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Braga A, Mora P, de Melo AC, Nogueira-Rodrigues A, Amim-Junior J, Rezende-Filho J, Seckl MJ. Challenges in the diagnosis and treatment of gestational trophoblastic neoplasia worldwide. World J Clin Oncol 2019; 10:28-37. [PMID: 30815369 PMCID: PMC6390119 DOI: 10.5306/wjco.v10.i2.28] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/12/2018] [Accepted: 01/01/2019] [Indexed: 02/06/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) is a rare tumor that originates from pregnancy that includes invasive mole, choriocarcinoma (CCA), placental site trophoblastic tumor and epithelioid trophoblastic tumor (PSTT/ETT). GTN presents different degrees of proliferation, invasion and dissemination, but, if treated in reference centers, has high cure rates, even in multi-metastatic cases. The diagnosis of GTN following a hydatidiform molar pregnancy is made according to the International Federation of Gynecology and Obstetrics (FIGO) 2000 criteria: four or more plateaued human chorionic gonadotropin (hCG) concentrations over three weeks; rise in hCG for three consecutive weekly measurements over at least a period of 2 weeks or more; and an elevated but falling hCG concentrations six or more months after molar evacuation. However, the latter reason for treatment is no longer used by many centers. In addition, GTN is diagnosed with a pathological diagnosis of CCA or PSTT/ETT. For staging after a molar pregnancy, FIGO recommends pelvic-transvaginal Doppler ultrasound and chest X-ray. In cases of pulmonary metastases with more than 1 cm, the screening should be complemented with chest computed tomography and brain magnetic resonance image. Single agent chemotherapy, usually Methotrexate (MTX) or Actinomycin-D (Act-D), can cure about 70% of patients with FIGO/World Health Organization (WHO) prognosis risk score ≤ 6 (low risk), reserving multiple agent chemotherapy, such as EMA/CO (Etoposide, MTX, Act-D, Cyclophosphamide and Oncovin) for cases with FIGO/WHO prognosis risk score ≥ 7 (high risk) that is often metastatic. Best overall cure rates for low and high risk disease is close to 100% and > 95%, respectively. The management of PSTT/ETT differs and cure rates tend to be a bit lower. The early diagnosis of this disease and the appropriate treatment avoid maternal death, allow the healing and maintenance of the reproductive potential of these women.
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Affiliation(s)
- Antonio Braga
- Postgraduate Program of Medical Sciences, Fluminense Federal University, Niterói 24033-900, Brazil
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Paulo Mora
- Postgraduate Program of Medical Sciences, Fluminense Federal University, Niterói 24033-900, Brazil
- Brazilian National Cancer, Hospital do Câncer 2, Rio de Janeiro 20220-410, Brazil
| | | | - Angélica Nogueira-Rodrigues
- Department of Internal Medicine, Faculty of Medicine, Minas Gerais Federal University, Belo Horizonte 30130-100, Brazil
| | - Joffre Amim-Junior
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Jorge Rezende-Filho
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, United Kingdom
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Braga A, Torres B, Burlá M, Maestá I, Sun SY, Lin L, Madi JM, Uberti E, Viggiano M, Elias KM, Berkowitz RS. Is chemotherapy necessary for patients with molar pregnancy and human chorionic gonadotropin serum levels raised but falling at 6months after uterine evacuation? Gynecol Oncol 2017; 143:558-564. [PMID: 27640962 DOI: 10.1016/j.ygyno.2016.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 09/06/2016] [Accepted: 09/10/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the outcomes of Brazilian patients with molar pregnancy who continue human chorionic gonadotropin (hCG) surveillance with those treated with chemotherapy when hCG was still positive, but falling at 6months after uterine evacuation. METHODS Retrospective chart review of 12,526 patients with hydatidiform mole treated at one of nine Brazilian reference centers from January 1990 to May 2016. RESULTS At 6months from uterine evacuation, 96 (0.8%) patients had hCG levels raised but falling. In 15/96 (15.6%) patients, chemotherapy was initiated immediately per FIGO 2000 criteria, while 81/96 (84.4%) patients were managed expectantly. Among the latter, 65/81 (80.2%) achieved spontaneous remission and 16 (19.8%) developed postmolar gestational trophoblastic neoplasia (GTN). Patients who received chemotherapy following expectant management required more time for remission (11 versus 8months; p=0.001), had a greater interval between uterine evacuation and initiating chemotherapy (8 versus 6months; p<0.001), and presented with a median WHO/FIGO risk score higher than women treated according to FIGO 2000 criteria (4 versus 2, p=0.04), but there were no significant differences in the need for multiagent treatment regimens (1/15 versus 3/16 patients, p=0.60). None of the women relapsed, and no deaths occurred in either group. CONCLUSION In order to avoid unnecessary exposure of women to chemotherapy, we no longer follow the FIGO 2000 recommendation to treat all patients with molar pregnancy and hCG raised but falling at 6months after evacuation. Instead, we pursue close hormonal and radiological surveillance as the best strategy for these patients.
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Affiliation(s)
- Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Maternity Ward of Santa Casa da Misericórdia do Rio de Janeiro), Rio de Janeiro, Rio de Janeiro, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Brazil.
| | - Berenice Torres
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Maternity Ward of Santa Casa da Misericórdia do Rio de Janeiro), Rio de Janeiro, Rio de Janeiro, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Brazil
| | - Marcelo Burlá
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Maternity Ward of Santa Casa da Misericórdia do Rio de Janeiro), Rio de Janeiro, Rio de Janeiro, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Izildinha Maestá
- Trophoblastic Diseases Center of the Clinical Hospital of Botucatu Medical School, Department of Gynecology and Obstetrics, São Paulo State University, Botucatu, São Paulo, Brazil
| | - Sue Yazaki Sun
- São Paulo Hospital Trophoblastic Disease Center, Paulista School of Medicine, São Paulo Federal University, São Paulo, São Paulo, Brazil
| | - Lawrence Lin
- São Paulo Clinics Hospital Trophoblastic Disease Center, University of São Paulo, São Paulo, São Paulo, Brazil
| | - José Mauro Madi
- Caxias do Sul Trophoblastic Disease Center, General Hospital of Caxias do Sul, School of Medicine, Center for Biological and Health Sciences, Caxias do Sul University, Caxias do Sul, Rio Grande do Sul, Brazil
| | - Elza Uberti
- Porto Alegre Trophoblastic Disease Center, Mario Totta Maternity Ward, Irmandade da Santa Casa de Misericórdia Hospital, Porto Alegre, Rio Grande do Sul, Brazil
| | - Maurício Viggiano
- Goiás Trophoblastic Disease Center, Clinical Hospital of Goiás, Goiás Federal University, Goiânia, Goiás, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Taylor F, Short D, Harvey R, Winter MC, Tidy J, Hancock BW, Savage PM, Sarwar N, Seckl MJ, Coleman RE. Late spontaneous resolution of persistent molar pregnancy. BJOG 2016; 123:1175-81. [DOI: 10.1111/1471-0528.13867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2015] [Indexed: 11/30/2022]
Affiliation(s)
- F Taylor
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - D Short
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - R Harvey
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - MC Winter
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - J Tidy
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - BW Hancock
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - PM Savage
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - N Sarwar
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - MJ Seckl
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - RE Coleman
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
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Agarwal R, Teoh S, Short D, Harvey R, Savage PM, Seckl MJ. Chemotherapy and human chorionic gonadotropin concentrations 6 months after uterine evacuation of molar pregnancy: a retrospective cohort study. Lancet 2012; 379:130-5. [PMID: 22130490 PMCID: PMC3262143 DOI: 10.1016/s0140-6736(11)61265-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Indications for chemotherapy in gestational trophoblastic disease include raised human chorionic gonadotropin (hCG) concentrations 6 months after uterine evacuation of hydatidiform mole, even when values are falling. We aimed to establish whether chemotherapy is always necessary in these patients. METHODS We retrospectively identified women registered between January, 1993, and May, 2008, at Charing Cross Hospital, London, UK, who had persistently high hCG concentrations 6 months after evacuation of hydatidiform mole. Rates of hCG normalisation, relapse, and death were assessed in patients continued under surveillance and those who received chemotherapy after 6 months. We postulated that a surveillance policy would be clinically acceptable if hCG values returned to normal in 75% of patients or more. FINDINGS 76 (<1%) of 13,960 patients with hydatidiform moles had persistently high hCG concentrations of more than 5 IU/L 6 months after evacuation. 66 (87%) patients continued under surveillance and hCG values spontaneously returned to normal without chemotherapy in 65 (98%) of these patients. Values in one patient did not become normal because of chronic renal failure, but she remains healthy. Ten patients received chemotherapy, and hCG concentrations returned to normal in eight (80%) of these individuals (surveillance vs chemotherapy groups p=0·044) and remained slightly high (6-11 IU/L) in two without any associated clinical problems off treatment. We noted no significant differences between individuals in the surveillance and chemotherapy groups, apart from lower median hCG concentrations 6 months after evacuation in those under surveillance than in those given chemotherapy (13 IU/L, range 5-887, vs 157 IU/L, range 6-6438; p=0·004). Overall, there were no deaths in this series. INTERPRETATION A surveillance policy seems to be clinically acceptable in patients with low and declining concentrations of hCG 6 months after evacuation of hydatidiform mole. FUNDING National Commissioning Group, Imperial Experimental Cancer Medicine Centre, Imperial Biomedical Research Centre, and Cancer Research UK.
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Affiliation(s)
| | - Suliana Teoh
- Charing Cross Gestational Trophoblastic Disease Centre, Imperial College NHS Healthcare Trust, London, UK
| | - Delia Short
- Charing Cross Gestational Trophoblastic Disease Centre, Imperial College NHS Healthcare Trust, London, UK
| | - Richard Harvey
- Charing Cross Gestational Trophoblastic Disease Centre, Imperial College NHS Healthcare Trust, London, UK
| | - Philip M Savage
- Charing Cross Gestational Trophoblastic Disease Centre, Imperial College NHS Healthcare Trust, London, UK
| | - Michael J Seckl
- Imperial College London, London, UK
- Charing Cross Gestational Trophoblastic Disease Centre, Imperial College NHS Healthcare Trust, London, UK
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Boufettal H, Coullin P, Mahdaoui S, Noun M, Hermas S, Samouh N. Les môles hydatiformes complètes au Maroc : étude épidémiologique et clinique. ACTA ACUST UNITED AC 2011; 40:419-29. [DOI: 10.1016/j.jgyn.2011.02.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2010] [Revised: 02/22/2011] [Accepted: 02/25/2011] [Indexed: 12/31/2022]
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Smith HO, Kohorn E, Cole LA. Choriocarcinoma and gestational trophoblastic disease. Obstet Gynecol Clin North Am 2006; 32:661-84. [PMID: 16310678 DOI: 10.1016/j.ogc.2005.08.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Gestational trophoblastic disease (GTD) encompasses a unique group of uncommon but interrelated conditions derived from placental trophoblasts. For the purposes of discussion GTD is the appropriate collective name for hydatidiform mole, whereas the term gestational trophoblastic neoplasia (GTN) is reserved for cases with persistent human chorionic gonadotropin (hCG) titer elevation after evacuation of hydatidiform mole, metastatic disease, or choriocarcinoma. Although the pathology and clinical behavior of CM and PM are different, the initial management of both conditions is surgical evacuation by suction curettage, determination of the baseline, and follow-up with (hCG) titers. There are guidelines for risk-factor scoring and a staging system that classifies untreated patients into distinct prognostic categories so that treatment outcomes can be objectively compared. The rates of GTN and choriocarcinoma are decreasing and survival has dramatically improved.
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Affiliation(s)
- Harriet O Smith
- University of New Mexico Health Sciences Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, 2211 Lomas Boulevard NE, Albuquerque, NM 87131-5286, USA.
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Chang TC, Yen TC, Li YT, Wu YC, Chang YC, Ng KK, Jung SM, Wu TI, Lai CH. The role of 18F-fluorodeoxyglucose positron emission tomography in gestational trophoblastic tumours: a pilot study. Eur J Nucl Med Mol Imaging 2005; 33:156-63. [PMID: 16220307 DOI: 10.1007/s00259-005-1873-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Accepted: 05/22/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE We conducted a pilot trial to evaluate the value of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) in gestational trophoblastic tumours (GTTs). METHODS Patients with placental site trophoblastic tumour (PSTT), high-risk GTT (World Health Organisation score > or =8, disease onset at postpartum or greater than 6 months after antecedent pregnancy), metastatic GTT, recurrent/resistant GTT after chemotherapy, or post-molar GTT with unexplained abnormal beta-hCG regression and patients undergoing re-evaluation after salvage treatment were enrolled. PET was undertaken within 1 week after computed tomography (CT). Clinical impacts of additional PET were determined on a scan basis. RESULTS A total of 14 patients were recruited. Sixteen PET scans were performed, with one patient having three serial studies. Benefits of additional PET were seen in 7 of 16 (43.8%) scans; these benefits included disclosure of chemotherapy-resistant lesions (n = 2), exclusion of false-positive CT lesions (n = 1), detection of an additional lesion not found by conventional imaging (n = 1) in high-risk GTT at the start of primary chemotherapy, and confirmation of complete response to treatment for PSTT or to salvage therapy for recurrent/resistant GTT (n = 3). On the other hand, in two instances there were false-negative PET findings, six scans yielded no benefit, and one showed an indeterminate lesion. CONCLUSION Our preliminary results suggest that 18F-FDG PET is potentially useful in selected patients with GTT by providing precise mapping of metastases and tumour extent upfront, by monitoring treatment response and by localising viable tumours after chemotherapy. A larger study is necessary to further define the role of 18F-FDG PET in GTT.
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Affiliation(s)
- Ting Chang Chang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
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Khan F, Everard J, Ahmed S, Coleman RE, Aitken M, Hancock BW. Low-risk persistent gestational trophoblastic disease treated with low-dose methotrexate: efficacy, acute and long-term effects. Br J Cancer 2004; 89:2197-201. [PMID: 14676794 PMCID: PMC2395266 DOI: 10.1038/sj.bjc.6601422] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The aim of this study was to evaluate the efficacy and toxicity of low-dose methotrexate with folinic acid rescue in a large series of consecutively treated patients with low-risk persistent gestational trophoblastic disease. Between January 1987 and December 2000, 250 patients were treated with intramuscular methotrexate (50 mg on alternate days 1, 3, 5, 7) with folinic acid (7.5 mg orally on alternate days 2, 4, 6, 8) rescue. The overall complete response rate without recurrence was 72% for first-line treatment and 95% for those who required second-line chemotherapy. Eight women (3.2%) had recurrence following remission and two (0.8%) had new moles. Two women (0.8%) died of their disease giving an overall cure of 99%. Only 10 women (4%) experienced grade III/IV toxicity during the first course of treatment and 13 women (5.2%) subsequently. Toxicity included mucositis and stomatitis, pleuritic chest pain, thrombocytopenia, uterine bleeding, abdominal pain, liver function changes, rash and pericardial effusion. A total of 59 women (23.6%) required second-line chemotherapy; 48 women had methotrexate resistance, eight had methotrexate toxicity and an empirical decision to change therapy was made in three. In all, 11 women (4.4%) had a hysterectomy before, during or after treatment; 141 women (56.4%) became pregnant following treatment: in 128 (90.7%), the outcome was successful. Methotrexate with folinic acid rescue is an effective treatment for low-risk persistent trophoblastic disease. It has minimal severe toxicity, excellent cure rates and does not appear to affect fertility.
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Affiliation(s)
- F Khan
- Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, The University of Sheffield, Weston Park Hospital, Whitham Road, Sheffield S10 2SJ, UK
| | - J Everard
- Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, The University of Sheffield, Weston Park Hospital, Whitham Road, Sheffield S10 2SJ, UK
| | - S Ahmed
- Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, The University of Sheffield, Weston Park Hospital, Whitham Road, Sheffield S10 2SJ, UK
| | - R E Coleman
- Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, The University of Sheffield, Weston Park Hospital, Whitham Road, Sheffield S10 2SJ, UK
| | - M Aitken
- Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, The University of Sheffield, Weston Park Hospital, Whitham Road, Sheffield S10 2SJ, UK
| | - B W Hancock
- Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, The University of Sheffield, Weston Park Hospital, Whitham Road, Sheffield S10 2SJ, UK
- Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, The University of Sheffield, Weston Park Hospital, Whitham Road, Sheffield S10 2SJ, UK. E-mail:
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Khabouze S, Erchidi IE, Bouchikhi C, Chahtane A, Kharbach A, Chaoui A. [Gestational trophoblastic diseases. Apropos of 105 cases]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2002; 30:42-9. [PMID: 11875864 DOI: 10.1016/s1297-9589(01)00256-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The authors report a retrospective study of 105 observations of gestational trophoblastic diseases managed at the university clinic of obstetric gynecology I (Pr Chaoui). Of this study, one listed 72 cases of complete mole hydatiforme with 5 cases of sacrofetal pregnancy. The invasive mole is found in 4 cases and the choriocarcinoma in 24 cases. The general frequency of this pathology is of 1/770 pregnancies. The age of our patients varies from 15 to 52 years with an average age 27 years and the multiparity is found in 50% of the cases. 103 patients (95.5%) consulted for metrorrhagia associated pelvic pains in 31 cases (30%). The toxic syndrome was present in 20 patients (12%) with a preeclampsy in 6 cases (5.71%). The physical examination showed a very increased uterus of size in 92 cases (87.5%) associated adnexal mass in 37 cases (35.2%). The diagnosis was especially echographic in the totality of the cases associated or not with a proportioning of plasmatic beta HCG or prolans urinary. The treatment of the trophoblastic disease varies simple endo-uterine aspiration (85%) until the chemotherapy treatment (32.4%), the hysterectomy was indicated in a third of the cases. The evolution of the non complicated mole hydatiforme was good in 100% of the cases, it quasi totality of the invasive moles presented a complete remission. Among the 24 choriocarcinoma, we deplore 4 deaths in a table of pulmonary, hepatic and cerebral metastases. In order to improve the forecast of these diseases, the diagnosis must be early with an adequate treatment and a rigorous monitoring.
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Affiliation(s)
- S Khabouze
- Clinique Universitaire de Gynécologie-Obstétrique I, Service Pr Chaoui, Maternité Souissi-Rabat, Maroc
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Hilario de la Rosa J, Rui Wamba M, Usandizaga J. Mola invasora y abdomen agudo: a propósito de un caso. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2002. [DOI: 10.1016/s0210-573x(02)77160-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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