Case Conference January 11th 2017

11-Jan-2017, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

January 11^th, 2017

Mrs X

Gestational trophoblast neoplasia stage III, 11 (high risk)

 

Case Description:

Patient complained of excessive abnormal vaginal bleeding. She also felt abdominal pain currently. The complaint was started since 2014 after her last curettage. The bleeding was not much at first. The excessive bleeding was started in December 2016.  She had a curettage in 2014 due to mola hydatidiform. She had her check at Koja Hospital and was diagnosed with uterine tumor, then she was referred to RSCM.

 

Physical examination on January 10^th, 2017:

General status:

CM. BP: 100/70mmHg, HR: 80 bpm, RR: 20x/m, T:36^oC, Height 155cm, Weight 57kg

Head: Pale conjungtiva (-/-)

Neck: supraclavicula lymph nodes (-/-)

Axilla: lymph nodes (-/-)

Thorax: symmetry shape and movement of hemithorax

Lung: vesicular breath sound on both lungs, no wheezing or rhales

Cardia: no murmur, no gallop

Abd: flat, no palpable mass

 

Extremity: inguinal lymph nodes (-/-)

Discussion

There are at least 2 clinical scenarios where a surgical approach is critical for the management of GTN; 1. surgical intervention for treatment complication or to allow stabilization to receive chemotherapy, 2. secondary hysterectomy and/or other extirpative procedures for drug resistant disease. For patients with recurrent or resistant GTN, a surgical approach may be curative. However, decisions regarding surgery must be individualized based upon the clinical scenario. The efficacy, feasibility, and type of surgery vary depending upon the site and extent of metastases. Approximately 50 percent of patients with high-risk, metastatic GTN will require adjuvant surgery to achieve cure, even in the presence of multi-organ involvement. 

In a retrospective study at the Severance Hospital (Eoh et.al.2015), 32 patients underwent 35 surgical procedures as part of the GTN treatment. The procedures included hysterectomy, lung resection, craniotomy, uterine wedge resection, uterine suturing for bleeding, salpingo-oophorectomy, pretherapy dilatation and curettage, adrenalectomy, nephrectomy, and uterine artery embolization. Of the 32 patients who underwent surgical procedures, 28 (87%) survived. Eleven patients underwent surgery for chemoresistant disease after receiving one or more chemotherapy regimens. Twelve patients underwent procedures to control tumor hemorrhage. Nine (81%) of 11 patients with chemoresistant disease survived, and 8 patients who underwent salvage surgery for chemoresistant disease received further chemotherapy. Of 21 patients who underwent hysterectomy, 19 (90%) achieved remission. All of three patients who had resistant foci of choriocarcinoma in the lung achieved remission through pulmonary resection.

Hysterectomy should be avoided if possible, especially for women who desire future childbearing. However, it may be indicated after chemotherapy, especially for heavy bleeding, large bulky intrauterine disease, or in the presence of sepsis. New England Trophoblastic Center revealed that a total of 98 patients were identified to have undergone hysterectomy for GTN from 1959 to 2009. In the entire cohort 85% (n = 83) achieved remission and 48% (n = 47) required chemotherapy after hysterectomy. Among the patients in the early cohort (n = 49), indications for hysterectomy included 15 (31%) for primary definitive management, 14 (29%) for chemotherapy resistant disease, 14 (29%) for bleeding and 6 (11%) for other reasons. Of the patients with hysterectomy for chemotherapy resistance, 9 (64%) achieved remission. In the more recent cohort (n = 49) indications for hysterectomy included 24 (49%) for primary definitive management, 19 (39%) for drug-resistant disease, 4 (8%) for bleeding and 2 (4%) for other reasons. Of the patients with hysterectomy for chemotherapy resistance, 16 (84%) achieved remission.

 

Although a study to develop a prediction of successful salvage surgery combine with chemotherapy needs a bigger study number, some attentions should be pay to proceed with this management. Table 5 showed pretreatment predictive factors that influenced the therapeutic response to surgical management combined with chemotherapy. The data suggest that age older than 35 years, antecedent non-molar pregnancy, distant metastasis outside of lungs and uterus, and a preoperative serum hCG level greater than 10 IU/L are important clinical predictors of treatment failure to surgery. Patients with 2 or more of these unfavorable predictors usually have poor prognosis, in which salvage surgery should be performed with caution.

Conclusion

Hysterectomy in both patients can provide a better chance to control the disease and lower the hCG level. For the first patient, it will be benefited since she is actually resistant to both EMACO and EP-EMA. The last patient will gain more control of the disease after hysterectomy.  Although, it should be done with caution since there are some unfavorable predictors. The first patient has high hCG level and non-mola pregnancy prior to this disease, while the second patient is more than 35 yo and also high hCG level. 

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