Diagnosis and management of gestational trophoblastic neoplasia

The FIGO Committee Report on the FIGO 2000 staging for gestational trophoblastic disease included criteria for the diagnosis of gestational trophoblastic neoplasia (GTN). It recommended investigative tools for diagnosing metastases. Anatomical and prognostic indicators were combined into a stage : risk score to stratify patients into low and high-risk groups. This is the first staging system to incorporate inclusive criteria that are likely to be adopted universally. The diagnostic evaluation of GTN is presented. The rationale of using the various investigative tools is discussed. The problem of measuring human chorionic gonadotrophin (hCG) levels using commercial kits and the phenomenon of 'phantom hCG' is explored. The use of single agent chemotherapy for low-risk disease versus multi-agent chemotherapy for high-risk disease is discussed. Controversies regarding when to stop chemotherapy are explored with a view to minimizing the short and long-term toxicity, in particular the small risk of developing a second malignancy. Recommendations for the follow up of patients after chemotherapy with particular reference to contraceptive advice and future pregnancies are discussed in the light of current evidence.