Case Conference July 19th 2017

19-Jul-2017, Divisi Ginekologi Onkologi RSCM

Mrs. Y

Malignant Trophoblastic Disease

 

 

Case Discription

Patient was referred from Mitra Keluarga hospital due to malignant trophoblastic disease for chemotherapy.

(P0A2, previous molar pregnancy and blighted ovum)

 

On September 2016 patient had blighted ovum pregnancy and was performed curettage. Pathologic specimen result was histology correspond to conception tissue. Two months after the pregnancy evacuation, patient had vaginal spotting for three weeks. Then she was performed US exam and was being said that she had polyp (no print of US data). She was performed curettage and the pathologic specimen result was tissue correspond to endometrial polyp. After curettage, the patient still complained of vaginal spotting. Then, she was performed US exam and being said that she still had polyp in her uterus.

Due to recurrent bleeding and history of hydatidiform mole in previous pregnancy, patient was performed quantitative beta HCG examination and the result was 27.030 IU/L. Three weeks later she was performed quantitative beta HCG examination again and the result was 103.286 IU/L. The she was referred to oncologist and said that she had low risk malignant trophoblastic disease. She was given MTX-Etoposide for 6 courses. But the lab result in 3 last consecutive examination did not show any improvement. Then she was referred to RSCM for given other regiment of chemotherapy (EMACO).

Now she was already treated with EMACO cycle I and the last beta HCG result was 762 IU/l

 

History of past illness

Hypertension, diabetes, asthma, allery, heart disease were denied

 

Marital status

Married 1x, 2014

 

Obstetric history

P0A2

I.                    June 2014, partial mola, curettage in Mitra Keluarga hospital with pathologic specimen result: show gravid decidua and villi choriallis. Some part showed hydropic degeneration, avascular stroma, anc some part with cisterna formation. Villi was layered by trophoblas which had some proliferative part. No sign of malignancy. Histologic correspond to partial hydatidiform mola.

1^st beta HCG >750.000 IU/l (18/6/2014); 2^nd beta HCG 267.59 IU/l (31/8/2014); 3^rd beta HCG 7.89 IU/l (9/10/2014);  4^th beta HCG <2 IU/l (11/1/2015)

II.                  September 2016, blighted ovum, curettage in Mitra Keluarga hospital

PA result

Macroscopic: Tissue fragments 25 cc, brown-black

Microscopic: The specimens consisted of  endometrial tissue with gravid decidua cell. Villi chorialis with fibrotic stroma. No sign of trophoblast proliferation. Conclusion: Correspond to blighted ovum

 

 

 

Physical Exam (2/6/2017)

 

Compos Mentis. BP: 120/80 HR 84 bpm, RR 20x/m,  T:36,2 C

BH 160 cm, BW 60 cm, IMT 23.4 kg/m²

General status:

No lymph nodes palpable

Lung: Vesicular breath sound, no rhales or wheezing

Abdomen:  supple, no pain on palpation

 

Gynecology status:

Inspection: no vaginal bleeding, vulva & external urethral orifice were normal

Inspekulo: smooth portio, smooth vaginal wall, no fluor albus, fluxus was negative

Vaginal touché: uterus anteflexed with normal shape and size, both parametrium were loose, no mass palpable on both adnexa

DISCUSSION

 

In this study, all patients were initially treated with MTX and folinic acid, which produced normal hCG values in approximately 70% of cases. During the observation, patients who diagnosed having chemoresistance of MTX were treated with second line regiment based on the last hCG level.

 

 

The results presented here indicate that single-agent dactinomycin does have significant activity in this disease and can produce complete responses in over 85% of those who are resistant to MTX when the serum hCG is relatively low. Moreover, dactinomycin does not compromise the long-term outcome of those who do subsequently require combination chemotherapy. For those who require a change of treatment, single-agent dactinomycin should be considered if the serum hCG is less than approximately 100 IU/L, whereas EMA/CO should still be used for those with higher hCG values. 

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