Treatment of gestational trophoblastic disease by type and stage

The following lists the standard treatment options according to the type of GTD and the stage and prognostic group of the disease. These treatments are discussed in more detail in separate sections about surgery, chemotherapy, and radiation therapy.

Hydatidiform moles (complete and partial moles)

The standard treatment for women who may wish to have children in the future is to remove the tumor by suction dilation and curettage (D&C). Women who no longer wish to have children usually have the option of choosing either suction D&C or hysterectomy (removal of the tumor and entire uterus). A hysterectomy ensures no tumor remains within the uterus but, like a D&C, it does not treat tumor cells that may have already spread outside the uterus.

Rarely, a hydatidiform mole occurs as part of a "twin" pregnancy, where there is a normal fetus along with the mole. In this case, the pregnancy is watched closely and typically allowed to continue. The mole is then treated after delivery.

Once the tumor is removed, a pathologist will look at it under a microscope for signs of choriocarcinoma or other malignant changes in the specimen. If there are none, then patients are carefully monitored with frequent measurements of blood HCG levels. The levels should drop and become undetectable within several months. If not, there may still be mole tissue deep in the uterus (an invasive mole) or elsewhere in the body.

Doctors recommend that women avoid becoming pregnant during the first year after diagnosis because pregnancy would raise HCG levels. Oral contraceptives may be used, but intrauterine devices (IUDs) should not be used at this time because of the risk of bleeding, infection, or other problems. Sometimes IUDs can cause problems that can look like tumor left in the uterus.

Chemotherapy (chemo) will likely be needed if the blood HCG level begins to rise or is still detectable after a reasonable time (often around 4 to 6 months), or if the pathologist finds choriocarcinoma in the tissue sample. About 1 in 5 women will need chemo after a molar pregnancy.

Stage I low-risk gestational trophoblastic tumors

This can be either persistent GTD (where the HCG level hasn't dropped to normal after treatment of a molar pregnancy) or a choriocarcinoma or placental site trophoblastic tumor that was found in the curettage specimen. The tumor is still confined to the uterus, and the prognostic score is less than 7.

Chemo with either methotrexate (with or without leucovorin/folinic acid) or actinomycin-D is the recommended treatment for stage 1, low risk disease. Hysterectomy may also be advised, particularly for women who no longer want to have babies. It may reduce the amount of chemo needed.

Chemo is given until there are no longer any signs of cancer, based on levels of HCG in the blood (the HCG level should return to normal after treatment). If the initial chemo drug does not get rid of the tumor, a second drug may be tried. If the HCG level is still detectable at this point, more intensive chemo with a combination of drugs may be needed.

Placental-site trophoblastic tumor (PSTT) is treated with hysterectomy. Chemo is usually not helpful. Since HCG is often not found at high levels in the blood with PSTT, blood levels of another hormone called human placental lactogen (hPL) may be checked and watched over time.

Epithelioid trophoblastic tumor (ETT) is also treated with hysterectomy. The HCG level may be slightly elevated, and if it is, it will be checked again after surgery. Chemo is not helpful in treating these tumors.

Stage II/lII low-risk gestational trophoblastic tumors

These tumors have spread to the genital structures or to the lungs, but the prognostic score is less than 7. Chemo with either methotrexate (with or without leucovorin) or actinomycin-D is curative in most cases. If a single drug does not get rid of the tumor, treatment with combination chemo is usually effective. In rare cases, surgical removal of the tumors plus chemo may be used. Blood HCG levels are measured after treatment and should return to normal.

PSTTs and ETTs do not respond well to chemo, so they are treated with hysterectomy (surgery to remove the uterus).

Stage II/III high-risk gestational trophoblastic tumors

These tumors have spread to the genital structures or to the lungs, and the prognostic score is 7 or higher. Standard treatment is usually an intensive combination chemo regimen such as EMA-CO (etoposide, methotrexate/leucovorin, and actinomycin-D, followed a week later by cyclophosphamide and vincristine). Other drug combinations, such as EMA-EP (etoposide, methotrexate/leucovorin, and actinomycin-D, followed a week later by etoposide and cisplatin), may also be used, although they may be reserved for use if the EMA-CO regimen isn't effective. In rare cases, surgical removal of the tumors plus chemo may be used. Blood HCG levels are measured after treatment and should return to normal.

PSTTs and ETTs do not respond well to chemo, so they are treated with surgery to remove the uterus (hysterectomy).

Stage IV gestational trophoblastic tumors

These tumors need intensive treatment because they have spread to distant sites such as the liver or brain. Combination chemo such as the EMA-CO regimen is the standard treatment. If the cancer has reached the brain, radiation therapy to the head is often used as well. In some cases, surgical removal of tumors may be used along with chemo. Sometimes methotrexate is given into the spinal fluid to treat tumors that have spread to the tissues around the brain and spinal cord. Again, blood HCG levels are measured after treatment and should return to normal.

PSTTs and ETTs do not respond well to chemo, so they are treated with surgery to remove the uterus and to remove tumors elsewhere in the body.

Recurrent gestational trophoblastic tumors

A tumor is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or bone). The type of treatment used depends on where the cancer recurs and what treatment the woman has already received.

For tumors that were first treated with surgery, single-drug chemotherapy may be used, unless a new risk factor puts the patient at high risk (in which case combination chemotherapy would be used). In women who have already had chemotherapy, a more intensive chemotherapy regimen would be used. Several different combinations of drugs might be tried, if needed. Again, if the cancer has reached the brain, radiation therapy to the head is often used. In some cases, surgical removal of tumors may be used as well.

Cure rates for GTD

Nearly 100% of women with complete or partial moles and low-risk GTD can be cured of their disease with appropriate treatment. PSTT has high cure rates, but the outlook isn't as good if the disease spreads outside of the uterus. Even for high-risk GTD, cure rates are as high as 80% to 90%, but will likely require more intensive treatment (combination chemotherapy, sometimes together with radiation and/or surgery).