Gestational Trophoblastic Neoplasia
A 26-year-old woman underwent suction evacuation of a complete hydatidiform mole 6 weeks ago. Weekly serum beta-hCG values over the past month are 3,100, 3,050, 3,200, and 3,100 IU/L. She has light vaginal bleeding, and ultrasound shows no retained tissue. Chest radiograph is clear. Which of the following is the most appropriate management?
- A.Referral for methotrexate chemotherapyCorrect
- B.Repeat uterine suction evacuation
- C.Total abdominal hysterectomy
- D.Continued observation with weekly beta-hCG
Explanation
After evacuation of a hydatidiform mole, beta-hCG should fall progressively to undetectable levels. A plateau across four values over three weeks, as here, is one of the FIGO diagnostic criteria for post-molar gestational trophoblastic neoplasia; the others are a rise of 10 percent or more across three values over two weeks, persistence of detectable hCG beyond 6 months, or histological diagnosis of choriocarcinoma. Persistent hCG signals viable trophoblastic tissue with invasive potential, most often an invasive mole and occasionally choriocarcinoma, which metastasises early to lung, vagina, brain, and liver. Management is referral to a gestational trophoblastic disease centre for staging with FIGO stage and WHO prognostic score, including chest imaging and pelvic ultrasound, and then chemotherapy. Low-risk disease with a WHO score of 6 or less is treated with single-agent methotrexate, often with folinic acid rescue, or dactinomycin, with cure rates approaching 100 percent. High-risk disease requires multi-agent regimens such as EMA-CO. Repeat evacuation risks perforation and haemorrhage and rarely avoids chemotherapy. Hysterectomy is reserved for uncontrolled bleeding, chemoresistant localised disease, or women who have completed childbearing. Continued observation alone allows progression and possible metastasis, so it is unsafe once criteria for neoplasia are met. Effective contraception must continue throughout hCG surveillance.
Why each option
- A.
- Correct. A plateaued beta-hCG after molar evacuation meets criteria for gestational trophoblastic neoplasia, which is treated with single-agent methotrexate after staging.
- B.
- Repeat evacuation rarely cures persistent disease and carries risks of perforation and haemorrhage; ultrasound already shows no retained tissue.
- C.
- Hysterectomy is reserved for haemorrhage, chemoresistant localised disease, or completed childbearing, and would remove her fertility unnecessarily.
- D.
- Observation is appropriate only while hCG is falling; a plateau defines neoplasia and demands treatment.
Reference: FIGO Cancer Report 2021, Gestational trophoblastic disease
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