Successful Management of a Case of Gestational Trophoblastic Neoplasia in a Young Woman

Abstract

A 23 year-old, recently married Omani lady was admitted with 7 weeks of amenorrhoea, abdominal pain and bleeding per vagina. Her abdominal examination was unremarkable; a bimanual examination showed a uterine size of 12 weeks gestation with a closed cervix. Serum β hCG was 284, 263 IU on admission. An ultrasonogram revealed a “snowstorm pattern” diagnostic of a complete hydatidiform mole. Suction evacuation and curettage was performed after the initial work-up. A histopathological examination confirmed complete hydatidiform mole. Weekly follow-up showed rising β hCG 3 weeks after evacuation. Staging investigations like computerised tomography (CT) of the chest and magnetic resonance imaging (MRI) of the abdomen and pelvis showed two tiny deposits in the lung and a myometrial invasion of 2 cm size, confirming low risk gestational trophoblastic neoplasia. After counselling, single agent chemotherapy was started with methotrexate. Actinomycin D was added later due to poor response to treatment as evidenced by suboptimal β hCG regression. β hCG returned to normal in 10 weeks time and remains negative on follow-up. Gestational trophoblastic diseases (GTD) include a spectrum of diseases with wide range of biologic behaviour. It includes the benign form, hydatidiform mole; locally malignant form, invasive mole, and frankly malignant form, choriocarcinoma. Although persistent, gestational trophoblastic tumours develop most commonly after a molar pregnancy, they may follow any gestation. The incidence of hydatidiform moles varies from 0.1 to 1%; 8–15% of them develop malignant sequelae.1 β hCG is the tumour marker used for the diagnosis and follow up of GTD. Hydatidiform moles need close follow-up due to their malignant potential. Recommended follow-up is weekly β hCG testing until 3 negative values, followed by monthly for another 6 months. Pregnancy should be avoided during this period. Invasive moles are characterised by local invasion into the myometrium with or without lung metastasis and present with persistently elevated β hCG, as in our case. Choriocarcinoma usually presents with symptoms of metastases like cough, dyspnoea, haemoptysis, headache, convulsion, stroke, and vaginal bleeding.2 The World Health Organization (WHO) scoring system based on prognostic factors is used for the risk stratification of the disease. A score of 6 or less is low risk disease and is treated with single agent chemotherapy. A score of 7 or greater is high-risk disease, which needs multiagent chemotherapy with or without local radiation/surgery.3 Choriocarcinoma is potentially curable and future fertility is unaffected if promptly treated. Women can conceive 1 year after completion of chemotherapy; there is no increased risk of pregnancy complications or congenital anomalies. The risk of recurrence of molar pregnancy is 1–3%, which should be ruled out by an early ultrasound.