Treatments for gestational trophoblastic disease

If you have gestational trophoblastic disease (GTD), your healthcare team will create a treatment plan just for you. It will be based on your health and specific information about the cancer. When deciding which treatments to offer for GTD, your healthcare team will consider:

• the type of GTD
• the stage and risk grouping
• previous treatment
• your wish to preserve fertility
• your personal preferences

You may be offered one or more of the following treatments for GTD.

Surgery is usually used to treat GTD. You may have surgery as the main treatment for GTD or if GTD comes back after other treatments.

The following types of surgery are used to treat GTD. You may also have other treatments before or after surgery.

Dilation and curettage (D&C) is a surgical procedure that opens the cervix and then uses a vacuum-like device and a small instrument to remove all abnormal tissue from the lining of the uterus. A woman may also be given a drug that causes the uterus to contract, which helps to push tissue from the uterus and minimize bleeding during the procedure.

A D&C is used to treat a complete or partial hydatidiform mole and allows for fertility to be preserved. It is often the only treatment needed to treat molar pregnancies.

Side effects of a D&C include pelvic cramps and vaginal spotting or bleeding.

Hysterectomy is the surgical removal of the uterus. A hysterectomy is rarely used to treat gestational trophoblastic neoplasia (GTN). It may be used for different reasons:

• there is no spread outside of the uterus and you don’t wish to have children
• as the main treatment for placental site trophoblastic tumours and epithelioid trophoblastic tumours
• for GTN that does not respond to chemotherapy
• to decrease the risk of cancer coming back (called recurrence)
• to treat late-stage tumours or large uterine tumours
• to manage symptoms of advanced GTD, such as uncontrollable bleeding and widespread infection (sepsis) in the pelvis

Find out more about hysterectomy.

Surgery may be used to treat GTD that has spread to distant sites in the body, such as the brain, intestines, kidneys, liver or lung, especially if the tumours are resistant to chemotherapy.

Side effects of surgery will depend mainly on the type of surgery and your overall health.

Find out more about side effects of surgery.

Chemotherapy uses anticancer (cytotoxic) drugs to destroy cancer cells. Chemotherapy is usually a systemic therapy. This means that the drugs travel through the bloodstream to reach and destroy cancer cells all over the body, including those that may have broken away from the primary tumour in the uterus. Most GTD can be cured by chemotherapy even if it is advanced.

Chemotherapy is a standard treatment for gestational trophoblastic neoplasia (GTN). It may be given as the main treatment, after surgery or if the GTN comes back (recurs) after treatment. If blood levels of human chorionic gonadotropin (HCG or b-HCG) start to stabilize, rise or are still measureable after a few months following surgery for a hydatidiform mole, it means you have a persistent mole (such as an invasive mole or a choriocarcinoma), which will need to be treated further with chemotherapy.

The most common chemotherapy drugs used to treat GTN or persistent hydatidiform moles include:

• methotrexate with or without leucovorin (folinic acid)
• dactinomycin (Cosmegen, actinomycin-D)
• etoposide (Vepesid, VP-16)
• vincristine (Oncovin)
• cisplatin
• bleomycin (Blenoxane)

Some of the common chemotherapy drug combinations used to treat high-risk GTD include:

• MAC – methotrexate, dactinomycin and chlorambucil (Leukeran)
• EMA-CO – etoposide , methotrexate with leucovorin and dactinomycin, followed a week later by cyclophosphamide (Procytox) and vincristine
• EMA-EP – etoposide, methotrexate with leucovorin and dactinomycin, followed a week later by etoposide and cisplatin
• VBP – vinblastine, bleomycin and cisplatin
• BEP - bleomycin, etoposide and cisplatin

Side effects of chemotherapy will depend mainly on the type of drug, the dose, how it’s given, how long the drug needs to be taken and your overall health. Some common side effects of chemotherapy drugs used for GTN are:

• fatigue
• nausea and vomiting
• sore mouth and throat
• loss of appetite
• low blood cell counts
• hair loss
• peripheral neuropathy (tingling and numbness in hands and feet)

Radiation therapy uses high-energy rays or particles to destroy cancer cells. External beam radiation therapy is the type of radiation therapy most often used to treat GTD. Radiation therapy isn’t used often to treat GTD unless it has spread and isn’t responding to chemotherapy. Radiation therapy may also be used to treat GTD that has spread to the brain.

Side effects of radiation therapy will depend mainly on the size of the area being treated, the total dose of radiation and the treatment schedule.

Find out more about side effects of radiation to the pelvis or to the brain.

Treatment depends on the type of GTD, stage and prognostic score.

Hydatidiform moles are a non-cancerous form of GTD. Surgery is usually the only treatment. Treatment options for hydatidiform moles include the following:

• A dilation and curettage (D&C) is the most common surgery and is an option for women who still want to have children. Sometimes a second D&C is needed if some molar tissue remains.
• A hysterectomy may be offered to women who no longer wish to have children.
• Chemotherapy is given for persistent hydatidiform moles.

Gestational trophoblastic neoplasia (GTN) includes invasive moles and gestational choriocarcinoma. They are almost always cancerous.

Treatment options for high-risk GTN are:

• chemotherapy, usually with a combination of drugs
• hysterectomy for women who no longer wish to have children
• surgery to remove metastases
• radiation therapy to treat brain metastasis

Placental site trophoblastic tumours andepithelioid trophoblastic tumours are very rare types of GTD. They are usually resistant to standard chemotherapy and are usually treated with a hysterectomy. Chemotherapy may be given if the tumour spreads to other parts of the body.

Treatment for GTD that has come back (recurred) after treatment depends on where the tumour has recurred and the previous treatments given. The following are treatment options for recurrent GTD or GTD that does not respond to drugs that were used in previous treatment:

• single drug chemotherapy may be used if the GTD was treated before with surgery
• a different drug combination may be used if chemotherapy was given before
• a hysterectomy or surgery to remove metastases may be done
• radiation therapy may be given, especially if GTD has spread to the brain

Follow-up after treatment is an important part of cancer care. You will need to have regular follow-up visits, especially in the first 1 to 2 years after treatment has finished. These visits allow your healthcare team to monitor your progress and recovery from treatment. Your follow-up plan will depend on the type of GTD you had and the treatment you received.

• Hydatidiform moles – blood HCG levels are usually taken every week until the results are normal for at least 3 weeks in a row. After that, they are taken every month for at least the next 6 months.
• Gestational trophoblastic neoplasia (GTN) – blood HCG levels are usually taken every week until the results are normal for at least 3 weeks in a row. After that, they are taken every month for at least the next 12 months. For stage 4 GTN, the blood HCG levels are taken every month for the next 24 months after they are normal for at least 3 weeks in a row.
• A physical exam may be done every 3 to 6 months for the first year, then about every 6 months.
• You may have other tests, such as chest x-rays and other imaging tests, from time to time.

If you did not have a hysterectomy (removal of the uterus), avoiding pregnancy during the follow-up period is important. Your doctor will talk to you about which type of birth control is best for you and how long you should wait before getting pregnant.

Some clinical trials in Canada are open to women with GTD. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.

To make the decisions that are right for you, ask your healthcare team questions about treatment.