Gestational trophoblastic neoplasia medical therapy: Difference between revisions

	Gestational trophoblastic neoplasia Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Gestational trophoblastic neoplasia from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Gestational trophoblastic neoplasia medical therapy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Gestational trophoblastic neoplasia medical therapy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Gestational trophoblastic neoplasia medical therapy
CDC on Gestational trophoblastic neoplasia medical therapy
Gestational trophoblastic neoplasia medical therapy in the news
Blogs on Gestational trophoblastic neoplasia medical therapy
Directions to Hospitals Treating Gestational trophoblastic neoplasia
Risk calculators and risk factors for Gestational trophoblastic neoplasia medical therapy

VisualWikitext

Latest revision as of 15:30, 13 March 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Monalisa Dmello, M.B,B.S., M.D. [2]

Overview

The mainstay of therapy for choriocarcinoma is chemotherapy.

Medical Therapy

Low-risk gestational trophoblastic neoplasia (FIGO Score 0–6)

The initial regimen is generally given until a normal beta human chorionic gonadotropin (beta-hCG) is achieved and sustained for 3 consecutive weeks (or at least for one treatment cycle beyond normalization of the beta-hCG).
A salvage regimen is instituted if any of the following occur:

A plateau of the beta-hCG for 3 weeks (defined as a beta-hCG decrease of 10% or less for 3 consecutive weeks)
A rise in beta-hCG of greater than 20% for 2 consecutive weeks
Appearance of metastasis

The chemotherapy regimen in the first-line management of low-risk gestational trophoblastic neoplasia (GTN) treatment include the following:^[1]

Preferred regimen(1): Methotrexate 50 mg IM on days 1, 3, 5, and 7 AND folinic acid 7.5 mg PO on days 2, 4, 6, and 8 (most common)
Preferred regimen(2): Dactinomycin 1.25 mg/m2 IV biweekly pulsed
Preferred regimen(3): Methotrexate 30 mg/m2 IM weekly
Alternative regimen(1): Methotrexate 1 mg/kg IM days 1, 3, 5, and 7 AND folinic acid 0.1 mg/kg IM days 2, 4, 6, and 8
Alternative regimen(2): Methotrexate 20 mg/m2 IM days 1 to 5, repeated every 14 days
Alternative regimen(3): Dactinomycin 12 μg/kg/day IV days 1 to 5, repeated every 2 to 3 weeks
Alternative regimen(4): Methotrexate 20 mg IM daily, days 1 to 5 AND dactinomycin 500 μg IV daily, days 1 to 5, repeated every 14 days
Alternative regimen(5): Dactinomycin 10 μg/kg/day, days 1 to 5, repeated every 2 weeks
Alternative regimen(6): Methotrexate 0.4 mg/kg/day IM daily on days 1 to 5, repeated after 7 days
Alternative regimen(7): Etoposide 100 mg/m2/day IV on days 1 to 5 OR 250 mg/m2 IV on days 1 and 3, at 10-day intervals

High-risk gestational trophoblastic neoplasia (FIGO Score ≥7) Treatment

Preferred regimen: EMA/CO (i.e., etoposide, methotrexate, and dactinomycin/cyclophosphamide and vincristine) is the most commonly used regimen.
The specifics are provided in table below.^[2]

Day	Drug	Dose
1	Etoposide	100 mg/m2 IV for 30 min
	Dactinomycin	0.5 mg IV push
	Methotrexate	300 mg/m2 IV for 12 h
2	Etoposide	100 mg/m2 IV for 30 min
	Dactinomycin	0.5 mg IV push
	Folinic Acid	15 mg or PO every 12 h × 4 doses, beginning 24 h after the start of methotrexate
8	Cyclophosphamide	600 mg/m2 IV infusion
	Vincristine	0.8–1.0 mg/m2 IV push (maximum dose 2 mg

Cycles are repeated every 2 weeks (on days 15, 16, and 22) until any metastasis present at diagnosis disappear and serum beta-human chorionic gonadotropin (beta-hCG) has normalized, then the treatment is usually continued for an additional three to four cycles.

Alternative regimen(1): MAC: Methotrexate AND folinic acid AND dactinomycin AND cyclophosphamide^[3]
Alternative regimen(2): Another MAC: Methotrexate AND dactinomycin AND chlorambucil
Alternative regimen(3): EMA: Etoposide AND methotrexate AND folinic acid AND dactinomycin (EMA/CO without the CO)
Alternative regimen(4): CHAMOCA: Methotrexate AND dactinomycin AND cyclophosphamide AND doxorubicin AND melphalan AND hydroxyurea AND vincristine
Alternative regimen(5): CHAMOMA: Methotrexate AND folinic acid AND hydroxyurea AND dactinomycin AND vincristine AND melphalan AND doxorubicin

Brain metastasis

Systemic methotrexate as part of the EMA component (i.e., etoposide, methotrexate, folinic acid, and dactinomycin) /CO (1 g/m2 IV for 24 hours, followed by folinic-acid rescue, 15 mg PO q6h for 12 doses starting 32 hours after methotrexate).
Patients with brain metastasis received an increased dose of systemic methotrexate of 1 g/m2 for 24 hours followed by folinic acid (15 mg PO q6h for 12 doses starting 32 hours after methotrexate).

Placental Site Trophoblastic Tumor Treatment

Tumors confined to the uterus (Féderation Internationale de Gynécologie et d’Obstétrique [FIGO] Stage I)

Hysterectomy is the treatment of choice

Tumors with extrauterine spread to genital structures (FIGO stage II)

Complete resection with or without adjuvant chemotherapy

Metastatic tumors (FIGO stages III and IV)

Polyagent chemotherapy
EMA/CO: Etoposide AND methotrexate with folinic acid rescue AND dactinomycin AND cyclophosphamide AND vincristine(most common)
EP/EMA: Etoposide AND cisplatin AND etoposide AND methotrexate AND dactinomycin
MAE: Methotrexate with folinic acid rescue AND dactinomycin AND etoposide

References

↑ Low-Risk Gestational Trophoblastic Neoplasia (FIGO Score 0–6) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_326 Accessed on October 8, 2015
↑ High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_328 Accessed on October 8, 2015
↑ High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_328 Accessed on October 8, 2015

Template:WH Template:WS

[abc-1] Low-Risk Gestational Trophoblastic Neoplasia (FIGO Score 0–6) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_326 Accessed on October 8, 2015

[xxx-2] High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_328 Accessed on October 8, 2015

[3] High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_328 Accessed on October 8, 2015

[1]

[2]

[3]

@@ Line 1: / Line 1: @@
 __NOTOC__
-{{Choriocarcinoma}}
+{{Gestational trophoblastic neoplasia}}
-{{CMG}}
+{{CMG}}{{AE}}{{MD}}
 ==Overview==
+The mainstay of therapy for choriocarcinoma is [[chemotherapy]].
+==Medical Therapy==
-==Chemotherapy==
+====Low-risk gestational trophoblastic neoplasia (FIGO Score 0–6)====
-====Low-Risk Gestational Trophoblastic Neoplasia (FIGO Score 0–6)====
+* The initial regimen is generally given until a normal beta [[human chorionic gonadotropin]] ([[Human chorionic gonadotropin|beta-hCG]]) is achieved and sustained for 3 consecutive weeks (or at least for one treatment cycle beyond normalization of the beta-hCG).
-Treatment commonly used treatment regimens include the following:<ref> Low-Risk Gestational Trophoblastic Neoplasia (FIGO Score 0–6) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_328 Accessed on October 8, 2015</ref>
+* A salvage regimen is instituted if any of the following occur:
+:* A plateau of the [[beta-hCG]] for 3 weeks (defined as a [[Human chorionic gonadotropin|beta-hCG]] decrease of 10% or less for 3 consecutive weeks)
-* The 8-day charing cross regimen. [[Methotrexate]] (50 mg IM on days 1, 3, 5, and 7) and [[folinic acid]] (7.5 mg PO on days 2, 4, 6, and 8). This may be the most common regimen worldwide
+:* A rise in [[Human chorionic gonadotropin|beta-hCG]] of greater than 20% for 2 consecutive weeks
-* Biweekly pulsed [[dactinomycin]] (1.25 mg/m2 IV)
+:* Appearance of [[metastasis]]
-* Weekly methotrexate (30 mg/m2 IM). Efficacy of this regimen appears to be low for choriocarcinoma and for patients with (FIGO) risk scores of 5 to 6
+The chemotherapy regimen in the first-line management of low-risk gestational trophoblastic neoplasia (GTN) treatment include the following:<ref name="abc">Low-Risk Gestational Trophoblastic Neoplasia (FIGO Score 0–6) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_326 Accessed on October 8, 2015</ref>
-Other regimens in less-common use include the following:
-* An 8-day regimen of methotrexate(1 mg/kg IM days 1, 3, 5, and 7) and folinic acid (0.1 mg/kg IM days 2, 4, 6, and 8)
+* Preferred regimen(1): [[Methotrexate]] 50 mg IM on days 1, 3, 5, and 7 {{and}} [[folinic acid]] 7.5 mg PO on days 2, 4, 6, and 8 (most common)
-* Methotrexate 20 mg/m2 IM days 1 to 5, repeated every 14 days
+* Preferred regimen(2):  [[Dactinomycin]] 1.25 mg/m2 IV biweekly pulsed
-* Dactinomycin 12 μg/kg/day IV days 1 to 5, repeated every 2 to 3 weeks
+* Preferred regimen(3):  [[Methotrexate]] 30 mg/m2 IM weekly
-* Methotrexate 20 mg IM daily, days 1 to 5; and dactinomycin 500 μg IV daily, days 1 to 5, repeated every 14 days
+* Alternative regimen(1): [[Methotrexate]] 1 mg/kg IM days 1, 3, 5, and 7 {{and}} folinic acid 0.1 mg/kg IM days 2, 4, 6, and 8
-* Dactinomycin 10 μg/kg/day, days 1 to 5, repeated every 2 weeks
+* Alternative regimen(2): [[Methotrexate]] 20 mg/m2 IM days 1 to 5, repeated every 14 days
-* Methotrexate 0.4 mg/kg/day IM daily on days 1 to 5, repeated after 7 days
+* Alternative regimen(3): [[Dactinomycin]] 12 μg/kg/day IV days 1 to 5, repeated every 2 to 3 weeks
-* [[Etoposide]] 100 mg/m2/day IV on days 1 to 5, or 250 mg/m2 IV on days 1 and 3, at 10-day intervals
+* Alternative regimen(4): [[Methotrexate]] 20 mg IM daily, days 1 to 5 {{and}} [[dactinomycin]] 500 μg IV daily, days 1 to 5, repeated every 14 days
+* Alternative regimen(5): [[Dactinomycin]] 10 μg/kg/day, days 1 to 5, repeated every 2 weeks
+* Alternative regimen(6): [[Methotrexate]] 0.4 mg/kg/day IM daily on days 1 to 5, repeated after 7 days
+* Alternative regimen(7): [[Etoposide]] 100 mg/m2/day IV on days 1 to 5 {{or}} 250 mg/m2 IV on days 1 and 3, at 10-day intervals
-===High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment===
+====High-risk gestational trophoblastic neoplasia (FIGO Score ≥7) Treatment====
+* Preferred regimen: EMA/CO (i.e., [[etoposide]], [[methotrexate]], and [[dactinomycin]]/[[cyclophosphamide]] and [[vincristine]]) is the most commonly used regimen.
-{| {{table}}
+* The specifics are provided in table below.<ref name="xxx">High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_328 Accessed on October 8, 2015</ref>
-| align="center" style="background:#f0f0f0;"|'''Day'''
+{| {{table}} cellpadding="4" cellspacing="0" style="border:#c9c9c9 1px solid; margin: 1em 1em 1em 0; border-collapse: collapse;"
-| align="center" style="background:#f0f0f0;"|'''Drug'''
+| align="center" style="background:#f0f0f0;" |'''Day'''
-| align="center" style="background:#f0f0f0;"|'''Dose'''
+| align="center" style="background:#f0f0f0;" |'''Drug'''
+| align="center" style="background:#f0f0f0;" |'''Dose'''
 |-
-| 1||Etoposide||100 mg/m2 IV for 30 min
+| 1||[[Etoposide]]||100 mg/m2 IV for 30 min
 |-
-|  ||Dactinomycin||0.5 mg IV push
+|  ||[[Dactinomycin]]||0.5 mg IV push
 |-
-|  ||Methotrexate||300 mg/m2 IV for 12 h
+|  ||[[Methotrexate]]||300 mg/m2 IV for 12 h
 |-
-| 2||Etoposide||100 mg/m2 IV for 30 min
+| 2||[[Etoposide]]||100 mg/m2 IV for 30 min
 |-
-|  ||Dactinomycin||0.5 mg IV push
+|  ||[[Dactinomycin]]||0.5 mg IV push
 |-
-|  ||Folinic Acid||15 mg or PO every 12 h × 4 doses, beginning 24 h after the start of methotrexate
+|  ||[[Folinic acid|Folinic Acid]]||15 mg or PO every 12 h × 4 doses, beginning 24 h after the start of methotrexate
 |-
-| 8||Cyclophosphamide||600 mg/m2 IV infusion
+| 8||[[Cyclophosphamide]]||600 mg/m2 IV infusion
 |-
-|  ||Vincristine||0.8–1.0 mg/m2 IV push (maximum dose 2 mg
+|  ||[[Vincristine]]||0.8–1.0 mg/m2 IV push (maximum dose 2 mg
 |}
+Cycles are repeated every 2 weeks (on days 15, 16, and 22) until any metastasis present at diagnosis disappear and serum beta-human chorionic gonadotropin (beta-hCG) has normalized, then the treatment is usually continued for an additional three to four cycles.
+* Alternative regimen(1): MAC: [[Methotrexate]] {{and}} [[folinic acid]] {{and}} [[dactinomycin]] {{and}} [[cyclophosphamide]]<ref>High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_328 Accessed on October 8, 2015</ref>
+* Alternative regimen(2): Another MAC: [[Methotrexate]] {{and}} [[dactinomycin]] {{and}} [[chlorambucil]]
+* Alternative regimen(3): EMA: [[Etoposide]] {{and}} [[methotrexate]]  {{and}} [[folinic acid]]  {{and}} [[dactinomycin]] (EMA/CO without the CO)
+* Alternative regimen(4): CHAMOCA: [[Methotrexate]] {{and}} [[dactinomycin]] {{and}} [[cyclophosphamide]] {{and}} [[doxorubicin]] {{and}} [[melphalan]] {{and}} [[hydroxyurea]] {{and}} [[vincristine]]
+* Alternative regimen(5): CHAMOMA: [[Methotrexate]] {{and}} [[folinic acid]] {{and}} [[hydroxyurea]] {{and}} [[dactinomycin]] {{and}} [[vincristine]] {{and}} [[melphalan]] {{and}} [[doxorubicin]]
+=====Brain metastasis=====
+* Systemic [[methotrexate]] as part of the EMA component (i.e., [[etoposide]], [[methotrexate]], [[folinic acid]], and [[dactinomycin]]) /CO (1 g/m2 IV for 24 hours, followed by folinic-acid rescue, 15 mg PO q6h for 12 doses starting 32 hours after methotrexate).
+* Patients with [[brain]] [[metastasis]] received an increased dose of systemic [[methotrexate]] of 1 g/m2 for 24 hours followed by folinic acid (15 mg PO q6h for 12 doses starting 32 hours after [[methotrexate]]).
+==Placental Site Trophoblastic Tumor Treatment==
+* [[Tumors]] confined to the [[uterus]] (Féderation Internationale de Gynécologie et d’Obstétrique [FIGO] Stage I)
+:* [[Hysterectomy]] is the treatment of choice
+* [[Tumors]] with extrauterine spread to genital structures (FIGO stage II)
+:* Complete resection with or without [[adjuvant chemotherapy]]
+* Metastatic tumors (FIGO stages III and IV)
+:* Polyagent chemotherapy
+:* EMA/CO: [[Etoposide]] {{and}} [[methotrexate]] with [[folinic acid]] rescue {{and}} [[dactinomycin]] {{and}} [[cyclophosphamide]] {{and}} [[vincristine]](most common)
+:* EP/EMA: [[Etoposide]] {{and}} [[cisplatin]] {{and}} [[etoposide]] {{and}} [[methotrexate]] {{and}} [[dactinomycin]]
+:* MAE: [[Methotrexate]] with [[folinic acid]] rescue {{and}} [[dactinomycin]] {{and}} [[etoposide]]
-Examples of other regimens that have been used include the following: <ref> High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment. National Cancer Institute. http://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq/#section/_328 Accessed on October 8, 2015</ref>
-* MAC: Methotrexate  {{and}} folinic acid  {{and}} dactinomycin {{and}} [[cyclophosphamide]].
-* Another MAC: Methotrexate  {{and}} dactinomycin  {{and}} [[chlorambucil]].
-* EMA: Etoposide  {{and}} methotrexate  {{and}} folinic acid  {{and}} dactinomycin (EMA/CO without the CO).
-* CHAMOCA: Methotrexate  {{and}} dactinomycin {{and}} cyclophosphamide  {{and}} [[doxorubicin]]  {{and}} [[melphalan]]  {{and}} hydroxyurea  {{and}} [[vincristine]].
-* CHAMOMA: Methotrexate  {{and}} folinic acid  {{and}} hydroxyurea  {{and}} dactinomycin  {{and}} vincristine  {{and}} melphalan  {{and}} doxorubicin.
 ==References==
 {{reflist|2}}
@@ Line 62: / Line 82: @@
 {{WH}}
 {{WS}}
+ [[Category:Up-To-Date]]
+[[Category:Oncology]]
+[[Category:Medicine]]
+[[Category:Gynecology]]
+[[Category:Surgery]]