Types of Treatment for Gestational Trophoblastic Disease

Executive Summary

Treatment (gestational trophoblastic disease) recommendations depend upon the size, grade and type of tumor, metastasis, possible side effects, and patient’s preferences and overall health. The common treatment for gestational trophoblastic disease involves surgery (Suction dilation and curettage (D&C), Hysterectomy- Simple and Supracervical) and chemotherapy (systemic chemotherapy, intramuscular (IM) injection (or shot), an intravenous (IV), and oral, use of drugs such as vincristine, methotrexate, etoposide, cyclophosphamide, dactinomycin, and cisplatin). Patients with high-risk metastatic disease are generally given combination chemotherapy with more than one drug involving EMA-CO and EMA-EP. Palliative care includes medication, nutritional changes, emotional and spiritual support and other relaxation therapies.

Treatment for Gestational Trophoblastic Disease

“Standard to care” refers to the best-known treatment. In cancer care, different doctors work together to bring out an overall treatment plan for the patient. This is a multidisciplinary team. 

Treatments recommendations depend on many factors:

  • The size, grade and type of tumour
  • Whether the tumour is applying pressure on vital parts of the brain
  • If the tumour has increased to other parts of the body
  • Possible side effects
  • The patient’s preferences and overall health

Surgery

Surgery is the removal of a tumour and surrounding healthy tissue during an operation. Therefore, it is usually the first treatment for a molar pregnancy and may be the only treatment necessary. A gynaecologist or gynecologic oncologist specializing in removing a tumour using surgery will typically operate.

For GTD, the extent of surgery is based on the tumor stage. Standard surgical options include ​1​:

Suction dilation and curettage (D&C)

During D&C, the doctor dilates the cervix and removes the tissues inside the uterus using a small vacuum-like device. After that, the uterus walls are scraped to remove any remaining molar tissue. Thus, the patient may receive an oxytocin drug that helps the uterus contract to standard size. A D&C is used in the case of molar pregnancy and allows for the preservation of future fertility. So, the side effects may include infection, scarring inside the uterus, vaginal bleeding, cramping, and blood clots ​2​. Hence, talk to the health care team about what to expect from this procedure.

Hysterectomy

A hysterectomy is the removal of the uterus and uterine cervix. Thus, in most instances of GTD, a hysterectomy is not necessary as the cure is possible with other treatments, including D&C and chemotherapy ​3​. A hysterectomy is good to reduce the risk of recurrence or to treat a tumor type of PSTT or ETT. Types of hysterectomy include:

Simple hysterectomy

The removal of the uterus and cervix.

Supracervical hysterectomy

The removal of the body of the uterus while preserving the uterine cervix.

Different techniques are used to perform a hysterectomy, including a traditional incision in the stomach or a method that uses several smaller incisions, called a laparoscopic hysterectomy. Side effects may include bleeding, pain, and infection. Pregnancy is not possible after a hysterectomy.

After surgery for GTD, the patient’s hCG level will be monitored with blood tests to make sure that it returns to normal levels. Suppose the hCG level remains high or increases after an initial drop. In that case, it may mean that tumour cells are still present, either in a portion of the original tumour—called a persistent or invasive mole—or the GTD has spread to another region. If this happens, additional treatment such as chemotherapy will be suggested. If the GTD surgery shows the presence of choriocarcinoma, chemotherapy is started straight away. Choriocarcinoma is cancerous and always requires chemotherapy.

Chemotherapy

Systemic therapy uses medication to kill cancer cells. This type of medication is given through the blood to reach cancer cells around the body. A gynecologic oncologist can also give chemotherapy to treat GTD.

Chemotherapy uses medicine to kill or stop the growth of cancerous cells. While, doctors give different chemotherapy depending upon the stage. The point that makes a difference is how the chemotherapy enters the body and which cells it affects.

Systemic chemotherapy enters the bloodstream to reach cancerous cells all over the body ​4​

Standard methods for chemotherapy include an intravenous (IV) tube placed into a vein using a needle or by capsule or pill taken orally.

Chemotherapy is the type of systemic therapy for Gestational Trophoblastic Disease. Chemotherapy is usually very effective in treating a molar pregnancy and some types of GTN but is not as effective with PSTT and ETT. Sometimes, doctors use chemotherapy as a single treatment, while they may combine it with surgery in other cases.

Common ways to give chemotherapy are an intramuscular (IM) injection (or shot), an intravenous (IV) tube placed into a vein using a needle, or a pill or capsule that is swallowed (orally).

A chemotherapy schedule usually consists of a certain number of cycles over a fixed period. A patient can be given one drug at a time or a combination of different drugs given simultaneously.

Common drugs of chemotherapy for GTD include –

  • Vincristine (Vincasar)
  • Methotrexate (Rheumatrex, Trexall)
  • Etoposide (available as a generic drug)
  • Cyclophosphamide (available as a generic drug)
  • Dactinomycin (Cosmegen)
  • Cisplatin (available as a generic drug)

Like surgery, the type of chemotherapy depends on the stage grouping of GTD, including whether the tumour is low risk or high risk. A low-risk invasive mole or a cancerous GTD spread can often be treated successfully with methotrexate alone or in combination with leucovorin (Fusilev). Another drug used is dactinomycin, especially if the patient’s liver is not entirely healthy. About 30% of patients with the low-risk disease will need additional treatment with a second drug.

Doctors generally provide combination chemotherapy with more than one drug to the patients with high-risk metastatic disease. Common combinations include:

  • EMA-CO: etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine
  • EMA-EP: etoposide, methotrexate, dactinomycin, etoposide, and cisplatin

HCG levels determine treatment results. Chemotherapy is helpful on until HCG levels are normal. Once HCG levels become normal to reduce the chances of recurrence, then doctors give additional cycles of chemotherapy. So, patients require 3 to 4 cycles of chemotherapy.

The side effects of chemotherapy depend on the patient and the dose used. Still, they can include fatigue, risk of infection, nausea and vomiting, mouth sores, hair loss, loss of appetite, neuropathy (numbness and tingling in the fingers and toes), and ototoxicity, which is loss of high-frequency hearing or ringing in the ears. These side effects usually go after completion of treatment. 

Palliative Care

Cancer and its treatment have side effects that can be mental, physical or financial and managing the effects are palliative or supportive care. Therefore, palliative care includes medication, nutritional changes, emotional and spiritual support and other relaxation therapies. 

Palliative care focuses on alleviating how you feel during treatment by managing symptoms and supporting patients and their families with other non-medical needs. Regardless of type and stage of Cancer age, any person may receive this type of care.

Remission and the chance of recurrence

When cancer not detected in the body, and there are no symptoms, this is remission. This may also be ‘no evidence of disease’ or ‘NED.’ Hence, a remission can be temporary or permanent. Many people worry about the recurrence of cancer.

If treatment doesn’t work

If cancer not treated or controlled, it leads to advanced or terminal cancer. Therefore, It is vital to have straightforward conversations with your health care team to express your feelings, preferences, and concerns. The health care team has unique skills, knowledge, and experience to assist patients and their families. Hence, ensuring that a person is physically comfortable, free from pain, and emotionally supported is extremely important.

References

  1. 1.
    Clark JJ, Slater S, Seckl MJ. Treatment of gestational trophoblastic disease in the 2020s. Current Opinion in Obstetrics & Gynecology. Published online December 15, 2020:7-12. doi:10.1097/gco.0000000000000674
  2. 2.
    Osborne RJ, Filiaci VL, Schink JC, et al. Second Curettage for Low-Risk Nonmetastatic Gestational Trophoblastic Neoplasia. Obstetrics & Gynecology. Published online September 2016:535-542. doi:10.1097/aog.0000000000001554
  3. 3.
    Ramesan CK, Thomas DS, Sebastian A, et al. Role of Hysterectomy in Gestational Trophoblastic Neoplasia. Indian J Surg Oncol. Published online April 29, 2021:386-390. doi:10.1007/s13193-021-01328-2
  4. 4.
    Alazzam M, Tidy J, Osborne R, Coleman R, Hancock BW, Lawrie TA. Chemotherapy for resistant or recurrent gestational trophoblastic neoplasia. Cochrane Database of Systematic Reviews. Published online January 13, 2016. doi:10.1002/14651858.cd008891.pub3