Modern management of gestational trophoblastic disease

Gestational trophoblastic disease is a disorder of pregnancy which may present in a very benign or malignant fashion. Hydatidiform mole complicates approximately 1 in 2000 pregnancies in the United States. The diagnosis may be made prior to evacuation if the signs and symptoms are kept in mind. When the patient presents with spontaneous expulsion of typical molar tissue, a complete evaluation is carried out, including physical examination, uterine curettage for histologic study, and initiation of weekly beta subunit of HCG determinations. At 8 weeks' post-evacuation, about 50% of patients continue to have detectable serum HCG levels. Of these patients, about half may develop chorioadenoma destruens (invasive mole) or choriocarcinoma and require chemotherapy (6, 16). Patient stratification in a clinical classification system based on anatomical extent of disease and certain risk factors is essential for proper management. Review of results obtained at gestational trophoblastic disease treatment centers has shown that with exception of the high-risk patient, virtually 100 per cent cure is possible with early diagnosis and appropriate treatment. Treatment of the high-risk patient with initial triple-drug chemotherapy and simultaneous irradiation of liver or brain metastases may be expected to yield a 90 per cent complete remission. If complete remission in the high-risk patient is maintained for 3 months after cessation of treatment, there appears to be a 98 per cent chance of remaining free of disease (47). The information accumulated in the 25 years since methotrexate was introduced into the treatment of gestational trophoblastic disease has made these excellent results possible. Aggressive multiagent chemotherapy, proper patient classification, radiation, surgery, and utilization of the beta subunit of HCG to monitor therapy are all pivotal in achieving these successes of modern management.