WHO SCORING
What WHO score is Age <40 given?
What is 0
Fetal parts present, p57 IHC +
Partial mole
What is the risk of development of GTN in follow up for partial molar pregnancy?
What is less than 3-5%
A partial mole is diagnosed. Weekly Hcg is <1. When is she done with surveillance Hcg? (ie when would you like to check another one and tell her she can get pregnant again)
What is 1 month
True or False. Hysterectomy does not improve rate of cure of GTN but does decrease number of cycles of chemotherapy needed.
True
Pre-treatment b-hCG is >10^5. What is the WHO score?
4
Diffuse hydropic villi, diffuse trophoblastic hyperplasia
What is a complete mole
What is the risk of GTN in a complete molar pregnancy?
What is 15-20%
An invasive mole is diagnosed with Stage I, WHO Score is 4. What is your recommended treatment?
Bonus: Explain how you decided which to choose :)
Single agent therapy with either Methotrexate or Actinomycin-D. I will typically start with MTX 5 day regimen given better tolerability and lower side effect profile. For those who said Act-D, could argue data that reveals improved efficacy (though the MTX regimen was not standardized - some received weekly, some 5-d, some 8-d)
How many cycles following normalization of hcg should you administer following treatment for GTN?
Most references say 2-3 consolidation cycles
How many WHO score points are given for lung mets under category "site of metastases"?
Zero!
Absence of chorionic villi and the presence of proliferating intermediate trophoblasts, cytotrophoblasts, and syncytiotrophoblasts.
What is choriocarcinoma
What percentage of cases of GTN arise from a molar pregnancy?
What is 50%
The patient in the prior stem fails single agent MTX. You re-calculate her WHO score and it is 4. Her disease is localized to the uterus. What now?
Either switch single agents (to Actinomycin D in this case) or hysterectomy with bilateral salpingectomy if childbearing is coplete.
What is the risk of standard treatment dose EMACO in patients with massive disease (WHO>12)?
What is Sudden tumor collapse with severe bleeding, metabolic acidosis, myelosuppression, septicemia, multi organ failure.
Any of the above gets points.
Name that Stage and WHO score. Age 45, initial bhcg 150,000, single isolated 2cm lung met, antecedent pregnancy was a complete mole 2 months ago.
What is Stage III; WHO score 6.
Arises from placental site extravillous intermediate trophoblasts. Absent Chorionic villi
What is Placental Site Trophoblastic Tumor? (PSTT)
Name 3 risk factors for development of GTD.
1. Prior molar pregnancy
2. Age >40
3. Ethnicity (Asian, Native American, African American descents)
A patient presents with choriocarcinoma and brain mets. You calculate her WHO score and it is 13. She is admitted for multiagent chemotherapy. What is essential in her treatment course prior to starting standard dose EMACO?
Induction chemotherapy
(Etoposide 100mg/m2 and cisplatin 20mg/m2 on days 1 and 2, repeated weekly for 1-3 weeks before normal dose treatment. Could also consider EP or EMA induction x4 cycles.)
A patient is being discharged from the hospital following administration of EMA (she will receive CO on Day 8). What medication (besides anti-emetics/supportive care meds) is essential for her to be discharged with?
Folinic acid (15mg PO every 12 hours x4 doses). Starts 24hours after MTX infusion starts, so usually patient goes home with 2 or 3 doses left still.
Name that Stage and WHO score. Age 45, initial bhcg 10,000, antecedent pregnancy was 2 years ago and full term, large 6cm tumor in the uterus, as well as multiple metastatic sites (10) in the liver, lungs, and brain.
IV: 19. This one's tough. What will be more important to know is that it is very high and she needs multi-agent chemo.
A precursor to epithelioid trophoblastic tumors, these typically have a Ki-67 proliferation index of 5%–10%.
In what country is the incidence of molar pregnancy 11.5 per 1000 deliveries?
What is Indonesia.
*remember, the prevalence of molar pregnancy is higher in Asia, Africa, and Central America than in the USA, Europe, and Australia
Name the 5 agents used in the multiagent chemotherapy regimen used to treat high risk GTN.
E-Etoposide
M-Methotrexate
A - Actinomycin D
C- Cyclosphosphamide
O- Oncovorin (AKA Vincristine)
Describe the treatment options historically used for GTN with brain metastases. Need all 4 for 500 points - Will give partial points.
1. Increase MTX dosing to 1g/m2 to allow BBB penetration.
2. Intrathecal MTX
3. Gamma knife radiation
4. WBRT (no longer recommended given no improved cure rates and added long term toxicity)