 78.6 and 68.2 per cent respectively for stages 1, 2, 3 and 4 respectively. The reasons for the poor survival in the 'high-risk' group are discussed. Colour doppler blood flow studies are now being carried out; its role needs further evaluation. Surgery and radiotherapy have only a limited role in the management of these cases.
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PMID:The management of gestational trophoblastic disease in developing countries such as Malaysia. 983 22

Gestational trophoblastic diseases are a heterogenous group of conditions ranging from the benign hydatidiform mole to the malignant choriocarcinoma. Optimal therapy in this group of diseases rest in the correct diagnosis, assessing their risk for malignant behavior using prognostic scoring systems and administering appropriate treatment. Their rarity makes it imperative that these patients are treated in special centres by experts. Benign moles are treated surgically with evacuation of the uterus or hysterectomy. In malignant gestational trophoblastic disease, chemotherapy is the treatment of choice; single agent for non-metastatic and low-risk metastatic disease and combination chemotherapy for high-risk metastatic disease. Judicious use of surgery and radiotherapy in these cases will improve the survival rate. With appropriate treatment, the cure rates approach 100% in the low-risk group and 80% to 85% in the high risk group.
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PMID:Optimal treatment in gestational trophoblastic disease. 991 43

Gestational trophoblastic disease (GTD) is a spectrum of rare neoplastic conditions that are highly curable, even in the presence of widely metastatic disease. These diseases vary from partial hydatidiform mole, which rarely metastasizes and infrequently requires treatment with chemotherapy, to choriocarcinoma, for which multi-agent chemotherapy is the standard treatment. Much has been learned regarding the epidemiology of this disease, and our understanding of the genetics underlying GTD is rapidly expanding. As technology such as ultrasonography and sensitive tests for beta-human chorionic gonadotropin have evolved, the presentation of molar pregnancy has significantly changed, although the incidence of persistent GTD has not decreased. This review highlights these recent advancements in the epidemiology, genetics, diagnosis, and treatment of gestational trophoblastic disease.
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PMID:Gestational trophoblastic diseases: new standards for therapy. 1097 58

Fertility and gynaecological malignancies have an important relationship. A clear inverse relationship exists between family size and the incidence of ovarian and endometrial cancer. Current methods of fertility control have an influence on subsequent development of various gynaecological malignancies. A slightly increased risk of breast cancer has been reported in current users and those who had used hormonal contraceptives (OCs) within 10 years; this risk declined with time and disappeared after 10 years. Women who started OC before age 20 had a higher relative risk; the disease did not spread beyond the breast in the majority. Most studies found OC to reduce the risk of ovarian and endometrial cancer. The relative risks of squamous cell carcinoma and adenomatous carcinoma of the cervix have been reported to be 1.3 and 1.5, respectively in ever-users of OCs; however, the aetiology of cervical cancer is multifactoral. Several reports suggest the beneficial effect of tubal ligation and breast feeding in reducing the risk of ovarian cancer. Therapy of gynaecological malignancies may have an influence on subsequent fertility. Amenorrhoea developing after treatment of hydatidiform mole may be due to choriocarcinoma, recurrent mole or a normal pregnancy. Choriocarcinoma can also develop after a partial mole. The risk of fetal teratogenicity from chemotherapy is present only if conception occurs during or immediately following the treatment cycles. Fertility is not impaired following chemotherapy. Successful pregnancies have occurred in women who have had widespread GTD including cerebral metastases. In the young patient with gynaecological malignancy preservation of fertility is possible. Fertility-sparing surgery may be safe in early ovarian epithelial cancers and even in advanced germ cell tumours. Recently, the fertility-sparing surgery of radical trachelectomy and pelvic lymphadenectomy has been carried out for early invasive cervical cancer in young women. Gynaecological cancer occurring in pregnancy is uncommon; it presents the clinician with a difficult situation to manage. In most instances the cancer is treated as though the patient is not pregnant; the timing and mode of delivery needs individualization. The overall prognosis for breast cancer complicating pregnancy is poor. Survival in cervical cancers diagnosed antepartum is similar to the non-pregnant patient. Ovarian cancer in pregnancy has a good prognosis because of the early stage at diagnosis.
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PMID:Chien-Tien Hsu Memorial Lecture. Fertility and gynaecologic malignancies. 1133 Jul 24

Gestational trophoblastic disease consists of a broad spectrum of conditions ranging from an uncomplicated partial hydatidiform molar pregnancy to stage IV choriocarcinoma with cerebral metastases. Fortunately, with the advent of combination chemotherapy, the patient with advanced-stage disease has a significant chance of achieving complete remission. In addition, several studies have demonstrated that patients with a history of gestational trophoblastic neoplasia do not experience an increased risk of complications with future pregnancies. Patients who have undergone chemotherapy do not seem to experience an increase in the risk for congenital anomalies in their offspring. Patients with a history of hydatidiform molar pregnancy should be advised that they are at increased risk of future molar pregnancies, with a risk of 1% in subsequent gestations after one molar pregnancy and a risk as high as 23% after two molar gestations. Although patients should be reassured regarding their reproductive future, they should be advised to seek prompt medical attention once gestation is suspected so that an early work-up can be initiated if pregnancy is confirmed.
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PMID:Gestational trophoblastic disease. 1176 53


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