Recent advances in gestational trophoblastic disease

Appraisal of hydatidiform mole incidence and registration rates in Ireland following the establishment of a National Gestational Trophoblastic Disease Registry

AIMS

This study aimed to re-evaluate the incidence of hydatidiform mole (HM) and determine gestational trophoblastic disease (GTD) registration rates in Ireland following the establishment of the National GTD Registry in 2017.

METHODS

We performed a 3-year retrospective audit of HM cases (January 2017 to December 2019) reported in our centre. In 2019, we surveyed Irish pathology laboratories to determine the number of HMs diagnosed nationally and compared this data to that recorded in the National GTD Registry. Additionally, we compared both local and national HM incidence rates to those reported internationally.

RESULTS

In the 3-year local audit, we identified 87 HMs among 1856 products of conception (POCs) providing a local HM incidence rate of 3.92 per 1000 births. The 1-year pathology survey recorded 170 HMs in 6008 POCs, yielding a national incidence rate of 2.86 per 1000 births. Importantly, the local HM incidence rate exceeded the national incidence rate by 37% and the local partial HM incidence (1 in 296 births) was 64% higher than the nationally incidence rate (1 in 484 births). Notably, 42% of the HM and atypical POCs diagnosed nationally were not reported to the National GTD Registry.

CONCLUSIONS

Our study reveals increased HM incidence rates both locally and nationally compared with previous Irish studies. The higher local PHM incidence may reflect more limited access to ploidy analysis in other pathology laboratories nationally. Significantly, almost half of the women with diagnosed or suspected HM were not registered with the National GTD Centre.

Ruptured ectopic pregnancy as complete hydatidiform mole: Case report and review of the literature

Usually, a hydatidiform mole (HM) develops inside the uterus. The occurrence of HM in ruptured tubal pregnancy is exceptional. Cases reported in the literature are scarce. In this article, a case of haemoperitoneum secondary to a ruptured fallopian tube by a complete mole is reported. A 50-year-old gravida 2, para 1 was admitted to the emergency department for acute abdominal pain. After the clinical examination, an abdominal sonography and CT scan were done, revealing the presence of an adnexal left mass associated with an important haemoperitoneum. A urine pregnancy test was done and was positive, indicating an immediate laparoscopic exploration. The laparoscopy revealed a haemoperitoneum secondary to a ruptured tubal mass. The pathological exam concluded a complete hydatidiform mole (CHM) invading the wall of the fallopian tube. Any acute abdominal pain in a potentially pregnant woman imposes first the routine realization of a pregnancy test. The occurrence of CHM in a ruptured fallopian tube is particularly rare and has exceptionally been diagnosed before the laparoscopic exploration.

Surveillance for gestational trophoblastic neoplasia following molar pregnancy: a cost-effectiveness analysis

BACKGROUND

Historically, published guidelines for care after molar pregnancy recommended monitoring human chorionic gonadotropin levels for the development of gestational trophoblastic neoplasia until normal and then for 6 months after the first normal human chorionic gonadotropin. However, there are little data underlying such recommendations, and recent evidence has demonstrated that gestational trophoblastic neoplasia diagnosis after human chorionic gonadotropin normalization is rare.

OBJECTIVE

We sought to estimate the cost-effectiveness of alternative strategies for surveillance for gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after complete and partial molar pregnancy.

STUDY DESIGN

A Markov-based cost-effectiveness model, using monthly cycles and terminating after 36 months/cycles, was constructed to compare alternative strategies for asymptomatic human chorionic gonadotropin surveillance after the first normal (none; monthly testing for 1, 3, 6, and 12 months; or every 3-month testing for 3, 6, and 12 months) for both complete and partial molar pregnancy. The risk of reduced surveillance was modeled by increasing the probability of high-risk disease at diagnosis. Probabilities, costs, and utilities were estimated from peer-reviewed literature, with all cost data applicable to the United States and adjusted to 2020 US dollars. The primary outcome was cost per quality-adjusted life year ($/quality-adjusted life year) with a $100,000/quality-adjusted life year willingness-to-pay threshold.

RESULTS

Under base-case assumptions, we found no further surveillance after the first normal human chorionic gonadotropin to be the dominant strategy from both the healthcare system and societal perspectives, for both complete and partial molar pregnancy. After complete mole, this strategy had the lowest average cost (healthcare system, $144 vs maximum $283; societal, $152 vs maximum $443) and highest effectiveness (2.711 vs minimum 2.682 quality-adjusted life years). This strategy led to a slightly higher rate of death from gestational trophoblastic neoplasia (0.013% vs minimum 0.009%), although with high costs per gestational trophoblastic neoplasia death avoided (range, $214,000 to >$4 million). Societal perspective costs of lost wages had a greater impact on frequent surveillance costs than rare gestational trophoblastic neoplasia treatment costs, and no further surveillance was more favorable from this perspective in otherwise identical analyses. No further surveillance remained dominant or preferred with incremental cost-effectiveness ratio of <$100,000 in all analyses for partial mole, and most sensitivity analyses for complete mole. Under the assumption of no disutility from surveillance, surveillance strategies were more effective (by quality-adjusted life year) than no further surveillance, and a single human chorionic gonadotropin test at 3 months was found to be cost-effective after complete mole with incremental cost-effectiveness ratio of $53,261 from the healthcare perspective, but not from the societal perspective (incremental cost-effectiveness ratio, $288,783).

CONCLUSION

Largely owing to the rare incidence of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after molar pregnancy, prolonged surveillance is not cost-effective under most assumptions. It would be reasonable to reduce, and potentially eliminate, current recommendations for surveillance after human chorionic gonadotropin normalization after molar pregnancy, particularly among partial moles. With any reduction in surveillance, patients should be counseled on symptoms of gestational trophoblastic neoplasia and established in routine gynecologic care.

A possible association between hydatidiform mole and the COVID-19 pandemic: A retrospective cohort study

Objective

To confirm an increase in the number of women with molar pregnancy during the COVID-19 pandemic.

Methods

In this retrospective cohort study, all patients with complete or partial mole diagnosed at our institution between January 1, 2010 and October 31, 2020, were included. To verify whether there was an increase in the incidence of hydatidiform mole (HM) and deliveries in 2020, the incidences for each year from January 2010 to October 2020 were recorded. In addition, we identified all women who were diagnosed with HM from January to October 2020, and compared them with a control group who underwent uterine evacuation for missed abortion of a singleton pregnancy during the same period. We also documented the time taken to diagnose missed abortion or molar pregnancy to check if a delay in diagnosis can explain the increase in HM incidence.

Results

Between 2016 and 2019, there was a statistically significant increase in the incidence of molar pregnancy. A further increase occurred in 2020 (odds ratio = 2.071). The mean gestational age of the embryo at the time of diagnosis was smaller in the HM group than in the missed abortion group (6.3 ± 1.67–7.4 ± 2.4, one-sided P = 0.034), meaning that it took more time (days) to diagnose molar pregnancy than missed abortion (22.38 ± 10.32 vs. 15.83 ± 7.83 days, P = 0.012).

Conclusion

There was a significant increase in the incidence of molar pregnancy during the COVID-19 pandemic, possibly because of the delay in receiving medical care. We recommend providing gynecological primary care services during a crisis, such as a pandemic.

NLRP7 and KHDC3L variants in Chinese patients with recurrent hydatidiform moles

OBJECTIVE

Recurrent hydatidiform moles are reportedly biparental complete moles and related to mutated NLRP7 and KHDC3L. This study was designed to identify mutations of gene NLRP7 and KHDC3L in biparental complete moles.

METHODS

In this study, we have screened NLRP7 and KHDC3L mutations in five patients with recurrent moles and five with sporadic moles. Molar tissues and blood samples were collected from patients and their partners. Genotypes of the molar tissues were determined based on short tandem repeat polymorphism. The coding exons of NLRP7 and KHDC3L were sequenced.

RESULTS

Two patients with recurrent moles had biparental complete moles, while all other patients had androgenetic complete moles. Three non-synonymous variants in NLRP7 (c.955 G>A, c.1280 T>C and c.1441 G>A) and one in KHDC3L (c.602 C>G) were identified in patients with recurrent moles. NLRP7 c.1441 G>A and c.1280 T>C were mutations found in the Chinese population, while c.1441 G>A was only detected in patients with biparental complete moles in this study.

CONCLUSIONS

Genotyping can be used to differentiate biparental complete moles from androgenetic moles and to predict the risk of recurrent moles in future pregnancies. NLRP7 c.1441 G>A may associate with biparental complete moles. Biparental complete moles exhibit genetic heterogeneity.

Understanding and management of gestational trophoblastic disease

Gestational trophoblastic disease or neoplasia covers a spectrum of benign and malignant conditions arising from pregnancies with highly abnormal development of trophoblastic tissue. In this brief review, we discuss the different features of these different conditions and their origins and risk factors and introduce some of the more novel and controversial treatment options currently being explored.

A Reappraisal of the Incidence of Placental Hydatidiform Mole Using Selective Molecular Genotyping

OBJECTIVE

Reports on the incidence of hydatidiform mole (HM) have varied depending on study population and methodology. This institutional-based study was undertaken to identify the incidence of HM in a modern obstetric practice using advanced laboratory diagnostic techniques.

METHODS

A retrospective review of consecutive hospital cases of HM was conducted for a 27-month period. Pathologic diagnoses of partial mole (PM) and complete mole (CM) were based on histopathologic assessment and selective use of p57 immunohistochemistry and molecular genotyping (MG) using formalin-fixed paraffin-embedded tissues.

RESULTS

During the study period, 14,944 obstetric deliveries took place at our institution. Forty-nine cases of HM (18 CMs, 31 PMs) were identified. Histopathology with the selective use of p57 immunohistochemistry was used in 25 of 49 HMs (18 CMs, 7 PMs). Histopathologic features were equivocal in the remaining cases (24/49 cases), and adjunctive MG was performed; all were PMs. The incidence of HM was 3.3/1000 deliveries. Partial mole was more prevalent with a CM (PM ratio, 1:1.72).

CONCLUSIONS

Our observed incidence of HM is greater than previous studies and is attributable to improved detection of PM cases. Molecular genotyping and cytogenetic evidence indicate that CM is almost half as common as PM. This ratio may be useful in benchmarking laboratory diagnosis and HM registries.

Gestational trophoblastic disease

Gestational trophoblastic disease encompasses a range of pregnancy-related disorders, consisting of the premalignant disorders of complete and partial hydatidiform mole, and the malignant disorders of invasive mole, choriocarcinoma, and the rare placental-site trophoblastic tumour. These malignant forms are termed gestational trophoblastic tumours or neoplasia. Improvements in management and follow-up protocols mean that overall cure rates can exceed 98% with fertility retention, whereas most women would have died from malignant disease 60 years ago. This success can be explained by the development of effective treatments, the use of human chorionic gonadotropin as a biomarker, and centralisation of care. We summarise strategies for management of gestational trophoblastic disease and address some of the controversies and future research directions.

Persistence and malignant sequelae of gestational trophoblastic disease: Clinical presentation, diagnosis, treatment and outcome

BACKGROUND

The major concern in gestational trophoblastic disease is management of persistent disease and malignant sequelae. However, prediction of response to treatment is difficult and methods used controversial.

AIM AND METHODS

To evaluate the usefulness of clinical presentation, methods of diagnosis and categorisation of risk in determining clinical outcomes, by analysis of a database of 705 registered patients collected over 30 years.

RESULTS

From the database, there were 97 patients who developed persistent disease and malignant sequelae on the basis of defined criteria - 80.4% had molar pregnancy and 19.6% non-molar pregnancy. Vaginal bleeding was not a common presentation; 59.8% had no clinical symptoms. According to protocol, monitoring by serial human chorion gonadotrophin (HCG) levels followed by imaging screen was used in all patients; histology was also available in 41.2% from hysterectomy and curettage specimens. There were 16 of 76 patients with persisting disease who had metastases (21.1%), and 2 of 20 patients with choriocarcinoma who had an antecedent molar pregnancy (10.0%). Based on five risk factors, 25 patients were categorised as 'high risk' and assigned to receive multi-drug chemotherapy. There were two deaths (2.1% for all malignant sequelae); both were from molar pregnancies. One patient failed to respond and the other suffered a complication of intensive chemotherapy.

CONCLUSION

Serial HCG levels remain the best monitor to determine therapeutic response. Categorisation of 'high risk' by five factors is useful in treatment. Albeit a small series, clinical outcome is favourable with a five-year survival of 89.7%.

Prevention of postmolar gestational trophoblastic neoplasia using prophylactic single bolus dose of actinomycin D in high-risk hydatidiform mole: a simple, effective, secure and low-cost approach without adverse effects on compliance to general follow-up or subsequent treatment

OBJECTIVE

To evaluate the efficacy of actinomycin D (Act-D) as prophylactic chemotherapy (P-Chem) to reduce postmolar gestational trophoblastic neoplasia (GTN) in patients with high-risk hydatidiform mole (Hr-HM).

METHODS

From 1987 to 2006, 265 Hr-HM were selected in a retrospective analysis of a nonrandomized clinical trial of 1090 patients with gestational trophoblastic disease (GTD) followed up at a Trophoblastic Disease Center (TDC) in southern Brazil. From 1996 to 2006, 163 received a single bolus dose of Act-D at time of uterine evacuation (Hr-HM-chem group); 102 with the same risk factors did not get P-Chem (Hr-HM-control group). Variables were: number of patients with postmolar GTN who required chemotherapy during follow-up, postmolar GTN morbidity, compliance and operational costs.

RESULTS

Postmolar GTN was diagnosed in 18.4% of the Hr-HM-chem patients (95% CI: 12.7-24.7) and in 34.3% of the Hr-HM-control patients (95% CI: 25.1-43.5). Postmolar GTN was 46% lower in P-Chem (RR=0.54; 95% CI: 0.35-0.82; NNT=7). P-Chem adverse effects were occasional and minor. When disease progressed to postmolar GTN, severity was the same, but costs were lower for the Hr-HM-chem group. Compliance with follow-up was high and similar in both groups.

CONCLUSIONS

Follow-up of patients with Hr-HM showed that a single bolus dose of prophylactic Act-D reduced the incidence of postmolar GTN. Compliance and postmolar GTN morbidity were not affected. Treatment costs and emotional complications were reduced. This prophylactic approach can be adopted before uterine evacuation in any TDC that treats Hr-HM patients that present with undelivered moles.

St. Jude Children's Research Hospital, Memphis, Tennessee: gestational choriocarcinoma

This paper describes a recent tumor board presentation conducted at our institution involving an adolescent with gestational choriocarcinoma. Despite its rarity in pediatrics, gestational choriocarcinoma offers unique diagnostic, treatment and off-therapy considerations in adolescent patients who have become pregnant. Key features and findings of the case as well as important management issues will be discussed.

Single-dose actinomycin D: Efficacy in the prophylaxis of postmolar gestational trophoblastic neoplasia in adolescents with high-risk hydatidiform mole

OBJECTIVE

To evaluate the efficacy of a single prophylactic dose of actinomycin D (Act-D) in the reduction of postmolar gestational trophoblastic neoplasia (GTN) in adolescents with high-risk hydatidiform mole (Hr-HM).

METHODS

In a retrospective study, 60 adolescents with Hr-HM were selected from a cohort of patients with gestational trophoblastic disease (GTD) followed at Santa Casa, Porto Alegre, Brasil. Twenty-nine received a single dose of Act-D at the time of uterine evacuation as prophylactic chemotherapy (P-chem) (study group) and 31 patients with the same risk factors did not received P-chem (control group). Patient follow-up was the same in both groups. Each group was analyzed for number of adolescents with postmolar GTN, morbidity associated with postmolar GTN, and reproductive outcomes.

RESULTS

Postmolar GTN was diagnosed in two (6.9%) adolescents (95% CI, 0.0-16.1) in the study group and in 9 (29.0%) patients (95% CI, 13-45) in the control group. The reduction of postmolar GTN with a single dose of Act-D used as P-chem was 76% (relative risk = 0.24; 95% CI, 0.06-0.99). Adverse effects of P-chem were minor. In the follow-up, when postmolar GTN were diagnosed, severity of disease was not increased, compliance with follow-up was not reduced, and reproductive outcomes after discharge were similar.

CONCLUSIONS

P-chem with a single dose of Act-D reduced postmolar GTN in 76% during follow-up of adolescents with Hr-HM. Since this regimen may reduce treatment costs, without affecting compliance with follow-up, it can be adopted by any Trophoblastic Disease Center.

Radiology of gestational trophoblastic neoplasia

Gestational trophoblastic neoplasia (GTN) encompasses a broad spectrum of placental lesions from the pre-malignant hydatidiform mole (complete and partial) through to the malignant invasive mole, choriocarcinoma and rare placental site trophoblastic tumour (PSTT). Ultrasound remains the radiological investigation of choice for initial diagnosis, and it can also predict invasive and recurrent disease. Magnetic resonance imaging is of invaluable use in assessing extra-uterine tumour spread, tumour vascularity, and overall staging. Positron emission tomography and computed tomography undoubtedly have a role in recurrent and metastatic disease, while angiography has a place in disease and complication management. This review will describe the relevant pathophysiology and natural history of GTN, and the use of imaging techniques in the diagnosis and management of these conditions.

[Place of surgery in the management of gestational trophoblastic tumors]

Gestational trophoblastic tumors are authentic malignant tumors of the conception. They are mostly chemosensitive. For young women, the place of the surgery seems now restricted and more and more codified. Hysterectomy keeps a certain interest for women who do not wish to preserve their fertility. Hysterectomy limits then the complications of chemotherapy. It optimizes the chances of recovery without recurrence. If chemotherapy must nevertheless be carried out, hysterectomy decreases the necessary number of cures to obtain complete remission of the disease. Surgery is also indispensable to chemoresistant tumors. It allows exeresis of localized residual sites or isolated metastases. Other indications for surgery include uncontrollable vaginal or intra-abdominal bleedings and placental site trophoblastic tumors.

Maladies trophoblastiques gestationnelles

BACKGROUND

Trophoblastic diseases correspond to a very heterogeneous group of rare pathology in young women which fertility should be preserved.

PATIENT AND METHODS

We conducted a retrospective study from 1997 to 2003, including all patients with molar pregnancy or trophoblatic tumor in our department of Obstetrics and Gynecology.

RESULTS

Fifteen patients were identified with 9 molar pregnancies, 5 trophoblastic tumors and 1 placental tumor of implantation site. The outcome was favorable for 14, and one patient died from her metastatic disease. For 4 patients we asked our university colleague for the optimal approach.

DISCUSSION

Management of molar pregnancies is well established. Persistent gestational disease is more rare and problematic with potential metastatic dissemination. Multidisciplinary care is often needed.

CONCLUSION

Persistent gestational disease should be managed in a highly specialized centre, as developed in the Lyon University Hospital.

Medical termination of pregnancy in the early first trimester

Surgical abortion using vacuum aspiration or dilatation and curettage has been the method of choice for termination of pregnancy up to 63 days' gestation since the 1960s. Over the last three decades many studies have explored the use of medical methods for inducing abortion at these gestations. Earlier regimens assessed the systemic and intrauterine injection of prostaglandins. This was followed in the 1980s by the introduction of the antiprogesterone, mifepristone. Since its introduction, the uptake of medical abortion has been steadily increasing in countries where it has been available for routine use. Most current clinical protocols require the use of prostaglandins in combination with anti-progesterones or antimetabolites. The safety, efficacy and acceptability of the medical regimen are now well established at all gestations of pregnancy. Provision of medical abortion increases the choice available to women, in particular those wishing to avoid surgery.

Molar gestations and hydropic abortions differentiated by p57 immunostaining

Classification of molar gestations into complete and partial and their differentiation from hydropic abortions traditionally are accomplished by morphology alone. The process sometimes may be inaccurate or inconclusive. With the availability of p57 immunostaining it may be possible to objectively classify these lesions. We used p57 for the differential diagnosis of hydropic abortions and molar gestations and correlated the findings with the clinical outcome of patients in each category. First, 86 cases were originally classified by histomorphology into hydropic abortion (42) and molar gestations (23 complete and 21partial). Based on the pattern of p57 staining the cases were reclassified into 45 hydropic abortions, 15 partial moles and 26 complete moles (3 cases with previous diagnosis of complete mole based on morphology were reclassified as hydropic abortion). Clinical follow-ups ranged from 6-24 months and showed persistent trophoblastic disease in 8 cases (31%) of complete moles and 3 cases (20%) of partial moles (p = 0.47). No hydropic abortion cases demonstrated persistent trophoblastic disease. One patient with partial mole developed choriocarcinoma. This study confirms that p57 objectively distinguishes hydropic abortions from molar gestations (partial and complete moles). This differentiation is clinically relevant since patients with hydropic abortions do not need to be followed while patients with molar gestations do.

MR imaging of retained products of conception

OBJECTIVE

The objective of this article is to describe the MR imaging appearances of retained products of conception.

CONCLUSION

Retained products of conception appear on MR imaging as an intracavitary uterine soft-tissue mass with variable amounts of enhancing tissue and variable degrees of myometrial thinning and obliteration of the junctional zone. These findings should not be misinterpreted as indicating gestational trophoblastic disease, particularly in the setting of a postpartum patient with a normal or minimally elevated beta-human chorionic gonadotropin level. MR imaging may also be helpful in showing anatomic variants that hinder successful instrumentation of the uterine cavity in patients with suspected retained products of conception.

Clinical aspects of gestational trophoblastic disease: A review based partly on 25-year experience of a statewide registry

BACKGROUND

Gestational trophoblastic disease is a fascinating group of pregnancy disorders characterised by abnormal proliferation of trophoblast, ranging from benign to malignant. Because the disease is uncommon, there is a need to formulate management with the assistance of collective information.

METHODOLOGY

A review of available information from English written literature was undertaken, especially data reported by registries around the world (Charing Cross Hospital in England, the North-western University and the New England area in the USA as well as our own experience in Queensland, Australia). Where possible, collated data from relevant studies were analysed to answer some of the questions posed in clinical practice, with reference to metastatic disease to liver and brain, twinning of molar gestation and coexisting fetus, and placental-site tumour.

RESULTS

We found that molar gestation can be classified according to its clinical presentation which influences the time taken to reach human chorionic gonadotropin (HCG) 'negativity' and the risk of persisting disease. Categorisation of risk is the basis for choice of chemotherapy to achieve good outcomes. Metastases to liver and brain remain problems in management; the development of 'new' metastases during chemotherapy is a very poor prognostic factor. In the variant of twinning with molar gestation and coexisting fetus, it is important to elucidate the fetal karyotype in planning management: a 69XXX fetus is not salvageable but a normal 46XX or 46XY fetus faces the prospect of early preterm delivery. The placental-site tumour is very rare; localised disease is curable by surgery; chemotherapy is less effective in disseminated disease. From collated worldwide data, the recurrence rate after one mole is 1.3% and after two or more is 20%. Reproductive outcome in subsequent pregnancies, even after multidrug chemotherapy, is not different from the general population. Because of the increased risk long-term of second tumours after multidrug chemotherapy a closer surveillance of these patients is necessary.

CONCLUSION

In general, the disease in its persisting or malignant form is 'a cancer model par excellence' because of an identifiable precursor condition, a reliable HCG marker, and sensitivity of the disease to cytotoxic drugs. With current management, retention of fertility is possible and normal reproductive outcome assured.

Cytokeratin 20 as a biomarker of gestational trophoblastic disease: diagnostic and prognostic significance

OBJECTIVES

This study was designed to examine whether cytokeratin 20 (CK20) is expressed in molar pregnancies and may therefore be used in the diagnosis of gestational trophoblastic disease (GTD). The potential of CK20 expression in predicting the evolution and the prognosis of the different subtypes of GTD was also assessed.

METHODS

A total of 48 samples were studied for CK20 expression by RT-PCR methodology. Among these, 24 samples were obtained by curettage of the uterine cavity of patients diagnosed with hydatidiform mole (14 complete moles and 10 partial moles), 4 samples were obtained from choriocarcinoma cell lines (2 JAR and 2 JEG), and 20 samples were of normal trophoblast (control group) obtained from patients that underwent elective termination of pregnancy.

RESULTS

Expression of CK20 was identified in all the samples of complete mole (CM), all choriocarcinoma cell lines, and 50% of the patients with partial mole (PM). None of the preparations of normal trophoblastic tissue from the control group expressed the CK20. A significant difference (P < 0.00001) was found in CK20 expression between samples of patients with GTD and control samples. Comparison between CK20 expression in CMs and PMs revealed a significantly more frequent expression of CK20 in CMs (P = 0.006). More than 50% of the patients with PMs that were positive for CK20 had an invasive evolution.

CONCLUSIONS

In our opinion, CK20 may assist in distinguishing between molar and normal trophoblastic tissue and may be considered a marker of GTD. In cases in which pathological classification of different subtypes of GTD is in doubt, CK20-positive expression is suggestive for a CM whereas CK20-negative is more indicative for PM.

Effects of cancer treatment on reproduction and fertility

OBJECTIVE

(1) To review the effects of cancer treatment on reproduction and fertility in both women and men and (2) to review current and new techniques that could be used to preserve fertility and hormone production in women who have undergone cancer treatment.

DATA SOURCES

Entries to MEDLINE and CANCERLIT through to October 2001 were searched for evidence relevant to this article.

METHODS OF STUDY SELECTION

This document is primarily based on large retrospective cohort series and case reports, as no randomized trials were available.

TABULATION, INTEGRATION, AND RESULTS

The first part of this review article focuses on the effects of radiation and chemotherapy on reproductive function and innovative medical and surgical techniques employed to minimize these effects. The second part of this article describes conservative methods of managing cervical, endometrial, and ovarian cancer for women who wish to preserve their fertility.

CONCLUSIONS

Over the last decade, there has been a trend toward trying to preserve reproductive function in young patients with malignancy. Information acquired over the last century on the reproductive effects of radiation and chemo-therapy has enabled us to tailor our treatment of various malignancies affecting young patients. As we learn more about the biology and clinical behaviour of gynaecologic malignancies, we are able to modify surgical management to preserve fertility in select cases. All of these trends are in keeping with our goal to optimize quality of life in cancer care without compromising safety or survival.

Subspecialty training: does it affect the outcome of women treated for a gynecologic malignancy?

A review of available direct and indirect scientific reports strongly suggests that subspecialty training increases the likelihood that the appropriate surgical procedure will be completed in women operated on for gynecologic cancer. It is likely that specialty care lessens the costs associated with diagnosis, treatment and surveillance, and frequently improves survival.