Estational Trophoblastic Disease

The management of hydatidiform mole with lung nodule: a retrospective analysis in 53 patients

Objective

To investigate the significance of lung nodule in hydatidiform mole, we retrospectively compared the clinical outcomes of those patients treated with different strategies.

Methods

The patients were divided into three groups: chemotherapy immediately once lung nodule was detected (group 1, n=17), delayed chemotherapy until human chorionic gonadotrophin (hCG) level met the diagnostic criteria for gestational trophoblastic neoplasia (GTN) (group 2, n=18), and hCG surveillance alone until hCG level was normalized spontaneously (group 3, n=18). The clinical parameters of these patients were collected and analyzed.

Results

Totally 53 (4.0%) patients were included from 1,323 cases with molar pregnancy during past 16 years. Among them, the diameters of lung nodules were 0.3–2.5 cm. Chemotherapy cycles for achieving hCG normalization and the failure rate of first-line chemotherapy in group 1 were significantly increased than that in group 2 (5 vs. 3 cycles, p=0.000, 58.8% vs. 11.1%, p=0.005). The hCG level of all 18 cases in group 3 was normalized spontaneously within 6 months. Of those, lung nodules of 9 patients disappeared spontaneously, accounting for 25% (9/36) of patients who initially selected observation. The proportion of single nodule in group 3 was significantly higher than that in group 2 (10/18 vs. 2/18, p=0.012).

Conclusion

Our results suggest that lung nodule alone is not an adequate indication of chemotherapy in molar pregnancy. hCG surveillance is safe for patients with lung nodule, especially with single nodule, as long as their hCG levels do not meet International Federation of Gynecology and Obstetrics diagnostic criteria for GTN.

Methotrexate for 2000 FIGO low-risk gestational trophoblastic neoplasia patients: efficacy and toxicity

OBJECTIVE

We sought to review efficacy and toxicity of an 8-day methotrexate (MTX) regimen in the treatment of patients with low-risk gestational trophoblastic neoplasia (GTN) from the French Trophoblastic Disease Reference Center.

STUDY DESIGN

Between 1999 and 2006, 142 low-risk GTNs were diagnosed according to International Federation of Gynecology and Obstetrics (FIGO) criteria for GTN and to the FIGO scoring system. We report their characteristics, remission/resistance/recurrence rates, and treatment toxicity.

RESULTS

The 8-day MTX regimen achieved a 77.5% remission rate. All patients but 1 (99.9%) achieved remission and remained disease free until the time of analysis. Severe (grade 3 or 4) blood/bone marrow toxicity and metabolic/laboratory toxicity was noted in 4.2% of cases, of which 2 (1.4%) were grade 4.

CONCLUSION

For patients with GTN diagnosed according to FIGO criteria and considered low risk according to the FIGO scoring system, an 8-day MTX regimen is an adequate treatment associating a high rate of remission to a low rate of toxicity.

Combination chemotherapy for high-risk gestational trophoblastic tumour

BACKGROUND

Gestational trophoblastic disease (GTD) includes gestational trophoblastic tumour and hydatidiform mole. Many women of reproductive age are affected by this disease although its incidence differs by geographical location. A number of chemotherapy regimens are used for treating the disease, such as methotrexate, actinomycin D and cyclophosphamide (MAC), methotrexate, actinomycin D, cyclophosphamide, doxorubicin, melphalan, hydroxyurea and vincristine (CHAMOC), etoposide, methotrexate and actinomycin (EMA) plus cyclophosphamide and vincristine (CO) (EMA-CO), etoposide, methotrexate and actinomycin (EMA) plus etoposide and cisplatin(EP) (EMA-EP). The efficacy of these drugs has not been systematically reviewed.

OBJECTIVES

To determine the efficacy and safety of combination chemotherapy in treating high-risk GTT.

SEARCH STRATEGY

Electronic searches of Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2008), MEDLINE, EMB and CBM, May 2008. Four journals were handsearched and other searching methods were used for identifying more studies.

SELECTION CRITERIA

The review included randomised controlled trials (RCTs) or quasi-RCTs of combination chemotherapy for treating high-risk GTT. Patients with placental-site trophoblastic tumour (PSTT), who had received chemotherapy in the previous two weeks, or patients with chemotherapy intolerance were excluded.

DATA COLLECTION AND ANALYSIS

Two investigators independently collected data using a data extraction form. Meta-analysis was not performed and the review was conducted as a narrative review.

MAIN RESULTS

One study with 42 participants was included in this review. It indicated that a MAC regimen was better than a CHAMOCA regimen for high-risk GTT because of lower toxicity. The quality of the study was unclear.

AUTHORS' CONCLUSIONS

The methodological limitations of the included study prevent any firm conclusions about the best combination chemotherapy regimen for high-risk GTT. High quality studies are required.

Management of a partial molar pregnancy: a case study report

Partial molar pregnancy with coexisting fetus is a rare complication of pregnancy and carries significant risks to both the mother and the fetus. Maternal risks include abnormal bleeding and the development of preeclampsia. The fetus frequently develops abnormally, often due to abnormal karyotype. This case presents a woman with a partial molar pregnancy with coexisting fetus, including diagnosis, plan of care, and delivery information.

Complete hydatidiform mole in a perimenopausal woman with a subsequent severe thyriotoxicosis

INTRODUCTION

Gestational trophoblastic disease is one form of abnormal pregnancy, with a median maternal age of 27-28 years. One complication of trophoblastic disease is the development of a secondary hyperthyroidism, which resolves rapidly after evacuation of the hydatidiform mole.

CASE REPORT

We report a case of a 53-year-old woman presenting with a complete hydatidiform mole and who developed a severe thyrotoxicosis after suction evacuation of the hydatidiform mole.

CONCLUSION

A severe thyriotoxicosis can occur even after surgical evacuation of the mole. Therefore, evaluation of the thyroid function prior to operation, especially with a high quantitative hCG, should be performed to avoid severe complications.

Combination chemotherapy for high-risk gestational trophoblastic tumour

BACKGROUND

Gestational trophoblastic disease (GTD) includes gestational trophoblastic tumour and hydatidiform mole. Many women of reproductive age are affected by this disease although its incidence differs by geographical location. A number of chemotherapy regimens are used for treating the disease, such as methotrexate, actinomycin D and cyclophosphamide (MAC), methotrexate, actinomycin D, cyclophosphamide, doxorubicin, melphalan, hydroxyurea and vincristine (CHAMOC), etoposide, methotrexate and actinomycin (EMA) plus cyclophosphamide and vincristine (CO) (EMA-CO), etoposide, methotrexate and actinomycin (EMA) plus etoposide and cisplatin(EP) (EMA-EP). The efficacy of these drugs has not been systematically reviewed.

OBJECTIVES

To determine the efficacy and safety of combination chemotherapy in treating high-risk GTT.

SEARCH STRATEGY

Electronic searches of MEDLINE, EMB, Cochrane Central Register of Controlled Trials (CENTRAL) and CBM were carried out. Four journals were handsearched and other searching methods were used for identifying more studies.

SELECTION CRITERIA

The review included randomized controlled trials (RCTs) or quasi-RCTs of combination chemotherapy for treating high-risk GTT. Patients with placental-site trophoblastic tumour (PSTT), who had received chemotherapy in the previous two weeks, or patients with chemotherapy intolerance were excluded.

DATA COLLECTION AND ANALYSIS

Two investigators independently collected data using a data extraction form. Meta-analysis was not performed and the review was conducted as a narrative review.

MAIN RESULTS

One study with 42 participants was included in this review. It indicated that a MAC regimen was better than a CHAMOCA regimen for high-risk GTT because of lower toxicity. The quality of the study was unclear.

AUTHORS' CONCLUSIONS

The methodological limitations of the included study prevent any firm conclusions about the best combination chemotherapy regimen for high-risk GTT. High quality studies are required.

Sonographic and Doppler imaging in the diagnosis and treatment of gestational trophoblastic disease: a 12-year experience

OBJECTIVE

To evaluate the clinical utility of sonography with Doppler examination in the diagnosis and treatment of gestational trophoblastic disease (GTD).

METHODS

A retrospective analysis of 355 cases of GTD seen over a 12-year period in 2 large university referral hospitals in China was performed. Clinical appearances, sonographic findings, Doppler waveforms, and patient outcomes were reviewed. Sonographic and Doppler examinations were performed to diagnose the presence of molar tissue, detect invasive disease, assess disease recurrence, and monitor the efficacy of chemotherapy. Doppler waveforms of 13 patients with normal early pregnancies were also examined for comparison.

RESULTS

Of the 355 patients with GTD, 106 had a classic hydatidiform mole (CHM), 33 had a partial hydatidiform mole (PHM), 184 had an invasive hydatidiform mole (IHM), and 32 had choriocarcinoma. Sonography showed abnormal molar tissue confined to the endometrial cavity in all cases of CHM. In cases of IHM and choriocarcinoma, soft tissue invasion and cystic vascular spaces within the myometrium were shown. Cases of PHM had a thickened, hydropic placenta with a concomitant fetus. Doppler waveforms showed resistive indices of 0.55 (SD, 0.06) for CHM, 0.56 (SD, 0.04) for PHM, 0.28 (SD, 0.06) for IHM, 0.25 (SD, 0.05) for choriocarcinoma, and 0.66 (SD, 0.04) for normal pregnancies. The abnormal sonographic and Doppler findings in invasive disease resolved when chemotherapy was successful.

CONCLUSIONS

Sonography and Doppler imaging were helpful in diagnosing GTD, in determining whether invasive disease was present, in detecting recurrence of disease, and in following the effectiveness of chemotherapy.

Unanswered questions in contraceptive management: What do the experts do?

CONTEXT

Several areas exist in the practice of contraception where evidence for practice is deficient, yet clinical decisions need to be made.

OBJECTIVES

The aim of the study was to find the practice habits of lead practitioners in the area of contraception in specific clinical scenarios where the published evidence is inadequate to provide clear guidance to clinicians. Results can provide 'Level V' evidence for practice for the 'nonexpert' practitioner.

DESIGN

Descriptive study.

PARTICIPANTS

The study was conducted as a postal questionnaire mailed to the 205 lead practitioners whose contact details were known through the Society of Consultants in Reproductive Health (hereafter referred to as 'consultants') working in reproductive health in the National Health Service.

RESULTS

A total of 138 consultants returned completed questionnaires (67% response rate). Important results included 100% of respondents being prepared to prescribe progestogen-only emergency contraception more than once in a cycle (contrary to product labelling) and 71% recommending two tablets daily of the progestogen-only pill for women of high body mass.

CONCLUSIONS

Some questions had responses that showed clear majorities, providing a clear guide to practice, while other areas remain doubtful. Comments from respondents indicated great interest in all areas covered and a desire for consensus on many of the issues. Certainly the licensing and the advice from pharmaceutical companies is conservative, and in many scenarios a majority of consultants indicated that in order to serve the best interests of their clients they feel constrained to practise outside the Summary of Product Characteristics.

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.