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Teaching pack: Gestational trophoblastic neoplasia

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9 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.

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  1. Teaching pack · Cancer · gynaecologic

    Gestational trophoblastic neoplasia

    Cancers that grow from placental tissue after a pregnancy. They make a hormone (hCG) that acts as a perfect blood test, and they were the first solid cancer ever cured by chemotherapy. Immunotherapy now rescues the few that resist drugs.

    Teaching pack: Gestational trophoblastic neoplasia · OnCo, CC BY 4.0 · not medical advice1 / 9
  2. What it is

    In two paragraphs

    Gestational trophoblastic neoplasia (GTN) follows a molar pregnancy (complete or partial hydatidiform mole) or, less often, any pregnancy, and includes invasive mole, choriocarcinoma, placental-site and epithelioid trophoblastic tumours. Serum hCG tracks disease burden with unique precision, so diagnosis is usually made from a plateau or rise in hCG after molar evacuation without histology. The FIGO 2000 prognostic score separates low-risk (single-agent methotrexate or actinomycin D) from high-risk disease (multi-agent EMA-CO), with ultra-high-risk patients started on low-dose induction etoposide-cisplatin to prevent early death.

    GTN is highly immunogenic (paternal antigens, PD-L1 expression), and PD-1 blockade produced durable complete remissions in chemotherapy-resistant disease (pembrolizumab, Ghorani 2017; avelumab TROPHIMMUN 2020), now in guidelines. Placental-site and epithelioid tumours are chemo-resistant and treated by hysterectomy. Outcomes depend on centralised care with hCG registries (Charing Cross, Sheffield, Brewer).

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  3. Standard of care

    What is given today, by setting

    SettingApproachGuideline
    Low-risk GTN (FIGO score 0-6)Single-agent methotrexate (8-day regimen) or pulsed actinomycin D; switch agent on resistance; consolidate 3 cycles after hCG normalisation.NCCN Category 2A
    High-risk GTN (score ≥7)EMA-CO (etoposide, methotrexate, actinomycin D / cyclophosphamide, vincristine); induction low-dose EP for ultra-high-risk; EP-EMA or TP/TE at relapse; surgery for resistant foci.NCCN Category 2A
    Chemotherapy-resistant GTNPD-1/PD-L1 blockade (pembrolizumab, avelumab), high-dose chemotherapy with stem-cell rescue in selected cases, hysterectomy or metastasectomy.not mapped
    PSTT / ETTHysterectomy; platinum-etoposide chemotherapy if metastatic or >4 years from antecedent pregnancy.not mapped
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  4. State of the art

    Where the field stands

    • The only cancer routinely diagnosed and monitored by a hormone alone, with near-universal cure.
    • Immunotherapy cures a majority of drug-resistant cases; trials (TROPHAMET, TROPHIMMUN) now test it earlier to avoid chemotherapy.
    • Centralised registries remain the model for how rare cancers should be managed.
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  5. History

    How we got here

    1. 1956Methotrexate cures metastatic choriocarcinoma (Li, Hertz, Spencer)
    2. 1973Charing Cross hCG surveillance service established
    3. 1979EMA-CO introduced by Bagshawe for high-risk disease
    4. 2000FIGO 2000 staging and prognostic score
    5. 2017Pembrolizumab cures chemoresistant GTN (Ghorani, Lancet)
    6. 2020TROPHIMMUN: avelumab in methotrexate-resistant low-risk GTN
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  6. Pipeline

    What is coming

    • Pembrolizumab (product)
    • Avelumab (product)
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  7. Open problems

    What nobody has solved

    • Late diagnosis where hCG surveillance after molar pregnancy is absent (much of the world).
    • Fertility and psychological burden of a pregnancy-related cancer.
    • PSTT/ETT chemo-resistance.
    • Cumulative etoposide exposure and second cancers.
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  8. Quiz

    Check understanding

    1. What is the standard treatment for stage II-III triple-negative breast cancer today?
      Answer
      Neoadjuvant pembrolizumab with carboplatin/paclitaxel then anthracycline chemotherapy, surgery, and adjuvant pembrolizumab (KEYNOTE-522); adjuvant olaparib for germline BRCA carriers with residual disease (OlympiA); capecitabine for residual disease without BRCA.
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  9. Sources

    Read the primary sources

    • NCCN Guidelines: GTN: https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1489
    • Charing Cross GTD service: https://www.hcgtrophoblastic.com/
    • NCI PDQ: GTD: https://www.cancer.gov/types/gestational-trophoblastic/patient/gtd-treatment-pdq
    • Wikipedia: https://en.wikipedia.org/wiki/Gestational_trophoblastic_disease
    • Guideline: https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1489
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