GTN creates rare tumors from pregnancy's placental cells that is usually treatable, even if it has spread.
What is gestational trophoblastic neoplasia?
Gestational trophoblastic neoplasia (GTN) occurs when a group of rare tumors develop from specialized cells that develop early in pregnancy. These cells play a crucial role in the formation and function of the placenta (trophoblastic). GTNs are the cancerous (neoplastic) forms of gestational trophoblastic disease (GTD), which are a rare group of conditions.
With GTN, the specialized cells grow abnormally and can become cancerous. GTN can commonly occur following molar pregnancies, where these cells grow into an abnormal mass of cysts inside the uterus instead of developing into a normal placenta and fetus. GTN can also happen after ectopic and normal pregnancies, as well as miscarriages.
GTN is rare. In the United States, it occurs in approximately 1 in every 1,000 to 3,000 pregnancies. Molar pregnancies are more common, occurring in about 1 in 1,000 pregnancies, and about 15 – 20% of complete molar pregnancies develop into GTN.
AHN Gynecologic Oncology Center of Excellence
The AHN Gynecologic Oncology Center of Excellence is a specialized center dedicated to the comprehensive care of women with gynecologic cancers and complex gynecologic conditions. We focus on cancer care from diagnosis to treatment to ringing the bell. We collaborate with specialists through our cancer center for customized treatment plans and exceptional care.
Why choose AHN for GTN treatment?
At the AHN Gynecologic Oncology Center of Excellence, we take a collaborative approach to your care. You meet with a devoted team of cancer specialists, typically within three days of diagnosis. Your team quickly works to design an effective treatment plan tailored to the stage of the cancer. We routinely discuss your progress and determine if we should change the treatment to better meet your needs. At the Cancer Institute, you can expect:
- Patient-centered care: We meet with you and your family to discuss the details of your treatment plan, so you feel confident and informed. You’ll see the same team of physicians throughout your care. Your doctors get to know you, your family, and your personal preferences. We also offer robust support services to keep you living the best quality of life during treatment.
- Sophisticated treatment: Your specific treatment will largely depend on how far the cancer has spread. We offer an array of options to stop the cancer in its tracks. Treatments include powerful chemotherapy and risk-reducing surgery, like the removal of fallopian tubes or ovaries.
- Access to clinical trials: We participate in many clinical trials, keeping you at the forefront of the latest treatment options.
Quick guide to gestational trophoblastic neoplasia
Gestational trophoblastic neoplasia symptoms and signs
Gestational trophoblastic neoplasia screening and diagnosis
Types and stages of gestational trophoblastic neoplasia
Gestational trophoblastic neoplasia treatment
Gestational trophoblastic neoplasia symptoms and signs
Gestational trophoblastic neoplasia (GTN) can show up in various ways, and its symptoms can sometimes mimic those of a normal pregnancy or other conditions. Therefore, it's crucial to be aware of the potential signs and seek medical evaluation if you experience any concerning symptoms, especially after a molar pregnancy, miscarriage, or ectopic pregnancy. Early detection and treatment are essential for successful outcomes.
The signs and symptoms of GTN can vary depending on the specific type of GTN, its location, and whether it has spread to other parts of the body. In many cases, the most common sign is persistent or irregular vaginal bleeding after a pregnancy. Other symptoms can include those related to elevated hormone levels or the presence of tumors in the uterus or other organs. Common symptoms and signs include:
- Persistent or irregular vaginal bleeding: This is the most common symptom, often occurring after a molar pregnancy, miscarriage, or ectopic pregnancy. The bleeding may be continuous or intermittent and can range from light spotting to heavy bleeding.
- Elevated hCG levels: Human chorionic gonadotropin (hCG) is a hormone produced during pregnancy. GTN can cause abnormally high levels of hCG, which can be detected through blood or urine tests.
- Pelvic pain or pressure: Some individuals may experience pain or pressure in the pelvic area due to the growth of the tumor in the uterus.
- Enlarged uterus: The uterus may be larger than expected for the gestational age.
- Symptoms of hyperthyroidism: GTN can sometimes cause hyperthyroidism due to the production of thyroid-stimulating substances. Symptoms may include rapid heartbeat, sweating, anxiety, and tremors.
- Symptoms related to metastasis (spread of cancer): If GTN spreads to other organs, it can cause additional symptoms depending on the location of the metastases. For example, lung metastases can cause coughing, shortness of breath, or chest pain.
Causes and risk factors
GTN develops from abnormal trophoblastic cells, which are cells that normally form when the placenta grows during pregnancy. The exact cause of why these cells become cancerous is not fully understood, but it is known to be related to genetic errors that occur during fertilization. Some of the causes include:
- Molar pregnancy: The most common cause of GTN is a molar pregnancy. Molar pregnancies occur when there is an abnormal fertilization of the egg, leading to the growth of abnormal tissue in the uterus instead of a normal embryo. There are two types of molar pregnancies:
- Complete molar pregnancy: In a complete molar pregnancy, there is no fetal tissue, and the abnormal trophoblastic cells grow throughout the uterus.
- Partial molar pregnancy: In a partial molar pregnancy, there may be some fetal tissue present, but it is usually abnormal and not viable.
- Non-molar pregnancy: GTN can also develop after a non-molar pregnancy, such as a miscarriage, ectopic pregnancy, or even a normal pregnancy, although this is rare. In these cases, some of the trophoblastic cells may become cancerous.
There are several factors that can increase the risk of developing GTN. Those risk factors can include:
- Prior molar pregnancy: Individuals who have had a molar pregnancy in the past are at a higher risk of developing GTN in a subsequent pregnancy.
- Age: Women over the age of 35 and under the age of 20 have a higher risk of molar pregnancy.
- Ethnicity: GTN is more common in certain ethnic groups, particularly in Asia and Latin America.
- Dietary factors: Some studies have suggested that a diet low in carotene and animal fat may increase the risk of molar pregnancy, but more research is needed.
- History of miscarriage: Individuals with a history of miscarriage may have a slightly increased risk of developing GTN.
- Blood type: Women with blood type A or AB may be at a slightly higher risk.
Gestational trophoblastic neoplasia screening and diagnosis
Since there's no single screening test for GTN, doctors look at a few things to figure it out:
- Hormone check (hCG): The main way is by measuring a pregnancy hormone called hCG. If these levels stay high or keep going up after a pregnancy (especially after a molar pregnancy), it's a big clue for GTN.
- Blood tests: Other blood tests help your doctor check your overall health.
- Imaging scans:
- Chest X-ray: This quickly checks if the condition has spread to your lungs.
- CT scan: This provides more detailed pictures of your uterus and other parts of your body to see where the GTN might be.
- Minor surgery (D&C): Often, a small procedure called a D&C is done. During this, a sample of tissue from your uterus is taken and examined under a microscope to confirm the diagnosis and identify the type of GTN.
Together, these steps help your medical team accurately diagnose GTN and plan your care.
Types and stages of gestational trophoblastic neoplasia
GTN is classified into different types based on the specific cells involved and the extent of the disease. The main types of GTN include:
- Invasive mole (invasive hydatidiform mole): This is the most common type of GTN. It occurs when a molar pregnancy invades the myometrium (the muscle layer of the uterus). It can also spread to nearby structures, such as the vagina or broad ligament.
- Choriocarcinoma: This is a rare and aggressive type of GTN that can develop after a molar pregnancy, miscarriage, ectopic pregnancy, or normal pregnancy. It is composed of malignant trophoblastic cells and has a high potential to metastasize (spread) to distant organs, such as the lungs, liver, and brain.
- Placental-site trophoblastic tumor (PSTT): This is a very rare type of GTN that develops from the placental implantation site. It tends to grow slowly and may occur months or years after a pregnancy. PSTT is often resistant to chemotherapy and may require surgical removal.
- Epithelioid trophoblastic tumor (ETT): This is another very rare type of GTN that is similar to PSTT. It also tends to grow slowly and may occur years after a pregnancy. ETT can be difficult to diagnose and treat.
Once your AHN care provider understands the type of GTN, they will figure out the stage of the disease. The staging system is used to determine the extent of the cancer and whether it has spread to other parts of the body. The staging system for GTN is based on the FIGO (International Federation of Gynecology and Obstetrics) staging system. It considers factors such as the location of the tumor, the presence of metastases, and the hCG level. An overview of the FIGO staging system for GTN follows:
- Stage 1: The tumor is confined to the uterus.
- Stage 2: The tumor has spread outside the uterus but is limited to the genital structures (e.g., vagina, ovaries, fallopian tubes).
- Stage 3: The tumor has spread to the lungs, with or without genital structure involvement.
- Stage 4: The tumor has spread to other distant sites, such as the brain, liver, or kidneys.
In addition to the stage, a risk scoring system is used to further classify GTN and guide treatment decisions. The risk score is based on factors such as:
- hCG level
- Size of the tumor
- Number of metastases
- Prior chemotherapy
- Interval from the end of the antecedent pregnancy
- Site of metastases
- Age
Based on the stage and risk score, GTN is classified as either low-risk or high-risk. Low-risk GTN is usually treated with single-agent chemotherapy, while high-risk GTN may require multi-agent chemotherapy, surgery, and/or radiation therapy.
Gestational trophoblastic neoplasia treatment
GTN is highly treatable, and the specific treatment depends on the type of GTN, the stage of the disease, and whether it has spread to other parts of the body. Radiation therapy can be used to treat GTN that has spread to the brain or other localized areas.
Chemotherapy
The most common treatment for GTN is chemotherapy, especially for invasive moles, choriocarcinoma, and metastatic disease. Chemotherapy drugs are highly effective at killing trophoblastic cells.
Surgery
When considering treatment for GTN, surgical options play a significant role, particularly in certain circumstances. Your AHN care team will be able to walk you through your options, but generally options include:
- Dilation and curettage (D&C): This procedure may be used to diagnose and to remove a molar pregnancy or localized GTN in the uterus.
- Hysterectomy: Removal of the uterus may be considered if chemotherapy is not effective or if the woman does not wish to have more children.
- Surgery to remove metastases: In some cases, surgery may be used to remove tumors that have spread to other organs, such as the lungs or brain.
Gestational trophoblastic neoplasia (GTN) FAQs
Any illness during pregnancy or that can interfere with pregnancy is sure to bring about a lot of questions. At AHN, our compassionate, experienced health care professionals are here to provide personalized care and treatment — and be your go-to for answers to any questions. To help you get started and provide resources you can trust, we’ve included answers to some frequently asked questions our patients often have around GTN. Feel free to use these as a guide in your discussions with your AHN care team. Having some background information can help make the conversation a little less overwhelming.
How do you treat gestational trophoblastic disease?
Treatment for gestational trophoblastic disease (GTD) depends on several factors, including the type of GTD, whether it has spread to other parts of the body (metastasis), and your overall health. At AHN, we focus on your specific needs and will design a treatment plan around those, but generally treatment for GTD includes:
- Surgery:
- Dilation and curettage (D&C): This is often the initial treatment for a molar pregnancy. It involves dilating the cervix and removing the abnormal tissue from the uterus.
- Hysterectomy: In some cases, especially if the patient does not desire future pregnancies, a hysterectomy (removal of the uterus) may be recommended. This can eliminate the risk of GTD recurrence in the uterus.
- Chemotherapy:
- Single-agent chemotherapy: For low-risk GTD, single-agent chemotherapy, such as methotrexate or actinomycin-D, is often used. These drugs are effective in destroying the abnormal cells.
- Multi-agent chemotherapy: For high-risk GTD or when single-agent chemotherapy is not effective, multi-agent chemotherapy regimens may be used. These regimens typically involve a combination of drugs like etoposide, methotrexate, actinomycin-D, cyclophosphamide, and vincristine (EMA/CO).
- Radiation therapy:
- In rare cases, radiation therapy may be used to treat GTD that has spread to the brain or other specific areas.
- Monitoring:
- After treatment, regular monitoring of hCG levels is crucial to ensure that the disease is completely eradicated. This typically involves blood tests every one to two weeks initially, then less frequently over a period of several months to years.
- Contraception is typically recommended during the monitoring period to avoid pregnancy, which can interfere with hCG level interpretation.
Can you get pregnant after gestational trophoblastic neoplasia?
Yes, it is usually possible to get pregnant after receiving treatment for gestational trophoblastic neoplasia (GTN). However, it is typically recommended to wait a certain period of time, usually six to 12 months after completing chemotherapy, before trying to conceive. This allows for monitoring of hCG levels and reduces the risk of complications.
What is the survival rate for gestational trophoblastic neoplasia?
The survival rate for gestational trophoblastic neoplasia (GTN) is generally very high, especially when the disease is detected early and treated appropriately. For low-risk GTN, the survival rate is close to 100%. Even in high-risk cases, with the use of intensive chemotherapy, survival rates are still quite good, often exceeding 80 – 90%.
What causes gestational trophoblastic neoplasia?
Gestational trophoblastic neoplasia (GTN) is caused by abnormal growth of trophoblastic cells, which are cells that normally develop into the placenta during pregnancy. It usually develops after a molar pregnancy, but can also occur after a normal pregnancy, miscarriage, or ectopic pregnancy. The exact reasons why these cells become cancerous are not fully understood, but genetic factors and abnormalities in the fertilization process may play a role.
How do you diagnose gestational trophoblastic neoplasia?
Gestational trophoblastic neoplasia (GTN) is diagnosed through a combination of methods:
- hCG blood tests: GTN is often suspected when human chorionic gonadotropin (hCG) levels remain high or rise after a molar pregnancy, miscarriage, or normal pregnancy.
- Pelvic examination: A physical examination to check for any abnormalities in the uterus or surrounding tissues.
- Ultrasound: Imaging of the uterus to look for any signs of GTN or persistent molar tissue.
- Chest X-ray or CT scan: To check if the GTN has spread to the lungs.
- Dilation and curettage (D&C): A procedure to remove tissue from the uterus for examination under a microscope.
What causes a molar pregnancy?
A molar pregnancy is caused by a genetic error during fertilization. In a complete molar pregnancy, the egg is empty, and it is fertilized by one or two sperm that duplicate their chromosomes, resulting in all genetic material coming from the father. In a partial molar pregnancy, the egg is fertilized by two sperm, or by one sperm that duplicates itself, resulting in three sets of chromosomes instead of the normal two.
How common is a molar pregnancy?
Molar pregnancies are relatively rare. They occur in approximately 1 in every 1,000 pregnancies. After a molar pregnancy, it's generally advised to wait for a period of time before trying to conceive again. This waiting period allows health care providers to monitor your human chorionic gonadotropin (hCG) levels, which are typically elevated in molar pregnancies. Regular monitoring ensures that any remaining molar tissue is detected and treated promptly, reducing the risk of complications. The typical recommendation is to wait six to 12 months after hCG levels have returned to normal before attempting another pregnancy.
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