What is the management for a diagnosis of gestational trophoblastic disease (GTD) found on ultrasound?

From the Guidelines

If you have an ultrasound finding of gestational trophoblastic disease (GTD), you should immediately consult with a gynecologic oncologist or specialist in high-risk obstetrics and undergo suction dilation and curettage (D&C) to remove the abnormal tissue from your uterus, as this is the safest method of evacuation 1.

Diagnosis and Treatment

The first step is to confirm the diagnosis with quantitative serum human chorionic gonadotropin (hCG) levels and additional imaging.

• Histological examination of the uterine contents is essential to achieve a correct diagnosis, as ultrasound findings can be unreliable 1.
• After the procedure, you'll need weekly hCG monitoring until levels normalize, then monthly monitoring for 6-12 months 1.

Chemotherapy

Depending on the type and stage of GTD, you may require chemotherapy.

• For low-risk disease, single-agent methotrexate (50 mg/m² intramuscularly weekly) or actinomycin D (1.25 mg/m² intravenously every 2 weeks) is typically used 1.
• High-risk disease requires multi-agent chemotherapy, commonly EMA-CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine) 1.

Follow-up and Contraception

You should avoid pregnancy during treatment and for at least one year after hCG normalization, using reliable contraception 1.

• The NCCN Guidelines recommend hCG assay monitoring every 1 to 2 weeks until levels have normalized, defined as 3 consecutive normal assays, and then twice in 3-month intervals to ensure levels remain normal 1. GTD results from abnormal proliferation of trophoblastic tissue that would normally form the placenta, and early intervention is crucial because some forms can become malignant and metastasize if left untreated 1.

From the FDA Drug Label

1.5 Gestational Trophoblastic Neoplasia Dactinomycin for Injection is indicated for the treatment of post-menarchal patients with gestational trophoblastic neoplasia, as a single agent or as part of a combination chemotherapy regimen. 2.5 Recommended Dosage for Gestational Trophoblastic Neoplasia The recommended dose of dactinomycin for injection for nonmetastatic and low-risk metastatic disease is 12 mcg/kg intravenously daily for five days as a single agent The recommended dose of dactinomycin for injection, as part of a multi-agent combination chemotherapy regimen, for high-risk metastatic disease is 500 mcg intravenously on Days 1 and 2 every 2 weeks for up to 8 weeks.

For an ultrasound finding of gestational trophoblastic disease, treatment with dactinomycin may be indicated. The recommended dosage is:

• 12 mcg/kg intravenously daily for 5 days as a single agent for nonmetastatic and low-risk metastatic disease
• 500 mcg intravenously on Days 1 and 2 every 2 weeks for up to 8 weeks as part of a multi-agent combination chemotherapy regimen for high-risk metastatic disease 2.

From the Research

Ultrasound Finding of Gestational Trophoblastic Disease

For an ultrasound finding of gestational trophoblastic disease, the following steps can be taken:

• The patient should undergo surgical uterine evacuation with suction and blunt curettage 3
• Medical uterine evacuation should not be used 3
• One representative sample of the evacuated tissue should be fixed for histopathologic investigation and one should be forwarded unfixed for genetic analysis 3
• Serum hCG should be measured on suspicion of hydatidiform mole and at the time of uterine evacuation 3

Follow-up and Monitoring

After the uterine evacuation, the following follow-up and monitoring can be done:

• Serum hCG should be measured weekly until there are two consecutive undetectable values (< 1 or < 2) for triploid and partial hydatidiform mole 3
• Serum hCG should be measured weekly until the value is undetectable (< 1 or < 2) for diploid hydatidiform mole, complete mole, or hydatidiform mole without valid ploidy determination 3
• If serum hCG is undetectable within 56 days after evacuation, the patient can be discharged from follow-up after an additional four monthly measurements 3
• If serum hCG is first normalized after 56 days, the patient should be followed up with monthly serum hCG measurement for six months 3

Treatment of Persistent Trophoblastic Disease

For persistent trophoblastic disease, the following treatment can be done:

• The patient should be referred to oncologic treatment 3
• Uterine re-evacuation as a treatment for persistent trophoblastic disease is not recommended due to low remission rate and risk of uterine perforation 3
• The primary treatment for persistent trophoblastic disease and invasive hydatidiform mole is methotrexate (MTX) 3
• For MTX-resistant persistent trophoblastic disease, actinomycin D (act D) can be added or replaced with MTX 3

Management of Gestational Trophoblastic Neoplasia

For gestational trophoblastic neoplasia, the following management can be done:

• Current International Federation of Gynecology and Obstetrics guidelines should be used for diagnosis and staging 4
• Treatment should be individualized based on risk factors, using less toxic therapy for patients with low-risk disease and aggressive multiagent therapy for patients with high-risk disease 4
• Patients with gestational trophoblastic neoplasia should be managed in consultation with an individual experienced in the complex, multimodality treatment of these patients 4