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__NOTOC__
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{{Choriocarcinoma}}
{{Gestational trophoblastic neoplasia}}
{{CMG}}
{{CMG}}{{AE}}{{MD}}
 
 
==Overview==
==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).  
The initial regimen is generally given until a normal beta human chorionic gonadotropin (beta-hCG) (for the institution) 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 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)
:* A rise in [[Human chorionic gonadotropin|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:<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>


A plateau of the beta-hCG for 3 weeks (defined as a beta-hCG decrease of 10% or less for 3 consecutive weeks).
* 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)
A rise in beta-hCG of greater than 20% for 2 consecutive weeks.
* Preferred regimen(2):  [[Dactinomycin]] 1.25 mg/m2 IV biweekly pulsed
Appearance of metastases.
* 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


The use of chemotherapy in the first-line management of low-risk GTN 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/_326 Accessed on October 8, 2015</ref>
====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.  
* 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). This may be the most common regimen worldwide
* 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>
* Preferred regimen(2):  [[Dactinomycin]] (1.25 mg/m2 IV), biweekly pulsed
{| {{table}} cellpadding="4" cellspacing="0" style="border:#c9c9c9 1px solid; margin: 1em 1em 1em 0; border-collapse: collapse;"
* Preferred regimen(3):  Methotrexate (30 mg/m2 IM), weekly efficacy of this regimen appears to be low for choriocarcinoma and for patients with (FIGO) risk scores of 5 to 6
| align="center" style="background:#f0f0f0;" |'''Day'''
* 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)
| align="center" style="background:#f0f0f0;" |'''Drug'''
* Alternative regimen(2): Methotrexate 20 mg/m2 IM days 1 to 5, repeated every 14 days
| align="center" style="background:#f0f0f0;" |'''Dose'''
* 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.<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>
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Day'''
| 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 metastases 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.
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(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(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(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(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
* Alternative regimen(5): CHAMOMA: [[Methotrexate]] {{and}} [[folinic acid]] {{and}} [[hydroxyurea]] {{and}} [[dactinomycin]] {{and}} [[vincristine]] {{and}} [[melphalan]] {{and}} [[doxorubicin]]


=====Brain metastasis=====
=====Brain metastasis=====
systemic methotrexate as part of the EMA component (i.e., etoposide, methotrexate, folinic acid, and dactinomycin) of EMA 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 orally every 6 hours for 12 doses starting 32 hours after methotrexate).  
* 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 metastases 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).  
* 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]]).
=====Lung metastases=====
 
cranial prophylaxis
==Placental Site Trophoblastic Tumor Treatment==
with cranial irradiation and intrathecal methotrexate 12.5 mg every 2 weeks with the CO (i.e., cyclophosphamide and vincristine) cycles.
 
* [[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==
==References==
{{reflist|2}}
{{reflist|2}}
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[[Category:Up-To-Date]]
[[Category:Oncology]]
[[Category:Medicine]]
[[Category:Gynecology]]
[[Category:Surgery]]

Latest revision as of 15:30, 13 March 2019

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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

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.

Brain metastasis

Placental Site Trophoblastic Tumor Treatment

  • Tumors confined to the uterus (Féderation Internationale de Gynécologie et d’Obstétrique [FIGO] Stage I)
  • Tumors with extrauterine spread to genital structures (FIGO stage II)
  • Metastatic tumors (FIGO stages III and IV)

References

  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
  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

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