Clinical management of trophoblastic disease in the United Kingdom

Abstract

Over the last 35 years the management of gestational trophoblastic disease (GTD) has been one of the success stories of clinical oncology. With proper follow-up and management, it should now be rare for any woman to die from a tumour deriving from GTD. This successful outcome is primarily due to 3 factors: 1.The most common prodrome to developing a gestational trophoblastic tumour (GTT) are patients presenting with hydatidiform moles (HM); these patients at risk of a GTT are registered for follow-up. 2.GTD and GTT always produce the pregnancy hormone, human chorionic gonadotrophin (hCG), allowing biochemical monitoring of all patients. 3.GTD and GTT are very sensitive to a range of cytotoxic agents. Patients presenting with HM need to have the uterine cavity evacuated to confirm the diagnosis and they are then followed up by serial hCG estimations to confirm whether or not the disease is regressing spontaneously. Approximately 8% of patients registered in the UK will need chemotherapy for GTD. It is important to recognise that GTT can occur after full-term pregnancies, stillbirths and abortions. A number of prognostic variables have been identified and patients can be categorised into low-, medium- and high-risk 1 so that their treatment is stratified with appropriate intensity, ranging from single agent methotrexate to intensive drug combinations such as the EMA/CO schedule. In high risk patients, salvage surgery is sometimes necessary. On completion of treatment, patients can be followed-up by serial hCG estimations to confirm complete remission. Subsequent fertility after chemotherapy is not significantly impaired and with a follow-up of 35 years since the initial cohort of women treated with chemotherapy, late sequelae of chemotherapy are remarkable by their low incidence.