In a study of 247 patients with complete molar pregnancy who prophylactically received a single course of actinomycin D (ActD) at the time of evacuation, local uterine invasion developed in 10 patients (4%), and no patients experienced metastasis (35). All 10 patients with local invasion achieved remission after one additional course of chemotherapy. Prophylactic chemotherapy, prevented metastasis and reduced the incidence and morbidity of local uterine invasion.
In two prospective randomized studies of prophylactic chemotherapy in patients with a complete mole, a significant decrease in persistent tumor was detected in patients with high-risk mole who received prophylactic chemotherapy (47% and 50% vs. 14%) (36–38). Prophylaxis may be particularly useful in the management of high-risk complete molar pregnancy, especially when hCG assessments for follow-up are unavailable or unreliable.
After molar evacuation, patients should be monitored with weekly determinations of β-subunit hCG levels until these levels are normal for 3 consecutive weeks, followed by monthly determinations until the levels are normal for 6 consecutive months (39). The average time to achieve the first normal hCG level after evacuation is about 9 weeks (40). After achieving nondetectable serum hCG levels, the risk of developing GTN approaches zero (41–43). If these findings are confirmed, it is possible that postmolar hCG surveillance could be safely abbreviated.
devices should not be inserted until the patient achieves a normal hCG level. If the patient does not desire surgical sterilization, either oral contraceptives or barrier methods should be used.
Increased incidence of postmolar persistent tumor was reported among patients who used oral contraceptives before gonadotropin remission (44). However, data from a prospective trial and other centers indicate that oral contraceptive use does not increase the risk of postmolar trophoblastic disease (45–47). It appears that oral contraceptives may be used safely after molar evacuation during the entire interval of hormonal follow-up.
Pulmonary At the time of diagnosis, lung involvement is visible by chest radiography in 80% of patients with metastatic GTN. Patients with pulmonary metastasis may have chest pain, cough, hemoptysis, dyspnea, or an asymptomatic lesion visible by chest radiography. Respiratory symptoms may be acute or chronic, persisting over many months.
GTN may produce four principal pulmonary patterns: 1.
2.
3.
4.
An embolic pattern caused by pulmonary arterial occlusion.
Table 39.2 Staging of Gestational Trophoblastic Tumorsb
Because respiratory symptoms and radiographic findings may be dramatic, the patient may be thought to have a primary pulmonary disease. Some patients with extensive pulmonary involvement have minimal, if any, gynecologic symptoms because the reproductive organs may be free of trophoblastic tumor. The diagnosis of GTN may be confirmed only after thoracotomy is performed, particularly in patients with a nonmolar antecedent pregnancy.
Pulmonary hypertension may develop in patients with GTN secondary to pulmonary arterial occlusion by trophoblastic emboli. The development of early respiratory failure requiring intubation is associated with a poor clinical outcome (49).
Central Nervous System Metastatic trophoblastic disease involves the brain in 10% of patients. Cerebral involvement is seen in patients with advanced disease; virtually all patients with brain metastasis have concurrent pulmonary or vaginal involvement or both. Because cerebral lesions frequently hemorrhage spontaneously, most patients develop acute focal neurologic deficits (50,51).
Staging An anatomic staging system for GTN was adopted by the International Federation of Gynecology and Obstetrics (FIGO) (Table 39.2). It is hoped that this staging system will encourage the objective comparison of data from various centers (52).