Case Conference May 31th 2017

31-Mei-2017, Divisi Ginekologi Onkologi RSCM

Case Conference

May 31^st, 2017

 

Mrs. Y,

 

 

 

Inadequate management of gestational trophoblast neoplasia on MTX chemotherapy

 

”Should the therapy of inadequate case change from single chemotherapy methotrexate to dactinomycin or carboplatin?”

 

Resident: Nur Hayati (T3B, Oncology-Gynecology Rotation)

 

 

Mrs. 27 years old, P1A1, was came to RSCM, seeking for second opinion. Patient was diagnosed as gestational trophoblast neoplasia (GTN). Patient had history of dilatation and curettage at Anugrah Bunda Khatulistiwa Hospital, on June 29^th 2015, and hystopathology result on August 5^th 2015 was confirmed as hydatidiform mole grade III. The β-hCG result post evacuation was 64,979.9, was diagnosed patient as low risk GTN. Patient was given single methotrexat, β-hCG result was 12,562.8. The gynecologist then decided to gave 6 cycles methotrexate, with last  β-hCG result was less than 5. Patient then stopped given methotrexate, then evaluate by Ultrasound. On first January 2016, patient was inserted IUD by gynecologist.

 

In RSCM, patient was rechecked of β-hCG level and was performed ultrasound, the image shows like an adenomyoma diametre 3.8 cm and conception remnant size 17 x 7 mm.

Hysteroscopy was performed, that shows trophoblast mass on uterine corpus at posterior part, with protruding mass in to myometrium and lateral right fundal. Hystopathology examination was taken from debris tissue. Post-hysteroscopic, patient was diagnosed as progressive GTN.

INTRODUCTION

Gestational trophoblastic neoplasia is highly respond to chemotherapy, but some cases has no responds. For non respond chemotherapy cases, surgery was suggested. Sometimes progressive GTN not respond to single chemotherapy. Should this patient changed the therapy to multiregiment chemotherapy only? How about surgery and multiregiment chemotherapy for those patients?

 

CLINICAL QUESTION

”Should the therapy of inadequate case change from single chemotherapy methotrexate to dactinomycin or carboplatin?”

 

METHODES

Search Strategy

The search was conducted on Pubmed on May 29^th  2017, using the search tool containing the keyword “single AND chemotherapy AND gestational AND trophoblastic AND neoplasia” (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. Search strategy, result, and the inclusion and exclusion criteria are shown in the flowchart.

 

The titles of the filtered results from Pubmed were screened using the inclusion criteria. A second screening was conducted by reading the abstract.

DISCUSSION

From publication search, methotrexate resistant low-risk gestational trophoblastic neoplasia (GTN) could be change to dactinomycin or carboplatin. For this case, single chemotherapy still could be use do to the risk score still 6 (without data of metastasis due to no available data.

 

From the journal, 90% patients achieving complete hCG response, 3 patients requiring combination chemotherapy or surgery, and 3 patients subsequently spontaneously resolving. 56 patients received EA chemotherapy with hCG complete response in 50 (89%) patients, and the remaining 6 patients were cured with further multi-agent chemotherapy or surgery. With carboplatin, 81% achieved an overall complete hCG response rate, with 4 patients requiring third-line EA. Carboplatin was well tolerated with no significant alopecia; myelosuppression was the most significant toxicity. Overall survival for all patients was 100%. Conclusion. These data show the continued excellent outcomes for methotrexate-resistant low-risk patients treated with single-agent dactinomycin or EA. Our experience with carboplatin is promising and provides an alternative regimen for methotrexate-resistant low-risk disease that avoids alopecia and in-patient treatment.

 

CONCLUSION

 

For this case, we still can change methotrexate monotherapy to another single chemotherapy by using etoposide, dactinomycin, or carboplatin as single chemotherapy

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