NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)GestationalTrophoblasticNeoplasiaersionOctoberVersion1.2022,10/06/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:43:45AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.adex*NadeemR.Abu-Rustum,MDΩ/ChairMemorialSloanKetteringCancerCenter*CatherynM.Yashar,MD§/ViceChairUCSanDiegoMooresCancerCenterKristinBradley,MD§UniversityofWisconsinCarboneCancerCenterRebeccaBrooks,MDΩUCDavisComprehensiveCancerCenterSusanaM.Campos,MD,MPH,MS?Dana-Farber/BrighamandWomen’sCancerCenterJunzoChino,MD§DukeCancerInstituteHyeSookChon,MDΩMoffittCancerCenterChristinaChu,MDΩFoxChaseCancerCenterDavidCohn,MDΩTheOhioStateUniversityComprehensiveCancerCenter-JamesCancerHospitalandSoloveResearchInstituteMartaAnnCrispens,MDΩVanderbilt-IngramCancerCenterShariDamast,MD§YaleCancerCenter/SmilowCancerHospitalElisabethDiver,MDΩStanfordCancerInstituteChristineM.Fisher,MD,MPH§UniversityofColoradoCancerCenterPeterFrederick,MDΩRoswellParkComprehensiveCancerCenterDavidK.Gaffney,MD,PhD§HuntsmanCancerInstituteattheUniversityofUtahRobertGiuntoliII,MDΩAbramsonCancerCenterattheUniversityofPennsylvaniaErnestHan,MD,PhDΩCityofHopeNationalMedicalCenterBrookeHowitt,MD≠StanfordCancerInstituteWarnerK.Huh,MDΩO'NealComprehensiveCancerCenteratUABJayanthiLea,MDΩUTSouthwesternSimmonsComprehensiveCancerCenterAndreaMariani,MDΩMayoClinicCancerCenterDavidMutch,MDΩSitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineLarissaNekhlyudov,MD,MPHTDana-Farber/BrighamandWomen’sCancerCenterMirnaPodoll,MD≠Vanderbilt-IngramCancerCenterStevenW.Remmenga,MDΩFred&PamelaBuffettCancerCenterR.KevinReynolds,MDΩUniversityofMichiganRogelCancerCenterRituSalani,MD,MBAΩUCLAJonssonComprehensiveCancerCenterRachelSisodia,MDΩMassachusettsGeneralHospitalCancerCenterPamelaSoliman,MD,MPHΩTheUniversityofTexasMDAndersonCancerCenterEdwardTanner,MDΩRobertH.LurieComprehensiveCancerCenterofNorthwesternUniversityStefanieUeda,MDΩUCSFHelenDillerFamilyComprehensiveCancerCenterRenataUrban,MDΩFredHutchinsonCancerResearchCenter/SeattleCancerCareAllianceStephanieL.Wethington,MD,MScΩTheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsEmilyWyse￥tientAdvocateKristineZanotti,MDΩCaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussigCancerInstituteΩGynecologicΩGynecologiconcologyTInternalmedicine?Medicaloncology≠Pathology§Radiotherapy/Radiationoncology*DiscussionSectiononcology*DiscussionSectionWritingCommitteeAngelaMotter,PhD￥PatientadvocacyesPanelDisclosuresVersion1.2022,10/06/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:43:45AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.adexGestationalTrophoblasticNeoplasiaSubcommitteeDavidMutch,MDΩ/LeadSitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicinerMDordCancerInstituteR.KevinReynolds,MDΩUniversityofMichiganRogelCancerCenteresPanelDisclosureslogiconcologyVersion1.2022,10/06/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:43:45AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.adexlievesthatthebestmanagementlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceandsusAllrecommendationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.itteeMembersryoftheGuidelinesUpdatesHydatidiformMole(Noninvasive)Workup,InitialTreatment,Monitoring,FindingsandAdditionalEvaluation(HM-1)PersistentPost-molarGTN,Treatment(HM-2)GestationalTrophoblasticNeoplasia(GTN)Workup(GTN-1)PrimaryTreatmentforLow-RiskGTN(GTN-2)TreatmentforPersistentGTN(GTN-3)PrimaryTreatmentforHigh-RiskGTN(GTN-4)PrimaryTreatmentforIntermediateTrophoblasticTumor:PSTTandETT(GTN-5)athologyGTNAherapyforGTNGTNBGynecologicSurvivorshipGTNCTheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2021.Version1.2022,10/06/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion1.2022,10/06/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:43:45AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.adexCNGuidelinesforGestationalTrophoblasticNeoplasiafromVersionincludeMoleNoninvasive?Monitoring;3rdbulletrevised:"Systemichormonalcontraception(oralcontraceptives)"?Footnotebisnew:IfhCGiselevatedwithnoevidenceofdiseaseonimaging,considerpossibilityofluteinizinghormone(LH)crossover,pituitaryhCG,orphantomhCG.Consultwithlaboratorymedicine/pathologytotestforphantomhCGwithserialdilutionstudyorcomparisonofserumtourinehCG.?Footnotegrevised:Oralcontraceptivespillsarepreferredoverintrauterinedevices(IUDs)becausetheysuppressendogenousLH/follicle-stimulatinghormone(FSH),whichmayinterferewithhCGmeasurementatlowlevels.(AlsoforGTN-2)?FindingspToppathway;Revisedlanguage:"Oneormoreofthefollowingindicatingpersistentpost-molarGTN:..."?Bulletremoved:hCGpersistence6monthsaftermolarevacuationpBottompathway:Revisedlanguage:"Histopathologicdiagnosisofchoriocarcinoma,PSTT/ETT,and/or..."?Staging;3rdbulletrevised:Chestx-raychangedto"Imaging(chestx-rayorchest/abdomen/pelvisCTscan"?Footnoteirevised:"...Ifthechestx-rayshowsmetastases,CTscanofthechest/abdomen/pelvicCTscanandbrainMRIofthebrainareindicated.GestationalTrophoblasticNeoplasia(GTN)GTN-1FootnotedrevisedIfhCGiselevated,buthyperglycosylatedhCGisnormalquiescentGTNmaybediagnosedandnottreatedlefttreatedGTN-2Low-riskGTN?Low-riskGTNconfirmed;ResponseAssessment;NormalhCGlevelbulletrevised:Continuesystemictherapyfor2–3treatmentcycles(3preferred)pasthCGnormalization.?Footnotejrevised:"Hysterectomywithsalpingectomyorrepeatendometrialcurettagemaybeconsideredifthereislocalizeddiseaseintheuterus.Hysterectomyispreferredandwherefertilitypreservationisnotdesired..."(AlsoforGTN-3)?Footnotelisnew:LybolC,etal.GynecolOncol2012;125:576-579.GTN-3TreatmentforPersistentGTN?RevisedpGoodresponsetoinitialtherapyfollowedbyhCGlevelplateauorre-elevation(hCG<3001000)?ResponseAssessment;Toppathway;NormalhCGlevel:–Continuesystemictherapyfor2–3(3preferred)treatmentcyclespastnormalizationp"GoodresponsetoinitialtherapyfollowedbyrapidriseinhCGlevel(hCG≥3001000)..."?Responseassessment;Bottompathway:NormalhCGlevels:–Continuesystemictherapyfor2–3(2preferred)treatmentcyclespastnormalization?AdditionalTreatment:"Administeretoposide/platinum-basedregimens..."GTN-4High-riskGTN?Incompleteresponsetotreatmentpathway;Additionaltreatmentrevised:"ConsideralternativeChemotherapyforpatientswhoareintoleranttoEP/EMA:Etoposide/Platinum-basedregimenswithbleomycin,ifosfamide,orpaclitaxel,and..."GTN-5Intermediatetrophoblastictumor:PSTTandETT?Metastaticpathway;Treatment:"Chemotherapywithaplatinum/etoposide-containingplatinum-basedregimen,suchas..."PrintedbyMinTangon3/14/20227:43:45AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.adexHydatidiformMole(Noninvasive)andGTNGTN-APrinciplesofPathologyPage1of2?Procedure:PelvicexenterationremovedPage2of2?ImmunohistochemicalMarkersforDifferentialDiagnosisofGTNTablepNewstatementadded:GATA-3isasensitivemarkerforbothbenignandmalignanttrophoblastproliferations,andmaybeusefulindistinguishingGTNfromnon-GTNtumors.pFirstcolumn:Entryrevisedto"Gestationalchoriocarcinoma"?Reference1updatedGTN-BSystemicTherapyforGTNPage1of6(RegimensforLow-RiskGTN)?Preferredregimens:Dactinomycinrevisedto"Preferreddosingoption:10–12mcg/kg(or0.5mgfixeddose)IVdailyx5days...Page2of6(High-riskGTN:PrimaryTherapyOptions)?Preferredregimens:EMA/COpVincristinedosingrevised:1mg/m20.8mg/m2(maximumof2mg)IVover5–10minutesonDay8Page3of6(High-riskGTN:PrimaryTherapyOptions)?PreferredregimenspEMA/EPdosingrevised?Etoposide100–150mg/m2IVonDay8?Cisplatin60–75mg/m2IVonDay8pEP/EMAdosingrevised?Etoposide100–150mg/m2onDay1?Cisplatin60–75mg/m2IVonDay1Page4of6(High-RiskGTN:TherapyforMethotrexate-ResistantGTN)?PreferredregimenspTP/TEdosingrevised:Cisplatin60–75mg/m2IVonDay1pBEP;Comments/Considerations:?Bulletrevised:PulmonaryfunctiontestingshouldbeperformedpriortoinitiationoftherapyandeveryfourthdosethereafterAssessmentofpulmonaryfunctiontests(PFTs),typicallyspirometryanddiffusingcapacityforcarbonmonoxide(DLCO),atbaselinepriortotreatmentandmonitoringPFTspriortoeachnewtreatmentcycleasclinicallyindicated.?Bulletremoved:Lifetimedoseofbleomycinshouldnotexceed270units.Page5of6(High-RiskGTN:AdditionalAgents/RegimensShowntoHaveSomeActivityinTreatingMultiagentChemotherapy-ResistantGTN)?ThefollowingUsefulinCertainCircumstancesregimenswereremoved(alsoforGTN-B6of6)p5-fluorouracil–basedregimenspGemcitabine±carboplatinPage6of6IntermediateTrophoblasticTumor(PSTTandETT)?TP/TE:Paclitaxel,cisplatin/paclitaxel,etoposide:MovedfromOtherRecommendedRegimenstoPreferredRegimensGTN-CPrinciplesofGynecologicSurvivorship?Psychosocialeffectsrevised:Psychosocialeffectsaftercancermayincludebepsychological(eg,depression,anxiety,fearofrecurrence,alteredbodyimage),financial(eg,returntowork,insuranceconcerns),and/orinterpersonal(eg,relationships,sexuality,intimacy)effectsinnature.?Clinicalapproach:p1stbullet:"...focusesonmanagingchronicdiseasemanagement,monitoringofcardiovascularriskfactors,providingrecommendedvaccinations..."p2ndbullet:"...physicalexamination,andconductprovideanynecessaryimagingand/orlaboratorytesting.Allwomenpatients,whethersexuallyactiveornot,shouldbeaskedaboutgenitourinarysymptoms,includingvulvovaginaldryness..."pNewbulletadded:Forpremenopausalpatients,hormonereplacementtherapyshouldbeconsidered.Version1.2022,10/06/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATES?CBCdifferentialandplateletcount?Liver/renal/thyroidfunctiontests/chemistryprofile?BloodtypeandscreenPrintedbyMinTangon3/14/20227:43:45AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?CBCdifferentialandplateletcount?Liver/renal/thyroidfunctiontests/chemistryprofile?BloodtypeandscreenasivedexWORKUPHPtxtxraya?Quantitativehumanchorionicassaybgonadotropin(assaybpAdministerRho(D)immuneglobulinifRhnegativeINITIALTREATMENTSuctiondilationandcurettage(D&C),preferablycdcdHysterectomygectomyegectomyeCompleteorpartialhydatidiformmoleMONITORINGf?H&P1monthafterinitialtreatment?hCGassayevery1–2weeksuntilnormalized?Systemichormonalcontraception(oralFINDINGSANDADDITIONALEVALUATIONforconsecutiveayshCGassayevery3monthsfor6monthshCGnrrisepost-molargestationaltrophoblasticneoplasia(GTN)aIfthechestx-rayispositiveformetastases,thenperformchest/abdomen/pelvicCTandbrainMRIandmanageasGTNafterinitialuterineevacuation.bIfhCGiselevatedwithnoevidenceofdiseaseonimaging,considerpossibilityofluteinizinghormone(LH)crossover,pituitaryhCG,orphantomhCG.Consultwithlaboratorymedicine/pathologytotestforphantomhCGwithserialdilutionstudyorcomparisonofserumtourinehCG.cUselargestcurettefeasible.Sharpcurettageaftersuction.Useuterotonicdrugsafterinitiatingevacuationofuterus.Oxytocinreceptorsmaybeabsent.dProphylacticchemotherapywithmethotrexateordactinomycinmaybeconsideredatthetimeofevacuationofahydatidiformmoleinpatientsathighriskforpost-molarGTN(age>40years,hCG>100,000mIU/mL,excessiveuterineenlargement,andthecaluteincysts>6cm)whenhCGfollow-upisunavailableorunreliable(WangQ,etal.CochraneDatabaseSystRev2017;9:CD007289).eHysterectomywithsalpingectomymaybeconsideredasinitialtreatmentforhydatidiformmoleinpatientswhodonotwishtopreservefertility.fAformalfollow-upprogramallowsforearlydetectionofGTNandlimitsexposuretocombinationchemotherapy(Sita-LumsdenA,etal.BrJCancer2012;107:1810-1814).SeePrinciplesofPathology(GTN-A).gOralcontraceptivesarepreferredoverintrauterinedevices(IUDs)becausetheysuppressendogenousLH/follicle-stimulatinghormone(FSH),whichmayinterferewithhCGmeasurementatlowlevels.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2022,10/06/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.agingchestxrayorchest/pelvisCTj?Determinecscorekchoriocarcinoma,hPrintedbyMinTangon3/14/20227:43:45AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022Nationalagingchestxrayorchest/pelvisCTj?Determinecscorekchoriocarcinoma,hasivedexFINDINGSOneormoreofthefollowingindicatingpersistentpost-molarGTN:?hCGlevelsplateaufor4consecutivevaluesover3weeks?hCGlevelsrise≥10%for3valuesover2weeksiagnosisiagnosisofPSTT/ETT,and/orpresenceofmetastaticdiseaseSTAGING?H&P(includingpelvicexam)?DopplerTREATMENTMONITORINGConsiderrepeatD&CorSingle-agentsystemictherapyasinGTN-2ithngectomyeveryweeksuntil3onsecutiveormalssaysfollowedbymonthlyfor6onthsmalizerriseChemotherapyasinGTN-3(<7prognosticscore)k(<7prognosticscore)kprognostictageIVSeeGTNhSeePrinciplesofPathology(GTN-A).iDopplerpelvicultrasoundisusedtoconfirmabsenceofpregnancy,measureuterinesize,anddeterminevolumeandvasculatureoftumorwithintheuterus.jIfthechestx-rayisnormal,nofurtherimagingisindicatedbeforecommencingtreatment.Ifthechestx-rayshowsmetastases,chest/abdomen/pelvicCTscanandbrainMRIareindicated.kSeeFIGOStagingSystemforGTN(ST-1)andPrognosticScoringIndexforGTN(ST-2).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2022,10/06/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.HistopathologicassessmentfPrintedbyMinTangon3/14/20227:43:45AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.HistopathologicassessmentfadexWORKUPareviouslydoneHP?RepeatCBCdifferentialandplateletcount?Repeatliver/renal/thyroidfunctiontests/chemistryprofilegingpChest/abdominal/pelvicCTscanwithging?BrainMRI(preferred)orCTwithcontrastifpulmonarymetastasisassaycdassaycdDetermineFIGOstageandprognosticscoreeFINDINGSgprognosticscoreprognosticscoree≥7prognosticStageIVIntermediatetrophoblastictumorh?Placentalsitetrophoblastictumor(PSTT)elioidtrophoblastictumorTTTREATMENTaIfvisiblelesionsareseeninlowergenitaltract,doNOTbiopsyduetoriskofhemorrhage.bIfcontrastiscontraindicated,otherimagingtechniquessuchasMRImaybeconsidered.cIfhCGiselevatedwithnoevidenceofdiseaseonimaging,considerthepossibilityofLHcrossoverorphantomhCG.Consultwithlaboratorymedicine/pathologytotestforphantomhCGwithserialdilutionstudyorcomparisonofserumtourinehCG.dIfhCGiselevated,buthyperglycosylatedhCGisnormal,quiescentGTNmaybediagnosedandleftuntreated.eSeeFIGOStagingSystemforGTN(ST-1)andPrognosticScoringIndexforGTN(ST-2).fSeePrinciplesofPathology(GTN-A).gConsiderconsultationwithaclinicianorcenterwithexpertiseinmanagementofgestationaltrophoblasticdiseases.hPrognosticscoringisnotvalidforintermediatetumors.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2022,10/06/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.GTN-1cycles(3preferred)lpastion?Continuesystemictherapyfor2–3treatmentPrintedbyMinTangon3/14/20227:43:45AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.cycles(3preferred)lpastion?Continuesystemictherapyfor2–3treatmentadexPRIMARYTREATMENTFORLOW-RISKGTNMONITORINGDURINGTREATMENTDIAGNOSISRESPONSEASSESSMENTMONITORINGDURINGTREATMENTDIAGNOSISRESPONSEASSESSMENTlTREATMENT?hCGassayeverymonthfor12months?Contraception(FollowedbyhCGlevelplateaumgentmedgentmedrognosticenitialrapyemictherapyoptionsi,j,k?Methotrexateinomycinweeks,atthestartofeachtreatmentcycleFollowedntrapidriseinhCGlevel(ntPoorresponsetoinitialtherapy:hCGlevelplateaus(<10%change)for3treatmentcyclesorhCGlevelrises(>10%change)iRegimensarecontinueduntil2–3fullcyclespastnormalizationofthehCG.for2treatmentcyclesjHysterectomywithsalpingectomyorrepeatendometrialcurettagemaybeconsideredifthereislocalizeddiseaseintheuterus.Hysterectomyispreferredandwherefertilitypreservationisnotdesired.Leaveovariesinsitu,eveninpresenceofthecaluteincysts.kSeeSystemicTherapyforGTN(GTN-B)forspecificrecommendations.lLybolC,etal.GynecolOncol2012;125:576-579.mhCGplateauduringtreatmentcanbedefinedasa<10%decreaseinhCGover3treatmentcycles.nSeePrinciplesofGynecologicSurvivorship(GTN-C).oOralcontraceptivesarepreferredoverintrauterinedevices(IUDs)becausetheysuppressendogenousLH/follicle-stimulatinghormone(FSH),whichmayinterferewithhCGmeasurementatlowlevels.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2022,10/06/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.GTN-2PrintedbyMinTangon3/14/20227:43:45AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.adexseoinitialtherapyollowedbyhCGlevelplateauorelevationhCG<1000)GoodresponsetoinitialtherapyfollowedbyrapidriseinhCGlevel(hCG≥1000)orPoorresponsetoinitialtherapyTREATMENTgTREATMENTFORPERSISTENTGTNMONITORINGDURINGTRTREATMENTginetherapykngeinetherapykotrexate?DactinomycinandwithsalpingectomyjwithsalpingectomyjhCGassayevery2weeks,atthestartofeachtreatmentcycletherapytocombinationEMACOktherapytocombinationEMACOkRepeatworkuptocheckformetastasisandwithsalpingectomyjwithsalpingectomyjhCGassayevery2weeks,atthestartofeachtreatmentcycleRESPONSEASSESSMENTpRESPONSEASSESSMENTpContinuesystemictherapyfor3rredtreatmentcyclespastonhCGlevelplateaus(<10%change)for2treatmentcyclesorhCGlevelrises(>10%change)for1treatmentcycleRepeatworkuptocheckformetastasisandTransitiontocombinationNormalhCGlevels?Continuesystemictherapyfor2–3(2preferred)treatmentcyclespastnormalizationhCGlevelplateaus(<10%change)for2treatmentcyclesorhCGlevelrises(>10%change)for1treatmentcyclesurgicalsurgicalasibleldTreatmentforHigh-RiskGTN(SeeGTN-4andGTN-B)gConsiderconsultationwithaclinicianorcenterwithexpertiseinmanagementofgestationaltrophoblasticdiseases.jHysterectomywithsalpingectomyorrepeatendometrialcurettagemaybeconsideredifthereislocalizeddiseaseintheuterus.Hysterectomyispreferredwherefertilitypreservationisnotdesired.Leaveovariesinsitu,eveninpresenceofthecaluteincysts.kSeeSystemicTherapyforGTN(GTN-B)forspecificrecommendations.nSeePrinciplesofGynecologicSurvivorship(GTN-C).pPost-treatmentimagingisnotrecommendedforfollow-upafterhCGnormalizationinpatientswithpost-molarGTNorchoriocarcinoma,wherehCGisareliabletumormarker.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.GTN-3Version1.2022,10/06/21?2021Nation