Management

In most instances the patient will be transferred to the specialist centre. In addition to the staging investigations previously outlined, patients may undergo further tests including:

♦ Measurement of other tumour markers

♦ Anti-HCG antibody scanning

Where it can be safely achieved, excision biopsy of a metastasis should be considered. This not only enables histological confirmation of the diagnosis but also permits genetic analysis to prove the gestational nature of the tumour. If there are only maternal genes and no paternal genes present then the patient has a non-gestational tumour (an ovarian choriocarcinoma or, more rarely, an epithelial tumour that has differentiated into choriocarcinoma). Frequently, however, biopsy is not possible and the diagnosis is made on the clinical history and other investigation findings. The patients are then scored and treated as described for molar disease. The indications for chemotherapy are:

♦ Evidence of metastases in brain, liver, or gastrointestinal tract; or radiological opacities >2 cm on chest X-ray.

♦ Histological evidence of choriocarcinoma.

♦ Heavy vaginal bleeding or evidence of gastrointestinal or intra-peritoneal haemorrhage.

♦ Pulmonary, vulval, or vaginal metastases unless HCG falling.

Table 23.4 Scoring system for gestational trophoblastic tumours

Score*

Prognostic factor

0

1

2

6

Age (years)

<39

>39

Antecedent pregnancy (AP)

Mole

Abortion or unknown

Term

Interval (end of AP to

chemo in months)

<4

4-7

7-12

>12

HCG iu/l

1G3—1G4

<1G3

1G4--1G5

>105

ABO blood group

A x O

B x A

(female x male)

O x A O or A

or O AB x A or O

x unknown

No of metastases

Nil

1-4

4-8

>8

Site of metastases

Not detected Spleen

GI tract

Brain

Lungs

Kidney

Liver

Vagina

Largest tumour mass

<3.0

3-5 cm

>5 cm

Prior chemotherapy

Single drug

2 or more drugs

* The total score for a patient is obtained by adding the individual scores for each prognostic factor. Lower risk, 0-5; medium risk, 6-8; high risk, >9.

* The total score for a patient is obtained by adding the individual scores for each prognostic factor. Lower risk, 0-5; medium risk, 6-8; high risk, >9.

♦ Rising HCG after evacuation.

♦ Serum HCG = 20 000 iu/l more than 4 weeks after evacuation, because of the risk of uterine perforation.

♦ Raised HCG 6 months after evacuation even if still falling.

Any of these are indications to treat following the diagnosis of GTD.

0 0

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