Chapter 093. Gynecologic Malignancies (Part 9)

Clinical Presentation Molar pregnancies are generally associated with first-trimester bleeding and excessive uterine size. About 45% of patients have ovarian theca-lutein cysts present on ultrasound. The β-hCG levels are generally markedly elevated. Fetal parts and heart sounds are not present. The diagnosis is generally made by the passage of grapelike clusters from the uterus, but ultrasound demonstration of the hydropic mole can be diagnostic. Patients suspected of a molar pregnancy require a chest film, careful pelvic examinations, and weekly serial monitoring of β-hCG levels.Gestational Trophoblastic Neoplasia: TreatmentPatients with hydatidiform moles require suction curettage coupled with postevacuation monitoring of β-hCG...
Nội dung trích xuất từ tài liệu:
Chapter 093. Gynecologic Malignancies (Part 9) Chapter 093. Gynecologic Malignancies (Part 9) Clinical Presentation Molar pregnancies are generally associated with first-trimester bleeding andexcessive uterine size. About 45% of patients have ovarian theca-lutein cystspresent on ultrasound. The β-hCG levels are generally markedly elevated. Fetalparts and heart sounds are not present. The diagnosis is generally made by thepassage of grapelike clusters from the uterus, but ultrasound demonstration of thehydropic mole can be diagnostic. Patients suspected of a molar pregnancy requirea chest film, careful pelvic examinations, and weekly serial monitoring of β-hCGlevels. Gestational Trophoblastic Neoplasia: Treatment Patients with hydatidiform moles require suction curettage coupled withpostevacuation monitoring of β-hCG levels. In most women (80%), the β-hCGtiter progressively declines within 8–10 days of evacuation (serum half-life is 24–36 h). Patients should be monitored on a monthly basis and should not becomepregnant for at least a year. Patients found to have invasive mole at curettage aregenerally treated with hysterectomy and chemotherapy. Approximately half ofpatients with choriocarcinoma develop the malignancy after a molar pregnancy,and the other half develop the malignancy after abortion, ectopic pregnancy, oroccasionally after a normal full-term pregnancy. Chemotherapy is used for gestational trophoblastic neoplasia and often aschemoprophylaxis after molar evacuation to reduce postmolar tumors. It is alsoused in hydatidiform mole if β-hCG levels rise or plateau or if metastases develop.Patients with invasive mole or choriocarcinoma require chemotherapy. Severalregimens are effective for low-risk patients, including methotrexate at 30 mg/m2intramuscularly on a weekly basis until β-hCG titers are normal. However,methotrexate (1 mg/kg) every other day for four doses, followed by leukovorin(0.1 mg/kg) intravenously 24 h after methotrexate, is associated with a cure rate of≥90% and low toxicity. Intermittent courses are continued until the β-hCG titerbecomes undetectable for 3 consecutive weeks; then patients are monitoredmonthly for a year. Patients with high-risk tumors (high β-hCG levels, disease presenting ≥4months after antecedent pregnancy, brain or liver metastasis, or failure of single-agent methotrexate) are initially treated with combination chemotherapy. EMA-CO (a cyclic non-cross-resistant combination of etoposide, methotrexate, anddactinomycin alternating with cyclophosphamide and vincristine); cisplatin,bleomycin, and vinblastine; and cisplatin, etoposide, and bleomycin are effectiveregimens. EMA-CO is now the regimen of choice for patients with high-riskdisease because of excellent survival rates (>80%) and less toxicity. The use ofetoposide carries a 1.5% lifetime risk of acute myeloid leukemia (sixteenfoldrelative risk) and other solid tumors. As a result, etoposide-containing regimensshould be reserved for patients with high-risk features. Patients with brain or livermetastases are usually treated with local irradiation to metastatic sites inconjunction with chemotherapy. Long-term studies of patients cured oftrophoblastic disease have not demonstrated an increased risk of maternalcomplications or fetal abnormalities with subsequent pregnancies. Further Readings Champion V et al: Quality of life in long-term survivors of ovarian germcell tumors: A gynecologic oncology group study. Gynecol Oncol 105:687, 2007[PMID: 17355890] Koutsky LA: A controlled trial of a human papilloma virus type 16 vaccine.N Engl J Med 347:1645, 2002 [PMID: 12444178] Lindor NM et al: Recommendations for the care of individuals with aninherited predisposition to Lynch Syndrome. JAMA 296:1507, 2006 [PMID:17003399] Modugno F: Ovarian Cancer and High Risk Women SymposiumPresenters. Ovarian cancer and high-risk women: Implications for prevention,screening and early detection. Gynecol Oncol 91:15, 2003 [PMID: 14529658] Ozols RF et al: Phase III study of cisplatin/paclitaxel compared withcarboplatin/paclitaxel in patients with optimally resected stage III epithelialovarian cancer. J Clin Oncol 21:3194, 2003 [PMID: 12860964] Randall ME et al: Randomized phase III trial of whole abdominalirradiation vs. doxorubicin and cisplatin chemotherapy in advanced endometrialcarcinoma: A Gynecologic Oncology Group study. J Clin Oncol 24:36, 2006[PMID: 16330675] Rose PG: Secondary surgical cytoreduction for advanced ovarian cancer. NEngl J Med 351:2489, 2004 [PMID: 15590951] Solomon D et al: The 2001 Bethesda System. JAMA 287:2114, 2002[PMID: 11966386] Stehman FB et ...