Changes in the management of high-risk gestational trophoblastic neoplasia in the National Trophoblastic Disease Center of Hungary

OBJECTIVE

To compare the clinical management of patients with high-risk gestational trophoblastic neoplasia (GTN) among the periods of 1977-1990, 1991-2000, and 2001-2012 at the National Trophoblastic Disease Center of Hungary and to assess the efficacy of the FIGO 2000 staging and risk factor scoring system in comparison to the original WHO prognostic scoring system (1983).

STUDY DESIGN

We reviewed the medical records of 185 patients with high-risk GTN. From 1977-2000, patients were classified according to the original WHO prognostic scoring system (1983). From 2001-2012, high-risk patients were categorized by the FIGO 2000 system. We assessed the efficacy of MAC and EMA-CO primary combination chemotherapies. For 1977-2006 and 2007-2012 we assessed the efficacy of MAC and EMA-CO primary combination chemotherapies.

RESULTS

From 1977-1990, 63 high-risk patients (average, 4-5 patients/year), from 1991-2000, 50 high-risk patients (average, 5 patients/year), and from 2001-2012, 72 high-risk patients (average, 6 patients/year) were treated primarily with combination chemotherapy (MAC and/or EMA-CO and/or CEB). From 1977-2006, 100 high-risk patients received MAC primary combination chemotherapy and 17 cases received EMA-CO. The ratio of primary MAC primarily with and EMA-CO therapy among our high-risk patients was 5.9 (100/17) over the referred period. From 2007-2012, 21 high-risk patients were treated with primary MAC chemotherapy and 16 patients received EMA-CO. The MAC/EMA-CO ratio over this time interval was 1.3 (21/16).

CONCLUSION

We attained complete remission in 95.7% of the high-risk patients. During the last 6 years the use of EMA-CO primary combination chemotherapy increased among our high-risk patients, which has resulted in increased efficacy and fewer side effects.

Color Doppler sonography as an adjunct to repeat uterine evacuation for gestational trophoblastic disease: case report

Repeat uterine evacuation is a therapeutic option for preserving fertility in patients with gestational trophoblastic neoplasms and chemoresistance, but remains controversial due to the risks of hemorrhage and perforation. A 25-year-old patient with low-risk gestational trophoblastic neoplasm became chemoresistant; however, chemotherapy reduced intrauterine tumor vascularity as observed by color Doppler sonography, suggesting that patients could undergo uterine evacuation without major risk of bleeding. After 18 months, she achieved a normal pregnancy. Serial assessment of tumor vascularity with color Doppler sonography may provide information regarding the appropriate time to perform a repeat uterine evacuation without significant bleeding.

[Therapeutic evaluation of cisplatin, etoposide, and bleomycin chemotherapy regimen in high-risk gestational trophoblastic neoplasia]

OBJECTIVE

To evaluate the effectiveness and safety of combination chemotherapy with bleomycin, etoposide and cisplatin (BEP) regimen on the patients with high-risk gestational trophoblastic neoplasia (GTN).

METHODS

Forty-two patients with high-risk GTN admitted in Sichuan Cancer Hospital between Jan.1997 and Oct. 2011 were analyzed retrospectively. The International Federation of Gynecology and Obstetrics (FIGO) prognostic score of all patients was more than 7. The mean age of patients was 30.2 years (range 20 - 49 years). All patients were treated with more than two cycles BEP regimen and followed up to the patients' death or at the end of Feb.2012. The clinical response, toxicity and the occurrence of secondary tumors were investigated.

RESULTS

Forty-two high-risk GTN patients received the total of 251 courses of the BEP regimen, the average number of courses for each patient was 6.0 courses. Thirty-seven patients achieved complete remission and 5 patients showed drug-resistant. The total complete remission rate of BEP regimen was 88% (37/42). Among the complete remission patients, the total courses of BEP regimen of cases getting normal serum β-hCG level was 129 courses (average 3.5 courses), and the total courses of cases achieving complete remission was 227 courses (average 6.1 courses). Among the 37 complete remission patients, 31 cases were treated with BEP regimen chemotherapy alone, 4 patients with BEP regimen chemotherapy combined with surgical treatment (1 case had no cancer after surgery) and 2 cases with BEP regimen chemotherapy combined with radiation therapy. Therefore, the complete remission rate of BEP regimen chemotherapy alone was 74% (31/42). There were 5 patients who showed drug-resistance after 24 courses of BEP regimen chemotherapy (average 4.8 courses), then received etoposide, methotrexate and dactinomycin (EMA)/cyclophosphamide and vincristine sulfate (CO) regimen chemotherapy after drug-resistance, 2 cases combined with radiation therapy, 1 case combined with surgical treatment. Ultimately, 4 cases achieved complete remission, 1 case died of cancer. The major toxicities of BEP regimen were included bone marrow suppression, digestive tract side effect and alopecic, followed by mild peripheral neuritis and abnormal liver function, rare cases of mild pulmonary toxicity. There were no severe anaphylaxis and obvious impairment of cardiac, liver, pulmonary and kidney function, except 1 patient (49 years old) had grade IV bone marrow suppression and pulmonary fibrosis worsened after chemotherapy. The bone marrow suppression was mainly I-III degree neutropenia, and Incidence rate was 66.5% (167/251). All the survival patients without secondary tumor.

CONCLUSION

For young high-risk GTN patients, BEP regimen chemotherapy may be safe and effective.

Role of hysterectomy in the management of patients with gestational trophoblastic neoplasia: importance of receiving treatment in reference centers

OBJECTIVE

To evaluate hysterectomy prevalence, indications and impact on clinical outcomes in a reference center in southern Brazil.

STUDY DESIGN

Institutional Ethical Committee approval was granted for this study. In a cohort study spanning 21 years, all patients who underwent hysterectomy for gestational trophoblastic neoplasia (GTN) were included, and technical differences between hysterectomy performed in the reference center and those performed elsewhere were evaluated as well.

RESULTS

Of 1,023 patients with gestational trophoblastic disease, 57 (5.6%) underwent hysterectomy (95% CI, 4.3-7.1). Hysterectomy incidence in 230 GTN patients was 17.7% (95%CI, 15.1-23.3). Indications for 41 hysterectomies in the reference center were as follows: primary treatment in 14 (34.1%) cases and secondary treatment in 27 (65.9%); of these, the main indications were GTN recurrence (7 [25.9%] cases), hemorrhage (6 [22.2%]), resistance to single-agent chemotherapy in patients who refused more aggressive treatment (6 [22.2%]), and tumor mass reduction (5 [18.5%]). Twelve (92.3%) of the 13 hysterectomies with bilateral oophorectomy were performed elsewhere (p < 0.001). Thirty-five (85.4%) patients had no complications, and median hospitalization time was short (3 +/- 4 days). None of the 4 deaths were associated with hysterectomy. In the reference center, when associated with hysterectomy, GTN cure rates reached 93% after 63 +/- 87 months of follow-up.

CONCLUSION

When treatment is in a reference center, hysterectomy frequency and morbidity may be low, and indications due to hemorrhage are significantly lower. Furthermore, at a reference center there is significantly greater ovarian preservation at the time of hysterectomy, and significantly more patients who undergo hysterectomy have low-risk GTN.

Actinomycin D for methotrexate-failed low-risk gestational trophoblastic neoplasia

OBJECTIVE

To determine outcomes and factors associated with failure of 5-day actinomycin D for treatment of methotrexate-failed low-risk gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

We reviewed the records of 358 patients treated with methotrexate 0.4 mg/kg (max 25 mg) IV push q.d. x 5 d every 14 d for FIGO-defined, low-risk GTN between 1979 and 2009. Actinomycin D 0.5 mg IV push q.d. x 5 d every 14 d was given to 64 of 68 patients (18%) who failed methotrexate: 48 (75%) for resistance and 16 (25%) for toxicity. Adjuvant surgery was used in selected patients. Clinical response and survival as well as factors affecting outcomes were analyzed retrospectively.

RESULTS

The complete response rate to secondary chemotherapy with actinomycin D for failed methotrexate treatment of low-risk GTN was 75% (48/64), including 71% (34/48) for methotrexate resistance and 88% (14/16) for methotrexate toxicity. All 20 patients (6%) who failed sequential single-agent chemotherapy with methotrexate and actinomycin D were placed into permanent remission with the use of multiagent chemotherapy with or without surgery. The only factor significantly associated with resistance to secondary actinomycin D chemotherapy was clinicopathologic diagnosis of choriocarcinoma versus postmolar GTN (56% versus 20%, p = 0.025).

CONCLUSION

Actinomycin D 0.5 mg IV q.d. x 5 d every 14 d used as secondary therapy in methotrexate-failed low-risk GTN resulted in a 75% complete response rate and eventual 100% cure with subsequent multiagent chemotherapy with or without surgery. Resistance to sequential methotrexate and actinomycin D chemotherapy was significantly associated with original FIGO score > or = 3 and clinicopathologic diagnosis of choriocarcinoma.

Importance of salvage therapy in the management of high-risk gestational trophoblastic neoplasia

OBJECTIVE

To assess the value of secondary therapy in the management of high-risk gestational trophoblastic neoplasia (GTN) after failure of initial multiagent chemotherapy.

STUDY DESIGN

Forty-nine women with high-risk GTN, including 29 who were treated primarily and 20 who were treated secondarily, completed treatment at the Brewer Trophoblastic Disease Center between 1986 and 2010. Initial chemotherapy consisted of etoposide, high-dose methotrexate with folinic acid, actinomycin D, cyclophosphamide and vincristine (EMA-CO) in 29 patients who were treated primarily and in 10 patients who had received single-agent chemotherapy before being treated at our center. Patients who had incomplete responses or developed resistance to EMA-CO or had previously received EMA-CO were treated with drug combinations employing etoposide and a platinum agent with methotrexate and actinomycin D (EMA-EP), bleomycin (BEP), ifosfamide (VIP, ICE) or paclitaxel (TP/TE). Adjuvant surgery and brain radiation were used in selected patients. Clinical response and survival as well as factors affecting outcomes were analyzed retrospectively.

RESULTS

Twenty-eight (57%) of the 49 patients developed resistance to EMA-CO: 13 (45%) of 29 treated primarily and 15 (75%) of 20 treated secondarily. Of the 13 patients who failed primary treatment with EMA-CO, 10 (77%) had lasting complete responses to EMA-EP (4), BEP (3), VIP (1), ICE (1) or TP/TE (1). Of the 15 patients who failed EMA-CO used as secondary therapy, 13 (87%) had lasting complete responses to EMA-EP (5), BEP (6) or ICE (2). Brain irradiation was given to 4 patients who developed brain metastases during treatment, 3 of whom survived. Operative procedures were performed to remove resistant foci of disease in the lungs (9) or uterus (2) in 11 (39%) of the 28 patients, 9 (82%) of whom survived. Survival was significantly influenced by hCG level at the start of salvage therapy (p<0.001), number of metastatic sites (p <0.02) and metastases to sites other than the lung and vagina (p<0.05).

CONCLUSION

Salvage therapy with platinum/etoposide-based drug regimens, often in conjunction with surgery and brain radiation, was successful in achieving cure in 82% of 28 high-risk GTN patients who failed initial multiagent chemotherapy and was ultimately responsible for survival in 53% of the 43 patients (88%) with high-risk GTN who were cured.

[Clinical analysis of patients with relapsed and chemo-resistant gestational trophoblastic neoplasia]

OBJECTIVE

To analyze and compare the clinical characteristics and the treatment outcome of the patients with chemo-resistant and relapsed gestational trophoblastic neoplasia (GTN).

METHODS

The clinical records of the patients with refractory GTN treated at the Peking Union Medical College Hospital (PUMCH) from Jan 2005 to Dec 2007 were retrospectively reviewed. According to the reasons for referral, all cases were classified as chemo-resistant GTN group who had never a normal serum human chorionic gonadotropin-beta subunit (β-hCG) level during their previous treatment, relapsed GTN group who had elevated serum β-hCG levels in the absence of the pregnancy after finished treatment 3 months or more, and undetermined GTN group who had elevated serum β-hCG levels in the absence of the pregnancy less than 3 months after completed treatment. The clinical features and treatment outcomes were compared between undetermined GTN group and chemo-resistant GTN group and also between undetermined GTN group and relapsed GTN group, respectively.

RESULTS

Of 81 patients with refractory GTN, 32 cases were defined as undetermined GTN, 38 cases as chemo-resistant GTN and 11 cases as relapsed GTN. The median number of previous chemotherapy regimens, the rate of serologic complete remission (SCR), the patients who needed to change regimens due to resistance, and the patients who needed to change regimens in the undetermined GTN group and the chemo-resistant GTN group were 2.3 versus 3.1 (P = 0.010), 100% (32/32) versus 66% (25/38, P < 0.01), 22% (7/32) versus 58% (22/38, P = 0.002) and 28% (9/32) versus 63% (24/38, P = 0.003), respectively. No significant difference were observed between undetermined GTN group and relapsed GTN group in clinical features, previous and current treatment or treatment outcome (all P > 0.05).

CONCLUSIONS

In order to evaluate accurately the treatment outcome of refractory GTN, it seems more appropriate for the patients who had reached the normal value of serum β-hCG when completed treatment to be defined as patients with relapsed GTN, while whose serum β-hCG levels elevated in the absence of the pregnancy after the completion of treatment, irrespectively of duration of stopping treatment. Comparing with the patients with chemo-resistant GTN, the outcome of patients with relapsed GTN is better.

[Epithelioid trophoblastic tumour]

Epithelioid trophoblastic tumour is a rare gestational trophoblastic disease. The diagnosis is based on microscopic morphology and immunohistochemical staining. It is important to avoid misdiagnosis, as this tumour is primarily treated by surgery rather than chemotherapy. We report a case and describe diagnostic criteria and differential diagnoses.

Sonographic appearance of gestational trophoblastic disease evolving into epithelioid trophoblastic tumor

Epithelioid trophoblastic tumor is a distinctive but rare trophoblastic tumor. It derives from intermediate trophoblastic cells of the chorion laeve and is usually associated with a previous gestational event. We report the case of a patient who had undergone dilatation and curettage for a missed miscarriage. Three months later gestational trophoblastic disease was suspected because of persistent vaginal bleeding and high levels of beta-human chorionic gonadotropin (beta-hCG). Transvaginal ultrasound revealed irregular echolucent lacunae within the myometrium, some of them filled with low-resistance, turbulent blood flow on Doppler examination, emphasizing the diagnosis of gestational trophoblastic disease. The patient was treated with 12 courses of multiagent chemotherapy. After a 2-year remission, a low rise in serum beta-hCG was observed. Transvaginal ultrasound revealed a well-circumscribed echogenic lesion with a diameter of 1.8 cm in the uterine fundus, with no detectable blood flow on Doppler imaging. A diagnosis of tumor of intermediate trophoblastic cells was suspected and total hysterectomy was performed. On pathological examination, the histological and immunohistochemical features were characteristic of epithelioid trophoblastic tumor. Most reported cases of epithelioid trophoblastic tumor have solitary nodules with sharp margins, which is consistent with our ultrasound findings. Ultrasound may be helpful in differentiating epithelioid trophoblastic tumor from placental-site trophoblastic tumor, another tumor of intermediate trophoblastic cells, which shows infiltrative growth insinuating between muscle fibers.

The role of surgery and radiation therapy in the management of gestational trophoblastic disease

The primary management of hydatidiform moles remains surgical evacuation followed by human chorionic gonadotropin level monitoring. Although suction dilatation and evacuation is the most frequent technique for molar evacuation, hysterectomy is a viable option in older patients who do not wish to preserve fertility. Despite advances in chemotherapy regimens for treating malignant gestational trophoblastic neoplasia, hysterectomy and other extirpative procedures continue to play a role in the management of patients with both low-risk and high-risk gestational trophoblastic neoplasia. Primary hysterectomy can reduce the amount of chemotherapy required to treat low-risk disease, whereas surgical resections, including hysterectomy, pulmonary resections, and other extirpative procedures, can be invaluable for treating highly selected patients with persistent, drug-resistant disease. Radiation therapy is also often incorporated into the multimodality therapy of patients with high-risk metastatic disease. This review discusses the indications for and the role of surgical interventions during the management of women with hydatidiform moles and malignant gestational trophoblastic neoplasia and reviews the use of radiation therapy in the treatment of women with malignant gestational trophoblastic neoplasia.

30 years' experience in the treatment of low-risk gestational trophoblastic neoplasia in Hungary

OBJECTIVE

To review the clinical experience in the treatment of patients with low-risk gestational trophoblastic neoplasia (GTN) over the past 30 years in a national trophoblastic disease center.

STUDY DESIGN

Between January 1, 1977, and December 31, 2007, 302 patients with low-risk GTN were treated. The patients were directed to our institution from all parts of Hungary. The patients were 14 to 53 years of age with an average age of 28.3 years. Methotrexate (MTX)/folinic acid or actinomycin-D (Act-D) primary chemotherapy was selected based upon the patient's stage and prognostic score of GTN.

RESULTS

Among 218 low-risk patients, 210 (96.3%) achieved remission as a result of MTX therapy. In 8 patients (3.7%), MTX-Act-D-cyclophosphamide (MAC) combination chemotherapy was needed to achieve complete remission, in some cases assisted by operation. Among 84 patients, 81 (96.4%) achieved remission as a result of Act-D therapy. In 3 cases (3.6%) complete remission was achieved by MAC combination chemotherapy. We detected metastases in 22.8% (69/302) of our low-risk patients. Chemotherapy, surgical intervention or other supplementary treatments resulted in 100% remission in cases of low-risk nonmetastatic and metastatic disease.

CONCLUSION

Our data indicate that MTX/folinic acid or Act-D should be the primary treatment in patients with nonmetastatic or metastatic low-risk GTN. Importantly, patients with resistance to single-agent chemotherapy regularly achieve complete remission with MAC combination chemotherapy. Results show that patient care under the direction of experienced clinicians serves to optimize the opportunity for cure and minimize morbidity.

The evolving role of hysterectomy in gestational trophoblastic neoplasia at the New England Trophoblastic Disease Center

OBJECTIVE

To identify indications for hysterectomy in patients with gestational trophoblastic neoplasia (GTN) and to evaluate outcomes of hysterectomy in those patients.

STUDY DESIGN

Patients who underwent hysterectomy were identified utilizing hospital medical records and the New England Trophoblastic Disease Center (NETDC) database from January 1, 1959-January 1, 2009. Demographic data as well as indication for hysterectomy, stage, World Health Organization score, chemotherapeutic regimens and outcomes were recorded. We further stratified our population into patients with hysterectomies before and after 1980 to assess how indications for and outcomes after hysterectomy may have changed at our institution over time.

RESULTS

A total of 98 patients were identified to have undergone hysterectomy for GTN. In the entire cohort 85% (n = 83) achieved remission and 48% (n = 47) required chemotherapy after hysterectomy. Among the patients in the early cohort (n = 49), indications for hysterectomy included 15 (31%) for primary definitive management, 14 (29%) for chemotherapy resistant disease, 14 (29%) for bleeding and 6 (11%) for other reasons. Of the patients with hysterectomy for chemotherapy resistance, 9 (64%) achieved remission. In the more recent cohort (n = 49) indications for hysterectomy included 24 (49%) for primary definitive management, 19 (39%) for drug-resistant disease, 4 (8%) for bleeding and 2 (4%) for other reasons. Of the patients with hysterectomy for chemotherapy resistance, 16 (84%) achieved remission. There was a statistically significant decline in the number of hysterectomies performed for bleeding. Hysterectomy was performed for bleeding in the early cohort (1959-1980) in 14 (29%) of 49 patients but in only 4 (8%) of 49 patients in the later cohort (1981-2009) (p = 0.02).

CONCLUSION

During the years 1959-2009 the number of hysterectomies performed for GTN at the NETDC has remained stable. However, at our center there has been a decline in the incidence of hysterectomy for life-threatening hemorrhage. Overall 83 (84.7%) patients with hysterectomy for GTN obtained remission. In patients who underwent hysterectomy to treat chemotherapy-resistant disease, 25 of 33 (75.8%) subsequently achieved complete remission. Hysterectomy continues to play an important role in the management of selected patients with GTN.

Hysterectomy in gestational trophoblastic neoplasia: Chiang Mai University Hospital's experience

Indications and outcomes of hysterectomy in women with gestational trophoblastic neoplasia (GTN) were reviewed at Chiang Mai University Hospital, Chiang Mai, Thailand. From January 1998 through December 2008, 18 women underwent simple transabdominal hysterectomy (TAH). Indications for TAH included suspicious lesions confined to the uterus (5), chemoresistant lesions confined to the uterus (7), hemoperitonium (4), and other diagnoses of gynecologic diseases (2). The final histology reports included choriocarcinoma (9), invasive mole (6), placental site trophoblastic tumor or PSTT (1), uterine fibroid without residual GTN (1), and unknown (1). Two women experienced massive blood loss (4700 ml and 7500 ml, respectively). Postoperatively, only one woman with diagnosis of PSTT did not receive other adjuvant treatment. One woman failed to survive. In conclusion, hysterectomy continues to be an important treatment strategy for selected women with GTN. The common indications include drug-insensitive disease, PSTT, and hemorrhagic complications.

[Pulmonary resection in the management of gestational trophoblastic neoplasia: a clinical study]

OBJECTIVE

To investigate the effect of surgical resection in the management of gestational trophoblastic neoplasia (GTN) patients with pulmonary metastases.

METHODS

A retrospective review of the medical records of 62 GTN patients who underwent pulmonary resection was carried out. The cases were divided into recurrent group (group A, n = 10), drug-resistant group (group B, n = 28), and the group with satisfactory response to chemotherapy but residual pulmonary lesion (s) (group C, n = 25). One patient underwent lobectomy twice, and she was allocated simultaneously to groups A and B. The patients' median age, antecedent pregnancy, International Federation of Gynecology and Obstetrics (FIGO) risk score, number of preoperative chemotherapy courses, preoperative beta-human chorionic gonadotrophin (beta-hCG) titer, lesion size, number of lobes affected, positive rate of histology, follow-ups and prognosis were compared between the three groups.

RESULTS

The proportion of high-risk patients in the three groups was 90%, 82% and 44%, respectively. The complete remission rates of the three groups were 90%, 79% and 100%, with relapse rates of 2/8, 15% and zero, respectively. Positive histology of the resected specimen was more frequently recognized in recurrent and drug-resistant groups (A 60%, B 36%, C 12%). In the drug-resistant group there were more preoperative chemotherapy sessions (A 3, B 7, C 5) and more patients with abnormal preoperative beta-hCG titer (A 50%, B 61%, C 12%).

CONCLUSIONS

Surgical resection is effective in the treatment of pulmonary metastases of GTN. Surgery is indicated when clinical evidence suggests that pulmonary metastatic disease causes relapse or drug-resistance and the lesions are relatively localized. Surgical resection is not recommended for patients with satisfactory response to chemotherapy but residual pulmonary lesions.

[Efficacy of surgical management combined with chemotherapy in the treatment of drug-resistant gestational trophoblastic neoplasm]

OBJECTIVE

To evaluate the efficacy of surgical management combined with chemotherapy in the treatment of drug-resistant gestational trophoblastic neoplasm (GTN) patients, and investigate factors influencing the outcome of the surgery combined with chemotherapy.

METHODS

Medical records of 42 patents with drug-resistant GTN who were treated by chemotherapy combined with surgical management at Peking Union Medical College Hospital from Jan 1996 to Jan 2006 were reviewed.

RESULTS

Among 42 patients, 32 achieved serologically complete remission (SCR) with an SCR rate of 76%, and 10 patients had a treatment failure. Treatment failure was more frequently seen in patients who also had metastasis of other sites except for lungs and vagina and patients with antecedent non-molar pregnancy (P = 0.023 and 0.017, respectively). Preoperative human chorionic gonadotropin-beta subunit (beta-hCG) titer > 10 U/L (P = 0.020), failure to reach normal serum titers of beta-hCG during treatment (P = 0.003), age > or = 35 years (OR: 12.6, 95% CI: 2.4 - 66.0, P = 0.002) and preoperative chemotherapy regimens > or = 4 (OR: 4.5, 95% CI: 1.0 - 20.1, P = 0.059) were also correlated with treatment failure. All the 10 patients with treatment failure had at least 3 of 6 above mentioned predictors of treatment failure.

CONCLUSIONS

Surgical management combined with chemotherapy is effective in the treatment of drug-resistant GTN. Age > or = 35 years, antecedent non-molar pregnancy, metastasis of other sites except for lungs and vagina, preoperative beta-hCG titer > 10 U/L, failure to reach normal serum titers of beta-hCG during treatment, and preoperative chemotherapy regimens > or = 4 are significant predictors of treatment failure. Patients with 3 or more predictors of treatment failure usually have poor prognosis. Therefore, surgical management should not be performed for these patients.

Sexual dysfunction as a complication of treatment of gestational trophoblastic neoplasia

OBJECTIVE

To examine the impact of gestational trophoblastic neoplasia (GTN) therapy on women's sexuality.

STUDY DESIGN

A questionnaire concerning various sexual problems experienced by patients treated with chemotherapy and/or surgery for GTN and in remission for 1 year or more was completed by 47 women in the outpatient clinic of the Trophoblastic Disease Section of our institution from January to June 2007.

RESULTS

Ninety-five percent of the subjects continued sexual activity after treatment, but there was an increase in the incidence of sexual problems, which resulted in a slight reduction in the quality of their sex lives. Seventy percent of the women experienced absent or low sexual desire, while 42% had dyspareunia and 45% had lubrication problems. Fifty-three percent experienced changes in the relationship with their partner within the first year after remission.

CONCLUSION

Sexual dysfunction is a common complication of treatment of GTN yet is given little attention as compared to other complications. Patient education and reassurance, with early diagnosis and intervention, are essential for a better quality of life for survivors.

[Imaging of gestational trophoblastic disease]

INTRODUCTION

Trophoblastic diseases correspond to a very heterogeneous group.

OBJECTIVE

To establish the importance of imaging in the management of trophoblastic diseases.

PATIENTS AND METHODS

Retrospective study from 1995 to 2008, including all patients with a gestational throphoblastic disease in our department.

RESULTS

Seventy-four cases were identified with 58 molar pregnancies, 14 trophoblastic tumors and two cases of hydatiform mole coexistent with a twin live fetus. Ultrasound's sensibility in case of hydatiform moles was 75.86%. It was sharply more important in case of a complete mole with a detection rate of 96.15% against 28% in case of partial mole. In trophoblastic tumors, ultrasound coupled with Doppler had shown signs of invasion in half of the cases. Four patients presented with lung metastases. Magnetic resonance imaging was performed in two cases.

DISCUSSION AND CONCLUSION

Ultrasound is of high-performance in the positive diagnosis of complete moles. Furthermore, it shows signs of invasion in case of trophoblastic tumors. In those cases, a radiological assessment guides the management even in the absence of histological proofs.

The changing role of thoracotomy in gestational trophoblastic neoplasia at the New England Trophoblastic Disease Center

OBJECTIVE

To review our experience with thoracotomy in gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

Nineteen thoracotomy patients from our database were identified. Thoracotomy was performed for therapeutic reasons in 11 patients and to clarify the diagnosis in eight.

RESULTS

Among the 11 patients with chemotherapy-resistant pulmonary tumors, 10 of 11 (90.9%) achieved remission with thoracotomy. Thoracotomy was more likely to be done to clarify diagnosis before 1980 (83%) than after 1980 (23%) (p = 0.04), when it became more likely to be done for therapeutic indications. Ten patients had solitary lung lesions and 9 had multiple lesions. Four patients died (21%), with an average survival after thoracotomy of 149 days; patients had bilateral or multiple lung lesions, median preoperative hCG was 58,000 mIU/mL and all were stage IV. Survivors had lower stage disease, were more likely to have solitary lesions and had lower preoperative hCG levels.

CONCLUSION

There have been several temporal changes in the indications for thoracotomy for GTN. In general, the optimal patient to achieve remission with thoracotomy will have stage III disease, a preoperative hCG of < 1,500 mIU/mL, and a solitary lung nodule resistant to chemotherapy. Likelihood of remission after thoracotomy is high in properly selected patients.

The role of adjuvant surgery in the management of gestational trophoblastic neoplasia

OBJECTIVE

To evaluate the role of different surgical procedures combined with chemotherapy in the management of gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

A retrospective descriptive analysis of data was done using charts of diagnosed cases of GTN from 1996 to 2006. The patients were classified according to FIGO staging and WHO prognostic scoring. Surgical procedures were evaluated as to indications, hospital stay, remission rate and number of chemotherapy cycles needed to achieve remission.

RESULTS

One hundred thirty-four patients underwent at least 1 major surgery in the form of hysterectomy, with uterine perforation and profuse vaginal bleeding as an indication for surgery. Common indications for adjuvant surgery are completed family size and resistance to chemotherapy. Two patients had excision of liver metastases, and 3 patients had lung resection.

CONCLUSION

With the increasing use of early surgical intervention combined with chemotherapy, we feel that we are maximizing the benefit that can be derived by our patients from our treatment protocol. We are decreasing the number of chemotherapeutic cycles needed to attain remission and in effect decreasing the exposure of the patients to toxicity from the chemotherapy.

Role of hysterectomy in managing persistent gestational trophoblastic disease

OBJECTIVE

To evaluate incidence, indications and outcomes of hysterectomy for gestational trophoblastic disease (GTD) and compare outcomes for patients who underwent primary hysterectomy with outcomes for those who underwent adjuvant hysterectomy.

STUDY DESIGN

Using the Sheffield Trophoblastic Tumour Centre database (January 1, 1986, until June 30, 2007), patients who underwent hysterectomy were identified, along with age, antecedent pregnancy, diagnosis date, hysterectomy date and chemotherapy and pathologic findings.

RESULTS

A total of 8,860 patients were registered at Weston Park Hospital, Sheffield. Of them, 627 (7.1%) needed chemotherapy and 62 (0.71%) underwent hysterectomy. The most frequent indication was resistance to chemotherapy in 22 of 62 (35.5%), followed by major hemorrhage in 21 of 62 (33.9%). Emergent hysterectomy was performed in 22 (35.5%). Mean International Federation of Gynecology and Obstetrics risk score was 6.5. Choriocarcinoma was the most frequent pathology (23), followed by invasive mole (10) and placental site trophoblastic tumor (9). Thirty-one patients needed chemotherapy after hysterectomy, 93.5% are in remission, 7 relapsed, 3 were cured and 4 died of disease.

CONCLUSION

Incidence of hysterectomy for GTD was 1 in 140. Patients who underwent hysterectomy represent a high-risk group, often having more aggressive pathology. Hysterectomy is valuable as primary and adjuvant treatments.

[Placental site trophoblastic tumor: case report and review of literature]

A 32-year-old para 3 patient is presented having suffered from a silent uterine rupture on the occasion of her second and third Caesarean sections. After the third Caesarean section, there was light uterine bleeding whilst the patient breastfed for five months. Amenorrhoea then ensued due to oral contraception. Regular clinical and ultrasound checks revealed negative serum beta-HCG values and retrovesicular resistance, which increased in size after 18 months and became symptomatic. Because the patient's family was complete, abdominal hysterectomy without adnexectomy was performed. Histology revealed a placental site trophoblastic tumour (PSTT). This is a rare tumour with malignant potential, whose prognosis depends on the stage of the primary tumour, the period of time between the last pregnancy and onset of disease, the patient's age, and the rate of mitosis, and whose progress cannot be assessed using the WHO Prognostic Index Score for Gestational Trophoblastic Disease. In therapeutic terms, hysterectomy is recommended. Chemosensitivity is low and, due to the infrequency of the tumours, the most suitable chemotherapy scheme is unknown. In the case of metastasising or recurrent PSTT, the EP/EMA regime has proved to be most effective.

Short communication: A review of the management by hysterectomy of 25 cases of gestational trophoblastic tumours from March 1993 to January 2006

We reviewed 25 cases of gestational trophoblastic tumours referred for surgical management from Charing Cross Hospital (the London centre for gestational trophoblastic disease [GTD]) over a 13-year period. The operation performed was total abdominal hysterectomy, with lymph node sampling in 9/25 (36%) women and bilateral salpingo-oophorectomy in 11/25 (44%) women. Radical hysterectomy and unilateral parametrectomy was required in 3/25 (12%) women. Three of 25 (12%) women failed to survive, i.e. the overall rate of survival was 88%. Management by hysterectomy of primary drug-resistant and relapse cases of GTD is a useful and safe adjunct to chemotherapy.