VIMS Journal: December 2015

Case Report

Fertility Preservation in A Young Woman with Gestational Trophoblastic Neoplasia

Prof. Sudip Saha, Dr. Biswajit Ghosh, Dr. Poushali Sanyal, Dr. Bidisha Roychoudhury

Abstract :
A patient with Gestational Trophoblastic Neoplasia (GTN) was treated by means of MTXFA. Changes in serum β-HCG levels and changes in USG findings were checked after regular intervals. Finally patient responded after 12 cycles of chemotherapy with 3 consecutive negative values of serum β-HCG. This is a case report of invasive mole in a 19 year old female with possibility to preserve reproductive health.GTN developed 3 months after spontaneous abortion in 8th week gestation.3 months after abortion and 1 month after GTN confirmed she started on her chemotherapy cycles with MTX-FA.

Keywords :
GTN, HCG, MTX-FA

Introduction:
Malignant GTN can develop as invasive mole, choriocarcinoma, PSTT. Ovarian theca lutein cysts usually follow malignant GTN. Reproductive organs can be severely damaged in malignant GTN. Early diagnosis and treatment according to accepted protocols could preserve reproductive health in malignant GTN. Serum β-HCG is of great value for early diagnosis and checking the effects of treatment.

Case Report :
A 19 year old female presented to a GP in the periphery around Jan'14 with history of amenorrhoea for 2 months with complaints of expulsion of products and pain abdomen. Her UPT was positive and USG reports showed incomplete abortion. She underwent D & E. During that time her Hb was 9.2 and blood group B+ve with TC, DC-WNL. Around end of Feb'14 she again presented with complaints of vomiting and no periods following D & E, her UPT was positive.USG (5/3/14) showed early intrauterine pregnancy of 5 weeks gestation with no cardiac activity. She was admitted in the periphery from 9/3/14 to 12/3/14 with complaints of low back pain. On examination she was pale with tenderness all over her abdomen. On bimanual pelvic examination the uterus was soft and bulky with suspected pelvic mass. Her sonography on 15/3/14 showed bulky uterus with no definite G.sac with few cystic areas in myometrial and endometrial cavities with? gestational trophoblastic disease which was confirmed with another scan few days later. Thus she was planned for D & E with endometrial biopsy in which endometrial biopsy showed only decidua like changes of the endometrium; serum β-HCG value was around 201841.65 mIU/ml. On 30/3/14 she complained of pain abdomen and on examination there was a pelvic lump. Thus she was adviced for a CT scan of pelvis in which the report came out to be? Intramural invasive mole. At that time her complete haemogram, liver, renal parameters, coagulation profiles all were within normal limits and serum β-HCG value (8/4/14) was 724133.17 mIU/ml.
With these reports she was admitted in our hospital and advised complete metastatic work up including serum biochemistry, chest x-ray, CT brain, which did not reveal any evidence of metastasis. Radiotherapy department was consulted and she was planned for chemotherapy with Methotrexate and Leucovorin. She received her first dose on 11/4/14 and at interval of 15 days she received total 6 cycles at our hospital. During this time her β-HCG was on 6/5/14- 5879.78, on 4/6/14-74.67, on 5/7/14-15.98 mIU/ml respectively. She was under follow up outside at Burdwan Medical College till October'14 with regular monitoring of her blood counts, liver and renal parameters. In September'14 her USG on 6/9/14 showed ? residual secondary in the myometrium with right ovarian lutein cyst; serum b-HCG 2.1mIU/ml. She received another 5 cycles of chemotherapy with Methotrexate and Leucovorin, the last dose of which was around 14/10/14 at Burdwan medical college. During this time all her metastatic work ups were within normal limits.
She received the 12th cycle of chemotherapy on 29/10/14 at our hospital and then finally on 28/11/14 her USG whole abdomen showed marginally bulky uterus with bilateral bulky ovaries. Serum β-HCG values in the next consecutive 3 months were within normal limits. Patient is still under follow up of radiotherapy and Gynae department in our hospital; presently on OCP having regular periods ; waiting to plan her future pregnancy eagerly.

Results :
This patient had long cycle of chemotherapy (12 cycles). USG confirmation of response to chemotherapy was of great help. In this patient the reproductive health could be preserved thankfully since she was so young. The treatment of this progressive malignant GTN was successful.

USG(15/3/14) showing? gestational trophoblastic disease

USG(15/3/14) showing? gestational trophoblastic disease

USG(6/9/14) showing ? residual secondary inmyometrium with RO lutein cyst

USG(6/9/14) showing ? residual secondary in myometrium with RO lutein cyst

USG(28/11/14))showing marginally bulky uterus

USG(28/11/14))showing marginally bulky uterus


Discussion :
Serum β-HCG is the most relevant parameter in GTN detection as well as in checking the efficacy of administered therapy[1,2]. Successful treatment of malignant GTN does not mean that reproductive health can always be preserved. Chemotherapy plus hysterectomy is sometimes the method of choice in advanced malignant GTN treatment[1,2,3,4]. Malignant GTN does not have specific sonographic pictures and it is not easy to detect specific changes in uterine structure. Massive tissue destruction, hypervascularisation, low R.I., ovarian theca luteal cysts could be characteristic USG findings for GTN. According to recommendations CRCOG[5,6] USG is of limited value in detection of partial mole and malignant GTN[5,6].

Conclusion :
Progressive changes in uterine structure could be of great help in therapy decisions along with changes of serum β-HCG levels. Treatment can be longlasting with good prognosis but it needs good collaboration between gynecologist, radiologist, radiotherapist and patient including all kinds of support.

References
  1. Bright N, Coleman RE, Gillespie AM , Hancock BW, Radstone CR, Tidy J(2000). Gestational trophoblastic disease: a study of mode of evacuation and subsequent need for treatment with chemotherapy.Gynecology Oncology (78) 309-312.

  2. Borchert LG, Hammond CB, Tyrey L et al. (1973). Treatment of metastatic disease : good and poor prognosis. American Journal of Obstetrics and Gynecology (115) 451-457

  3. Goldstein DP, Hancock BW, Kohorn EI et al (2000). Combining the staging system of the International Federetion of Gynecology and Obstetics with the scoring system of the World Health Organisation for trophoblastic neoplasia. Report of the Working Committee of the International Society for the Study of Trophoblastic Disease and the International Gynecologic Cancer Society. International.Journal of Gynecological Cancer (10) 84-88.

  4. Newlands ES(2000) Presentation and management of persistent gestational trophoblastic disease and gestational trophoblastic tumours in the UK. In: Hancock B.W., Newlands E.S., Berkowitz. R. S., Cole L.A, editors. Gestational Trophoblastic Diseases 2nd ed. Sheffield: International Society for the study of Trophoblastic Diseases. (www.isstd.org/gtd/index.html)

  5. Lukiæ R, Nikoliæ B(2004) Choriocarcinomapostdisease ultrasonographic findings. International Journal of Gynecology Cancer(14) 677-679.

  6. Altaras M, Goldberger S, Maymon R, Shulman A, Tepper R (1994). The role of color Doppler flow in the management of nonmetastatic gestational trophoblastic disease. Gynecology and Obstetric Investigations 38 (1) 14-17.

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