indiacancer.org - Gestational Trophoblastic Tumors

Gestational Trophoblastic Tumors

		What is Conception?
		What are Gestational Trophoblastic Tumours?
		How do Gestational Trophoblastic Tumours present?
		How are Gestational Trophoblastic Tumours detected?
		What are staging and grading?
		How are Gestational Trophoblastic Tumours treated?
		What are the side effects of treatment for Gestational Trophoblastic Tumors?
		What is the importance of follow up?

What is Conception?

The joining of the sperm and the egg in order to produce or have the potential to produce a viable living foetus is called conception. The process occurs in the uterus, which is a hollow muscular pear-shaped organ. It is a process which is only seen in women during the years when they are able to have children, that is when they are still having their valid menstrual periods.

What are Gestational Trophoblastic Tumours?

Gestational trophoblastic tumours are very rare cancers in women, which are produced from those cells of conception which turn malignant. Basically, two types of gestational trophoblastic tumours have been identified - hydatidiform mole and choriocarcinoma.

A molar pregnancy or the hydatidiform mole occurs in a patient in whom the sperm and egg has joined without the development of a baby in the uterus. What it does produce is a cluster of grape-like cysts. It does not spread outside the uterus to the other parts of the body.

On the other hand, choriocarcinoma may have started initially like a molar pregnancy or from tissue that remain in the uterus following an incomplete abortion or after the delivery of the baby. From the uterus then it spreads to other parts of the body immediately.

A very rare type of gestational trophoblastic tumour originates in the uterus in the place where the placenta had been attached. These are called placental site trophoblastic diseases.

How do Gestational Trophoblastic Tumours present?

These tumours are extremely difficult to detect. When initially in their growth phase, the patient may be overjoyed to feel that it is actually a real pregnancy and it may fool the doctor as well. But if there is vaginal bleeding and not menstrual bleeding and, if the woman has some signs and symptoms of pregnancy but the baby has not moved at the expected time, then the doctor should be seen.

How are Gestational Trophoblastic Tumours detected?

Besides the history , there is a search for a lesion in the uterus or in the neighbouring areas.

The doctor will order an ultrasound, which is an imaging investigation, to find out if there are any space-occupying lesions seen in the uterus.

The doctor will perform or order a very important tumor marker or blood study, which is called beta HCG or beta human chorionic gonadotropin. This is a special hormone, which is produced during normal pregnancy. If there is no evidence of pregnancy but levels of beta hCG are present in the woman's blood, then it is clearly a sign of a gestational trophoblastic tumour. Thus, this tumour marker study becomes extremely important.

What are staging and grading?

	These are terms with which you must become familiar, if you are dealing with any form of cancer. When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs. The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive. Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome. Staging may require additional imaging tests such as CT Scan, MRI, Sonography of the abdomen, IVU, Bone scan or chest X-ray. Hydatidiform mole - Is as described above.If it is pushing into the muscle of the uterus, then it is known as an invasive mole or a choriocarcinoma. Placental site gestational trophoblastic tumour - Is as described above. It basically involves the area where the placenta had erstwhile been attached and may be invading into the muscle and adjoining area. Non-metastatic. The cancer cells have grown to involve the uterus following treatment for a hydatidiform mole or following an abortion, which is incomplete, or the delivery of the baby, but there is no evidence of spread to outside the uterus. Metastatic gestational trophoblastic tumour with a good prognosis. These cells have grown inside the uterus on tissues remaining following treatment for the above conditions and have spread to other parts of the body but there are signs of good prognosis, which means that the following criteria are fulfilled:
		The level of beta hCG in the blood is low.
		Cancer has not spread to the liver or the brain.
		Last pregnancy was less than 4 months back.
		The patient has never before received chemotherapy.
	Metastatic gestational trophoblastic tumour with a poor prognosis. The cancer cells have grown inside the uterus from the tissues described above. They have spread outside the uterus and the criteria which have been described above were exactly reversed. One more criteria can be added that it all began after the completion of a normal pregnancy. Recurrent. This is a disease which has come back after the primary therapy for the cancer is over. It may recur in the uterus itself or in other parts of the body.

How are Gestational Trophoblastic Tumours treated?

	A lot depends on the patient's constitution, the grade of her disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes an oncosurgeon, a gynecologist and a medical oncologist. Treatment strategies. The bastions of treatment for gestational trophoblastic cancers are surgery and chemotherapy. Radiation may also be used as an add-on. As far as surgery for gestational trophoblastic tumors is concerned, one of the operations described below may be performed: A D&C or a dilatation and curettage with suction evacuation is a procedure in which the opening of the uterus or the cervix is dilated and then any material which remains in the uterus is carefully scraped out or sucked out. This is a procedure used exclusively for hydatidiform moles. Hysterectomy is an operation to take out the uterus. Usually the ovaries are preserved, because these patients are usually still in the childbearing age and removal of the ovaries at this early age can cause hormonal imbalance. This can be done safely without any expectations of compromise. The best attempt to control these cancer cells circulating in the body and lodged at various places is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy. This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks). The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer. Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after. Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used. For hydatidiform moles, one of the following treatment options may be exercised:
		D&C and suction evacuation.
		Hysterectomy.
	For placental site gestational trophoblastic tumors, one of the following treatment options will be exercised:
		Hysterectomy.
	For nonmetastatic gestational trophoblastic tumors, one of the following treatment options may be exercised:
		Chemotherapy.
		Hysterectomy, where the patient no longer wishes to have any children.
	For good prognostic metastatic gestational trophoblastic tumors, one of the following treatment options may be used:
		Chemotherapy.
		Hysterectomy.
		Chemotherapy followed by hysterectomy if the cancer remains following chemotherapy.
	Poor prognostic metastatic gestational trophoblastic tumors. The treatment is usually chemotherapy; but radiation may be given at places where it is feasible such as in the brain.

What are the side effects of treatment for Gestational Trophoblastic Tumors?

	Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are her chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems.

What is the importance of follow up?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination ), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.