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Case History

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Image not available. A 30-year-old woman, 2 months pregnant, presented with vaginal bleeding. Examination of the uterus suggests a 4-month pregnancy. Her human chorionic gonadotrophin (hCG) levels are markedly elevated and there are no fetal heart sounds. Abdominal ultrasound suggests the diagnosis of a molar pregnancy.

How should the condition be managed?

What are the most common sites of metastatic disease?

What forms of chemotherapy are available for choriocarcinoma?

What is the outcome and how should patients be monitored?

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Background

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Image not available. Gestational trophoblastic neoplasia (GTN) comprises a spectrum of neoplastic conditions that arise from placental trophoblastic tissue after abnormal fertilization.1,2 These disorders are uncommon and can be classified into three distinct groups:

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  • Hydatidiform mole (complete or partial) - pre-malignant, can metastasize if become persistent.

  • Choriocarcinoma - malignant.

  • Placental site trophoblastic tumour (PSTT) - malignant, very rare.

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These tumours are generally chemosensitive (except PSTT), can be monitored with a tumour-specific, semiquantitative marker, β-hCG, and have a cure rate of over 90%, making them almost unique in the world of oncology.3 Most molar pregnancies resolve spontaneously, but about 10–20% of women develop persistent GTN.1 This can become metastatic and often requires further treatment - either chemotherapy or surgery.

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In northern Europe and USA, the incidence of hydatidiform mole is around 1 in 1500–2000 pregnancies and of choriocarcinoma is 0.7/1000 pregnancies.2 The incidence is higher in Chinese, Malays, Indonesians and Native Alaskans, and lowest in Caucasians.

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Classic symptoms of GTN include hyperemesis gravidarum, excessive uterine enlargement, early severe pre-eclampsia and hyperthyroidism. However, with the advent of high-resolution ultrasonography, GTN is now being diagnosed at a much earlier stage (8.5–9.5 weeks' versus 16–18 weeks' gestation) and therefore, in the developed world, the women are usually treated before these classic symptoms develop.4 Women with GTN usually present with vaginal bleeding between 6 and 12 weeks into the pregnancy. They may also be large-for-dates and have more nausea and vomiting compared with a normal pregnancy, possibly due to high levels of hCG. GTN can also be an incidental finding either on ultrasound scanning in early pregnancy or on histological examination of products of conception of spontaneously passed tissue or after a therapeutic termination of pregnancy.2,5 In women with no known antecedent pregnancy or term pregnancy, it can be more difficult to detect and may present with abnormal vaginal bleeding, postpartum haemorrhage or symptoms secondary to metastatic disease. Persistent GTN should be suspected in any pregnancy or in any woman of reproductive age where the woman represents with persistent abnormal vaginal bleeding, or develops new and acute respiratory or neurological symptoms.

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Discussion

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How should the condition be managed?

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Image not available. The initial management of this patient includes suction uterine evacuation to remove tumour, confirm the diagnosis histologically, and aid in controlling vaginal bleeding.4–6...

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