GTD Treatment and Side Effects
After the diagnosis of complete or partial hydatidiform mole is made or suspected, the uterine contents are removed by dilation and evacuation (D&E). Hysterectomy may be advisable in older patients who have completed childbearing to reduce the risk of malignancy. After the uterus is emptied, testing for human chorionic gonadotropin should be performed every week in order to determine if the molar pregnancy is malignant. If the molar pregnancy is benign the hormone level will become undetectable in 8-12 weeks. Hormone testing should be continued until three weekly negative levels are obtained, then followed by monthly tests for six months, after which pregnancy is permitted. During the six month follow-up it is important to avoid pregnancy. The use of oral contraceptives is safe.
A rise in the hormone level indicates that the molar pregnancy is malignant GTD (also called gestational trophoblastic neoplasia, GTN). More tests will be done to find out if the cancer has spread from the uterus to other parts of the body—this is called staging. Even if GTD has spread to other parts of the body, it is still highly curable.
The treatment of malignant GTD depends on the stage and number of risk factors which determine the type of drugs that will most likely cure the disease. The factors that are characteristic of women who are likely to be cured by one or more single chemotherapy drugs (called low-risk malignant GTD) are:
- The last pregnancy was less than 4 months ago
- The level of hCG in the blood is low
- The cancer has not spread to the liver, brain or other distant organs
- The patient has not received chemotherapy treatments earlier
The risk factors of women who develop malignant GTD who are NOT likely to be cured by one or more single chemotherapy drugs and who require treatments containing multiple agents to effect cure (called high-risk malignant GTD) are:
- The last pregnancy was more than four months ago
- The level of hCG in the blood is high
- The cancer has spread to the liver, brain and/or other distant organs
- The patient received chemotherapy earlier and the cancer did not go away
- The tumor began after completion of a normal pregnancy
Three kinds of treatment are used for malignant GTD: surgery (removing the cancer), chemotherapy (using drugs to kill the cancer) and radiation therapy (uses high energy x-rays to kill cancer cells and shrink tumors). The most common operation used for malignant GTD is hysterectomy, an operation to take out the uterus. Surgery may also be used to remove cancer involving the lungs and other organs which have not gone away with drug therapy.
Follow-up After Treatment
Hormone follow-up by measuring the level of hCG in the blood continues until the hormone level is normal for three weeks, then should continue monthly for 12 months (24 months or patients with Stage IV disease). During that time the patient should avoid pregnancy. Women who conceive within 12 months of completing chemotherapy have an increased risk of miscarriage, particularly if they have received multiple chemotherapeutic agents. If pregnancy occurs before follow-up is complete, tumor relapse may be difficult to detect and diagnosis of relapse may be delayed.
The chemotherapy used for the treatment of malignant GTD is generally well tolerated without long-term side effects with two exceptions:
- The use of multi-agent chemotherapy is associated with an earlier menopause.
- Women with high-risk GTN who require multi-agent chemotherapy which includes a drug called etoposide and survive for more than 25 years should be advised that they may be at increased risk of developing secondary tumors, particularly acute myeloid leukemia, colon cancer, melanoma and breast cancer.
GTD is a highly curable disease. Women with hydatidiform mole have an excellent prognosis and women with malignant GTD (called GTN) usually have a very good prognosis. Choriocarcinoma, for example, is an uncommon, yet almost always curable cancer. Although choriocarcinoma is a highly malignant tumor and life-threatening disease, it is very sensitive to chemotherapy. 85 to 90 percent of women with low-risk malignant GTD are cured by the initial chemotherapy and the remaining are cured by the use of stronger combinations of drugs or surgery. Similarly, 85 to 90 percent of women who develop high-risk malignant GTD are cured by chemotherapy used together with the selective use of surgery and radiation. Approximately ten to 15 percent of women with high-risk malignant GTD will develop drug resistance after prolonged chemotherapy. This group is made up of patients with stage IV disease that involves distant organs such as the brain, liver and bowel. Specially designed chemotherapy treatments using drugs that have been shown to be effective against other cancers are being employed to prolong life for many of these women.
Becoming Pregnant Again
After completing hormone follow-up for hydatidiform mole, women may try for pregnancy whenever they wish. The risk of another molar pregnancy is low. More than 98 percent of women who become pregnant following a molar pregnancy will not have a further hydatidiform mole or be at increased risk for complications. Since patients with hydatidiform mole are at increased risk of another molar pregnancy, it is advisable for them to undergo ultrasound examinations at ten weeks of gestation to determine if the pregnancy is progressing normally.
Most women who require treatment for malignant GTD can become pregnant again and can have normal pregnancy outcomes. After chemotherapy is completed women should postpone pregnancy for 12 months (24 months for women with stage IV disease) while they are being followed with hormone testing to make sure the tumor does not recur. There does not appear to be an increase rate of congenital malformation irrespective of the chemotherapy used. Following GTD the expectation of normal future pregnancy is about comparable to the general population.