How Should Early Gestational Trophoblastic Disease Be Managed?

Abstract

Gestational trophoblastic disease refers to benign (complete and partial hydatidiform mole) and malignant (invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor) subtypes of abnormal proliferation of the placental trophoblast. Complete and (less often) partial hydatidiform moles may progress into persistent trophoblastic disease, which is indicated by a plateau or rise in hCG levels. Hydatidiform mole is best managed by suction curettage and careful follow-up of hCG levels. With a sensitive hCG assay, hCG follow-up after molar evacuation can be discontinued after normal levels have been achieved. The use of prophylactic chemotherapy for prevention of persistent trophoblastic disease and second curettage for low-risk persistent disease after hydatidiform mole remains controversial. Methotrexate chemotherapy is most frequently used in the treatment of low-risk persistent trophoblastic disease; a trial that compares methotrexate versus actinomycin D chemotherapy is ongoing. Women should wait until 12 months after completing chemotherapy and have consistently normalized hCG levels before attempting another pregnancy. Hysterectomy and lymph node dissection is the preferred treatment for localized placental site trophoblastic tumors. Due to its rare occurrence, centralization of the management of trophoblastic disease is recommended and leads to improved survival.