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GYNECOLOGICAL ONCOLOGY . . . CONT.

• metastases usually appear early • may present with respiratory symptoms, neurological symptoms, etc... • 1/3 cases choriocarcinoma presents with symptoms related to metastases • vagina and vulva appear as dark hemorrhagic nodules • increasing emaciation, weakness, and anemia as disease progresses diagnosis • as for benign GTN • metastatic work-up • pelvic exam • blood work (CBC, renal and hepatic function tests) • pre-evacuation ßhCG • chest x-ray • CT head, thorax, abdomen

Table 13. Classification of Metastatic GTN

Good Prognosis

  • short duration

    • disease present < 4 months from the antecedent pregnancy

  • low pre-treatment ßhCG titre

    • < 100 000 IU/24 hour urine or < 40 000 mIU/mL of blood

  • no metastases to brain or liver

  • no significant prior chemotherapy

Poor Prognosis

  • long duration

    • > 4 months from antecedent pregnancy

  • high pre-treatment ßhCG titre

    • > 100 000 IU/24 hour urine or > 40 000 mIU/mL of blood

  • brain or liver metastases

  • significant prior chemotherapy

  • metastatic disease following term pregnancy

Table 14. Management and Outcome of Metastatic GTN

Type

  • Good Prognosis

Treatment

  • medical treatment with methotrexate (course of 4 IM injections q48 hours with folinic acid rescue; repeated q2-3 weeks unless side effects; stop when ßhCG is undetectable in blood on 3 consecutive weeks)

  • avoid pregnancy for 1-2 years

  • surgical treatment with hysterectomy considered if chemotherapy is unsuccessful or if childbearing not desired

  • Poor Prognosis

  • combination chemotherapy with methotrexate,

actinomycin, chlorambucil

  • radiation used in patients with brain or liver metastases

  • follow ßhCG for 5 years

  • avoid pregnancy for 1-2 years

MCCQE 2000 Review Notes and Lecture Series

Notes

Outcome

  • 90-95% cured

  • 50-70% cured

  • death due to brain and liver

metastases

Gynecology 51

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