Case Conference February 22nd 2017

22-Feb-2017, Divisi Ginekologi Onkologi RSCM

Mrs Y

Low risk of gestational trophoblastic neoplasia

PPDS: Danny Maesadatu (T3B, Oncology Rotation)

 

CASE DESCRIPTION (February 13^th 2017)

Patient came to the clinic for chemotherapy methothrexate (MTX) third series.

-          It was second pregnancy with LMP on last week of June. Previous obstetric history was blighted ovum and performed curettage on 2011.

-          First ANC on early August, just perform test pack in midwives, result positive. Patient had spotting during pregnancy and it was felt bigger than usual.

 

-          Second ANC (mid of September 2016), perform US with OBGYN at RSIA Bun, and it was said molar pregnancy and suggested to go to RSU Tangerang (September 19^th 2016). Performed US and also said the same thing and plan to evacuation.

-          September 19^th 2016, the b-hCG (beta human chorionic gonadotrophin) was 324.854 with normal thyroid profile (TSHs 0,22, FT4 1,49).

-          Patient performed curettage (at September 20^th 2016) at RSIA Bun due to suspected molar pregnancy, but histopathology examination was not performed.

-          Patient had  history of vaginal bleeding since September 30^th 2016.

-          After curettage, the bleeding still occurred and b-hCG  was checked. The level was 2560 (November 7^th 2016). Then, patient was referred to RSCM due to gestational trophoblastic disease.

-          Patient was checked again the b-hCG level on November 11^th 2016 (result 2.850), planned for chemotherapy, but patient want to prepare for ID card and BPJS insurance.

-          On December 27^th 2016, patient came to clinic and bring the result b-hCG level was 104.108.

 -          Physical examination compos mentis with stable hemodynamic. Rectovaginal examination revealed quite enlarged uterus, no adnexal mass, loose parametrium.

-          Fetomaternal ultrasound revealed the uterus quite enlarged. There was solid mass intracavity with vesicular part in the left corpus, size 30x18 mm, another half part was in intracavity and myometrium, probably came from malignant trophoblastic disease. Stratum basalis regular, except on th mass area. Endocervix and portio were normal. Both ovary within normal limit. No abnormal mass in both adnexa.

Conclusion: malignant trophoblast disease.

-          Then patient was scheduled for chemotherapy.

 METHODS

Search strategy

The search was conducted on Pubmed and ScienceDirect February 15^th, 2017, using the search tool containing the keywords “"low risk gestational trophoblastic neoplasia" and methotrexate and combined therapy” (Table 1). Search results were filtered by the engine according to the following criteria: articles published in the past 5 years, human species, and English language.

 

DISCUSSION

Number of successful rate of chemotherapy in low risk GTN were vary in many studies. There is only one retrospective study involving 100 patients with combined methotrexate and dactinomycin therapy for low risk GTN. The primary cure rate was around 98% and the median of 3 cycles could reach to normal values.¹

 

Another study, the complete remission for methotrexate, dactinomycin, and combined regimens were 69%, 71,4%, and 79,1%, respectively with no statistically significant.²

 

Cochrane review on 2016, stated that dactinomycin has better primary cure rate than methotrexate (risk ratio (RR) 0,65, 95% confidence interval (CI) 0,57 to 0,75; six trials, 577 participant), and failure rate was higher in methotrexate than dactinomycin (RR 3,55, 95% CI 1,81 to 6,95).

 

Low risk GTN with score 5-6 has high failure rate with single agent chemotherapy. Some studies explore the cure rate of combined therapy with the result were 80% or more, even though the studies method were retrospective. FIGO score 5-6 is a risk factor for relapse condition in methotrexate than score 0-4 (crude hazard ratio (HR) 1,79, 95% CI 0,53 to 5,99), but this study emphasizing the score on antecedent pregnancy (post term pregnancy) and more than 4 courses of methotrexate are the most risk factors in failure of complete remission.

While FIGO score 0-4 has a high number of cure rate than score 5-6, this system can not universally predict the outcome. For FIGO score 5-6, single chemotherapy agent can be given for initial treatment and spare the combined regimens for the failure cases.

 

CONCLUSION

Low risk GTN with score 5-6 can be given with single chemotherapy agent as initial treatment. Further therapeutic study for this condition is needed to evaluate the efficacy of single chemotherapy compared with combined regimens. 

 

 

 

  

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