Because placental-site tumors are resistant to chemotherapy, hysterectomy for presumed nonmetastatic disease is the only curative treatment. Patients with metastatic placental site trophoblastic tumor may still achieve remission, but their tumors are less responsive to chemotherapy (59).
Single-agent chemotherapy is the preferred treatment in patients with stage I disease who desire to retain fertility (60). At the NETDC from July 1965 through June 2008, primary single-agent chemotherapy was administered to 561 patients with stage I GTN and 434 patients (77.4%) attained complete remission. The remaining 127 patients with resistant disease subsequently achieved remission after combination chemotherapy or surgical intervention.
When a patient’s disease is resistant to single-agent chemotherapy and she desires to preserve fertility, combination chemotherapy should be administered. If the patient’s disease is resistant to single-agent and combination chemotherapy and she wants to retain fertility, local uterine resection may be considered. When local resection is planned, a preoperative ultrasonography, MRI, or arteriography may help to define the site of the resistant tumor.
Low-risk disease treated with primary single-agent chemotherapy has a high (approximately 80%) rate of remission in contrast to high-risk disease that usually does not achieve remission with single-agent treatment and requires treatment with primary intensive combination chemotherapy.
Vaginal metastases may bleed profusely because they are highly vascular and friable. When bleeding is substantial, it may be controlled by packing the vagina or by wide local excision. Infrequently, arteriographic embolization of the hypogastric arteries may be required to control hemorrhage from vaginal metastases (61).
At the NETDC from July 1965 through June 2008, of the 139 patients with low-risk stages II or III disease, 114 (82%) attained complete remission with single-agent chemotherapy. The remaining 25 (18%) patients who had disease resistant to single-agent treatment subsequently achieved remission with combination chemotherapy.
Thoracotomy Thoracotomy has a limited but important role in the management of pulmonary metastases. If a patient has a persistent viable pulmonary metastasis following intensive chemotherapy, thoracotomy may be indicated to excise the resistant focus. A thorough metastatic workup should be performed before surgery is undertaken to exclude other sites of persistent disease. It is important to realize that fibrotic pulmonary nodules may persist indefinitely on chest radiography, even after complete gonadotropin remission is attained. In patients undergoing thoracotomy for resistant disease, chemotherapy should be administered postoperatively to treat potential occult sites of micrometastasis.
Hysterectomy may be required in patients with metastatic disease to control uterine hemorrhage or sepsis. In patients with extensive uterine tumor, hysterectomy may substantially reduce the trophoblastic tumor burden and limit the need for multiple courses of chemotherapy (62).
All patients with low-risk GTN (stages I through III) should undergo follow-up with: 1.
Weekly measurement of hCG levels until they are normal for 3 consecutive weeks.
2.
Monthly measurement of hCG values until levels are normal for 12 consecutive months.
3.
Effective contraception during the entire interval of hormonal follow-up.