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Treatment for gestational trophoblastic disease (GTD) is given by cancer specialists (oncologists). Some specialize in surgery, some in radiation therapy and others in chemotherapy (drugs). These doctors work with the woman with cancer to decide on a treatment plan.
Treatment plans are designed to meet the unique needs of each person with cancer. Treatment decisions for GTD are based on:
Treatment for gestational trophoblastic tumours should be started as soon as possible after diagnosis.
Surgery is one of the main treatments for GTD. Surgery may be used:
Dilation and curettage (D&C) is a surgical procedure that dilates (opens) the cervix and then uses a vacuum-like device and a small, sharp instrument (curette) to remove tissue from the lining of the uterus. A woman may also be given a drug that causes the uterus to contract, which helps to push tissue from the uterus.
D&C is a treatment option for women diagnosed with complete or partial hydatidiform moles by human chorionic gonadotropin (HCG or b-HCG) testing or ultrasound. D&C will not be done if a gestational choriocarcinoma is suspected because this type of tumour bleeds very easily.
Women whose HCG levels do not return to normal after D&C or medical termination of a pregnancy (see below) will require further treatment. Women who are diagnosed with gestational choriocarcinoma or placental type trophoblastic tumour will also need further treatment.
Medical termination of pregnancy is a treatment option for women who are not eligible to have a D&C. Women who cannot have a D&C and who have their pregnancies terminated are at an increased risk of persistent trophoblastic disease.
Hysterectomy is the surgical removal of the uterus. Hysterectomy may be offered to women with malignant GTD that has not spread outside of the uterus and who no longer wish to have children. Hysterectomy may also be recommended to women with malignant GTD that does not respond to chemotherapy.
Hysterectomy is the primary treatment for women with placental site trophoblastic tumours because this type of cancer does not respond well to chemotherapy.
Surgery may be done for GTD that has spread to distant sites in the body, such as the brain, intestines, kidney, liver, lungs and spleen. In the case of brain metastases, surgery may only be done if a tumour is close to the surface of the brain.
Side effects of surgery for GTD will mainly depend on the:
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to treat cancer. It is usually a systemic therapysystemic therapyTreatment that travels through the bloodstream to reach cells all over the body. that circulates throughout the body and destroys cancer cells, including those that may have broken away from the primary tumour.
Chemotherapy is a standard treatment for malignant GTD. It may be given:
Single-agent chemotherapy is used for low-risk GTD (metastatic and non-metastatic) in women who wish to have children. The most common chemotherapy drugs include:
Combination chemotherapy is used for high-risk GTD (metastatic or non-metastatic). The most common chemotherapy combinations include:
The time between chemotherapy cycles is usually 14–21 days. It is rarely longer than 21 days. HCG levels are closely monitored. Once the HCG level returns to normal, chemotherapy is usually given for 1-3 more cycles.
Side effects of chemotherapy will depend mainly on:
Radiation therapy uses high-energy rays or particles to destroy cancer cells. External beam radiation therapy is the type of radiation therapy most often used to treat GTD. Radiation therapy may be used in combination with methotrexate intrathecal chemotherapy to treat GTD that has spread to the brain.
Side effects of radiation therapy to the brain will depend mainly on the:
Women with high-risk GTD may need to be treated with supportive therapy. Supportive therapy helps to reduce some of the side effects associated with certain drugs so doctors can give the appropriate dose of chemotherapy.
Supportive therapy may include:
Treatment of GTD depends on the type and level of risk. Since hydatidiform moles are a benign form of GTD, they are treated differently. Placental site trophoblastic tumours are malignant forms of GTD and they are also treated differently (see below).
Treatment options for hydatidiform moles may include:
Low-risk GTD includes invasive moles and gestational choriocarcinoma that is most likely to respond to treatment.
Low-risk GTD may be treated with:
High-risk GTD includes invasive moles and gestational choriocarcinoma that may be less responsive to treatment.
High-risk GTD may be treated with:
Treatment for recurrent GTD depends on where the tumour has recurred and what type of treatment a woman previously had for the disease. GTD that recurs or does not respond to drugs used in earlier treatments may be treated with:
Placental site trophoblastic tumours are a very rare type of GTD. They usually don’t spread beyond the muscle wall of the uterus (myometrium). This type of tumour is very resistant to chemotherapy, so it is often treated with a hysterectomy. Lymph nodes may also be removed at the time of surgery.
In the rare situation where placental site trophoblastic tumours spread to other parts of the body (metastasize), chemotherapy may be offered. There is little research on the best type of chemotherapy for metastatic placental site trophoblastic tumours. The types of chemotherapy given may include:
Clinical trials investigate new and better ways to prevent, detect and treat cancer. There are a few clinical trials in Canada that are open to women with GTD. For more information, go to clinical trials.
GTD behaves differently in each woman, and a standard follow-up schedule would not work for everyone. Women with GTD should talk to their doctor about a follow-up plan that suits their individual situation. Follow-up care is often shared among the cancer specialists (oncologists), surgeon, gynecologist and the family doctor.
After treatment has ended, new symptoms and symptoms that don’t go away should be reported to the doctor without waiting for the next scheduled appointment. These may include:
The chance of GTD recurring is greatest within the first year, so close follow-up is needed during this time.
Follow-up after GTD treatment varies. Follow-up visits are usually scheduled:
During a follow-up visit, the doctor usually asks questions about the side effects of treatment and how the woman is coping. The doctor may do a complete physical examination, including:
Tests may be ordered as part of follow-up or if the doctor suspects the cancer has come back (has recurred).
Human placental lactogen (hPL) testing
Imaging tests are rarely ordered for follow-up because HCG is a simple way to tell if treatment is working or diagnose a recurrence of GTD. A woman will usually have an imaging test if the HCG level rises or does not return to normal. Imaging tests that may be done include:
If the doctor suspects that a woman has had a recurrence of GTD, other tests may be ordered. These may include:
If a recurrence is found during follow-up, the oncology team will assess the woman with cancer to determine the best treatment options.