Gestational Trophoblastic Tumour

What are gestational trophoblastic tumours?

Gestational trophoblastic tumour, a rare cancer in women, is a disease in which cancer (malignant) cells grow in the tissues that are formed following conception (the joining of sperm and egg). Gestational trophoblastic tumours start inside the uterus, the hollow, muscular, pear-shaped organ where a baby grows. This type of cancer occurs in women during the years when they are able to have children. There are two types of gestational trophoblastic tumours: hydatidiform mole and choriocarcinoma.

If a patient has a hydatidiform mole (also called a molar pregnancy), the sperm and egg cells have joined without the development of a baby in the uterus. Instead, the tissue that is formed resembles grape-like cysts. Hydatidiform mole does not spread outside of the uterus to other parts of the body.

If a patient has a choriocarcinoma, the tumour may have started from a hydatidiform mole or from tissue that remains in the uterus following an abortion or delivery of a baby. Choriocarcinoma can spread from the uterus to other parts of the body. A very rare type of gestational trophoblastic tumour starts in the uterus where the placenta was attached. This type of cancer is called placental-site trophoblastic disease.

Gestational trophoblastic tumour is not always easy to find. In its early stages, it may look like a normal pregnancy. A doctor should be seen if the there is vaginal bleeding (not menstrual bleeding) and if a woman is pregnant and the baby hasn’t moved at the expected time.

If there are symptoms, a doctor may use several tests to see if the patient has a gestational trophoblastic tumour. An internal (pelvic) examination is usually the first of these tests. The doctor will feel for any lumps or strange feeling in the shape or size of the uterus. The doctor may then do an ultrasound, a test that uses sound waves to find tumours. A blood test will also be done to look for high levels of a hormone called beta-HCG (beta human chorionic gonadotropin) which is present during normal pregnancy. If a woman is not pregnant and HCG is in the blood, it can be a sign of gestational trophoblastic tumour.

The chance of recovery (prognosis) and choice of treatment depend on the type of gestational trophoblastic tumour, whether it has spread to other places, and the patient’s general state of health.

Stage Explanation

Stages of gestational trophoblastic tumours

Once gestational trophoblastic tumour has been found, more tests will be done to find out if the cancer has spread from inside the uterus to other parts of the body (staging). A doctor needs to know the stage of the disease to plan treatment. The following stages are used for gestational trophoblastic tumour:
Hydatidiform mole

Cancer is found only in the space inside the uterus. If the cancer is found in the muscle of the uterus, it is called an invasive mole (choriocarcinoma destruens).
Placental-site gestational trophoblastic tumours

Cancer is found in the place where the placenta was attached and in the muscle of the uterus.
Nonmetastatic

Cancer cells have grown inside the uterus from tissue remaining following treatment of a hydatidiform mole or following an abortion or delivery of a baby. Cancer has not spread outside the uterus.
Metastatic, good prognosis

Cancer cells have grown inside the uterus from tissue remaining following treatment of a hydatidiform mole or following an abortion or delivery of a baby. The cancer has spread from the uterus to other parts of the body. Metastatic gestational trophoblastic tumours are considered good prognosis or poor prognosis.

Metastatic gestational trophoblastic tumour is considered good prognosis if all of the following are true:

1. The last pregnancy was less than 4 months ago.
2. The level of beta-HCG in the blood is low.
3. Cancer has not spread to the liver or brain.
4. The patient has not received chemotherapy earlier.

Metastatic, poor prognosis

Cancer cells have grown inside the uterus from tissue remaining following treatment of a hydatidiform mole or following an abortion or delivery of a baby. The cancer has spread from the uterus to other parts of the body. Metastatic gestational trophoblastic tumours are considered good prognosis or poor prognosis.

Metastatic gestational trophoblastic tumour is considered poor prognosis if any the following are true:

1. The last pregnancy was more than 4 months ago.
2. The level of beta-HCG in the blood is high.
3. Cancer has spread to the liver or brain.
4. The patient received chemotherapy earlier and the cancer did not go away.
5. The tumour began after the completion of a normal pregnancy.

Recurrent

Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the uterus or in another part of the body.

Treatment Option Overview

How gestational trophoblastic tumour is treated

There are treatments for all patients with gestational trophoblastic tumour. Two kinds of treatment are used: surgery (taking out the cancer) and chemotherapy (using drugs to kill cancer cells). Radiation therapy (using high-energy x-rays to kill cancer cells) may be used in certain cases to treat cancer that has spread to other parts of the body.

The doctor may take out the cancer using one of the following operations:

1. Dilation and curettage (D & C) with suction evacuation is stretching the opening of the uterus (the cervix) and removing the material inside the uterus with a small vacuum-like device. The walls of the uterus are then scraped gently to remove any material that may remain in the uterus. This is used only for molar pregnancies.
2. Hysterectomy is an operation to take out the uterus. The ovaries usually are not removed in the treatment of this disease.

Chemotherapy uses drugs to kill cancer cells. It may be taken by pill or put into the body by a needle in a vein or muscle. It is called a systemic treatment because the drugs enter the bloodstream, travel through the body, and can kill cancer cells outside the uterus. Chemotherapy may be given before or after surgery or alone.

Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumours. Radiation may come from a machine outside the body (external-beam radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes into the area where the cancer cells are found (internal radiation).
Treatment by stage

Treatment of gestational trophoblastic tumour depends on the stage of the disease, and the patient’s age and overall condition.

Standard treatment may be considered because of its effectiveness in patients in past studies, or participation in a clinical trial may be considered. Not all patients are cured with standard therapy and some standard treatments may have more side effects than are desired. For these reasons, clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information. Clinical trials are ongoing in most parts of the country for most stages of gestational trophoblastic tumour.

Hydatidiform Mole

Treatment may be one of the following:

1. Removal of the mole using dilation and curettage (D & C) and suction evacuation.
2. Surgery to remove the uterus (hysterectomy).

Following surgery, the doctor will follow the patient closely with regular blood tests to make sure the level of beta-HCG in the blood falls to normal levels. If the blood level of beta-HCG increases or does not go down to normal, more tests will be done to see whether the tumour has spread. Treatment will then depend on whether the patient has nonmetastatic disease or metastatic disease (see the treatment sections on metastatic or nonmetastatic disease).

Placental-Site Gestational Trophoblastic Tumours

Treatment will probably be surgery to remove the uterus (hysterectomy).

Nonmetastatic Gestational Trophoblastic Tumours

Treatment may be one of the following:

1. Chemotherapy.
2. Surgery to remove the uterus (hysterectomy) if the patient no longer wishes to have children.

Good Prognosis Metastatic Gestational Trophoblastic Tumours

Treatment may be one of the following:

1. Chemotherapy.
2. Surgery to remove the uterus (hysterectomy) followed by chemotherapy.
3. Chemotherapy followed by hysterectomy if cancer remains following chemotherapy.

Poor Prognosis Metastatic Gestational Trophoblastic Tumours

Treatment will probably be chemotherapy. Radiation therapy may also be given to places where the cancer has spread, such as the brain.

Recurrent Gestational Trophoblastic Tumours

Treatment will probably be chemotherapy.


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