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.

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.

Complete hydatidiform mole in women aged 40 to 49 years

OBJECTIVE

To describe the clinical course of women aged 40 to 49 presenting with complete hydatidiform mole.

STUDY DESIGN

All cases of complete mole diagnosed at the New England Trophoblastic Disease Center were reviewed. A total of 82 patients met the study criteria.

RESULTS

Study patients had a mean age of 44.2 years, gravidity of 4.6 and parity of 2.6. The mean hCG on presentation was 230,484 mIU/mL. Most patients presented with abnormal vaginal bleeding (77%). Of the 82 patients, 83% underwent dilation and curettage without prophylactic chemotherapy; 53% of those patients developed gestational trophoblastic neoplasia (GTN). Patients who developed GTN were significantly more likely both before and after evacuation to have higher hCG levels than those who did not. There were no GTN cases among patients receiving either prophylactic chemotherapy or upfront hysterectomy. Aggressive upfront therapy was associated with shortened time to hCG normalization and fewer lines of surgical or chemotherapeutic therapy.

CONCLUSION

All women in their 40s with complete mole are at high risk for GTN and might benefit from aggressive upfront therapy. Those patients with hCG levels >175,000 mIU/mL constitute an "ultra-high-risk" group for whom prophylactic chemotherapy or hysterectomy should be especially considered.

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.

Reduction of postmolar gestational trophoblastic neoplasia by early diagnosis and treatment

OBJECTIVE

To compare contemporary and historical clinical presentation of complete moles (CMs) and the rates of gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

A study was conducted of a current cohort of 108 consecutive cases of CM from 3 medical centers in Israel accrued during a 5-year period and 87 CM cases reported by the New England Trophoblastic Disease Center (NETDC) from the years 1988 to 1993. Clinical presentation and the rate of GTN of our cohort of CM and cases from the NETDC were compared.

RESULTS

Fewer current CMs presented with vaginal bleeding than historic NETDC cases (52% vs. 84%, p <0.001, respectively), and a greater proportion of current patients with CM were referred to termination of the pregnancy due solely to ultrasonographic findings (38% vs. 9%, p < 0.001, respectively). GTN rates were significantly lower in the current patients with CM compared to NETDC controls (14% vs. 23%, p<0.05, respectively).

CONCLUSION

First-trimester ultrasound examination leads to early diagnosis of molar and of nonviable pregnancies subsequently histologically diagnosed as CM. The early evacuation of the molar pregnancy is associated with a reduction in the rate of GTN.

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.

[Survey of gestational trophoblastic disease incidence among 3.6 million pregnancies in China]

OBJECTIVE

To survey incidence of gestational trophoblastic disease (GTD) in China and to provide useful information for prevention and better treatment of the disease.

METHODS

The survey was retrospectively carried out from 1991 to 2000 and included 143 hospitals in the following seven Chinese provinces: Zhejiang, Jiangsu, Fujian, Anhui, Jiangxi, Shanxi and Henan.

RESULTS

Excluding incomplete data, data from 118 hospitals from seven provinces were finally analyzed. The total numbers of pregnancy and GTD were 3,674, 654 and 14,222, respectively. The GTD cases occurred mainly among 20 - 34 year old women, which accounted for 85.5% of total GTD. The incidence of GTD was 3.87 per thousand. There were 9,194 cases (64.6%) of hydatidiform, 3,452 cases (24.3%) of invasive mole, 1521 cases (10.7%) of choriocarcinoma, 55 cases (0.4%) of placenta-site trophoblastic tumor, respectively.

CONCLUSIONS

The results of this survey are reliable and representative due to large sampling and hospital-based data collection. The incidences of GTD decreased significantly compared with 1950s'. It is important to take pathological examination for GTD and to diagnose complate mole and partial mole correctly.