MicroRNA Expression Profiling in Hydatidiform Mole for the Prediction of Postmolar GTN : MicroRNA Profile in Postmolar GTN

Objectives: The primary aim of the study was to identify miRNAs that were differentially expressed between complete hydatidiform moles (CHMs) that turned out to be gestational trophoblastic neoplasia (GTN) [GTN moles] and CHMs that regressed spontaneously after evacuation [remission moles]. The secondary aim was to study the profiles of miRNA expressions in CHMs. Methods: A case-control study was conducted on GTN moles and remission moles. We quantitatively assessed the expression of 800 human miRNAs from molar tissues using Nanostring nCounter. Results: From a pilot study, 21 miRNAs were significantly downregulated in GTN moles compared to the remission moles. Five of them (miR-566, miR-608, miR-1226-3p, miR-548ar-3p and miR-514a-3p) were downregulated for >4 folds. MiR-608 was selected as a candidate for further analysis on 18 CHMs (9 remission moles and 9 GTN moles) due to its striking association with malignant formation. MiR-608 expression was slightly lower in GTN moles compared to the remission moles, that is, 2.22 folds change [p = 0.063]. Conclusion: We identified 21 miRNAs that were differentially expressed between GTN moles and remission moles suggesting that miRNA profiles can distinguish between the two groups. Although not reaching statistically significant, miR-608 expression was slightly lower in GTN moles compared to remission moles.

Histological Examination of Tissue Obtained in Early Pregnancy Loss

Background It is a routine practice to send histological sample after surgical evacuation of early pregnancy loss. Objective This study was carried out to see the justification of regular histological study by carrying out the histological study of early pregnancy loss and to find the prevalence of gestational trophoblastic disease in early pregnancy loss. Method It was a descriptive prospective study, conducted in Nepal medical college teaching hospital from February to October 2020 in Obstetrics and Gynaecology department. Clinical data such as age, parity, gestational age and diagnosis were collected of 130 patient of early pregnancy loss. Then histological study were sent after surgical evacuation. Result Among the age group, 21-30 age group was maximum. (64.61%), more than half of the patient was primigravida (53.07%) and most of the cases were between 6 to 9 weeks of gestation. Incomplete abortions were maximum (43.07%), missed abortions 38.46%, blighted abortions 16.15%, enevitable abortions 1.53% and septic abortion was 0.76%. Among histological finding, 72.30% were product of conception, 15.38% of the cases had no product of conception, decidual tissue only in 6.92%, partial mole in one case (0.76%), complete mole in one case (0.76%) and hydrophic changes in one case (0.76%). The total cases of Gestational trophoblastic diseases (GTD) were 3(2.30%). Conclusion In our study we found 2.3% of cases of GTD, which was quite high in compare to Western word. So it is a good practice to do histological study of all cases of EPL in our country to detect GTD, determining cause for recurrent pregnancy loss and detecting unexpected fetal pathology.

Evaluation of a routine second curettage for hydatidiform mole: a cohort study

OBJECTIVE

The aim of this study was to evaluate routine second curettage for hydatidiform mole (HM) by comparing the characteristics and outcomes of developing gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

This was a cohort study including 173 patients diagnosed with HM between January 2002 and August 2019 who were followed up at Nagoya University Hospital, Japan. After an evacuation, 105 and 68 patients were managed with the routine method (routine group) and elective method (elective group) for a second curettage, respectively. The routine second curettage was performed around 7 days after the first evacuation. Patients in the elective group underwent a second curettage if there was ultrasonographic evidence of molar remnants in the uterine cavity. Socio-clinical factors were retrospectively compared between the routine and elective groups, and between patients showing regression and those who developed GTN.

RESULTS

The incidence of GTN was 15.2% in the routine group and 20.6% in the elective group, and the difference was not significant (P = 0.364). The median GTN risk score was significantly higher in the routine group than in the elective group (P = 0.033). Presence of a complete HM, gestational age, and a pre-treatment human chorionic gonadotropin level of ≥ 200,000 mIU/mL were independent risk factors for GTN in molar patients.

CONCLUSION

The incidence of GTN was unchanged but the risk score of GTN was higher in the routine group than in the elective group. Routine second curettage may not be necessary, but further study will be needed to confirm this.

Does hormonal contraception during molar pregnancy follow-up influence the risk and clinical aggressiveness of gestational trophoblastic neoplasia after controlling for risk factors?

OBJECTIVE

To evaluate the influence of hormonal contraception (HC) on the development and clinical aggressiveness of gestational trophoblastic neoplasia (GTN) and the time for normalization of human chorionic gonadotropin (hCG) levels.

METHODS

A retrospective cohort study was conducted with women diagnosed with molar pregnancy, followed at the Rio de Janeiro Trophoblastic Disease Center, between January 2005 and January 2015. The occurrence of postmolar GTN and the time for hCG normalization between users of HC or barrier methods (BM) during the postmolar follow-up or GTN treatment were evaluated.

RESULTS

Among 2828 patients included in this study, 2680 (95%) used HC and 148 (5%) used BM. The use of HC did not significantly influence the occurrence of GTN (ORa: 0.66, 95% CI: 0.24-1.12, p=0.060), despite different formulations: progesterone-only (ORa: 0.54, 95% CI: 0.29-1.01, p=0.060) or combined oral contraception (COC) (ORa: 0.50, 95% CI: 0.27-1.01, p=0.60) or with different dosages of ethinyl estradiol: 15mcg (ORa, 1.33, 95% CI 0.79-2.24, p=0.288), 20mcg (ORa: 1.02, 95% CI: 0.64-1.65, p=0.901), 30mcg (ORa: 1.17, 95% CI: 0.78-1.75, p=0.437) or 35mcg (ORa: 0.77, 95% CI: 0.42-1.39, p=0.386). Time to hCG normalization ≥10weeks (ORa: 0.58, 95% CI: 0.43-1.08, p=0.071) or time to remission with chemotherapy≥14weeks (ORa: 0.60, 95% CI: 0.43-1.09, p=0.067) did not significantly differ among HC users when compared to patients using BM, when controlling for other risk factors using multivariate logistic regression.

CONCLUSIONS

The use of HC during postmolar follow-up or GTN treatment does not seem to increase the risk of GTN or its severity and does not postpone the normalization of hCG levels.

Fertility outcome after laparoscopic salpingostomy or salpingectomy for tubal ectopic pregnancy A 12-years retrospective cohort study

AIM

To compare the subsequent reproductive outcome after laparoscopic salpingostomy or salpingectomy for tubal ectopic pregnancy (EP).

MATERIAL OF STUDY

A retrospective cohort study was conducted between January 2002 and May 2014 on 132 women admitted to Unit of Gynecology and Obstetrics of the Department of Human Pathology in Adulthood and Childhood "G. Barresi", "Gaetano Martino" Hospital, University of Messina (Italy), with EP and who received surgical treatment, including laparoscopic salpingectomy (n=57) or salpingostomy (n=75). Main outcomes included intrauterine pregnancy (IUP), recurrent EP and persistent trophoblastic disease rates.

RESULTS

The IUP rates up to 24 months after surgery were 56.1% for salpingectomy and 60% for salpingostomy. The 2-year recurrent EP rates were 5.3% for salpingectomy and 18.7% for salpingostomy. The persistent trophoblastic disease rate were 1.8% for salpingectomy and 12% for salpingostomy.

DISCUSSION

Our results show that the reproductive outcomes after laparoscopic salpingectomy are similar to those observed after conservative treatment.

CONCLUSIONS

In the surgical treatment of EP, the clinician should choose the best treatment in accordance with the patient, considering the severity of the disease, the clinical characteristics of the patient and her desire to preserve fertility.

KEY WORDS

Ectopic pregnancy, Salpingectomy,Salpingostomy.

Risk factors for persistent gestational trophoblastic neoplasia

This retrospective study evaluated the risk factors for persistent gestational trophoblastic disease (GTN) and determined their odds ratios. This study included 100 cases with GTN admitted to our clinic. Possible risk factors recorded were age, gravidity, parity, size of the neoplasia, and beta-human chorionic gonadotropin levels (beta-hCG) before and after the procedure. Statistical analyses consisted of the independent sample t-test and logistic regression using the statistical package SPSS ver. 15.0 for Windows (SPSS, Chicago, IL, USA). Twenty of the cases had persistent GTN, and the differences between these and the others cases were evaluated. The size of the neoplasia and histopathological type of GTN had no statistical relationship with persistence, whereas age, gravidity, and beta-hCG levels were significant risk factors for persistent GTN (p < 0.05). The odds ratios (95% confidence interval (CI)) for age, gravidity, and pre- and post-evacuation beta-hCG levels determined using logistic regression were 4.678 (0.97-22.44), 7.315 (1.16-46.16), 2.637 (1.41-4.94), and 2.339 (1.52-3.60), respectively. Patient age, gravidity, and beta-hCG levels were risk factors for persistent GTN, whereas the size of the neoplasia and histopathological type of GTN were not significant risk factors.

Gestational trophoblastic disease

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

Endometrial sampling in patients with trophoblastic disease after suction curettage

OBJECTIVE

To determine intrauterine pathology in patients with postmolar gestational trophoblastic neoplasia (GTN) and hydatidiform mole after suction curettage. Safety profiles of endometrial sampling in this setting are also evaluated.

STUDY DESIGN

In this prospective study, 24 cases with persistent GTN or postevacuation hydatidiform mole were recruited. Endometrial pathology was evaluated by Endocell. Clinical characteristics, safety of the instrument and pathology results were analyzed.

RESULTS

During August 2006 to July 2007, 15 cases with postmolar GTN and 9 cases of postevacuation mole were recruited. Of 15 cases of postmolar GTN, 2 (13%) showed molar tissue. All 9 cases of postevacuation hydatidiform mole showed benign endometrial tissue or normal trophoblast in endometrial sampling pathology. No patients in this study had severe vaginal bleeding or infection after endometrial sampling. Analysis of endometrial sampling pathology as a diagnostic test for GTN showed a sensitivity of 0.133 (95% CI 0.037-0.379).

CONCLUSION

Endometrial sampling by Endocell is safe in patients with gestational trophoblastic disease. Although the pathology findings from endometrial sampling had low sensitivity in diagnosing GTN, we encourage a larger prospective trial to confirm this result.

Influence of age as a factor in the outcome of gestational trophoblastic neoplasia

OBJECTIVE

To question whether older patients have a worse prognosis or poorer outcomes with chemotherapeutic regimens.

STUDY DESIGN

All gestational trophoblastic disease (GTD) cases registered between January 1986 and September 2006 (n = 8,536) were reviewed and stratified for age. Chi2 analysis was used to ascertain whether significant differences existed with regard to patient age and histologic diagnosis or treatment requirement. Logistic regression analysis was used to predict chemotherapeutic outcomes in patients > 40 years age (n = 50).

RESULTS

An increased relative risk of high-risk pathology and need for treatment in the > 40 years age-group was found. Modification of the World Health Organization risk by removing the age score or altering the age score was significant on univariate analysis but did not actually improve the predictive ability with regard to patient treatment outcomes either with first-line or overall therapy.

CONCLUSION

Patient age may not be a risk factor for gestational trophoblastic neoplasia. With birth rates in women > 40 years and maternal age at first pregnancy significantly increasing in the United Kingdom, it is important to improve our understanding of the relationship between GTN and maternal age.

First epidemiological data from the French Trophoblastic Disease Reference Center

OBJECTIVE

The objective of the study was to describe women registered at the new French Trophoblastic Disease Reference Center and particularly the rates of gestational trophoblastic neoplasia (GTN) after molar pregnancies.

STUDY DESIGN

Epidemiological data from a prospective cohort of women registered between November 1999 and November 2004 were analyzed.

RESULTS

Four hundred forty-eight women were registered. The referent pathologist reclassified 32% and 5% of assumed partial mole (PM) and complete mole (CM), respectively. GTN developed in 30 of 212 patients with singleton CM (14%) and in 5 of 108 with singleton PM (5%). Among 131 patients with GTN (35 women followed up after registration for a mole and 96 registered for a GTN), 115 (88%) were low-risk and 16 (12%) were high-risk patients according to 2000 International Federation of Gynecology and Obstetrics (FIGO) scoring system.

CONCLUSION

Creation of trophoblastic disease reference centers is desirable to improve treatment of patients. Our results will have to be compared with future publications based on the new 2000 FIGO oncology committee recommendations.

Postevacuation hCG levels and risk of gestational trophoblastic neoplasia among women with partial molar pregnancies

OBJECTIVE

To develop human chorionic gonadotropin (hCG) criteria that determine a patient's risk of developing persistent gestational trophoblastic neoplasia (GTN) or achieving remission after partial mole evacuation.

STUDY DESIGN

We used a database from the New England Trophoblastic Disease Center to analyze hCG levels from 284 women with partial molar pregnancies diagnosed between 1973 and 2003.

RESULTS

An hCG level >199 mIU/mL in the third through eighth week following molar evacuation was associated with at least a 35% risk of GTN.

CONCLUSION

Women with partial mole who have elevated hCG levels within the first few weeks after molar evacuation are at increased risk for developing GTN.

Changing trends in gestational trophoblastic disease

OBJECTIVE

The New Mexico Tumor Registry (NMTR) and Surveillance, Epidemiology and End Results (SEER) registries were utilized to determine (30+)-year trends in gestational trophoblastic disease and choriocarcinoma.

STUDY DESIGN

Age-adjusted incidence rates of gestational trophoblastic disease per 100,000 woman-years (1973-2003) and ratios per live births and pregnancies were calculated using data abstracted from the NMTR and state vital records. SEER data (1973-2002) were used to calculate age-adjusted incidence rates, estimated annual percentage change (EAPC) and relative survival rates for choriocarcinoma.

RESULTS

In New Mexico there were 1,153 cases affecting 377 non-Hispanic whites, 504 Hispanics and 241 American Indians, with respective incidence rates of 3.494, 5.150 and 9.991 (p < 0.0001). American Indian incidence rates decreased 53.3%, from 13.34 (1988-1992) to 6.23 (1998-2002). Within SEER (1973-2002), there were 504 gestational choriocarcinomas. The 30-year incidence rate was 0.132 and decreased by 37.7% (EAPC, -2.1% per year; p=0.0001)-by 40.1% for whites, 55.9% for blacks and 62.1% for others. However, over the previous 10 years, rates among blacks (0.097 vs. 0.259, p = 0.01) and for distant disease (0.044 vs. 0.071, p = 0.046) increased.

CONCLUSION

Disparities in incidence rates by race/ethnicity in New Mexico are decreasing. An increase in rates among blacks and distant disease diagnosis may be the consequence of fewer regional trophoblastic centers in the United States.

25 years' experience in the treatment of gestational trophoblastic neoplasia in Hungary

OBJECTIVE

To review our clinical experience in the treatment of gestational trophoblastic neoplasia (GTN) over the past 25 years in our national trophoblastic disease center.

STUDY DESIGN

Between January 1, 1977, and December 31, 2001, we treated 355 patients with GTN. The patients were between 14 and 53 years of age, with an average of 28.3. Primary chemotherapy was selected based on the patient's stage of gestational trophoblastic tumor (GTT) and prognostic score.

RESULTS

We found metastases in 49.3% (175 of 355) of our patients. Of 173 patients, 162 (93.2%) achieved remission as a result of methotrexate therapy. In 11 patients (6.8%) complete remission was achieved by combination chemotherapy, in some cases assisted by operation. Of 68 patients, 63 (92.6%) achieved remission as a result of actinomycin D therapy, and 5 (7.4%) achieved complete remission by combination chemotherapy. Chemotherapy, surgical intervention or other supplementary treatments resulted in 100% successful therapy in cases of nonmetastatic and low-risk metastatic disease.

CONCLUSION

According to our experience, methotrexate/folinic acid or actinomycin D should be the primary treatment in patients with nonmetastatic or low-risk metastatic GTN. Patients with resistance to single-agent chemotherapy regularly achieve remission with combination chemotherapy.

Management of gestational trophoblastic neoplasia with metastasis to the central nervous system: A 12-year review at the Philippine General Hospital

OBJECTIVE

To evaluate the clinical characteristics, treatment modalities and outcomes of patients with intracranial metastases resulting from gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

A retrospective study was done of patients with brain metastases due to GTN admitted to the Trophoblastic Diseases Section, Department of Obstetrics and Gynecology, Philippine General Hospital, from January 1992 to December 2004. Systemic chemotherapy in the form of methotrexate, etoposide, actinomycin D, cyclophosphamide and vincristine was the treatment of choice. Concomitant whole brain irradiation at a dose of 2,000-3,000 cGy (in 10 fractions of 200-300 cGy) was also given.

RESULTS

During 1992-2004, 30 patients with stage IV GTN (brain metastases) were diagnosed based on history, physical examination and computed tomography of the brain at the Philippine General Hospital. Of the 30 patients, 17 (56.7%) belonged to the "early" group (having central nervous system [CNS] symptoms on presentation), while 13 (43.3%) were in the "late" group (individuals who developed lesions during chemotherapy or who had relapsed after initial complete or partial remission). Headache was the most common neurologic symptom. Thirteen received etoposide, methotrexate, actinomycin D with cisplatin and etoposide, 5 received EMACE, 6 received methotrexate actinomycin-D and cyclophosphamide and 1 received methotrexate, etoposide, actinomycin-D. Of the 30 patients, 14 (46.7%) received concurrent whole brain irradiation. Eight (27%) patients responded to treatment and were considered in remission; remission was achieved in 6 of 17 (35%) in the early group and 2 of 13 (15%) in the late group. The mean survival time for the early CNS group was 7.3 months; it was 8.3 months for the late CNS group.

CONCLUSION

Intracranial metastasis in GTN is a curable disease that carries compromised survival because of difficulty in implementing the treatment regimen, patient noncompliance and late diagnosis.

Relapsed gestational trophoblastic neoplasia: A 20-year experience

OBJECTIVE

To review relapsed gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

Patients who had relapsed GTN between 1978 and 2001 at Queen Mary Hospital were included in the study. Records were reviewed and data analyzed regarding treatment, follow-up and survival.

RESULTS

Eighteen patients with relapsed GTN were identified. Patients' ages ranged from 21 to 56 years, with a median of 34. Eight were classified as low risk, 1 as medium risk and 9 as high risk at the time of diagnosis. Seven, 3 and 8 patients were treated with single-, dual- and multiple-agent chemotherapy, respectively. The median interval between remission and relapse was 6.5 months (range, 1-132). The time interval to relapse did not correlate with patient mortality (Mann-Whitney U test, p = 0.873). Four patients died of the disease, and all of them were classified and treated as low risk at the time of diagnosis. Three were lost to follow-up at some point. The remaining patient had relapsed choriocarcinoma and developed progressive disease despite intensive multiple-modality treatment. The overall survival rate for relapsed GTN was 77.8%.

CONCLUSION

Patients with relapsed GTN are salvageable. Failure of treatment seems attributable to patients who defaulted treatment or follow-up and presented late with massive disease.

Management of postmolar gestational trophoblastic disease with methotrexate and folinic acid: 15 years of experience

OBJECTIVE

To study the incidence of postmolar gestational trophoblastic disease (GTD) following hydatidiform mole and to evaluate the effectiveness of single-agent chemotherapy using methotrexate with folinic acid rescue.

STUDY DESIGN

A prospective study of all cases of hydatidiform mole diagnosed and treated in the department of obstetrics and gynecology, Medical College, Calicut, India, was started in June 1990 to determine the incidence of postmolar GTD and the effectiveness of single-agent chemotherapy with methotrexate and folinic acid in postmolar nonmetastatic GTD.

RESULTS

For the 15-year period from June 1990 to May 2005, 1,569 cases of hydatidiform mole were diagnosed and managed at our institution. The incidence of postmolar GTD among 1,569 cases of hydatidiform mole was 20.4%. Of the 321 cases of postmolar GTD diagnosed, 284 patients (88.5%) achieved complete remission with the methotrexate/folinic acid regimen. Fourteen multiparous patients (4.4%) underwent hysterectomy with methotrexate/folinic acid and achieved remission. Thus, 92.9% of patients with postmolar GTD had complete remission with the methotrexate/folinic acid regimen. The rest of the cases required multiagent therapy.

CONCLUSION

Regular follow-up of patients after evacuation of hydatidiform mole will detect cases of postmolar GTD at an early stage. Single-agent chemotherapy with methotrexate was effective in 92.9% of our cases.

Gestational trophoblastic disease in ectopic pregnancy: A case series

OBJECTIVE

To describe 6 cases of gestational trophoblastic disease (GTD) in ectopic pregnancy admitted to Hospital Universitario de Caracas (HUC).

STUDY DESIGN

Medical records of 6 patients admitted to the Obstetrics and Gynecology Department, HUC, from 1996 to 2004 were reviewed. They underwent surgery with a diagnosis of ectopic pregnancy, and histologic analysis revealed GTD. Clinical trends were analyzed.

RESULTS

The prevalence of GTD in ectopic pregnancy was 0.16:1,000 deliveries. The mean patient age was 29 years. The preceding gestation was a term delivery in 4 and abortion in 2. The mean gestational age at admission was 8 weeks. All patients complained of abdominal pain, and 3 of them also had vaginal bleeding. Ultrasound revealed an adnexal tumor in 5 cases; this tumor and hemoperitoneum (6 cases) were the most frequent surgical findings. Histopathologic diagnosis was partial mole in 5 and choriocarcinoma in 1. Four patients were lost to follow-up.

CONCLUSION

In this series the prevalence of ectopic GTD was high. The condition can mimic the usual symptoms of ectopic pregnancy, especially when a hemoperitoneum is present. It is important to apply strict histologic criteria for GTD when a sample of ectopic pregnancy is analyzed and to monitor those patients with careful human chorionic gonadotropin follow-up.

Persistent gestational trophoblastic disease is rarely, if ever, derived from non-molar first-trimester miscarriage

Traditional epidemiologic data suggest that persistent gestational trophoblastic disease (pGTD), may follow, and be derived from, either molar pregnancy, non-molar term pregnancy or first-trimester non-molar miscarriage. We examined a database of cases of possible or probable hydatidiform moles and proven pGTD derived from the Regional Trophoblastic Disease Unit, Charing Cross Hospital, London. There were 424 cases (6%), in whom the initial registered diagnosis was that of PHM or CHM but central histopathological review diagnosed a definite non-molar hydropic abortion (HA). In eight of the 424 (2%), although the histology of the most recent index pregnancy was that of non-molar miscarriage, there was a previous history of pregnancy affected by hydatidiform mole; two of these developed subsequent pGTD. Of a further 86 cases referred for a histopathological opinion prior to registration which demonstrated definite non-molar HA, none developed pGTD (zero of 510 (0%, 95% CI 0-0.7%)). During the same period there were 352 cases with pGTD requiring chemotherapy. In 31 cases, the only known pregnancy was the preceding apparent non-molar HA. However, of these, there were only three cases in whom the preceding histological products of conception had been centrally reviewed and were suggestive of non-molar pregnancy. However, in all three of these cases, the specimens were inadequate for definite exclusion of molar pregnancy. In one case in whom no material was available for review, molecular genetic analysis using restriction fragment length polymorphisms was carried out, and the choriocarcinoma was genetically derived from a previous molar pregnancy rather than the preceding HA. There were therefore no cases identified on the database of the trophoblastic disease unit of pGTD requiring treatment in whom the trophoblastic tumour could be genetically proven to have arisen from the preceding first trimester non-molar HA. We suggest that the risk of pGTD developing from a histologically confirmed non-molar HA is less than 1 in 50,000 and that the majority of pGTD cases previously reported to have been caused by a non-molar miscarriage probably represent disease due to an unrecognised early molar pregnancy.

Gestational trophoblastic disease

Gestational trophoblastic disease is a spectrum of pregnancy disorder arising from the placental trophoblastic tissues. It characterised by the secretion of a distinct tumour marker, the beta-HCG. This condition is highly curable even in the presence of metastasis. The incidence of this disease is higher in the Asian population. The major well-established risk factors for gestational trophoblastic disease are advanced maternal age and a past history of gestational trophoblastic disease. Common clinical presentations include vaginal bleeding in early trimester, uterus larger than gestational age, absence of fetal parts after 20 weeks of gestation. Ultrasonography is a reliable non-invasive tool for diagnosis of gestational trophoblastic disease in the clinical setting. All placental tissue following miscarriage or curettage should have histopathological evaluation to exclude gestational trophoblastic disease. Since this group of disorders is one of the highly curable neoplasms, early diagnosis and prompt treatment is necessary.

The clinical presentation, treatment, and outcome of patients diagnosed with possible ectopic molar gestation

The objective of this study was to determine the clinical presentation, treatment, and outcome of patients diagnosed with possible ectopic molar gestation registered with the Trophoblastic Disease Screening and Treatment Centre, Weston Park Hospital, Sheffield between 1986 and 2000. From the 5581 women registered, those with a diagnosis of ectopic molar pregnancy were identified from a computer database. Information regarding the relevant history of each patient and the clinical presentation, treatment, and outcomes of gestational trophoblastic disease (GTD) was determined by reviewing referral forms, case notes, and pro formas completed by the referring gynecologist. Histological review of the cases was undertaken where possible. Suspected ectopic molar gestations comprised 31/5581 (0.55%) of registrations. Known risk factors for ectopic pregnancy were identified in 79% of cases. Central histological review confirmed only six cases of GTD: three choriocarcinoma and three early complete moles. Four patients subsequently required chemotherapy. All patients are now in complete remission. We conclude that ectopic GTD is uncommon, with a UK incidence of approximately 1.5 per 1,000,000 births. Initial management is usually surgical removal of the conceptus, pathological suspicion of the diagnosis and registration with a screening center. Chemotherapy may be required and the prognosis is excellent.

Epidemiology of gestational trophoblastic diseases

The epidemiology of gestational trophoblastic diseases is unclear. Problems with collection and interpretation of differing data abound. Hydatidiform mole (HM) is associated with abnormal gametogenesis and/or fertilization. This is further influenced by age, ethnicity and a prior history of an HM suggesting a genetic basis for its aetiology. Whilst a prior HM is significant in the development of trophoblastic neoplasia there is no clear explanation for the development of gestational trophoblastic neoplasia in association with a normal gestation. The development and improvements in suction curettage, termination of pregnancy, contraceptive techniques, diagnostic imaging and biochemical testing have been associated not only with a fall in the birth rate, but also with a reduction in the incidence of trophoblastic diseases. Future study should examine the mechanism of malignant change in normal and abnormal trophoblast.

Is there a relationship between treatment for infertility and gestational trophoblastic disease?

BACKGROUND

The aim of the study was to record the incidence of treatment for infertility prior to development of gestational trophoblastic disease (GTD).

METHODS AND RESULTS

A retrospective analysis was undertaken of 231 consecutive women receiving chemotherapy for persistent GTD at Weston Park Hospital, Sheffield, from 1991 to 2001. Three patients in this group had received treatment for infertility prior to their molar pregnancy. In a control group of 226 patients not requiring treatment for persistent GTD, four had had treatment for infertility just before their molar pregnancy, and in a further control group of 208 'normal' pregnancies, eight patients had had treatment for infertility prior to conception.

CONCLUSION

We conclude that we can demonstrate no relationship between infertility treatment and subsequent development of GTD.

Epidemiology and aetiology of gestational trophoblastic diseases

Gestational trophoblastic diseases (GTD) consist of a group of neoplastic disorders arising from placental trophoblastic tissue after normal or abnormal fertilisation. The WHO classification of GTD includes hydatidiform mole, invasive mole, choriocarcinoma, placental site trophoblastic tumour, and miscellaneous and unclassified trophoblastic lesions. GTD have a varying potential for local invasion and metastases and they generally respond to chemotherapy. Broad variations in the distribution of GTD exist worldwide, with higher frequencies in some parts of Asia, the Middle East and Africa, but the extent to which they can be attributed to methodological difficulties in obtaining accurate rates is unclear. Maternal age and a history of GTD have been established as strong risk factors for hydatidiform mole and choriocarcinoma. We review published data on the worldwide distribution of GTD, original data from cancer- registry-based statistics on choriocarcinoma, and major aetiological hypotheses, including parental age, AB0 blood groups, history of GTD, reproductive factors, oral contraceptive use, and other environmental factors.

Gestational trophoblastic tumor after medical abortion

BACKGROUND

Nonmetastatic gestational trophoblastic tumor occurring after early elective medical abortion using mifepristone and misoprostol is unusual.

CASE

A young woman at 6 to 7 weeks' gestation presented with brown spotting requesting medical abortion. Pretreatment ultrasound was consistent with an abnormal pregnancy. Passage of tissue ensued after mifepristone-misoprostol administration. Recovery was normal, with a postabortion ultrasound on day 16 showing a reduction in intracavitary contents. The patient declined surveillance with serial beta-human chorionic gonadotropin (beta-hCG) levels and was lost to follow-up. Sixty days after initial treatment, she presented to a hospital with a history of intermittent bleeding and underwent curettage, revealing a complete hydatidiform mole. Chemotherapy was instituted when levels of hCG plateaued. Complete hCG regression occurred after three weekly injections of methotrexate, and postmolar surveillance is uneventful to date.

CONCLUSION

Gestational trophoblastic tumor may occur after early medical abortion.

Gestational trophoblastic syndrome: an audit of 112 patients. A South African experience

Gestational trophoblastic disease (GTD) represents a spectrum of histologically distinct entities including molar pregnancy and choriocarcinoma. The incidence of GTD varies in different parts of the world with high incidences in countries like Japan (2 / 1000 pregnancies). With the advent of sensitive assays for detection of serum beta human chorionic gonadotrophin (HCG) and ultrasound, GTD can now be detected earlier in pregnancy. To date no studies have been reported from South Africa regarding the epidemiology, management, and outcome of patients with GTD. This study was a retrospective audit based on 112 patients with GTD treated at King Edward VIII Hospital, Durban, South Africa. Clinical records of patients were reviewed with regards to presentation, investigation, management and outcome. Of 112 patients, there were 78 patients (70%) with hydatidiform mole and 34 patients (30%) with choriocarcinoma. The mean age of patients was 28.5 years (SD 8.1 years). The majority of patients were Black females (94.6%) while 4.4% were Asian and 1% Coloured females. The most common presenting symptom was vaginal bleeding (93.8%). There were 74 patients (66.7%) who had a previous normal term pregnancy and only two patients (1.8%) had previous molar pregnancies. Suction curettage was the main treatment modality for patients with molar pregnancy while choriocarcinoma was treated primarily with chemotherapy. A total of 72 percent of patients with molar pregnancy and 28 percent with choriocarcinoma had complete remission after initial treatment. Twelve patients died during the course of treatment mainly due to late presentation and advanced metastatic disease. Complete cure was achieved in 89% of patients. Age, parity, previous history, initial uterine size, presence of theca-lutein cysts, and initial betaHCG concentration was not found to be prognostic for persistent trophoblastic disease. In the present study, the incidence of molar pregnancy and choriocarcinoma was 1.2 / 1000 and 0.5 / 1000 deliveries, respectively. This is much lower than those quoted from countries such as Japan. However, the incidence quoted from our study may be overestimated as this was a hospital-based study and most of the uncomplicated deliveries occur in referring centers. Only 20% of patients in this study were above the age of 35 years with a mean age of 28.5 years. The majority of patients were of Black African ethnic origin mainly due to the fact that our hospital is a referral center for Black patients. Similar to other studies, the majority of patients with molar pregnancy were treated with suction curettage while the majority of patients with choriocarcinoma were treated with chemotherapy. Overall, spontaneous remission was achieved in 60% of patients with molar pregnancy and an overall complete cure was achieved in 89% of patients.

Correlation of risk categorization in gestational trophoblastic tumor between old and new combined staging and scoring system

AIM

To determine the correlation of risk categorization in gestational trophoblastic tumor between the revised International Federation of Gynecology and Obstetrics (FIGO) staging system combined with the original World Health Organization (WHO) scoring system, and the new FIGO staging system combined with the modified WHO scoring system.

METHODS

We reviewed the medical records of 124 patients with gestational trophoblastic disease seen at Songklanagarind Hospital from 1988 to 2000. All patients were classified retrospectively by the FIGO staging system (both the revised system in 1992 and the new system in 2000) and the WHO scoring system (both the original and the modified one). The correlation of risk categorization between the revised FIGO staging system combined with the original WHO scoring system (old combined system), and the new FIGO staging system combined with the modified WHO scoring system (new combined system) was studied, and the remission rates in discrepant groups were identified.

RESULTS

The mean score was 9.7+/-5.0 (range 1-21) for the original WHO and 8.3+/-5.0 (range 1-20) for the modified WHO. The correlation of risk categorization between old and new combined systems was 97.9%. There was no patient in the low risk group as classified by the old combined system, but patients were classified as in the high risk group by the new combined system. One patient, who was in the high risk group classified by the old combined system, but in the low risk group classified by the new combined system, achieved complete remission after treatment with single agent chemotherapy.

CONCLUSION

There was good correlation between the old and the new combined systems.

Ethnic differences at risk for gestational trophoblastic disease in New Mexico: A 25-year population-based study

OBJECTIVE

The purpose of this study was to compare gestational trophoblastic disease incidence rates with the use of population-based data.

STUDY DESIGN

All incident cases between 1973 and 1997 and live birth, pregnancy, and women at risk were tabulated with the use of data that were derived from the New Mexico Tumor Registry and Vital Records and Health Statistics Annual Reports. Statistical methods included trends analyses, odds ratios, and Poisson regression.

RESULTS

Of 939 total cases, 312 non-Hispanic white women, 399 Hispanic white women, 201 American Indian women, and 27 other women were affected. Age-adjusted incidence rates were significantly higher for American Indian women (11.16%) compared with non-Hispanic (3.57%) or Hispanic white women (5.32%); the probability value was <.001. When live birth (1:438 women) and pregnancy (1:486 women) denominators were considered, American Indian women alone were at increased risk, and the ratio increased by 56% over 25 years. American Indian women were also at increased risk for partial mole (relative risk, 4.03; 95% CI, 2.57-6.31), invasive mole (relative risk, 26.7; 95% CI, 7.81-93.14), and choriocarcinoma (relative risk, 6.29; 95% CI, 1.81-22.66) variants.

CONCLUSION

American Indians are at increased risk relative to the other predominant ethnic groups in New Mexico. Age-adjusted standardization provided a reproducible measurement that may be applicable across other registries.

[Risk factors for gestational trophoblastic tumors following complete hydatidiform mole]

OBJECTIVES

The aim of our study was to determine the factors associated with higher incidence of trophoblastic tumours following complete hydatidiform mole.

MATERIAL AND METHODS

Epidemiological and clinical factors were studied in eighty five patients with complete hydatidiform mole evacuated from 1973 to 1997 in Department of Obstetrics and Gynecology Medical University of Gdańsk. Univariate and multivariate analysis were used to study of group.

RESULTS AND CONCLUSIONS

In the analysis of 85 patients we found three prognostically independent factors that were associated with higher incidence of trophoblastic tumours after the complete hydatidiform mole: pre-evacuation hCG level, presence of prominent theca lutein cysts (greater than 6 cm in diameter) and molar pregnancy in the patient's past history. Persistent vomiting was a symptom of lower significance as a risk factor of trophoblastic tumour.

Gestational trophoblastic neoplasia and evidence-based medicine

OBJECTIVE

To determine whether protocols for the management of gestational trophoblastic neoplasia conform to the principles of evidence-based medicine.

STUDY DESIGN

Protocols for the management of low- and high-risk gestational trophoblastic neoplasia were examined to determine to what extent they conformed to the principles of evidence-based medicine.

RESULTS

Nearly all current chemotherapy regimens for gestational trophoblastic neoplasia are based on the experience of management of various risk groups, variously defined. Some prospective, randomized studies were flawed by faulty selection criteria. Local population variations may influence the results of management.

CONCLUSION

The management of trophoblastic neoplasia is based on physician experience. Nearly all prospective, randomized studies have been flawed. There is a need for carefully planned prospective studies with stringent inclusion criteria to determine the most effective and cost-effective and least toxic therapy, particularly for low-risk neoplasia.