Management Of Choriocarcinoma,2

MANAGEMENT OF CHORIOCARCINOMA By Dr. Obi-Thomas E

History taking Physical examination Investigations Treatment; – Suction evaluation – Chemotherapy – Surgical remedies – Radiotherapy Dr Obi-Thomas E

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History – Usually ammenorrhoea – Abortion or miscarriages – Normal delivery – Bleeding PV – Evacuation

Physical – Vaginal bleeding – Vaginal discharges – Grapelike discharges – Large uterine size for GA – Others Dr Obi-Thomas E

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Investigation – Quantitative serum BHCG – FBC + PLTS – Coagulation studies – LFT – TFT – Bld E/U/Cr – Bld grping x crossmatching x Rhesus factor – CXR

Dr Obi-Thomas E

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Treatment – Suction curettage (complete mole) – Medical evacuation using oxytocin or prostaglandin (partial mole) – Chemotherapy is controversial – Hysterectomy + adjuvant chemotherapy (invasive mole + PSTT) – Relatively resistant to chemotherapy

Dr Obi-Thomas E

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Choriocarcinoma – Treatment based on staging and prognostic risk scoring system – Chemotherapy (Single agent therapy / combination therapy) – Surgical – Radiotherapy

Dr Obi-Thomas E

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Indications for use of Chemotherapy: – High levels of HCG (serum > 20,000 iu/L, urine >30,000 iu/24 hours). >4 wks postevacuation. – Persisting uterine haemorrhage – Rise in hCG post-evacuation – Plateauing level post-evacuation – Evidence of choriocarcinoma on histology. – Evidence of metastasis

Dr Obi-Thomas E

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FIGO Staging – Stage I – Dx limited to the uterus IA No risk factor IB one risk factor IC two risk factor

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Stage II – Dx limited to pelvic genital structures Stage III – Dx extends to the lungs Stage IV – All distant metastasis.

Risk factors – HCG level – Interval of antecedent pregnancy – Prior chemotherapy

Dr Obi-Thomas E

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Prognostic scoring system for predicting chemotherapy resistance (Ranging from zero to four) – – – – – – – – –

Age (yrs) less or equal to 39 yrs or > 39 yrs Antecedent pregnancy (mole, abortion, term) Interval in mouths (<4, 4-6, 7-12, > 12) HCG (< 103, 103-104, 104-105, >105) ABO group (0, A or A, 0. B, AB) Tumour size (3-5. >5) Site (spleen, kidneys. GIT, liver. Brain) Number (1-3. 4-8. >8) Chemotherapy (1 drug. Greater than or equal to 2 drugs)

Scoring:

– Low less than or equal to 4, – Moderate 5-7 – High >7 Dr Obi-Thomas E Choriocarcinoma

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Type of Treatment based on staging – Stage I – single agent chemotherapy using MTX-FA – 1.0mg/kg IM (1,3,5 and 7) – FA 0.1mg/kg IM or PO (2,4, 6 and 8) – MTX 0.4mg/kg/d JV or IM daily for 5 days. – Actinomycin D

Course is 2-3 at 6-7 days interval – Toxicity – Resistance: Plateauing or rise in HCG

Dr Obi-Thomas E

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Stage II and III – Px with low or moderate may benefit from 10 single agent therapy.(85%-90% treated) – MAC – EMA – CO for high risk. –Days 1,2 and 8. – Resistance: EMA –CE, -MTX 1 gm from 100mg/nf

Stage IV – 10 combination – EMA-CO – MTX is intrathecal for cerebral involvement – Resistance – EMA-CE Dr Obi-Thomas E

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Surgery with adjuvant chemotherapy – Pulmonary lobectomy – Hepatic resection – Craniotomy

Poor prognosis for cerebral metastasis Ideal for PSTT. <50% salvaged by hysterectomy alone. Radiation with adjurvant chemotherapy

Dr Obi-Thomas E

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Follow-UP – Wkly until undetectable for 3 wks (esp. I,II and III) – Monthly for 1 yr – Monthly for 2 yrs for IV Dr Obi-Thomas E

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