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Coopmans L, Larsson A, Joneborg U, Lok C, van Trommel N. Surgical Management of Gestational Trophoblastic Disease. Gynecol Obstet Invest 2023; 89:214-229. [PMID: 37788661 DOI: 10.1159/000534065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 09/04/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Gestational trophoblastic disease (GTD) is a rare pregnancy-related condition consisting of premalignant and malignant forms arising from proliferation of trophoblastic cells. The malignant forms are collectively referred to as gestational trophoblastic neoplasia (GTN) and are highly sensitive to chemotherapy. However, surgical procedures remain indispensable in the diagnosis and treatment of GTD. OBJECTIVES The aim of this review was to summarize surgical interventions in the treatment of GTD and GTN. We reviewed indications, efficacy, possible complications, and oncological outcomes of surgery. METHODS Three searches were performed in the databases of PubMed, Embase, and the Cochrane Library to create an up-to-date overview of existing literature on the following subjects: (1) the role of primary hysterectomy in GTD and GTN; (2) the role of second curettage in GTD and GTN; (3) fertility sparing surgery in GTN; (4) surgical management of metastases. Included articles originated from the time period 1952-2022. Articles written in English, Spanish, and French were included. OUTCOMES Thirty-eight articles were found and selected. Surgical evacuation through suction curettage is most used and advised in the treatment of GTD. A second curettage could be beneficial in patients with low hCG levels and low FIGO scores. In women who have completed their families, primary hysterectomy might be considered as the risk of subsequent GTN is lower than after suction curettage. In case of the rare forms of GTN (epithelioid trophoblastic tumor or placental site trophoblastic tumor) surgical tumor resection remains the most important step in treatment. Data on fertility sparing surgery in GTN are scarce and this treatment should be considered experimental. CONCLUSION AND OUTLOOK Surgery remains an important part of treatment of GTD and is sometimes indispensable to achieve curation. Further collection of evidence is needed to determine treatment steps.
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Affiliation(s)
- Leonoor Coopmans
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands,
| | - Agnes Larsson
- Department of Gynecologic Cancer Surgery, Karolinska University Hospital and Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Ulrika Joneborg
- Department of Gynecologic Cancer Surgery, Karolinska University Hospital and Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Christianne Lok
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nienke van Trommel
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Fertility-sparing uterine lesion resection for young women with gestational trophoblastic neoplasias: single institution experience. Oncotarget 2018; 8:43368-43375. [PMID: 28108735 PMCID: PMC5522152 DOI: 10.18632/oncotarget.14727] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/09/2017] [Indexed: 11/25/2022] Open
Abstract
Purpose To evaluate the oncological safety and pregnant outcomes of fertility-sparing uterine lesion resection in treating gestational trophoblastic neoplasias. Results After the treatment of surgery and chemotherapy, all the patients achieved complete remission. With a median follow-up time of 44 months (range, 6-188), 3 patients (3.85%) relapsed within 3-26 months. Multivariate analysis showed that tumor size was the independent risk factor of recurrence and the cutoff value was 4.2cm. Among 37 patients who attempted to conceive, 31 achieved clinical pregnancy. The rate of pregnancy and live birth were 83.8% and 77.4%. Uterine rupture did not occurred no matter in cesarean section or vaginal delivery. No congenital abnormalities were reported among the live births. Methods From January 1995 to December 2014, 78 patients with gestational trophoblastic neoplasias who underwent fertility-sparing uterine lesion resection at Peking Union Medical College Hospital were reviewed. The complete remission rate, fertility rate, pregnant outcomes and risk factors of recurrence were analyzed. Conclusions Fertility-sparing uterine lesion resection might be considered as a safe and reasonable alternative for high-selected young women to remove uterine lesion in the treatment of gestational trophoblastic neoplasias.
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FERTILITY-SPARING HYSTEROTOMY IN MALIGNANT TROPHOBLASTIC TUMOURS TREATMENT. EUREKA: HEALTH SCIENCES 2017. [DOI: 10.21303/2504-5679.2017.00341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim is to improve treatment efficacy and life quality of patients with malignant trophoblastic tumours.
Fertility-sparing hysterotomy with uterine reconstruction was carried in 16 patients aged of 17 to 32 years: 2 cases due to urgent and 13 – due to planned indications.
On the basis of research, the indications for the urgent and planned fertility-sparing hysterotomy with uterine reconstruction in patients with malignant trophoblastic tumours were formulated. No postoperative complications. Steady remission in all cases. Follow up from 1 to 17 years (averaged 9.2 years).
1. Localized uterine resection with uterine reconstruction – the method of choice in malignant trophoblastic tumours surgical treatment;
2. Fertility-sparing hysterotomy with uterine reconstruction is only possible in centers which are experienced in the complex multimodality treatment of gestational trophoblastic neoplasms;
3. Basic requirement of fertility-sparing surgery is beginning adjuvant chemotherapy as soon as possible.
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Hasanzadeh M, Vahid Roodsari F, Ahmadi S, Gavedan Mehr M, Azadeh T. Fertility sparing surgery in gestational trophoblastic neoplasia: A report of 4 cases. Int J Reprod Biomed 2016. [DOI: 10.29252/ijrm.14.9.603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Sherer DM, Dalloul M, Cho Y, Mylvaganam SR, Adeyemo I, Zinn HL, Abulafia O. Spontaneous first-trimester perforation of the uterus following Cesarean scar pregnancy choriocarcinoma. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:519-521. [PMID: 26690679 DOI: 10.1002/uog.15843] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/09/2015] [Accepted: 12/16/2015] [Indexed: 06/05/2023]
Affiliation(s)
- D M Sherer
- Department of Obstetrics and Gynecology, Divisions of Maternal Fetal Medicine, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, New York, NY, USA
| | - M Dalloul
- Department of Obstetrics and Gynecology, Divisions of Maternal Fetal Medicine, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, New York, NY, USA
| | - Y Cho
- Gynecologic Oncology, State University of New York (SUNY), Downstate Medical Center, Brooklyn, New York, NY, USA
| | - S R Mylvaganam
- Gynecologic Oncology, State University of New York (SUNY), Downstate Medical Center, Brooklyn, New York, NY, USA
| | - I Adeyemo
- Department of Obstetrics and Gynecology, Divisions of Maternal Fetal Medicine, State University of New York (SUNY), Downstate Medical Center, 450 Clarkson Avenue, Box 24, Brooklyn, New York, NY, USA
| | - H L Zinn
- Department of Radiology, State University of New York (SUNY), Downstate Medical Center, Brooklyn, New York, NY, USA
| | - O Abulafia
- Gynecologic Oncology, State University of New York (SUNY), Downstate Medical Center, Brooklyn, New York, NY, USA
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Dasari P. Missing choriocarcinoma may be easy but not suspecting it in a high-risk case can be potentially fatal. BMJ Case Rep 2015; 2015:bcr-2014-208526. [PMID: 25883254 DOI: 10.1136/bcr-2014-208526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 27-year-old woman, fourth gravida, with three prior consecutive vesicular moles was diagnosed with a recurrent vesicular mole on ultrasonography (USG) and had very low β-human chorionic gonadotropin (HCG) values. During suction evacuation no vesicles were seen and on repeat USG the patient was diagnosed to have fibroid uterus. She was discharged at request and advised to undergo MRI to rule out choriocarcinoma. The MRI was interpreted as fibroid uterus with degeneration. After 3 weeks of suction evacuation, the patient presented with acute abdomen. She underwent emergency laparotomy for haemoperitoneum and was diagnosed as invasive mole with perforation; total hysterectomy was performed. Her β-HCG after laparotomy was more than 200,000 mIU/L, and the histopathological examination revealed choriocarcinoma. When methotrxate, adriamycin and cyclophosphamide (MAC) therapy was advised, the patient initially received methotrexate monotherapy; after three cycles her β-HCG started rising after an initial drop, and the patient required four cycles of EMACO to achieve remission.
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Affiliation(s)
- Papa Dasari
- Department of Obstetrics and Gynaecology, JIPMER, Puducherry, India
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Feng F, Xiang Y. Surgical management of chemotherapy-resistant gestational trophoblastic neoplasia. Expert Rev Anticancer Ther 2014; 10:71-80. [DOI: 10.1586/era.09.169] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sánchez-Ferrer ML, Hernández-Martínez F, Machado-Linde F, Ferri B, Carbonel P, Nieto-Diaz A. Uterine Rupture in Twin Pregnancy with Normal Fetus and Complete Hydatidiform Mole. Gynecol Obstet Invest 2014; 77:127-33. [DOI: 10.1159/000355566] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 09/10/2013] [Indexed: 11/19/2022]
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Tse K, Ngan HY. Gestational trophoblastic disease. Best Pract Res Clin Obstet Gynaecol 2012; 26:357-70. [DOI: 10.1016/j.bpobgyn.2011.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 11/29/2011] [Indexed: 10/14/2022]
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May T, Goldstein DP, Berkowitz RS. Current chemotherapeutic management of patients with gestational trophoblastic neoplasia. CHEMOTHERAPY RESEARCH AND PRACTICE 2011; 2011:806256. [PMID: 22312558 PMCID: PMC3265241 DOI: 10.1155/2011/806256] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 03/01/2011] [Indexed: 01/14/2023]
Abstract
Gestational trophoblastic neoplasia (GTN) describes a heterogeneous group of interrelated lesions that arise from abnormal proliferation of placental trophoblasts. GTN lesions are histologically distinct, malignant lesions that include invasive hydatidiform mole, choriocarcinoma, placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT). GTN tumors are generally highly responsive to chemotherapy. Early stage GTN disease is often cured with single-agent chemotherapy. In contrast, advanced stage disease requires multiagent combination chemotherapeutic regimens to achieve a cure. Various adjuvant surgical procedures can be helpful to treat women with GTN. Patients require careful followup after completing treatment and recurrent disease should be aggressively managed. Women with a history of GTN are at increased risk of subsequent GTN, hence future pregnancies require careful monitoring to ensure normal gestational development. This article will review the workup, management and followup of women with all stages of GTN as well as with recurrent disease.
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Affiliation(s)
- Taymaa May
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New England Trophoblastic Disease Center, Harvard Medical School, Boston, MA 02115, USA
| | - Donald P. Goldstein
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New England Trophoblastic Disease Center, Harvard Medical School, Boston, MA 02115, USA
| | - Ross S. Berkowitz
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, New England Trophoblastic Disease Center, Harvard Medical School, Boston, MA 02115, USA
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Xie C, Zheng L, Li ZY, Zhao X. Spontaneous uterine perforation of choriocarcinoma with negative beta-human chorionic gonadotropin after chemotherapy. Med Princ Pract 2011; 20:570-3. [PMID: 21986018 DOI: 10.1159/000330028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Accepted: 02/14/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To report an extremely rare case of spontaneous uterine perforation of choriocarcinoma with negative beta-human chorionic gonadotropin (β-hCG) post-chemotherapy. CLINICAL PRESENTATION AND INTERVENTION We present a 35-year-old choriocarcinoma patient whose serial serum β-hCG levels following a fifth course of chemotherapy had been within the normal range, but who developed spontaneous uterine perforation with intra-abdominal hemorrhage after eight courses of combined chemotherapy. The patient then underwent an emergency hysterectomy and survived. CONCLUSION Patients with persistent focus of disease in the uterus might experience uterine perforation even after adequate chemotherapy, and therefore, the follow-up for patients after chemotherapy is very important.
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Affiliation(s)
- Chuan Xie
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, PR China
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Estrella JLDC, Soriano-Estrella AL. Conservative Management of Uterine Rupture in Gestational Trophoblastic Neoplasia: A Report of 2 Cases. Int J Gynecol Cancer 2009; 19:1666-70. [DOI: 10.1111/igc.0b013e3181a84252] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cases of gestational trophoblastic neoplasia (GTN) with uterine rupture are often catastrophic owing to profuse bleeding, which could be potentially lethal. Management often entails removal of the uterus. Among patients in the reproductive age who have not completed their desired family size, such a procedure could be unacceptable. To address this, uterine resection of localized disease has been performed to preserve fertility. However, in some cases, resection would not leave much of the uterus for future fertility. Hence, primary repair of the rupture could be done. Two cases of uterine rupture in low-risk GTN conservatively managed with primary uterine rupture repair using hemostatic stitches and postoperative single-agent chemotherapy are presented. Both patients were in their early reproductive years and with a great desire to preserve future fertility. The extent of the disease was evaluated in both cases intraoperatively before considering this conservative approach. Such management proved to be effective for both cases. The 2 cases presented are the first reported successful cases in literature on which primary repair of uterine tumor rupture by oversewing with figure-of-eight stitches were done. One should then consider this as a new option in the management of patients who have GTN with uterine rupture, highly desirous of pregnancy, with large uterine tumors but relatively small areas of rupture for which simple stitches would suffice in providing adequate hemostasis.
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Behtash N, Karimi Zarchi M. Placental site trophoblastic tumor. J Cancer Res Clin Oncol 2007; 134:1-6. [PMID: 17701427 DOI: 10.1007/s00432-007-0208-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Accepted: 03/23/2007] [Indexed: 10/23/2022]
Abstract
Placental site trophoblastic tumor (PSTT) is a rare neoplasm that rises from intermediate trophoblasts and commonly presents with low and variable concentration of HCG immunoactivity in serum, which can be difficult to differentiate from early stage choriocarcinoma/gestational trophoblastic neoplasm (GTN) or quiescent gestational trophoblastic disease. PSTT can occur after a normal pregnancy, spontaneous abortion, termination of pregnancy, ectopic or molar pregnancy. There is a wide clinical spectrum of presentation and behavior ranging from a benign condition to an aggressive disease with fatal outcome. Nontrophoblastic malignancies such as germ cell tumors or other tumors secreting low HCG must also be considered in the differential diagnosis. Because treatments for these conditions are different, a means of differentiating PSTT from other diagnoses is important. Surgery is the cornerstone of treatment. Chemotherapeutic regimen should be EMA/CO for first line chemotherapy; EMA/EP should be used in EMA/CO refractory cases. This article reviews the literatures on this rare but fatal disease.
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Affiliation(s)
- Nadereh Behtash
- Gynecology Oncology Department, Vali-asr Hospital, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Keshavarz Boulevard, Tehran 14194, Iran.
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