Effects of prophylactic chemotherapy for persistent trophoblastic disease in patients with complete hydatidiform mole

The role of single-dose prophylactic methotrexate in the prevention of post-molar gestational trophoblastic neoplasia in patients with high-risk molar pregnancy

INTRODUCTION

Prophylactic chemotherapy (PC) has been suggested to be effective in prevention of post molar gestational trophoblastic neoplasia (PGTN) in patients with high-risk molar pregnancies. The goal of this study is to assess the efficacy of single dose methotrexate as PC in terms of spontaneous remission, time to remission, and progression to PGTN.

MATERIALS AND METHODS

Patients with molar pregnancy were recruited to the study and underwent cervical dilation and suction curettage. Patients who had pathologically proven complete hydatidiform mole were evaluated with abdominal ultrasonography to confirm complete evacuation and absence of remnants. These patients were allocated to two groups: group one received Methotrexate 50 mg/m2 via intramuscular injection, while group two did not. PGTN was defined according to the 2018 FIGO criteria. For patients with confirmed PGTN, the following variables were recorded: occurrence of metastasis, resistance to first-line chemotherapy and time to βHCG level normalization.

RESULTS

Eighty patients were enrolled to the study, of which 22 cases (27.5%) received PC. It was found that PC with MTX did not significantly influence spontaneous remission (18 (81.8%) Vs 37 (63.7%), p value: 0.12) or time to remission (57 ± 22.5 Vs 61.24 ± 21.78 days, p value: 0.46) in high-risk molar pregnancies. Moreover, among patients in PC group and control group, 4 cases (18.2%) and 21 patients (36.3%) progressed to PGNT, respectively (p value: 0.12). Although patients in PC group tended to be diagnosed in lower stages compared to patients in control group, this difference was insignificance (p value: 0.95). Among patients who developed to PGTN, PC did not reduce the frequency of metastatic disease, resistance to first-line chemotherapy, or the time interval to serum βHCG level normalization (all p values > 0.05).

CONCLUSION

This study suggests that a single-dose MTX as PC may not be an effective therapeutic option for preventing PGTN in patients with high-risk molar pregnancy.

The effect of prophylactic chemotherapy on treatment outcome of postmolar gestational trophoblastic neoplasia

OBJECTIVE

To evaluate whether prophylactic chemotherapy (P-chem) increased the drug resistance rate of postmolar GTN and whether the first-line chemotherapy should be different from P-chem.

METHODS

Postmolar GTN received P-Chem was defined as P-Chem group. Postmolar GTN without P-chem was randomly selected as control group according to the ratio of 1:3 (P-chem:control) and matched by age for low risk and high risk GTN separately.

RESULTS

Totally 455 low-risk and 32 high-risk postmolar GTN patients were included. WHO risk score, chemotherapy cycles to achieve hCG normalization and resistant rate were similar between P-chem (27 cases) and control (81 cases) group. Among low-risk GTN patients, interval from hydatidiform mole to GTN was significantly longer in P-chem group than control (44 vs 69 days, P = 0.001). Total chemotherapy cycles and resistant rate were similar between low-risk GTN treated with same agent as P-chem (group A) and alternative agent (group B). But group A needed more chemotherapy cycles to achieve hCG normalization than group B.

CONCLUSIONS

P-chem delayed the time to GTN diagnosis, but didn't increase risk score or lead to drug resistance of postmolar GTN. Alternative agent different from P-chem had the potential of enhancing chemotherapy response in low- risk postmolar GTN.

Molar pregnancy in the last 50 years: A bibliometric analysis of global research output

Molar pregnancy is a gestational trophoblastic disease characterized by an abnormal growth of placental tissues because of a nonviable pregnancy. The understanding of the pathophysiology and management of molar pregnancy has significantly increased in the recent years. This study aims to determine the characteristics and trends of published articles in the field of molar pregnancy through a bibliometric analysis. Using the Scopus database, we identified all original research articles on molar pregnancy from 1970 to 2020. Bibliographic and citation information were obtained, and visualization of collaboration networks of countries and keywords related to molar pregnancy was conducted using VOSviewer software. We obtained a total of 2009 relevant papers published between 1970 and 2020 from 80 different countries. The number of publications continued to increase through the years. However, the number of publications in molar pregnancy is still low compared to the other research fields in obstetrics and gynecology. The USA (n = 421, 32.1%), Japan (n = 199, 15.2%), and the UK (n = 191, 14.6%) contributed the greatest number of publications in this field. The top journals which contributed to the field of molar pregnancy include AJOG (n = 91), Obstetrics and Gynecology (n = 81), and the Gynecologic Oncology (n = 57). The most cited articles in molar pregnancy include papers on the genetics and chromosomal abnormalities in molar pregnancies. The focus of current research in this field was on elucidating the molecular mechanism of hydatidiform moles. Our bibliometric analysis showed the global research landscape, trends and development, scientific impact, and collaboration among researchers in the field of molar pregnancy.

Guideline No. 408: Management of Gestational Trophoblastic Diseases

OBJECTIVE

This guideline reviews the clinical evaluation and management of gestational trophoblastic diseases, including surgical and medical management of benign, premalignant, and malignant entities. The objective of this guideline is to assist health care providers in promptly diagnosing gestational trophoblastic diseases, to standardize treatment and follow-up, and to ensure early specialized care of patients with malignant or metastatic disease.

INTENDED USERS

General gynaecologists, obstetricians, family physicians, midwives, emergency department physicians, anaesthesiologists, radiologists, pathologists, registered nurses, nurse practitioners, residents, gynaecologic oncologists, medical oncologists, radiation oncologists, surgeons, general practitioners in oncology, oncology nurses, pharmacists, physician assistants, and other health care providers who treat patients with gestational trophoblastic diseases. This guideline is also intended to provide information for interested parties who provide follow-up care for these patients following treatment.

TARGET POPULATION

Women of reproductive age with gestational trophoblastic diseases.

OPTIONS

Women diagnosed with a gestational trophoblastic disease should be referred to a gynaecologist for initial evaluation and consideration for primary surgery (uterine evacuation or hysterectomy) and follow-up. Women diagnosed with gestational trophoblastic neoplasia should be referred to a gynaecologic oncologist for staging, risk scoring, and consideration for primary surgery or systemic therapy (single- or multi-agent chemotherapy) with the potential need for additional therapies. All cases of gestational trophoblastic neoplasia should be discussed at a multidisciplinary cancer case conference and registered in a centralized (regional and/or national) database.

EVIDENCE

Relevant studies from 2002 onwards were searched in Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and Cochrane Systematic Reviews using the following terms, either alone or in combination: trophoblastic neoplasms, choriocarcinoma, trophoblastic tumor, placental site, gestational trophoblastic disease, hydatidiform mole, drug therapy, surgical therapy, radiotherapy, cure, complications, recurrence, survival, prognosis, pregnancy outcome, disease outcome, treatment outcome, and remission. The initial search was performed in April 2017 and updated in May 2019. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional significant articles were identified through cross-referencing the identified reviews. The total number of studies identified was 673, with 79 studies cited in this review.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of Directors of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of Directors for the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework. See the online appendix tables for key to grading and interpretation of recommendations.

BENEFITS

These guidelines will assist physicians in promptly diagnosing gestational trophoblastic diseases and urgently referring patients diagnosed with gestational trophoblastic neoplasia to gynaecologic oncology for specialized management. Treating gestational trophoblastic neoplasia in specialized centres with the use of centralized databases allows for capturing and comparing data on treatment outcomes of patients with these rare tumours and for optimizing patient care.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Directive clinique no 408 : Prise en charge des maladies gestationnelles trophoblastiques

OBJECTIF

Cette directive passe en revue l'évaluation clinique et la prise en charge des maladies gestationnelles trophoblastiques, notamment les traitements chirurgicaux et médicamenteux des tumeurs bénignes, prémalignes et malignes. L'objectif de la présente directive clinique est d'aider les fournisseurs de soins de santé à rapidement diagnostiquer les maladies gestationnelles trophoblastiques, à normaliser les traitements et le suivi et à assurer des soins spécialisés précoces aux patientes dont l'atteinte est maligne ou métastatique. PROFESSIONNELS CONCERNéS: Gynécologues généralistes, obstétriciens, médecins de famille, sages-femmes, urgentologues, anesthésistes, radiologistes, anatomopathologistes, infirmières autorisées, infirmières praticiennes, résidents, gynécologues-oncologues, oncologues médicaux, radio-oncologues, chirurgiens, omnipraticiens en oncologie, infirmières en oncologie, pharmaciens, auxiliaires médicaux et autres professionnels de la santé qui traitent des patientes atteintes d'une maladie gestationnelle trophoblastique. La présente directive vise également à fournir des renseignements aux parties intéressées qui prodiguent des soins de suivi à ces patientes après le traitement.

POPULATION CIBLE

Femmes en âge de procréer atteintes d'une maladie gestationnelle trophoblastique.

OPTIONS

Les femmes ayant reçu un diagnostic de maladie gestationnelle trophoblastique doivent être orientées vers un gynécologue afin qu'il réalise une évaluation initiale, envisage une intervention chirurgicale primaire (évacuation ou hystérectomie) et effectue un suivi. Il y a lieu d'orienter les femmes ayant reçu un diagnostic de tumeur trophoblastique gestationnelle vers un gynécologue-oncologue afin qu'il effectue la stadification tumorale, établisse le score de risque et envisage l'intervention chirurgicale primaire ou un traitement systémique (mono- ou polychimiothérapie) et la nécessité d'éventuels traitements supplémentaires. Il est recommandé de discuter de chaque cas de néoplasie gestationnelle trophoblastique lors d'une réunion multidisciplinaire de cas oncologiques et de l'inscrire dans une base de données centralisée (régionale et/ou nationale). DONNéES PROBANTES: Des recherches ont été effectuées au moyen des bases de données Embase et MEDLINE, du Cochrane Central Register of Controlled Trials et de la Cochrane Database of Systematic Reviews afin de trouver les études publiées depuis 2002 utilisant un ou plusieurs des mots clés suivants : trophoblastic neoplasms, choriocarcinoma, trophoblastic tumor, placental site, gestational trophoblastic disease, hydatidiform mole, drug therapy, surgical therapy, radiotherapy, cure, complications, recurrence, survival, prognosis, pregnancy outcome, disease outcome, treatment outcome et remission. La recherche initiale a été effectuée en avril 2017; une mise à jour a été faite en mai 2019. Les données probantes pertinentes ont été sélectionnées aux fins d'inclusion selon l'ordre suivant : méta-analyses, revues systématiques, directives cliniques, essais cliniques randomisés, études de cohortes prospectives, études observationnelles, revues non systématiques, études de séries de cas et rapports. D'autres articles pertinents ont été trouvés en recoupant les revues répertoriées. Le nombre total d'études relevées était de 673, dont 79 études sont citées dans la présente revue. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs. La direction et le conseil d'administration de la Société de gynéco-oncologie du Canada ont passé en revue le contenu de la version préliminaire et ont soumis des commentaires à prendre en considération. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication. La qualité des données probantes a été évaluée au moyen des critères de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). Consulter les tableaux dans l'annexe en ligne pour connaître les critères de notation et d'interprétation des recommandations. BéNéFICES, RISQUES, COûTS: Les présentes recommandations aideront les médecins à diagnostiquer rapidement les maladies gestationnelles trophoblastiques et à orienter de façon urgente les patientes ayant reçu un diagnostic de maladie gestationnelle trophoblastique en gynécologie oncologique pour une prise en charge spécialisée. Le traitement des néoplasies gestationnelles trophoblastiques en centre spécialisé combiné à l'utilisation de bases de données centralisées permet de recueillir et de comparer des données sur les résultats thérapeutiques des patientes atteintes de ces tumeurs rares et d'optimiser les soins aux patientes. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).

The management of hydatidiform mole using prophylactic chemotherapy and hysterectomy for high-risk patients decreased the incidence of gestational trophoblastic neoplasia in Vietnam: a retrospective observational study

The management of hydatidiform mole (HM) and the incidence of post-molar gestational trophoblastic neoplasia (GTN) in Vietnam has not been reported to date. This study aimed to study the incidence of HM and post-molar GTN and identify factors associated with post-molar GTN at a tertiary hospital in Vietnam. Five hundred and eighty-four patients who were treated for HM at Tu Du Hospital between January and December 2010 were included in this study. The mean age and gestational age at the first evacuation were 28.8 years old and 11.0 weeks, respectively. After the initial evacuation and pathological examination, 87 patients who were older than 40 or did not wish to have children underwent a hysterectomy, while the others underwent second curettage. All 472 patients who had human chorionic gonadotropin (hCG) ≥ 100,000 IU/L before treatment received one cycle of methotrexate with folinic acid as prophylactic chemotherapy. The incidence of HM was 11.1 per 1,000 deliveries; 47 patients (8.0%) developed post-molar GTN. Gestational week, hCG level at one week after the first evacuation, and pathological remnants were significantly associated with the development of post-molar GTN. The results of this study suggest that prophylactic chemotherapy and hysterectomy may be useful for high-risk HM patients to reduce post-molar GTN in settings in which the risk of post-molar GTN and loss to follow-up after HM are greater and hCG measurements and appropriate GTN treatments are unavailable. However, future studies on the long-term outcomes and side effects of prophylactic therapies on HM are required.

Comparison of different therapeutic strategies for complete hydatidiform mole in women at least 40 years old: a retrospective cohort study

BACKGROUND

There are three main therapeutic strategies, namely expectant management (dilation and curettage only), prophylactic chemotherapy and prophylactic total hysterectomy for treating older women with complete hydatidiform mole (CHM). However, the scientific community has so far, not unanimously accepted the above-mentioned methods. The objective of this study was to evaluate the effectiveness of these therapeutic strategies in preventing post-molar gestational trophoblastic neoplasia (GTN) pertaining to patients with CHM who were at least 40 years old.

METHODS

Hundred and seventy-one patients from our hospital who had histologically been diagnosed of CHM and underwent treatment from January 2004 to December 2013 were included. All patients were followed continuously for a minimum of 2 years after which relevant clinical data were extracted and analysed.

RESULTS

All patients were divided to three groups. Group 1 consisted of 124 patients, treated by expectant management, and the incidence of post-molar GTN was 37.1%. Group 2 included 12 patients who received prophylactic chemotherapy, with an incidence of 41.7%. The remaining 35 patients, Group 3, underwent prophylactic total hysterectomy, with the lowest incidence of 11.4%. A significantly lower incidence was noted in group 3 as compared to group 1 (P = 0.004). GTN patients who received prophylactic chemotherapy required, on average, longer time to be diagnosed of GTN and had higher probability of chemotherapy resistance (P = 0.031 and P = 0.024).

CONCLUSIONS

This retrospective analysis showed that prophylactic total hysterectomy was the most effective therapeutic strategy for treating CHM in women at least 40 years old of age.

Prophylactic chemotherapy for hydatidiform mole to prevent gestational trophoblastic neoplasia

BACKGROUND

This is an update of the original Cochrane Review published in Cochrane Library, Issue 10, 2012.Hydatidiform mole (HM), also called a molar pregnancy, is characterised by an overgrowth of foetal chorionic tissue within the uterus. HMs may be partial (PM) or complete (CM) depending on their gross appearance, histopathology and karyotype. PMs usually have a triploid karyotype, derived from maternal and paternal origins, whereas CMs are diploid and have paternal origins only. Most women with HM can be cured by evacuation of retained products of conception (ERPC) and their fertility preserved. However, in some women the growth persists and develops into gestational trophoblastic neoplasia (GTN), a malignant form of the disease that requires treatment with chemotherapy. CMs have a higher rate of malignant transformation than PMs. It may be possible to reduce the risk of GTN in women with HM by administering prophylactic chemotherapy (P-Chem). However, P-Chem given before or after evacuation of HM to prevent malignant sequelae remains controversial, as the risks and benefits of this practice are unclear.

OBJECTIVES

To evaluate the effectiveness and safety of P-Chem to prevent GTN in women with a molar pregnancy. To investigate whether any subgroup of women with HM may benefit more from P-Chem than others.

SEARCH METHODS

For the original review we performed electronic searches in the Cochrane Gynaecological Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2012), MEDLINE (1946 to February week 4, 2012) and Embase (1980 to 2012, week 9). We developed the search strategy using free text and MeSH. For this update we searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 5, 2017), MEDLINE (February 2012 to June week 1, 2017) and Embase (February 2012 to 2017, week 23). We also handsearched reference lists of relevant literature to identify additional studies and searched trial registries.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of P-Chem for HM.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion in the review and extracted data using a specifically designed data collection form. Meta-analyses were performed by pooling data from individual trials using Review Manager 5 (RevMan 5) software in line with standard methodological procedures expected by Cochrane methodology.

MAIN RESULTS

The searches identified 161 records; after de-duplication and title and abstract screening 90 full-text articles were retrieved. From these we included three RCTs with a combined total of 613 participants. One study compared prophylactic dactinomycin to no prophylaxis (60 participants); the other two studies compared prophylactic methotrexate to no prophylaxis (420 and 133 participants). All participants were diagnosed with CMs. We considered the latter two studies to be of poor methodological quality.P-Chem reduced the risk of GTN occurring in women following a CM (3 studies, 550 participants; risk ratio (RR) 0.37, 95% confidence interval (CI) 0.24 to 0.57; I² = 0%; P < 0.00001; low-quality evidence). However, owing to the poor quality (high risk of bias) of two of the included studies, we performed sensitivity analyses excluding these two studies. This left only one small study of high-risk women to contribute data for this primary outcome (59 participants; RR 0.28, 95% CI 0.10 to 0.73; P = 0.01); therefore we consider this evidence to be of low quality.The time to diagnosis was longer in the P-Chem group than the control group (2 studies, 33 participants; mean difference (MD) 28.72, 95% CI 13.19 to 44.24; P = 0.0003; low-quality evidence); and the P-Chem group required more courses to cure subsequent GTN (1 poor-quality study, 14 participants; MD 1.10, 95% CI 0.52 to 1.68; P = 0.0002; very low quality evidence).There were insufficient data to perform meta-analyses for toxicity, overall survival, drug resistance and reproductive outcomes.

AUTHORS' CONCLUSIONS

P-Chem may reduce the risk of progression to GTN in women with CMs who are at a high risk of malignant transformation; however, current evidence in favour of P-Chem is limited by the poor methodological quality and small size of the included studies. As P-Chem may increase drug resistance, delays treatment of GTN and may expose women toxic side effects, this practice cannot currently be recommended.

A Novel Prediction Model for Postmolar Gestational Trophoblastic Neoplasia and Comparison With Existing Models

OBJECTIVE

The aim of this study was to comparatively study a novel model and existing models of predicting postmolar gestational trophoblastic neoplasia (GTN).

METHODS

Two hundred twenty-two patients with complete hydatidiform moles were enrolled retrospectively. A natural regression was noted in 195 patients (spontaneous regression group), whereas the remaining 27 patients entered postmolar GTN (postmolar GTN group). The upper limits of the 95% confidence interval of human chorionic gonadotropin (hCG) values and hCG regression rates were calculated aggregately from the spontaneous regression group. The 4 prediction models (weekly hCG regression curve and weekly hCG regression rate curve reported by previous studies; daily hCG regression curve and daily hCG regression rate curve pioneered by us) were then plotted. The individual hCG curve of the postmolar GTN group was plotted and compared with the prediction models, respectively. The individual hCG curve superimposing the prediction curve was considered showing an elevated risk of GTN.

RESULTS

All patients with postmolar GTN were preidentified by daily hCG regression rate curve. The other 3 prediction models had a considerable rate of failure in identification. Mean diagnosis time of daily hCG regression rate curve was significantly lower (P = 0.008), with an average of 15.3 days gained compared with International Federation of Gynecology and Obstetrics criteria. Cochran Q test showed that daily hCG regression rate curve produced a significantly better performance in predicting postmolar GTN than weekly hCG regression curve (P = 0.01).

CONCLUSIONS

Our data showed that daily hCG regression rate curve gives a better prediction of postmolar GTN and might potentially enhance the monitoring of patients with molar pregnancy, especially those who could not adhere to International Federation of Gynecology and Obstetrics protocols. However, this preliminary research should not change current clinical practice until further validation is carried out.

LINE-1 Methylation Patterns as a Predictor of Postmolar Gestational Trophoblastic Neoplasia

Objective. To study the potential of long interspersed element-1 (LINE-1) methylation change in the prediction of postmolar gestational trophoblastic neoplasia (GTN). Methods. The LINE-1 methylation pattern from first trimester placenta, hydatidiform mole, and malignant trophoblast specimens were compared. Then, hydatidiform mole patients from 11999 to 2010 were classified into the following 2 groups: a remission group and a group that developed postmolar GTN. Specimens were prepared for a methylation study. The methylation levels and percentages of LINE-1 loci were evaluated for their sensitivity, specificity, and accuracy for the prediction of postmolar GTN. Results. First, 12 placentas, 38 moles, and 19 malignant trophoblast specimens were compared. The hydatidiform mole group had the highest LINE-1 methylation level (p = 0.003) and the ^uC^uC of LINE-1 increased in the malignant trophoblast group (p ≤ 0.001). One hundred forty-five hydatidiform mole patients were classified as 103 remission and 42 postmolar GTN patients. The %^mC^uC and %^uC^mC of LINE-1 showed the lowest p value for distinguishing between the two groups (p < 0.001). The combination of the pretreatment β-hCG level (≥100,000 mIU/mL) with the %^mC^uC and %^uC^mC, sensitivity, specificity, PPV, NPV, and accuracy modified the levels to 60.0%, 92.2%, 77.4%, 83.8%, and 82.3%, respectively. Conclusions. A reduction in the partial methylation of LINE-1 occurs early before the clinical appearance of malignant transformation. The %^mC^uC and %^uC^mC of LINE-1s may be promising markers for monitoring hydatidiform moles before progression to GTN.

Prophylactic chemotherapy for hydatidiform mole to prevent gestational trophoblastic neoplasia

BACKGROUND

Hydatidiform mole (HM), also called a molar pregnancy, is characterised by an overgrowth of foetal chorionic tissue within the uterus. HMs may be partial (PM) or complete (CM) depending on their gross appearance, histopathology and karyotype. PMs usually have a triploid karyotype, derived from maternal and paternal origins, whereas CMs are diploid and have paternal origins only. Most women with HM can be cured by evacuation of retained products of conception (ERPC) and their fertility preserved. However, in some women the growth persists and develops into gestational trophoblastic neoplasia (GTN), a malignant form of the disease that requires treatment with chemotherapy. CMs have a higher rate of malignant transformation than PMs. It may be possible to reduce the risk of GTN in women with HM by administering prophylactic chemotherapy (P-Chem). However, P-Chem given before or after evacuation of HM to prevent malignant sequelae remains controversial, as the risks and benefits of this practice are unclear.

OBJECTIVES

To systematically review the evidence for the effectiveness and safety of P-Chem to prevent GTN in women with a molar pregnancy.

SEARCH METHODS

We performed electronic searches in the Cochrane Gynaecological Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2012), MEDLINE (1946 to February week 4, 2012) and EMBASE (1980 to week 9, 2012). The search strategy was developed using free text and medical subject headings (MESH). We handsearched reference lists of relevant literature to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of P-Chem for HM.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion in the review and extracted data using a specifically designed data collection form. Meta-analyses were performed by pooling data from individual trials using RevMan 5.1 software.

MAIN RESULTS

We included three RCTs with a combined total of 613 participants. One study compared prophylactic dactinomycin to no prophylaxis (60 participants); the other two studies compared prophylactic methotrexate to no prophylaxis (420 and 133 participants). All participants were diagnosed with CMs. We considered the latter two studies to be of poor methodological quality.P-Chem reduced the risk of GTN occurring in women following a CM (3 studies, 550 participants; RR 0.37; 95% confidence interval (CI) 0.24 to 0.57; I(2) = 0%; P < 0.00001), However, owing to the poor quality of two of the included studies, we performed sensitivity analyses excluding these two studies. This left only one small study of high-risk women to contribute data for this primary outcome (59 participants; RR 0.28; 95% CI 0.10 to 0.73; P = 0.01), therefore we consider this evidence to be of a low quality.The time to diagnosis was longer in the P-Chem group than the control group (2 studies, 33 participants; mean difference (MD) 28.72; 95% CI 13.19 to 44.24; P = 0.0003) and the P-Chem group required more courses to cure subsequent GTN (1 poor-quality study, 14 participants; MD 1.10; 95% CI 0.52 to 1.68; P = 0.0002). We consider this evidence to be of a low to very low quality for similar reasons to those listed above.There were insufficient data to perform meta-analyses for toxicity, overall survival, drug resistance and reproductive outcomes.

AUTHORS' CONCLUSIONS

P-Chem may reduce the risk of progression to GTN in women with CMs who are at a high risk of malignant transformation; however, current evidence in favour of P-Chem is limited by the poor methodological quality and small size of the included studies. As P-Chem may increase drug resistance, delay treatment of GTN and expose women unnecessarily to toxic side effects, this practice cannot currently be recommended.

Suppression of hydatidiform molar growth by inhibiting endogenous brain-derived neurotrophic factor/tyrosine kinase B signaling

Brain-derived neurotrophic factor (BDNF)/tyrosine kinase B (TrkB) receptor signaling promotes trophoblast growth in normal and abnormal pregnancy. It also regulates the growth of malignant trophoblastic, choriocarcinoma cells. However, possible involvement of this signaling system in hydatidiform mole, another major gestational trophoblastic disease, has not been determined. Here, we found the expression of BDNF in syncytiotrophoblasts and its receptor, TrkB, in cytotrophoblasts of hydatidiform mole using real-time RT-PCR and immunoassays. In molar explant cultures, treatment with soluble TrkB ectodomain or a Trk receptor inhibitor K252a inhibited trophoblast outgrowth as well as decreased cytotrophoblast proliferation and cellular viability based on histopathological analyses and glucose metabolism monitoring. These inhibitors also increased apoptosis and caspase-3/7 activities. In an in vivo model of hydatidiform molar growth based on xenotransplantation of molar tissues into kidney capsules of SCID mice, treatment with K252a suppressed molar growth as reflected by decreased trophoblast proliferation and their invasion into mouse kidney, reduced tissue levels of chorionic gonadotropin-β, and increased apoptosis. Based on PCR array analyses to identify changes in expression profiles of cell cycle- and apoptosis-related genes in cultured molar explants, suppression of endogenous TrkB signaling led to decreases in key cell cycle-stimulatory and checkpoint genes together with the down-regulation of different antiapoptotic genes. Our findings demonstrate the importance of paracrine signaling by the BDNF/TrkB system in the proliferation and survival of molar trophoblasts. Inhibition of BDNF/TrkB signaling could provide a novel medical treatment for hydatidiform mole.

Incidence, management, and outcome of molar pregnancies at a tertiary care hospital in quetta, pakistan

Molar pregnancies represent a significant burden of disease on the spectrum of gestational trophoblastic diseases. The incidence appears to be higher in women from South Asia. The purpose of our prospective study was to determine the incidence, presentation, and outcomes of all molar pregnancies at our institution. During the study period, there were a total of 16,625 patients admitted to our department; out of whom 85 patients were diagnosed with a molar pregnancy. Vaginal bleeding was the commonest symptom (94.2%); theca lutein cysts were noted in 39% of the cases. Suction, dilatation, and curettage were noted to be the preferred method in almost all cases; hysterectomy was done in 12 (14.1%) patients. Single-agent chemotherapy was employed in high-risk patients and was well tolerated. Mean followup for these patients was 5.7 months (range 1–24 months). None of these patients developed persistent trophoblastic disease, invasive mole, or choriocarcinoma during the follow-up period.

Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole

Gestational trophoblastic disease includes hydatidiform mole (complete and partial) and gestational trophoblastic neoplasia (invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor). The epidemiology, pathology, clinical presentation, and diagnosis of each of these trophoblastic disease variants are discussed. Particular emphasis is given to management of hydatidiform mole, including evacuation, twin mole/normal fetus pregnancy, prophylactic chemotherapy, and follow-up.

Reproductive outcome after discharge of patients with high-risk hydatidiform mole with or without use of one bolus dose of actinomycin D, as prophylactic chemotherapy, during the uterine evacuation of molar pregnancy

OBJECTIVE

To evaluate whether prophylactic chemotherapy (P-chem) with one bolus dose of actinomycin D (Act-D) during the uterine evacuation of patients with high-risk hydatidiform mole (Hr-HM) affects reproductive outcomes in subsequent pregnancies.

METHODS

From 1987 to 2006, 1090 patients with gestational trophoblastic disease (GTD) were evaluated at a Trophoblastic Disease Center in southern Brazil; 265 with Hr-HM were selected and retrospectively analyzed. From 1996 to 2006, 163 received one bolus dose of Act-D at the time of uterine evacuation (Hr-HM-chem group); 102 with the same risk factors did not get P-chem (Hr-HM-control group). In March 2009, the number of pregnancies, progression of first pregnancy, and association of low age and low parity with subsequent pregnancy were evaluated.

RESULTS

The percentage of patients that became pregnant was similar in both groups (Hr-HM-control: 59.5%; Hr-HM-chem group: 45.7%; p=0.069) and independent of HM progression. Percentages of no pregnancies because of age (> or =40 years) or hysterectomy were also similar. Type of subsequent pregnancy was not statistically different between groups, and the rate of live births associated with pregnancies for which US showed a live fetus was high. Frequency of repeat GTD was unexpectedly high in both groups (4.2% and 6.3%; p=1.00).

CONCLUSIONS

P-chem did not affect reproductive outcomes for patients with Hr-HM. Patients allowed to become pregnant again in both groups had high rates of live births associated with normal pregnancies. Chances of a subsequent pregnancy were higher in the low age and low parity subgroups.

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.

Early identification of persistent trophoblastic disease with serum hCG concentration ratios

The objective of the present study was to assess the diagnostic potential of serum human chorionic gonadotropin (hCG) ratios obtained at different intervals after evacuation of hydatidiform mole to diagnose persistent trophoblastic disease (PTD) and to compare its diagnostic accuracy with the current FIGO 2000 criteria as a gold standard. We calculated hCG ratios from serum hCG concentrations of 204 patients (86 with and 118 without PTD) registered with the Dutch Central Registry for Hydatidiform Moles between 1977-2004. The hCG ratios obtained in week 1, 3, and 5 after evacuation identified, respectively, 20%, 52%, and 79% of patients with PTD (median: 3.0 weeks) at the 95% specificity level, while FIGO 2000 criteria identified, respectively, 0%, 16%, and 66% (median: 4.7 weeks). It is concluded that a serum hCG ratio identifies patients with PTD approximately 2 weeks earlier than the internationally accepted FIGO 2000 criteria and identifies more than 75% of patients who develop PTD by the fifth week after evacuation.

Postmenopausal complete hydatidiform mole: a case report

BACKGROUND

Gestational trophoblastic neoplasia (GTN) is a disease with a course of trophoblastic proliferation, and histologically classified as partial hydatidiform mole, complete mole, invasive and metastatic mole, choriocarcinoma and placental site trophoblastic tumor. Occurrence of GTN in postmenopausal women is rare.

CASE

We report the case of a 56-year-old postmenopausal woman with a complete mole. The patient was admitted to gynecology outpatient clinic with abdominal pain, nausea and vomiting for about 1 month. Ultrasound examination revealed enlargement of the uterus with endometrial thickness containing hypo/hyper echogeneous and cystic areas. Serum beta-HCG was tested against the possibility of GTN because of the appearance in sonography and was found >5000. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. The serum level of beta-HCG has decreased from initially observed 188,000-0 U/ml in 4th week. The resected uterus contained an endometrial, cystic, grapelike tumor. Microscopic examination demonstrated hydropic degeneration of all the chorionic villi with trophoblastic cell proliferation consistent with a complete hydatidiform mole.

CONCLUSION

To our knowledge, our case is the fourth description in the world literature of a benign complete hydatidiform mole in a postmenopausal woman. Although benign gestational trophoblastic disease generally occurs in women of reproductive age and is extremely rare in postmenopausal women, when evaluating patients who are in postmenopausal period the diagnosis of hydatidiform mole must always be considered.

Gestational Trophoblastic Disease

Hydatidiform mole, a disorder of fertilization, comprises complete and partial molar pregnancy. The pathologic and clinical features of complete and partial mole are well-described. Because of earlier diagnosis, however, the clinical presentation of complete molar pregnancy has significantly changed in recent years. The earlier diagnosis of complete mole is associated with more subtle pathologic findings than later molar pregnancy. The use of immunohistochemical techniques for the detection of maternally imprinted genes as ancillary testing in the diagnosis of complete and partial mole is therefore increasing. Although most molar pregnancies are sporadic, a familial syndrome of recurrent hydatidiform mole has been described. Further research will hopefully lead to identification of the gene defect responsible for this uncommon syndrome. Fortunately, patients with molar pregnancies can generally anticipate normal future reproduction. Close hCG follow-up after molar pregnancy is required to rule out development of postmolar gestational trophoblastic neoplasia. Recent studies suggest that a shorter period of postmolar follow-up may be reasonable for patients with both complete and partial molar pregnancy.

Gestational trophoblastic disease

This review summarizes the primary management of molar pregnancies, surveillance after evacuation, and the evaluation and management of malignant gestational trophoblastic neoplasia (GTN). Most women with gestational trophoblastic disease can be successfully managed with preservation of their normal reproductive function. It is important to manage molar pregnancies properly to minimize acute complications and identify malignant sequelae promptly. Current International Federation of Gynecology and Obstetrics (FIGO) guidelines for making the diagnosis and staging of GTN allow uniformity for reporting results of treatment. It is important to individualize treatment for women with malignant GTN based upon risk factors, using less toxic therapy for patients with low-risk disease and aggressive multiagent therapy for those with high-risk disease. Patients with malignant GTN should be managed in consultation with an individual experienced in the complex, multimodality treatment of these patients.

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.

Choriocarcinoma and gestational trophoblastic disease

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.

Diagnosis of hydatidiform mole and persistent trophoblastic disease: diagnostic accuracy of total human chorionic gonadotropin (hCG), free hCG {alpha}- and {beta}-subunits, and their ratios

OBJECTIVE

Human chorionic gonadotropin (hCG) is widely used in the management of hydatidiform mole and persistent trophoblastic disease (PTD). Predicting PTD after molar pregnancy might be beneficial since prophylactic chemotherapy reduces the incidence of PTD.

DESIGN

A retrospective study based on blood specimens collected in the Dutch Registry for Hydatidiform Moles. A group of 165 patients with complete moles (of which 43 had PTD) and 39 patients with partial moles (of which 7 had PTD) were compared with 27 pregnant women with uneventful pregnancy.

METHODS

Serum samples from patients with hydatidiform mole with or without PTD were assayed using specific (radio) immunoassays for free alpha-subunit (hCGalpha), free beta-subunit (hCGbeta) and 'total' hCG (hCG + hCGbeta). In addition, we calculated the ratios hCGalpha/hCG + hCGbeta, hCGbeta/hCG + hCGbeta, and hCGalpha/hCGbeta. Specificity and sensitivity were calculated and paired in receiver-operating characteristic (ROC) curve analysis, resulting in areas under the curves (AUCs).

RESULTS

hCGbeta, hCGbeta/hCG + hCGbeta and hCGalpha/hCGbeta show AUCs ranging between 0.922 and 0.999 and, therefore, are excellent diagnostic tests to distinguish complete and partial moles from normal pregnancy. To distinguish partial from complete moles the analytes hCGbeta, hCG + hCGbeta and the ratio hCGalpha/hCGbeta have AUCs between 0.7 and 0.8. Although hCGalpha, hCGbeta and hCG + hCGbeta concentrations are significantly elevated in patients who will develop PTD compared with patients with spontaneous regression after evacuation of their moles, in predicting PTD, these analytes and parameters have AUCs <0.7.

CONCLUSIONS

Distinction between hydatidiform mole and normal pregnancy is best shown by a single blood specimen with hCGbeta, but hCGbeta/hCG + hCGbeta and hCGalpha/hCGbeta are also excellent diagnostic parameters. To predict PTD, hCGalpha, hCGbeta, hCG + hCGbeta and hCGalpha/hCGbeta are moderately accurate tests, although they are not accurate enough to justify prophylactic chemotherapy treatment for prevention of PTD.

Pharmacotherapy of gestational trophoblastic disease

Gestational trophoblastic neoplasms are the most responsive of all solid tumours to chemotherapy leading to an overall cure rate of > 90%. Non-metastatic disease (FIGO Stage I) and low-risk metastatic disease (FIGO Stages II and III; WHO score < 7) can be treated with single-agent methotrexate or actinomycin D protocols resulting in a survival rate approaching 100%. Metastatic high-risk disease (FIGO Stage IV or WHO score > 7) should be treated with initial intensive multimodality therapy with combination chemotherapy, consisting of etoposide, high-dose methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) and adjuvant radiotherapy and surgery when indicated. Despite this aggressive approach, approximately 30% of patients with high-risk disease will fail initial therapy or relapse from remission. Salvage chemotherapy with drug regimens containing platinum agents and etoposide, usually in conjunction with bleomycin or ifosfamide, as well as surgical resection of sites of resistant disease, will ultimately result in a survival rate of 80 - 90% for metastatic high-risk disease.

How long should patients be followed after molar pregnancy? Analysis of serum hCG follow-up data

OBJECTIVE

We analyzed human chorionic gonadotropin (hCG) follow-up data of patients with molar pregnancy. Women often do not complete recommended post-disease screening. Our purpose was to determine if continuing follow up of uncomplicated molar cases beyond attaining undetectable hCG levels is necessary for detecting relapse of gestational trophoblastic disease.

STUDY DESIGN

One hundred fifty patients treated at Hungarian National Health Center were analyzed. Those who developed persistent disease before hCG had become undetectable were excluded from further analysis (n=24; 16%).

RESULTS

Among 126 uncomplicated cases, 72 patients (57%) completed follow up, and 54 (43%) discontinued their protocol before it had been completed. Of 120 patients who achieved at least one undetectable hCG level, none had any evidence of relapse.

CONCLUSION

In uncomplicated hydatidiform mole, our analysis indicates that once undetectable serum hCG levels are attained, relapse is unlikely. Although further monthly checks are advisable, the likelihood of recurrence appears very low.

Gestational trophoblastic disease

Gestational trophoblastic disease consists of a broad spectrum of conditions ranging from an uncomplicated partial hydatidiform molar pregnancy to stage IV choriocarcinoma with cerebral metastases. Fortunately, with the advent of combination chemotherapy, the patient with advanced-stage disease has a significant chance of achieving complete remission. In addition, several studies have demonstrated that patients with a history of gestational trophoblastic neoplasia do not experience an increased risk of complications with future pregnancies. Patients who have undergone chemotherapy do not seem to experience an increase in the risk for congenital anomalies in their offspring. Patients with a history of hydatidiform molar pregnancy should be advised that they are at increased risk of future molar pregnancies, with a risk of 1% in subsequent gestations after one molar pregnancy and a risk as high as 23% after two molar gestations. Although patients should be reassured regarding their reproductive future, they should be advised to seek prompt medical attention once gestation is suspected so that an early work-up can be initiated if pregnancy is confirmed.

Gestational trophoblastic disease

BACKGROUND

Gestational trophoblastic disease consists of a group of interrelated diseases, including molar pregnancy, placental site trophoblastic tumor, and choriocarcinoma.

METHODS

Advances in the diagnosis and management of gestational trophoblastic diseases over the past 5 years were reviewed.

RESULTS

Molar pregnancy is now categorized as complete or partial on the basis of gross and microscopic histopathologic and karyotypic findings. Early detection of persistent gestational trophoblastic tumor (GTT) depends on careful postmolar gonadotropin follow-up and consideration of the diagnosis for any woman of reproductive age with unexplained gynecologic and/or systemic symptoms. Triple therapy with methotrexate, actinomycin D, and cyclophosphamide was once the preferred treatment for patients with high risk metastatic GTT but induced remission in only about 50%. Treatment with etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine is now the preferred regimen for treatment of high risk metastatic GTT and has been shown to induce remission in about 70% of patients.

CONCLUSIONS

Important advances have been made in the diagnosis and treatment of patients with gestational trophoblastic disease, and patients can be reassured that they can anticipate normal reproductive functioning.

Effects of prophylactic chemotherapy for postmolar trophoblastic disease in patients with complete hydatidiform mole

An analysis of 233 patients with complete hydatidiform mole admitted to Hacettepe University Hospital between 1964 and 1988 has been carried out. Methotrexate was administered prophylactically to 19 of 120 low-risk and to 52 of 113 high-risk patients. The difference in the incidence of postmolar gestational trophoblastic disease between prophylactically untreated and treated groups of either low-risk (13.9% versus 5.3%, P greater than 0.01) or high-risk (26.2% versus 25.0%, P greater than 0.01) patients was found to be statistically insignificant. Drug toxicity and mortality rates were 16.9% and 2.8%, respectively. It is concluded that prophylactic chemotherapy is not highly effective in the prophylaxis of postmolar gestational trophoblastic disease. Strict follow-up through sensitive betahuman chorionic gonadotropin assays should be the standard management of postmolar patients.

DNA content as a prognostic index in gestational trophoblastic neoplasia

Hydatidiform mole will progress to malignant gestational trophoblastic neoplasia (GTN) in some cases. Aneuploidy and high proliferative activity are associated with malignant tumors. Molar pregnancy tissue was considered a precursor to malignant GTN, and was studied retrospectively using paraffin-embedded tissue to determine whether aneuploidy or proliferative rates measured on molar tissue could predict a malignant course. Tissues from 51 complete hydatidiform moles were analyzed for nuclear DNA content by flow cytometric techniques. A chart review identified the clinical course after evacuation of the mole. A satisfactory DNA histogram was generated in 40 cases. Of the 40 patients, 22 (55%) had spontaneous resolution, and 18 patients (45%) required treatment for persistent GTN. The molar tissue was found to be euploid in 27 cases and aneuploid in 13 cases. Eight of the twenty-seven euploid cases (30%) required treatment after evacuation, whereas 10 of the 13 aneuploid cases (77%) required treatment after molar evacuation. Proliferative index (PI) was compared with treatment requirements. Average PI was 0.11 +/- 0.10 for the treatment group and 0.08 +/- 0.06 for the spontaneous resolution group. The correlation of clinical course with ploidy was significant (P less than 0.01). The association with proliferative index was not (P greater than 0.05). Aneuploidy, therefore, identifies a high-risk group of molar pregnancies, and may represent those that have undergone one stage of malignant transformation.