Gestational trophoblastic neoplasia medical therapy: Difference between revisions
Jump to navigation
Jump to search
No edit summary |
No edit summary |
||
| (2 intermediate revisions by 2 users not shown) | |||
| Line 3: | Line 3: | ||
{{CMG}}{{AE}}{{MD}} | {{CMG}}{{AE}}{{MD}} | ||
==Overview== | ==Overview== | ||
The mainstay of therapy for choriocarcinoma is [[chemotherapy]]. | The mainstay of therapy for choriocarcinoma is [[chemotherapy]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
====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]] (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]] ([[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 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 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 beta-hCG of greater than 20% for 2 consecutive weeks | :* A rise in [[Human chorionic gonadotropin|beta-hCG]] of greater than 20% for 2 consecutive weeks | ||
:* Appearance of [[metastasis]] | :* 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> | 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> | ||
* 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(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(2): [[Dactinomycin]] 1.25 mg/m2 IV biweekly pulsed | ||
* Preferred regimen(3): Methotrexate 30 mg/m2 IM weekly | * 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(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(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(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(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(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(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 | * 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==== | ====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: 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 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> | * 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> | ||
{| {{table}} | {| {{table}} cellpadding="4" cellspacing="0" style="border:#c9c9c9 1px solid; margin: 1em 1em 1em 0; border-collapse: collapse;" | ||
| align="center" style="background:#f0f0f0;"|'''Day''' | | align="center" style="background:#f0f0f0;" |'''Day''' | ||
| align="center" style="background:#f0f0f0;"|'''Drug''' | | align="center" style="background:#f0f0f0;" |'''Drug''' | ||
| align="center" style="background:#f0f0f0;"|'''Dose''' | | 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 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. | 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) /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). | * 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 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). | * 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]]). | ||
==Placental Site Trophoblastic Tumor Treatment== | ==Placental Site Trophoblastic Tumor Treatment== | ||
* Tumors confined to the uterus (Féderation Internationale de Gynécologie et d’Obstétrique [FIGO] Stage I) | * [[Tumors]] confined to the [[uterus]] (Féderation Internationale de Gynécologie et d’Obstétrique [FIGO] Stage I) | ||
:* [[Hysterectomy]] is the treatment of choice | :* [[Hysterectomy]] is the treatment of choice | ||
* Tumors with extrauterine spread to genital structures (FIGO stage II) | * [[Tumors]] with extrauterine spread to genital structures (FIGO stage II) | ||
:* Complete resection with or without adjuvant chemotherapy | :* Complete resection with or without [[adjuvant chemotherapy]] | ||
* Metastatic tumors (FIGO stages III and IV) | * Metastatic tumors (FIGO stages III and IV) | ||
:* Polyagent chemotherapy | :* Polyagent chemotherapy | ||
:* EMA/CO: Etoposide {{and}} methotrexate with folinic acid rescue {{and}} dactinomycin {{and}} cyclophosphamide {{and}} vincristine(most common) | :* 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 | :* EP/EMA: [[Etoposide]] {{and}} [[cisplatin]] {{and}} [[etoposide]] {{and}} [[methotrexate]] {{and}} [[dactinomycin]] | ||
:* MAE: Methotrexate with folinic acid rescue {{and}} dactinomycin {{and}} etoposide | :* MAE: [[Methotrexate]] with [[folinic acid]] rescue {{and}} [[dactinomycin]] {{and}} [[etoposide]] | ||
==References== | ==References== | ||
| Line 82: | Line 82: | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[Category:Up-To-Date]] | |||
[[Category:Oncology]] | |||
[[Category:Medicine]] | |||
[[Category:Gynecology]] | |||
[[Category:Surgery]] | |||
Latest revision as of 15:30, 13 March 2019
|
Gestational trophoblastic neoplasia Microchapters |
|
Differentiating Gestational trophoblastic neoplasia from other Diseases |
|---|
|
Diagnosis |
|
Treatment |
|
Case Studies |
|
Gestational trophoblastic neoplasia medical therapy On the Web |
|
American Roentgen Ray Society Images of Gestational trophoblastic neoplasia medical therapy |
|
Gestational trophoblastic neoplasia medical therapy in the news |
|
Blogs on Gestational trophoblastic neoplasia medical therapy |
|
Directions to Hospitals Treating Gestational trophoblastic neoplasia |
|
Risk calculators and risk factors for Gestational trophoblastic neoplasia medical therapy |
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
- 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.[2]
| 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.
- Alternative regimen(1): MAC: Methotrexate AND folinic acid AND dactinomycin AND cyclophosphamide[3]
- 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(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
Brain metastasis
- 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 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).
Placental Site Trophoblastic Tumor Treatment
- 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
- ↑ 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
- ↑ 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
- ↑ 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