Case Conference July 5th 2017

05-Jul-2017, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

July, 5th 2017

Mrs.X

 

Case Description:

Patient have nausea and vomitus since 4 months ago and bleeding (referred from RSU Tangerang with GTN high risk). P1A1, patient had a molar pregnancy and curettaged in 2011, and gave birth in 2015.

 

Physical examination on September 16^th, 2016:

General status:

CM. BP: 135/98 HR: 100x/m RR: 20 T: 36,5 C , Heights: 154 cm. Weights: 59 Kg

Head: Pale conjunctiva (+/+), icteric sclera (-/-)

Thorax: mammae lump (-/-) mass (-/-),  symmetry shape and movement of hemithorax

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

Cardia: no murmur, no gallop

Abd: mass palpated at 2 fingers below umbilicus, solid mass, mobile, strict border, tenderness was positive, defans muscular negative

Extremity: warm acral.

 

Gyn status:

Inspection: Vagina/urethra normal

Inspeculo: portio was smooth, fluxus (+)

RVT:

-      Portio was smooth, adnexal mass not palpable, uterus was enlarged with upper pool border until 3 fingers below umbilicus, hard consistency.

-      Rectum mass negative

-      Rectum mucosa smooth

-      Lower pool mass was not palpable

 

US Result, September 21^st, 2016

Description: uterus anteflexed, enlarged, in anterior corpus there was vascular mass extra cavum sized 100 x 98 mm. Endometrium stratum basalis regular, 5 mm. Endocervix and portio normal. Both ovaries within normal limit. (There were multiple lutein cysts in right ovary).

Summary: Vascular mass extracavum origined choriocarcinoma

 

 

 

Chest X-ray result, September , 19^th, 2016

Summary:

-      Nodul multiple in both lungs DD/ lung metastase

-      There was no radiologic abnormalities in Cardiac

 

 

 

US Result, May 17^th, 2017

Description: uterus anteflexed, enlarged, in anterior corpus, there was vascular mass (minimal) extra cavum sized 11 x 8 mm (mass size decrease than the previous US).  In anterior and posterior corpus, there was hipoechoic mass , strict border with sized 9 and 5 mm, origin from intramural uterine fibroid(small). Endometrium basalis stratum was regular, 1 mm.

Endocervix and portio were normal. Both ovaries within normal limit. There was no abnormal mass in both adnexas.

 

Summary: Vascular mass extracavum origin from choriocarcinoma. (Mass sized decrease than previous USG).  Intramural uterine fibroid.

Discussion

Sometimes after standard regimens of EMA-CO and EMA-EP, some patients get some progress or relapse. In salvage regimens, platinum compounds serve as a very effective element of combination. The best described regimen is EMA-EP. However, when this fails, various other combination of platinum can be tried, which include (a) cisplatin, vinblastine, and bleomycin (PVB); (b) cisplatin, etoposide, bleomycin, and adriamycin (PEBA); (c) etoposide, ifosfamide, and cisplatin (VIP); and (d) TE/TP.

Rathod et al. reported single case reports of combination of PC, which is the largest study on combination of paclitaxel with carboplatin (PC) regimen in refractory GTN. The response rate in the present study with combination of PC is 75% (6/8), whereas survival was 62.5% (5/8). In their subgroup analysis with TP/TE regimen after EMA-CO failure, Wang et al reported 50% response rate and 44% survival.

Because these patients are heavily pretreated, we saw a host of toxicities. These include febrile neutropenia, mucositis, and thrombocytopenia. In patients with liver metastasis, this combination is relatively less toxic when compared with other third-line agents and makes this regimen as the first choice in patients who are refractory to EMA-CO and EMA-EP. This PC regimen reduces the use of etoposide, and hence its associated complications such as secondary malignancies are decreased in the long term.

Feng et al, performed a retrospective research for patients with chemotherapy-resistant GTN. Adjuvant surgical procedures, especially hysterectomy and pulmonary resection, were used to remove foci of chemotherapy resistant disease in selected patients. Before performing the surgery, computed tomography or MRI of the brain, chest, abdomen, and pelvis US were performed to document the presence of uterine disease or disease elsewhere. If there was no evidence of distant metastasis, hysterectomy or hysterotomy for excision of lesion in the uterus was performed. If the disease was isolated in the lung, lung lobectomy was performed.

From 61 patients who underwent hysterectomy, 47 patients (77%) showed complete remission, while 10 patients showed treatment failure. A number of clinical parameters that may influence the response to salvage surgery were explored. Several factors were found to be significantly different between the groups whose treatment succeeded and those whose treatment failed, including age (p = 0.022), antecedent non-molar pregnancy (p = 0.022), the presence of metastasis outside of lungs (p = 0.026), and preoperative serum β-hCG level (p=0.027).  Patients with age older than 35 years or preoperative serum β-hCG level greater than 10 IU/L will have an almost 50% chance of treatment failure.

 

Conclusions

In this patient, the combination of PC regimen is the best choice, considering this patient has level of β-hCG is 180 and had antecendent non-molar pregnancy before the disease occured, that will have almost 50% chance of failure if we performed surgery.

 

 

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