Case Conference April 18th 2018

18-Apr-2018, Divisi Ginekologi Onkologi RSCM

 

CASE CONFERENCE

 

Mrs P, 20 yo, P0A1, 418-07-35

 

Gestational Trophoblastic Neoplasia

 

 

 

I.      Case Description

 

Patient was refereed to RSCM from Marsidi Judono Hospital Belitung with Gestational Trophoblatic Neoplasia. Patient with history of curettage due to molar pregnancy in 2016, she was then referred to RSCM, and was suggested to perform hcg evaluation, but due to financial problem, the patient refused and went back home.

 

On Decemer 2017, she complained of vaginal bleeding and mass palpabled on her abdomen. She went to the doctor, where she did the Bhcg level examination, with result > 225.000 mIu/mL. She was then referred to RSCM. USG result was suspected trophoblast malignancy on placental site (result of the previous mole in 2016) with invasion until serosa layer dd/ new case of invasive mole.

 

                              

 

Physical Examination on April 17^th , 2018

 

a.      General status:

 

CM. BP: 110/70 mmHg, HR: 94 x/min, T: 36°C, RR: 20 x/min,

 

Head                : Pale conjunctiva (-/-) icteric sclera (-/-)

 

Thorax : symmetry shape and movement of hemithorax

 

Lung                 : vesicular breath sound on both lungs, neither wheezing nor         

 

                                      rhales

 

Cardia              : no murmur, no gallop

 

Abdomen         : mass palpated until umbilicus, immobile, pain (-)

 

Extremity         : warm, no oedema

 

 

 

Gynecology examination:

 

Inspection        : vulva urethra were normal

 

RVT                  : uterus enlarged until umbilicus, no adnexal mass palpated, rectal mucose was smoth

 

 

 

Work Up

 

II.      Laboratory Result on  MArch 123^rd, 2018:

 

Bhcg > 225.000

 

 

 

a.        Pathology Anatomy Result on September, 27th 2016

 

Makroskopik: Beberapa potong jaringan terfragmentasi, tampaknya dari jaringan yang sama, volume 2 cc, putih  bening sebagian keabu-abuan, kenyal, tidak dijumpai gelembung

 

Mikroskopik: Sediaan dari kuretase uterus dijumpai villi-villi korialis berbagai ukuran sebagian distended dilapisi sel-sel trofoblas, proliferasi ringan, stroma villi mengalami degenerasi hidrofik dan avaskuler, di antaranya tampak beku darah dan nekrosis. Tidak dijumpai tanda-tanda ganas pada sediaan ini.

 

Kesimpulan: Mola hidatidosa komplit dengan proliferasi ringan sel-sel trofoblas

 

Catatan: apakah jenis tumor pada riwayat operasi sebelumnya? Kami tidak menemukan data di arsip kami

 

 

 

 

 

 

 

     b.    US Result on April 17^th 2018

 

Description: Uterus enlarged with uterine cavity filled with solid mass size 125 x 75 mm. Mass contained of venous type vascularization. Most part of the mass was in clear border (seemed to be bordered with stratum basalis endometrium), except a little part  in the fundal area, where it reached the serosa layer. CAn be detected endometrium ( in the cranial of the uterus, pushed by the mass). Portio  and endocervix were within normal limit. Both ovaries were within normal limit. There were no abnormal mass on both of the ovaries ( adnexa free from invasion dan there was no mass detected from the previous mole)

 

Liver and both kidneys were within  normal limit.

 

Bhcg quantitative : 225.000 (high)

 

Conclusion: suspected trophoblast malignancy on placental site (result of the previous mole in 2016) with invasion until serosa layer dd/ new case of invasive mole.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.    US result on November 24^th 2016

 

Description: Uterus anteflexed, size and shape normal. Miometrium homogen. There was no abnormal mass on the myometrium nor the uterine cavity. Endometrial basalis stratum regular, 2 mm. Portio and endocervix were within  normal limit. Both ovaries were within normal limit. On the right adnexa : there was enlarged tube size 44 x 15 x 22 mm, the tubal wall was intact and not detected abnormal mass or gestational sac inside. There was hemoperitoneal. Bhcg urine + (24 November 2016).

 

Conclusion : There was no signof GTN. Right tube edema and hemoperitoneal ( a little). Suspected (post) right tubal abortion dd/ tubal pregnancy

 

Suggestion : serial Bhcg quantitative evaluation. Be aware if there was an increasing bhcg

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Problems to be discussed

 

Is surgery better than chemotherapy for patient with gestational trophoblastic neoplasia high risk in young age?

 

 

 

Clinical question in this case will be developed by PICO approach

 

Patient	gestational trophoblastic neoplasia high risk in young age
Intervention	surgery
Comparison	chemotherapy
Outcome	overall survival

 

 

 

 

 

METHODS

 

Search strategy

 

In order to answer the question above, we conduct a searching in PubMed site by using keywords, gestational trophoblastic neoplasia AND high risk AND surgery AND chemotherapy AND young age. The search was conducted on PubMed on April, 17^th 2018, there were 11 journals matched. Search strategy in PubMed conducted on

 

 

 

Engine	Search terms	Results
PubMed	gestational trophoblastic neoplasia AND high risk AND surgery AND chemotherapy AND young age	11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1. Flowchart of search strategy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Critical Appraisal

 

Article 1

 

Al-Husaini H, et al. Gestational trophoblastic neoplasia: treatment outcomes from a single institutional experience. Clin Transl Oncol  

 

 

 

Article 2

 

Eoh KJ, et al. Fertility-sparing uterine lesion resection for young women with gestational trophoblastic neoplasias: single institution experience. Obstet Gynecol Sci 2015;58(4):277-283

 

 

 

	1st art	2nd art
A. Are the study results valid
1.  Was there a representative and well-defined sample patients at a similar point in the course of disease?	yes	yes
2. Was follow-up sufficiently long and complete?	yes	yes
3. Were objective and unbiased outcome criteria used?	no	no
4. Was there adjustment for important prognostic factors?	yes	yes
B. What were the results?
1. How large is the likelihood of the otcome events in a specific period of time?	N/A	N/A
2. How precise are the estimates of likelihood? (consider 95% CI)	74% vs 94%	N/A
C. Can the results be applied to your patients?
1. Were the study patients similar to my own?	yes	yes
2. Are the results useful for reassuring or counseling patients?	yes	yes
3. Is the treatment feasible in my setting?	yes	yes
D. Conclusions
1. The results or recommendation are valid?	yes	yes
2. The results clinically important?	yes	yes
3. The results are relevant to my practice?	yes	yes

 

 

 

 

 

Discussion

 

 

 

The proliferative process arising from an aberrant fertilization event that has potential to develop into invasive malignant neoplasm is known as gestational trophoblastic disease (GTD). This includes hydatidiform mole (complete and partial) and gestational trophoblastic neoplasia (GTN), which encompasses persistent/invasive mole, choriocarci- noma, placental site trophoblastic tumors, and epithelioid trophoblastic tumor.

 

Most commonly, GTN is diagnosed following molar pregnancy, but it can also occur after any gestation including miscarriages and term pregnancies. Any form of GTN can metastasize and the most common metastatic site is lung (80 %) followed by vagina (30 %), brain and liver (10 %). GTN is highly sensitive to chemotherapy and most curable cancer with success rate exceeding 90 %. It represents one of the only cancers for which single-agent chemotherapy is still in wider use. Therapeutic decision is based on the International Federation of Gynecology and Obstetrics (FIGO) anatomic staging and prognostic scoring index. The low-risk group can be treated with single-agent chemotherapy resulting in the survival rate approaching 100 %. The high-risk group requires initial multi-agent chemotherapy with or without adjuvant radiation therapy and surgery to achieve a survival rate of 80–90 %. GTNs are highly responsive to chemotherapy especially in choriocarcinomas even with distant metastasis. Although surgery was considered as a less important approach in the management of GTNs, selected surgical procedures may be necessary for removing chemo-resistant or persistent lesions in uterus and metastatic sites, and for curing severe complications. Hysterectomy is recommended when lesion is localized in uterus, but loss of fertility is the major concern for young women.

 

Al-Husaini, et al performed a study to report the outcomes of gestational trophoblastic neoplasia (GTN) at a single institution and to determine the factors affecting response to chemotherapy and survival. They retrospectively reviewed the data of 221 patients treated at their center. GTN Patients were assigned to low-risk or high-risk based on the WHO risk factor scoring system. The result was in high-risk group, 94 % achieved complete remission to initial chemotherapy with etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine (EMA-CO). Salvage chemotherapy, surgical intervention or radiation therapy resulted in overall complete remission of 90 % in low-risk and 73 % in high-risk groups.

 

Wang et al, performed a study to evaluate the oncological safety and pregnant outcomes of fertility- sparing uterine lesion resection in treating gestational trophoblastic neoplasias. They reviewed 78 patients with gestational trophoblastic neoplasias who underwent fertility-sparing uterine lesion resection at Peking Union Medical College Hospital. They analyzed The complete remission rate, fertility rate, pregnant outcomes and risk factors of recurrence. The indications for surgery were persistent lesion, chemoresistant lesion, unclear diagnosis and suspected uterine rupture. The mean preoperative serum β-hCG level in above was 0.7 (range, 0-4.4) IU/L, 123.8 (range, 5.8-1294) IU/L, 494.9 (range, 15.8-3071.3) IU/L, and 73321.2 (range, 14160-213857) IU/L, respectively. The mean size of lesion in the uterus was 3.7 (range, 3.0-8.1) cm.

 

After the treatment of surgery and chemotherapy, all the patients achieved complete remission. With a median follow-up time of 44 months (range, 6-188), 3 patients (3.85%) relapsed within 3-26 months. Multivariate analysis showed that tumor size was the independent risk factor of recurrence and the cutoff value was 4.2cm. Among 37 patients who attempted to conceive, 31 achieved clinical pregnancy. The rate of pregnancy and live birth were 83.8% and 77.4%. Due to lack of big sample about lesion resection surgery in other centers, the suitable tumor size for surgery is not definite. Large lesion especially with unclear border may increase the risk of tumor residues. Although the result of our study showed that the tumor size was the independent risk factor of recurrence and the cutoff value was 4.2cm, it should be noted that, the 95% of confidence interval in multivariate analysis was relative broad due to only 3 cases relapsed in our series. Larger sample was needed to confirm this finding.

 

 

 

 Conclusion

 

In this patient the tumor mass is quite big and uterine rupture can happened anytime. If possible, we can try to perform  a lesion resection, since the patient is 20 years old and P0. And chemotherapy can be given afterwards.

 

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