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Gestational trophoblastic tumors (GTTs) are rare but highly curable tumors arising from the products of conception in the uterus. The prognosis for cure of patients with GTTs is good even when the disease has spread to distant organs, especially when only the lungs are involved. The probability of cure depends on the following:
Selection of treatment depends on these factors plus the patient’s desire for future pregnancies. Human chorionic gonadotropin, produced normally during pregnancy, is abnormally elevated in the blood and urine of patients with this group of diseases and is a sensitive marker to indicate the presence or absence of disease before, during, and after treatment.
The most common antecedent pregnancy is that of a hydatidiform mole, usually a genetic disorder of pregnancy in which only placental-like tissue is present. The patient will present with abnormal bleeding from onset of pregnancy and may have a uterus which is much larger than expected. Sonography is the preferred method of diagnosis, and suction dilation and curettage (D & C) is the preferred method of evacuation. Of utmost importance is careful follow-up with serum beta HCG (BHCG) weekly until less than 100 mIU/mL and then every two weeks. The patient should have a careful pelvic examination every other week and a chest x-ray every 4-6 weeks. Once the titer of serum BHCG has fallen to normal levels, these two examinations need no longer be done; however, BHCG titers need to be repeated every 2 weeks for 3 months, then monthly for 3 months, then every 2 months for 6 months, then every 6 months for 3 years. Each patient should be counseled in the use of a reliable birth control method. Any patient who develops an increasing level of serum BHCG, a plateau of the BHCG over 3 weeks, or persistent elevation of BHCG after 16 weeks of follow-up should be considered as having gestational trophoblastic neoplasia and should undergo the appropriate work-up and treatment. Similarly, any patient who develops metastatic disease during follow-up should be staged and undergo treatment.
Choriocarcinoma most commonly follows a molar pregnancy but can follow a normal pregnancy, ectopic pregnancy, or abortion, and should always be considered when a patient has continued vaginal bleeding in the postdelivery period. Other common signs include bizarre neurologic symptoms in a female within the reproductive age group and asymptomatic lesions on routine chest x-ray.
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