Second curettage versus conventional chemotherapy in avoiding unnecessary chemotherapy and reducing the number of chemotherapy courses for patients with gestational trophoblastic neoplasia: A systematic review and meta-analysis

BACKGROUND

Chemotherapy is the recommended treatment for gestational trophoblastic neoplasia (GTN). Second curettage had been advocated to avoid unnecessary chemotherapy and to reduce the courses of chemotherapy; however, consensus has not been reached as there are arguments claiming its inability of inducing complete regression.

OBJECTIVES

The present study was performed to clarify the effectiveness of second curettage for avoiding unnecessary chemotherapy and lowering the number of chemotherapy courses in patients with post-molar GTN.

SEARCH STRATEGY

Seven predominant electronic databases were searched, including four English databases and three Chinese databases, from the inception of each database until January 31, 2023.

SELECTION CRITERIA

Studies were included if they were: (1) human, (2) explicitly indicated exposure to second curettage, (3) explicitly indicated control to conventional chemotherapy, (4) explicitly indicated the participants were patients with gestational trophoblastic neoplasia (GTN), and (5) compared the outcome of interest as the number of the course of chemotherapy.

DATA COLLECTION AND ANALYSIS

Two authors extracted and analyzed the data independently. Disagreements were reconciled by reviewing the full text by a third author. The data of study location, data collection, study design, number of participants, intervention strategy, control strategy, the follow-up period, outcome, adverse events were analyzed.

MAIN RESULTS

With regard to avoiding unnecessary chemotherapy, the overall pooled effect size of the second curettage group had a significant advantage over the conventional chemotherapy group with an OR of 0.02 (95% CI: 0.00-0.06). Meanwhile, for reducing the number of chemotherapy courses, the overall pooled effect size of the second curettage group had significant advantage over the conventional chemotherapy group with a mean difference of -2.11 (95% CI: -3.72 to -0.51).

CONCLUSION

The second curettage group had a significant advantage over the conventional chemotherapy group in avoiding unnecessary chemotherapy and reducing the number of chemotherapy courses. Further larger multi-center randomized controlled trials should be conducted to confirm our results and to clarify the optimal patients' group for second curettage in patients with post-molar GTN.

The role of surgery in gestational trophoblastic disease: an overview

Gestational trophoblastic disease comprises a group of rare, and potentially malignant, conditions that arise from abnormal trophoblastic proliferation. When there is invasion and evidence of metastatic disease, gestational trophoblastic neoplasia is used. While chemotherapy is the mainstay of treatment for gestational trophoblastic neoplasia, the role of surgery has come full circle in recent years. Before the introduction of highly effective systemic treatment options, surgery was the default treatment. Surgery for gestational trophoblastic neoplasia often yielded unsatisfactory results and mortality remained high. In recent years, the role of adjuvant surgery in the management of gestational trophoblastic neoplasia has been examined with great interest. We aim to provide an overview of the various surgical approaches employed in managing gestational trophoblastic neoplasia, including their indications, techniques, and outcomes. Additionally, we discuss whether there is a role to do less in surgery for gestational trophoblastic neoplasia and describe our experience with a modified surgical technique for its treatment. By summarizing the current evidence, this article highlights the significant contributions of surgery to the holistic management of patients with gestational trophoblastic neoplasia and provides a framework on which to base management and treatment programs.

Chemotherapy is not needed when complete evacuation of gestational choriocarcinoma leads to hCG normalization

BACKGROUND

The standard treatment for gestational choriocarcinoma is chemotherapy.

OBJECTIVE

To describe the risk of recurrence with expectant management of gestational choriocarcinoma that has reached a normal human chorionic gonadotropin level after tumor removal without adjuvant chemotherapy.

METHODS

A retrospective multicenter international cohort study was conducted from 1981 to 2017 involving 11 gestational trophoblastic disease reference centers with patient's follow-up extended until 2023. Clinical and biological data of included patients were extracted from each center's database. The inclusion criteria were i) histological diagnosis of gestational choriocarcinoma in any kind of placental tissue retrieved, ii) spontaneous normalization of human chorionic gonadotropin level following choriocarcinoma retrieval, iii) patient did not receive any oncological treatment for the choriocarcinoma, iv) and at least 6 months of follow-up after the first human chorionic gonadotropin level normalization.

RESULTS

Among 80 patients with retrieved gestational choriocarcinoma and whose human chorionic gonadotropin level normalized without any other oncological therapy, none had a recurrence of choriocarcinoma after a median follow-up of 50 months. The median interval between choriocarcinoma excision and human chorionic gonadotropin level normalization was 48 days. The International Federation of Gynecology and Obstetrics/World Health Organization risk score was ≤6 in 93.7% of the cases.

CONCLUSIONS

This multicenter international study reports that selected patients with gestational choriocarcinoma managed in gestational trophoblastic disease reference centers did not experience any relapse when the initial tumor evacuation is followed by human chorionic gonadotropin level normalization without any additional treatment. Expectant management may be a safe approach for highly selected patients.

Pneumothorax caused by metastatic gestational trophoblastic neoplasia: a case report

INTRODUCTION

Gestational trophoblastic neoplasia (GTN) is a group of malignant neoplasms that arise from abnormal proliferation of trophoblastic tissue. The metastatic spread rate is depended on the histopathological type, with pulmonary metastases being the most common (80%) in patients with metastases. Pneumothorax as a primary manifestation is extremely rare. We hereby discuss a unique case of spontaneous hemi-pneumothorax due to metastatic GTN in a 30-weeks pregnant woman.

CASE PRESENTATION

A 25-year-old woman - G2 P0 A1 - was admitted to our maternal intensive care department with atypical respiratory symptoms. A chest x-ray revealed a large right sided pneumothorax. The patient underwent an urgent percutaneous chest tube. Since halting of the suction resulted in residual pneumothorax, a video-assisted thoracoscopic surgery (VATS) with wig resection of a bullous lesion was performed followed by chemical pleurodesis. Histopathological examination identified the lesion as a gestational trophoblastic metastasis with some features of choriocarcinoma. After primary section Caesarea adjuvant chemotherapy (MTX) was instigated with rapid decline of serum HCG values. Six months after surgery she was doing well with no biochemical or radiographic evidence of recurrent metastasis.

CONCLUSION

Lung metastases are common in patients with metastatic GTN; however, pneumothorax is an extremely rare complication. We report a case of pneumothorax in a 30-week pregnant woman caused by pulmonary spread of GTN from a previous miscarriage. This case illustrates that in patients with pneumothorax and a history of miscarriage, metastatic GTN should be considered as a possible cause.

Pulmonary resection of residual lesions of pulmonary metastasis from gestational trophoblastic neoplasia

OBJECTIVE

To evaluate the prognosis and recurrence in patients with residual lesions of pulmonary metastasis from gestational trophoblastic neoplasia after initial treatment, and to explore the clinical significance of pulmonary resection.

METHODS

A retrospective analysis was performed on 606 patients with residual lesions from pulmonary metastasis after receiving standardized chemotherapy as initial treatment in Peking Union Medical College Hospital from January 2002 to December 2018. Patients were divided into surgery (51 patients) and non-surgery (555 patients) groups. The prognosis of these patients was compared. Risk factors affecting recurrence were analyzed to explore the effect of pulmonary resection.

RESULTS

Among low risk patients, complete remission rate was 100% and recurrence rate was <1% in both groups. Among high risk patients, complete remission and recurrence rates were 93.5% and 10.3% in the surgery group and 94.7% and 14.3% in the non-surgery group, respectively. There was no significant difference in prognostic features between the two groups (all p>0.05). No significant difference was found in recurrence rates based on recurrence risk factors (≥3.2 cm residual lung lesions, prognosis score ≥9.0, and drug resistance) between the two groups (all p>0.05).

CONCLUSION

After standardized chemotherapy, pulmonary resection was not necessary for initially treated stage III gestational trophoblastic neoplasia patients whose blood β human chorionic gonadotropin levels normalized and residual lung lesions remained stable. These patients should be closely monitored during follow-up, regardless of the size of the residual lung lesions or high/low risk score, especially within a year after complete remission.

High-intensity focused ultrasound as a pretreatment combined with hysteroscopic resection for gestational trophoblastic neoplasia with chemotherapy intolerance: a case report

BACKGROUND

Due to resistance and intolerance to chemotherapy, localized lesion resection may be required in some patients with Gestational trophoblastic neoplasia (GTN), which may lead to massive bleeding. In this case report, we describe the successful use of high-intensity focused ultrasound (HIFU) as an effective pretreatment method for surgical procedure in a patient with GTN to reduce the perioperative risk and the impact on fertility.

CASE PRESENTATION

A 26-year-old woman was diagnosed with high-risk GTN (FIGO Stage III: 12 prognostic scores) after a hydatidiform mole. The fifth chemotherapy cycle was interrupted due to severe chemotherapy toxicity. However, the uterine lesion was still present and the beta-human chorionic gonadotropin (β-hCG) level was not restored to normal. Therefore, ultrasound-guided HIFU was performed as a pretreatment method to shrink the lesion and prevent massive bleeding during localized lesion resection. The effectiveness of ablation was evaluated immediately using contrast-enhanced ultrasound and Color Flow Doppler ultrasonography. One month after HIFU treatment, the uterine lesion was completely resected under hysteroscopic surgery. During the surgery, HIFU was found to have shrunk the lesion and there was minimal bleeding (5 mL). The uterine cavity morphology and menstruation returned to normal after surgery. The patient has showed no signs of recurrence as of one-year follow-up.

CONCLUSION

Ultrasound-guided HIFU ablation may be a new choice for high-risk GTN patients with chemoresistance or chemo-intolerance. As a noninvasive pretreatment method, HIFU can shrink the uterine lesion, and reduce the risk of bleeding with no obvious effect on fertility.

Epithelioid Trophoblastic Tumour: A Case with Genetic Linkage to a Child Born over Seventeen Years Prior, Successfully Treated with Surgery and Pembrolizumab

Epithelioid trophoblastic tumours are rare neoplasms showing differentiation towards the chorion leave-type intermediate cytotrophoblast, with only a handful of cases being reported in the literature. These tumours are slow-growing and are typically confined to the uterus for extended periods of time. While the pathogenesis is unclear, they are thought to arise from a remnant intermediate trophoblast originating from prior normal pregnancies or, less frequently, gestational trophoblastic tumours. A protracted time period between the gestational event and tumour development is typical. This case describes a 49-year-old previously healthy female who presented with a completely asymptomatic uterine mass, discovered incidentally during a routine gynaecological assessment. The pathological analysis of the hysterectomy specimen confirmed an epithelioid trophoblastic tumour, involving the uterus and cervix. This is a rare gynaecological tumour. A comparative short tandem repeat analysis revealed genetic similarities to a previous healthy gestation seventeen years prior. She was successful treated with adjuvant pembrolizumab, with no evidence of disease recurrence to date.

A novel approach with concomitant laparoscopic uterine artery ligation and D&C as initial treatment for complicated gestational trophoblast disease in cesarean scar and cervical ectopic pregnancies

OBJECTIVE

Gestational trophoblast disease (GTD) in low-lying implantation ectopic pregnancy (LLIEP) is extremely rare. Surgical removal of GTD lesions which is the initial treatment of choice carries a high risk of intraoperative massive bleeding. Adequate management is challenging and inconclusive.

CASE REPORT

We present two unusual cases with a diagnosis of GTD in advanced LLIEP. The first case had choriocarcinoma in cesarean scar and the second case had mole pregnancy in cervix. Both cases were managed with laparoscopy uterine artery ligations followed by transvaginal intrauterine curettage and vacuum aspiration with a small amount of surgical blood loss and then resumed regular menstruation. To understand the different surgical approaches and their potential advantages in managing such rare diseases, relevant cases in the literature were reviewed.

CONCLUSION

Much attention should be paid to avoid massive bleeding at initial surgical intervention in patients with GTD in advanced LLIEP. This novel approach with combination of laparoscopic uterine artery ligations and evacuating curettage in selected patients is highly recommended to minimize surgical blood loss. The obvious advantages include technical feasibility, less surgery-related bleeding and potential fertility preservation.

Curative effect of second curettage for treatment of gestational trophoblastic disease - Results of the Belgian registry for gestational trophoblastic disease

OBJECTIVE

We assessed the curative effect of a second curettage in patients with persistent hCG serum levels after first curettage for a gestational trophoblastic disease (GTD).

STUDY DESIGN

This prospective observational study used the data of the Belgian register for GTD between July 2012 and January 2017. We analysed the data of patients who underwent a second curettage. We included 313 patients in the database. Primary endpoints were need for second curettage and chemotherapy.

RESULTS

Thirty-seven patients of the study population (12 %) underwent a second curettage. 20 had persistent human chorionic gonadotropin hormone (hCG) elevation before second curettage. Of them, 9 patients (45 %) needed no further treatment afterwards. Eleven patients (55 %) needed further chemotherapy. Nine (82 %) were cured with single-agent chemotherapy and 2 patients (18 %) needed multi-agent chemotherapy. Of the 37 patients, patients with hCG levels below 5000 IU/L undergoing a second curettage were cured without chemotherapy in 65 % versus 45 % of patients with hCG level more than 5000 IU/L. Of the ten patients with a hCG level below 1000 IU/L, eight were cured without chemotherapy.

CONCLUSIONS

Patients with post-mole gestational trophoblastic neoplasia can benefit from a second curettage to avoid chemotherapy, especially when the hCG level is lower than 5000 IU/L.

Outcomes of minimally invasive versus open abdominal hysterectomy in patients with gestational trophoblastic disease

OBJECTIVE

The aim of this study is to compare surgical and oncologic outcomes for women undergoing MIH or open abdominal hysterectomy (OAH) for management of gestational trophoblastic disease (GTD).

METHODS

Patients who underwent hysterectomy for GTD between January 1, 2009 and December 31, 2018 were identified using an institutional database and tumor registry. Patients were stratified based on indication for and mode of hysterectomy.

RESULTS

39 patients underwent hysterectomy for GTD - 22 MIH and 17 OAH. 26 hysterectomies (66.7%) were performed for primary treatment of GTD, 7 (17.9%) for chemoresistance, 2 (5.1%) for uterine hemorrhage, and 4 (10.3%) for other indications. Mean tumor size (4.2 vs 4.6 cm; p = .81) and operative time (136 vs 163 mins; p = .42) were similar in both groups. MIH was associated with significantly less blood loss (71.5 vs 427.3 ml; p = .03) and shorter hospital stay (1.5 vs 3.9 days, p = .02) than OAH. Postoperative histology comprised 12 complete moles (6 invasive), 8 choriocarcinomas, 9 placental site trophoblastic tumors and 9 epithelioid trophoblastic tumors. Median follow-up was 67.2 months (50.2 MIH, 79.3 OAH; range 11.1-131.2) and there was no difference in remission (81.8% MIH vs 76.5% OAH; p = .68). There were 7 recurrences (4 MIH, 3 OAH) and 3 deaths (2 MIH, 1 OAH). Overall survival was 97.3% at 2 years and 88.5% at 5 years. There was no significant difference in 5-year survival by mode of surgery (MIH 90.9%, OAH 83.3%; p = .40).

CONCLUSIONS

Patients undergoing MIH at our centers have similar oncologic outcomes, lower surgical blood loss and shorter hospital stay compared to those undergoing OAH. Overall survival is similar regardless of mode of surgery.

Sequential metastasis to the liver and pancreas 4 years after gestational trophoblastic neoplasia: a case report

This case report describes a 43-year-old female initially diagnosed with gestational trophoblastic neoplasia that then experienced metastasis to the liver and then subsequently to the pancreas nearly 4 years after the primary diagnosis. After resection of the body and tail of the pancreas, the postoperative histopathological examination confirmed a placental site trophoblastic tumour that had developed after several cycles of chemotherapy for the original primary tumour and the liver metastases. This type of sequential recurrence of gestational trophoblastic neoplasia in the primary site or metastatic sites, such as the liver or pancreas, can be cured by a comprehensive treatment strategy involving surgery and/or salvage chemotherapy and continuous follow-up over a long period, especially for patients with a high-risk status.

Surgery including fertility-sparing treatment of GTD

Gestational trophoblastic disease (GTD) consists of a spectrum of diseases, including hydatidiform moles, invasive mole, metastatic mole, choriocarcinoma, placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). GTD is a relatively uncommon disease occurring in women of reproductive age, with high cure rates. Primary treatment of hydatidiform moles includes uterine evacuation, followed by close monitoring of serial hCG levels to detect for post-molar gestational trophoblastic neoplasia (GTN). In patients with GTN, the main therapy consists of chemotherapy, although some surgical procedures are important in selected patients to achieve curing. Hysterectomy is the mainstay treatment for PSTT or ETT and may be considered in selected patients for management of hydatidiform mole and malignant GTN especially in chemoresistant disease. Resection of metastatic lesions such as in the lung or brain can be considered in selected patients with isolated chemoresistant tumour. Surgical treatment of GTD will be discussed in this chapter.

Cost-effectiveness of second curettage for treatment of low-risk non-metastatic gestational trophoblastic neoplasia

OBJECTIVE

Low-risk non-metastatic gestational trophoblastic neoplasia (GTN) has been treated with single agent chemotherapy, but second curettage is emerging as an alternative strategy with reported cure rates of 40%. We sought to estimate the cost-effectiveness of second curettage as the first line treatment of low-risk GTN.

METHODS

A decision-analytic model was created using TreeAge software to compare costs and outcomes for women with WHO staged low-risk GTN undergoing treatment with 5-day methotrexate (MTX), biweekly pulsed actinomycin-D, or second curettage. Probabilities were derived from the literature. Outcomes of interest included side effects from chemotherapy, need for additional agents, hemorrhage, uterine perforation, and cure rates. Utilities were applied to discounted life expectancy at a rate of 3% to generate quality adjusted life years (QALYs). Sensitivity analyses were then performed in order to assess the robustness of our assumptions.

RESULTS

Of the three treatment arms, MTX was associated with the lowest cost and had similar QALYs to the other studied modalities. Second curettage was associated with 49 additional cures when applied to a theoretic cohort of 1000 women, as well as an additional 83 hemorrhages and 17 uterine perforations. Sensitivity analysis on the cure rate of second curettage revealed that second curettage was not cost-effective over MTX unless its probability of cure was 98%.

CONCLUSION

Our study found 5-day MTX was the cost-effective strategy for treatment of women with low-risk, non-metastatic GTN when compared to second curettage and actinomycin-D. In a carefully selected patient population, second curettage may be an additional treatment strategy.

Incidence and outcome of gestational trophoblastic disease in lower Egypt

BACKGROUND

Gestational trophoblastic disease (GTD) defines a spectrum of proliferative disorders of trophoblastic epithelium of the placenta. Incidence, risk factors, and outcome may differ from one country to another.

OBJECTIVE

To describe incidence, patient characteristics, treatment modalities, and outcome of GTD at Mansoura University which is a referral center of Lower Egypt.

METHODS

An observational prospective study was conducted at the GTD Clinic of Mansoura University. The patients were recruited for 12 months from September 2015 to August 2016. The patients' characteristics, management, and outcome were reported.

RESULTS

We reported 71 clinically diagnosed GTD cases, 62 of them were histologically confirmed, 58 molar (33 CM and 25 PM) in addition to 4 initially presented GTN cases. Mean age of the studied cases was 26.22 years ± 9.30SD. Mean pre-evacuation hCG was 136170 m.i.u/ml ±175880 SD. Most of the cases diagnosed accidentally after abnormal sonographic findings (53.2%). Rate of progression of CM and PM to GTN was 24.2% and 8%, respectively.

CONCLUSION

The incidence of molar pregnancy and GTN in our locality was estimated to be 13.1 and 3.2 per 1000 live births respectively. We found no significance between CM and PM regarding hCG level, time to hCG normalization, and progression rate to GTN.

Role of hysterectomy in chemoresistant gestational trophoblastic neoplasia

No abstract provided.

Analysis of Clinical Characteristics and Outcomes in 7 Patients with Re-recurrent Gestational Trophoblastic Neoplasia

OBJECTIVE

To analyze the clinical characteristics and outcomes of patients with re-recurrent gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

A total of 547 patients with typical GTN at our institution from 2000-2012 were enrolled in this retrospective study. Of 547 cases, 29 relapsed after initial remission, and 7 of 29 patients with recurrent GTN had repeat relapses. The detailed clinical charac- teristics of patients with re-recurrent GTN were eval- uated.

RESULTS

The recurrence and re-recurrence rates in 547 patients with GTN were 5.3% and 24%, respective- ly. In 7 patients with re-recurrent GTN the mean age was 43 years. The mean level of serum [-hCG before each treatment was 11,405 IU/L. The mean time interval from last treatment to recurrence was 38 months. All 7 patients received first- and second-line chemotherapy, and 4 of them required salvage chemotherapy. The total number of chemotherapy courses administered was 137 (mean= 6). In conjunction with chemotherapy, surgery was performed in all 7 patients. After final treatment 7 patients had a median follow-up of 20 months. Although 1 died secondary to disease progression, the remaining 6 achieved serologic complete remission.

CONCLUSION

Our anal- ysis suggests that surgical intervention and intensive chemotherapy could be equally important for the treatment of . the patients with re-recurrent GTN. Be- cause the patients have a favorable prognosis, the principles of treatment for re-recurrent GTN should strive to cure.disease rather than simply relieve the symptoms of disease or delay the time of relapse.

Gestational Trophoblastic Neoplasia and Pregnancy Outcome After Routine Second Curettage for Hydatidiform Mole A Retrospective Observational Study

OBJECTIVE

To investigate gestational trophoblastic neoplasia (GTN), fertility, and pregnancy outcome in molar patients who underwent routine second curettage.

STUDY DESIGN

Eighty-two patients who visited our hospital for hydatidi- form mole between 2002 and 2011 were registered in this study. All patients had sec- ond curettage around the 7th day after first evacuation. We performed retrospective analysis on several factors between a remission group and a GTN group.

RESULTS

Fourteen patients (17.1%) had chemotherapy after being diagnosed with GTN. Multivariate analysis revealed that the hCG value before first evac- uation was only one independent prognostic factor for GTN. The median follow-up period was 45.5 months, and 41 patients had 62 pregnancies after remission of hydatidiform mole and GTN. The fertility rate was 80% in 45 patients with desire for a baby, and 39 pregnancies (62.9%) ended in live births without congenital malformation.

CONCLUSION

The incidence of GTN was not lower in hydatidiform mole with routine second curettage. An independent prognostic factor for GTN- was the hCG value before the first evac- uation in molar patients. Our results suggest that rou- tine second curettage does not affect the fertility rate or increase a risk of adverse outcomes in subsequent prej- nancies.

Gestational trophoblastic disease in a Greenlandic Inuit: diagnosis and treatment in a remote area

We report on a 21-year-old pregnant Greenlandic Inuit woman, who presented at a small local hospital in Northern Greenland. The patient suffered from lower abdominal pain, irregular bleeding and vomiting. urine-human chorionic gonadotropin (U-hCG) was positive. Ultrasonography showed the typical 'snow-storm' images of a mole pregnancy. Owing to the fact that local physicians were able to perform an ultrasound, proper diagnosis could be established, and the patient was transferred to the regional hospital, located nearly 1200 km away. At the regional hospital, uterine evacuation was performed under general anaesthesia. Blood analysis showed that serum hCG returned to undetectable levels, and the patient recovered uneventfully. Our case shows that ultrasonography is a valuable diagnostic tool also in remote areas. In Greenland, geographical distances are large and weather conditions can be extreme, and in this report, we discuss how healthcare can be optimised in remote areas.

A retrospective analysis of patients treated for gestational trophoblastic diseases: a 4-year experience of a tertiary hospital

AIM

To study incidence, clinical outcome, and follow-up data of the gestational trophoblastic disease (GTD) in patients diagnosed in the present Department.

MATERIALS AND METHODS

This study included the authors' retrospective clinical records regarding the cases of GTD which were diagnosed and followed up between January 2011 and January 2015. Patients' age, gravidity and parity, obstetric history, subgroup of GTD, gestational weeks, management results, and pre-post treatment β-hCG levels was investigated and an incidence study was constituted.

RESULTS

Total of 56 GTD cases were hospitalized and clinical records of 16,840 normal spontaneous deliveries were evaluated during the study period. The incidence of GTD was 3.3/1,000 cases. After histopathological examination, nine of 47 cases were partial molar pregnancy, whereas 38 cases were complete moles. There were no choriocarcinoma and invasive moles. All cases were treated with vacuum curettage without complication.

CONCLUSION

The GTD incidence in this clinic is high with a rate of 3.3/1,000 per pregnancy compared to Turkish literature. High birth rates of our population may play a role in high incidence results. Further investigation in this field is essential.

[Value of laparoscopic surgery in the diagnosis of suspected gestational trophoblastic neoplasia cases with uterine mass]

OBJECTIVE

To evaluate the value of laparoscopic surgery in the diagnosis of suspected gestational trophoblastic neoplasia (GTN) cases with uterine mass.

METHODS

The clinical characteristics of patients underwent laparoscopic surgery for a suspected diagnosis of GTN with uterine mass in Peking Union Medical College Hospital from November 2009 to November 2014 were retrospectively reviewed and analyzed. GTN and other pregnant-related disease were definitely diagnosed by pathological findings. The prognoses of the GTN cases were also investigated.

RESULTS

Sixty-two patients with a suspected diagnosis of GTN with uterine mass were studied. Among them, 17 cases were definitely diagnosed as GTN, including 8 choriocarcinoma, 5 invasive mole and 4 placental site trophoblastic tumor (PSTT). The other 45 cases were diagnosed as benign pregnancy-related diseases, including 29 cornual pregnancy, 6 cesarean scar pregnancy, 5 placenta accreta, 4 intramural uterine pregnancy and 1 exaggerated placental site. There were no significantly differences between the two groups in average age, preoperative value or tendency of β-hCG, and location or size of lesions (P>0.05). More GTN patients showed a history of hydatidiform mole [5/17 vs 4% (2/45) , P>0.05], and more patients with benign pregnancy-related disease showed a history of cesarean section [38% (17/45) vs 1/17, P>0.05]. No serious perioperative complication was found in these patients received laparoscopic surgery. All GTN patients achieved complete remission by chemotherapy later. Except for 1 case loss, no recurrence was found in 11 low-risk stage I cases with an average follow-up period of 11- 66 months, 1 high-risk stage I case with a follow-up period of 61 months and 4 cases PSTT with a follow-up period of 13-66 months.

CONCLUSIONS

There were some atypical GTN cases with uterine mass, which were difficult to be differentiated from benign pregnancy-related diseases according to the clinical characteristics. Laparoscopic surgery with a pathologic diagnosis could be an essential way with efficiency and safety.

Clinical response to a second uterine curettage in patients with low-risk gestational trophoblastic disease: a pilot study

OBJECTIVE

To determine the curative effect of a repeat uterine evacuation in patients with low-risk gestational trophoblastic neoplasia.

STUDY DESIGN

Patients with low-risk gestational trophoblastic neoplasia (GTN)(N=12), diagnosed according to the International Federation of Gynecology and Obstetrics 2002 guidelines, were enrolled in a prospective cohort study. Primary outcomes were need for chemotherapy after second uterine evacuation and number of chemotherapy courses needed to achieve complete remission.

RESULTS

Ten patients (83%) did not require chemotherapy and were cured bya second curettage. Two patients failed to respond to the second curettage and received single-agent chemotherapy with actinomycin-D (1.25 mg/m2 biweekly, slow intravenous administration). Both patients responded to chemotherapy as second-line therapy. A 100% remission rate was achieved, with no recurrence at the 1-year follow-up. One patient (8%) had a uterine perforation.

CONCLUSION

Second curettage has a favorable response rate. It seems reasonable to perform a second curettage in patients with low-risk GTN in settings where serum beta-hCG assay follow-up is highly reliable and available. However, its potential complications and inconvenience must be discussed critically with each patient.

Fertility-sparing partial hysterectomy for gestational trophoblastic neoplasia: an analysis of 36 cases

OBJECTIVE

To evaluate the success of partial hysterectomy in treating gestational trophoblastic neoplasia (GTN) and preserving fertility.

STUDY DESIGN

A retrospective review was conducted on 36 patients with GTN who underwent adjuvant fertility-sparing partial hysterectomy at the Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, China, between 1991 and 2008.

RESULTS

Of 36 patients, 34 had fertility-sparing partial hysterectomy; 2 required full hysterectomy due to excessive bleeding during surgery. All women went into remission from their disease. Twenty-five subsequently achieved clinical pregnancy, resulting in a total of 23 live births.

CONCLUSION

Partial hysterectomy with chemotherapy can be effective in treating GTN while preserving future fertility. This should be considered as an option for women who wish to pursue pregnancy in the future.

Changes in the management of high-risk gestational trophoblastic neoplasia in the National Trophoblastic Disease Center of Hungary

OBJECTIVE

To compare the clinical management of patients with high-risk gestational trophoblastic neoplasia (GTN) among the periods of 1977-1990, 1991-2000, and 2001-2012 at the National Trophoblastic Disease Center of Hungary and to assess the efficacy of the FIGO 2000 staging and risk factor scoring system in comparison to the original WHO prognostic scoring system (1983).

STUDY DESIGN

We reviewed the medical records of 185 patients with high-risk GTN. From 1977-2000, patients were classified according to the original WHO prognostic scoring system (1983). From 2001-2012, high-risk patients were categorized by the FIGO 2000 system. We assessed the efficacy of MAC and EMA-CO primary combination chemotherapies. For 1977-2006 and 2007-2012 we assessed the efficacy of MAC and EMA-CO primary combination chemotherapies.

RESULTS

From 1977-1990, 63 high-risk patients (average, 4-5 patients/year), from 1991-2000, 50 high-risk patients (average, 5 patients/year), and from 2001-2012, 72 high-risk patients (average, 6 patients/year) were treated primarily with combination chemotherapy (MAC and/or EMA-CO and/or CEB). From 1977-2006, 100 high-risk patients received MAC primary combination chemotherapy and 17 cases received EMA-CO. The ratio of primary MAC primarily with and EMA-CO therapy among our high-risk patients was 5.9 (100/17) over the referred period. From 2007-2012, 21 high-risk patients were treated with primary MAC chemotherapy and 16 patients received EMA-CO. The MAC/EMA-CO ratio over this time interval was 1.3 (21/16).

CONCLUSION

We attained complete remission in 95.7% of the high-risk patients. During the last 6 years the use of EMA-CO primary combination chemotherapy increased among our high-risk patients, which has resulted in increased efficacy and fewer side effects.

Color Doppler sonography as an adjunct to repeat uterine evacuation for gestational trophoblastic disease: case report

Repeat uterine evacuation is a therapeutic option for preserving fertility in patients with gestational trophoblastic neoplasms and chemoresistance, but remains controversial due to the risks of hemorrhage and perforation. A 25-year-old patient with low-risk gestational trophoblastic neoplasm became chemoresistant; however, chemotherapy reduced intrauterine tumor vascularity as observed by color Doppler sonography, suggesting that patients could undergo uterine evacuation without major risk of bleeding. After 18 months, she achieved a normal pregnancy. Serial assessment of tumor vascularity with color Doppler sonography may provide information regarding the appropriate time to perform a repeat uterine evacuation without significant bleeding.

[Therapeutic evaluation of cisplatin, etoposide, and bleomycin chemotherapy regimen in high-risk gestational trophoblastic neoplasia]

OBJECTIVE

To evaluate the effectiveness and safety of combination chemotherapy with bleomycin, etoposide and cisplatin (BEP) regimen on the patients with high-risk gestational trophoblastic neoplasia (GTN).

METHODS

Forty-two patients with high-risk GTN admitted in Sichuan Cancer Hospital between Jan.1997 and Oct. 2011 were analyzed retrospectively. The International Federation of Gynecology and Obstetrics (FIGO) prognostic score of all patients was more than 7. The mean age of patients was 30.2 years (range 20 - 49 years). All patients were treated with more than two cycles BEP regimen and followed up to the patients' death or at the end of Feb.2012. The clinical response, toxicity and the occurrence of secondary tumors were investigated.

RESULTS

Forty-two high-risk GTN patients received the total of 251 courses of the BEP regimen, the average number of courses for each patient was 6.0 courses. Thirty-seven patients achieved complete remission and 5 patients showed drug-resistant. The total complete remission rate of BEP regimen was 88% (37/42). Among the complete remission patients, the total courses of BEP regimen of cases getting normal serum β-hCG level was 129 courses (average 3.5 courses), and the total courses of cases achieving complete remission was 227 courses (average 6.1 courses). Among the 37 complete remission patients, 31 cases were treated with BEP regimen chemotherapy alone, 4 patients with BEP regimen chemotherapy combined with surgical treatment (1 case had no cancer after surgery) and 2 cases with BEP regimen chemotherapy combined with radiation therapy. Therefore, the complete remission rate of BEP regimen chemotherapy alone was 74% (31/42). There were 5 patients who showed drug-resistance after 24 courses of BEP regimen chemotherapy (average 4.8 courses), then received etoposide, methotrexate and dactinomycin (EMA)/cyclophosphamide and vincristine sulfate (CO) regimen chemotherapy after drug-resistance, 2 cases combined with radiation therapy, 1 case combined with surgical treatment. Ultimately, 4 cases achieved complete remission, 1 case died of cancer. The major toxicities of BEP regimen were included bone marrow suppression, digestive tract side effect and alopecic, followed by mild peripheral neuritis and abnormal liver function, rare cases of mild pulmonary toxicity. There were no severe anaphylaxis and obvious impairment of cardiac, liver, pulmonary and kidney function, except 1 patient (49 years old) had grade IV bone marrow suppression and pulmonary fibrosis worsened after chemotherapy. The bone marrow suppression was mainly I-III degree neutropenia, and Incidence rate was 66.5% (167/251). All the survival patients without secondary tumor.

CONCLUSION

For young high-risk GTN patients, BEP regimen chemotherapy may be safe and effective.

Role of hysterectomy in the management of patients with gestational trophoblastic neoplasia: importance of receiving treatment in reference centers

OBJECTIVE

To evaluate hysterectomy prevalence, indications and impact on clinical outcomes in a reference center in southern Brazil.

STUDY DESIGN

Institutional Ethical Committee approval was granted for this study. In a cohort study spanning 21 years, all patients who underwent hysterectomy for gestational trophoblastic neoplasia (GTN) were included, and technical differences between hysterectomy performed in the reference center and those performed elsewhere were evaluated as well.

RESULTS

Of 1,023 patients with gestational trophoblastic disease, 57 (5.6%) underwent hysterectomy (95% CI, 4.3-7.1). Hysterectomy incidence in 230 GTN patients was 17.7% (95%CI, 15.1-23.3). Indications for 41 hysterectomies in the reference center were as follows: primary treatment in 14 (34.1%) cases and secondary treatment in 27 (65.9%); of these, the main indications were GTN recurrence (7 [25.9%] cases), hemorrhage (6 [22.2%]), resistance to single-agent chemotherapy in patients who refused more aggressive treatment (6 [22.2%]), and tumor mass reduction (5 [18.5%]). Twelve (92.3%) of the 13 hysterectomies with bilateral oophorectomy were performed elsewhere (p < 0.001). Thirty-five (85.4%) patients had no complications, and median hospitalization time was short (3 +/- 4 days). None of the 4 deaths were associated with hysterectomy. In the reference center, when associated with hysterectomy, GTN cure rates reached 93% after 63 +/- 87 months of follow-up.

CONCLUSION

When treatment is in a reference center, hysterectomy frequency and morbidity may be low, and indications due to hemorrhage are significantly lower. Furthermore, at a reference center there is significantly greater ovarian preservation at the time of hysterectomy, and significantly more patients who undergo hysterectomy have low-risk GTN.

Actinomycin D for methotrexate-failed low-risk gestational trophoblastic neoplasia

OBJECTIVE

To determine outcomes and factors associated with failure of 5-day actinomycin D for treatment of methotrexate-failed low-risk gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

We reviewed the records of 358 patients treated with methotrexate 0.4 mg/kg (max 25 mg) IV push q.d. x 5 d every 14 d for FIGO-defined, low-risk GTN between 1979 and 2009. Actinomycin D 0.5 mg IV push q.d. x 5 d every 14 d was given to 64 of 68 patients (18%) who failed methotrexate: 48 (75%) for resistance and 16 (25%) for toxicity. Adjuvant surgery was used in selected patients. Clinical response and survival as well as factors affecting outcomes were analyzed retrospectively.

RESULTS

The complete response rate to secondary chemotherapy with actinomycin D for failed methotrexate treatment of low-risk GTN was 75% (48/64), including 71% (34/48) for methotrexate resistance and 88% (14/16) for methotrexate toxicity. All 20 patients (6%) who failed sequential single-agent chemotherapy with methotrexate and actinomycin D were placed into permanent remission with the use of multiagent chemotherapy with or without surgery. The only factor significantly associated with resistance to secondary actinomycin D chemotherapy was clinicopathologic diagnosis of choriocarcinoma versus postmolar GTN (56% versus 20%, p = 0.025).

CONCLUSION

Actinomycin D 0.5 mg IV q.d. x 5 d every 14 d used as secondary therapy in methotrexate-failed low-risk GTN resulted in a 75% complete response rate and eventual 100% cure with subsequent multiagent chemotherapy with or without surgery. Resistance to sequential methotrexate and actinomycin D chemotherapy was significantly associated with original FIGO score > or = 3 and clinicopathologic diagnosis of choriocarcinoma.

Importance of salvage therapy in the management of high-risk gestational trophoblastic neoplasia

OBJECTIVE

To assess the value of secondary therapy in the management of high-risk gestational trophoblastic neoplasia (GTN) after failure of initial multiagent chemotherapy.

STUDY DESIGN

Forty-nine women with high-risk GTN, including 29 who were treated primarily and 20 who were treated secondarily, completed treatment at the Brewer Trophoblastic Disease Center between 1986 and 2010. Initial chemotherapy consisted of etoposide, high-dose methotrexate with folinic acid, actinomycin D, cyclophosphamide and vincristine (EMA-CO) in 29 patients who were treated primarily and in 10 patients who had received single-agent chemotherapy before being treated at our center. Patients who had incomplete responses or developed resistance to EMA-CO or had previously received EMA-CO were treated with drug combinations employing etoposide and a platinum agent with methotrexate and actinomycin D (EMA-EP), bleomycin (BEP), ifosfamide (VIP, ICE) or paclitaxel (TP/TE). Adjuvant surgery and brain radiation were used in selected patients. Clinical response and survival as well as factors affecting outcomes were analyzed retrospectively.

RESULTS

Twenty-eight (57%) of the 49 patients developed resistance to EMA-CO: 13 (45%) of 29 treated primarily and 15 (75%) of 20 treated secondarily. Of the 13 patients who failed primary treatment with EMA-CO, 10 (77%) had lasting complete responses to EMA-EP (4), BEP (3), VIP (1), ICE (1) or TP/TE (1). Of the 15 patients who failed EMA-CO used as secondary therapy, 13 (87%) had lasting complete responses to EMA-EP (5), BEP (6) or ICE (2). Brain irradiation was given to 4 patients who developed brain metastases during treatment, 3 of whom survived. Operative procedures were performed to remove resistant foci of disease in the lungs (9) or uterus (2) in 11 (39%) of the 28 patients, 9 (82%) of whom survived. Survival was significantly influenced by hCG level at the start of salvage therapy (p<0.001), number of metastatic sites (p <0.02) and metastases to sites other than the lung and vagina (p<0.05).

CONCLUSION

Salvage therapy with platinum/etoposide-based drug regimens, often in conjunction with surgery and brain radiation, was successful in achieving cure in 82% of 28 high-risk GTN patients who failed initial multiagent chemotherapy and was ultimately responsible for survival in 53% of the 43 patients (88%) with high-risk GTN who were cured.

[Clinical analysis of patients with relapsed and chemo-resistant gestational trophoblastic neoplasia]

OBJECTIVE

To analyze and compare the clinical characteristics and the treatment outcome of the patients with chemo-resistant and relapsed gestational trophoblastic neoplasia (GTN).

METHODS

The clinical records of the patients with refractory GTN treated at the Peking Union Medical College Hospital (PUMCH) from Jan 2005 to Dec 2007 were retrospectively reviewed. According to the reasons for referral, all cases were classified as chemo-resistant GTN group who had never a normal serum human chorionic gonadotropin-beta subunit (β-hCG) level during their previous treatment, relapsed GTN group who had elevated serum β-hCG levels in the absence of the pregnancy after finished treatment 3 months or more, and undetermined GTN group who had elevated serum β-hCG levels in the absence of the pregnancy less than 3 months after completed treatment. The clinical features and treatment outcomes were compared between undetermined GTN group and chemo-resistant GTN group and also between undetermined GTN group and relapsed GTN group, respectively.

RESULTS

Of 81 patients with refractory GTN, 32 cases were defined as undetermined GTN, 38 cases as chemo-resistant GTN and 11 cases as relapsed GTN. The median number of previous chemotherapy regimens, the rate of serologic complete remission (SCR), the patients who needed to change regimens due to resistance, and the patients who needed to change regimens in the undetermined GTN group and the chemo-resistant GTN group were 2.3 versus 3.1 (P = 0.010), 100% (32/32) versus 66% (25/38, P < 0.01), 22% (7/32) versus 58% (22/38, P = 0.002) and 28% (9/32) versus 63% (24/38, P = 0.003), respectively. No significant difference were observed between undetermined GTN group and relapsed GTN group in clinical features, previous and current treatment or treatment outcome (all P > 0.05).

CONCLUSIONS

In order to evaluate accurately the treatment outcome of refractory GTN, it seems more appropriate for the patients who had reached the normal value of serum β-hCG when completed treatment to be defined as patients with relapsed GTN, while whose serum β-hCG levels elevated in the absence of the pregnancy after the completion of treatment, irrespectively of duration of stopping treatment. Comparing with the patients with chemo-resistant GTN, the outcome of patients with relapsed GTN is better.

[Epithelioid trophoblastic tumour]

Epithelioid trophoblastic tumour is a rare gestational trophoblastic disease. The diagnosis is based on microscopic morphology and immunohistochemical staining. It is important to avoid misdiagnosis, as this tumour is primarily treated by surgery rather than chemotherapy. We report a case and describe diagnostic criteria and differential diagnoses.

Sonographic appearance of gestational trophoblastic disease evolving into epithelioid trophoblastic tumor

Epithelioid trophoblastic tumor is a distinctive but rare trophoblastic tumor. It derives from intermediate trophoblastic cells of the chorion laeve and is usually associated with a previous gestational event. We report the case of a patient who had undergone dilatation and curettage for a missed miscarriage. Three months later gestational trophoblastic disease was suspected because of persistent vaginal bleeding and high levels of beta-human chorionic gonadotropin (beta-hCG). Transvaginal ultrasound revealed irregular echolucent lacunae within the myometrium, some of them filled with low-resistance, turbulent blood flow on Doppler examination, emphasizing the diagnosis of gestational trophoblastic disease. The patient was treated with 12 courses of multiagent chemotherapy. After a 2-year remission, a low rise in serum beta-hCG was observed. Transvaginal ultrasound revealed a well-circumscribed echogenic lesion with a diameter of 1.8 cm in the uterine fundus, with no detectable blood flow on Doppler imaging. A diagnosis of tumor of intermediate trophoblastic cells was suspected and total hysterectomy was performed. On pathological examination, the histological and immunohistochemical features were characteristic of epithelioid trophoblastic tumor. Most reported cases of epithelioid trophoblastic tumor have solitary nodules with sharp margins, which is consistent with our ultrasound findings. Ultrasound may be helpful in differentiating epithelioid trophoblastic tumor from placental-site trophoblastic tumor, another tumor of intermediate trophoblastic cells, which shows infiltrative growth insinuating between muscle fibers.

The role of surgery and radiation therapy in the management of gestational trophoblastic disease

The primary management of hydatidiform moles remains surgical evacuation followed by human chorionic gonadotropin level monitoring. Although suction dilatation and evacuation is the most frequent technique for molar evacuation, hysterectomy is a viable option in older patients who do not wish to preserve fertility. Despite advances in chemotherapy regimens for treating malignant gestational trophoblastic neoplasia, hysterectomy and other extirpative procedures continue to play a role in the management of patients with both low-risk and high-risk gestational trophoblastic neoplasia. Primary hysterectomy can reduce the amount of chemotherapy required to treat low-risk disease, whereas surgical resections, including hysterectomy, pulmonary resections, and other extirpative procedures, can be invaluable for treating highly selected patients with persistent, drug-resistant disease. Radiation therapy is also often incorporated into the multimodality therapy of patients with high-risk metastatic disease. This review discusses the indications for and the role of surgical interventions during the management of women with hydatidiform moles and malignant gestational trophoblastic neoplasia and reviews the use of radiation therapy in the treatment of women with malignant gestational trophoblastic neoplasia.

30 years' experience in the treatment of low-risk gestational trophoblastic neoplasia in Hungary

OBJECTIVE

To review the clinical experience in the treatment of patients with low-risk gestational trophoblastic neoplasia (GTN) over the past 30 years in a national trophoblastic disease center.

STUDY DESIGN

Between January 1, 1977, and December 31, 2007, 302 patients with low-risk GTN were treated. The patients were directed to our institution from all parts of Hungary. The patients were 14 to 53 years of age with an average age of 28.3 years. Methotrexate (MTX)/folinic acid or actinomycin-D (Act-D) primary chemotherapy was selected based upon the patient's stage and prognostic score of GTN.

RESULTS

Among 218 low-risk patients, 210 (96.3%) achieved remission as a result of MTX therapy. In 8 patients (3.7%), MTX-Act-D-cyclophosphamide (MAC) combination chemotherapy was needed to achieve complete remission, in some cases assisted by operation. Among 84 patients, 81 (96.4%) achieved remission as a result of Act-D therapy. In 3 cases (3.6%) complete remission was achieved by MAC combination chemotherapy. We detected metastases in 22.8% (69/302) of our low-risk patients. Chemotherapy, surgical intervention or other supplementary treatments resulted in 100% remission in cases of low-risk nonmetastatic and metastatic disease.

CONCLUSION

Our data indicate that MTX/folinic acid or Act-D should be the primary treatment in patients with nonmetastatic or metastatic low-risk GTN. Importantly, patients with resistance to single-agent chemotherapy regularly achieve complete remission with MAC combination chemotherapy. Results show that patient care under the direction of experienced clinicians serves to optimize the opportunity for cure and minimize morbidity.

The evolving role of hysterectomy in gestational trophoblastic neoplasia at the New England Trophoblastic Disease Center

OBJECTIVE

To identify indications for hysterectomy in patients with gestational trophoblastic neoplasia (GTN) and to evaluate outcomes of hysterectomy in those patients.

STUDY DESIGN

Patients who underwent hysterectomy were identified utilizing hospital medical records and the New England Trophoblastic Disease Center (NETDC) database from January 1, 1959-January 1, 2009. Demographic data as well as indication for hysterectomy, stage, World Health Organization score, chemotherapeutic regimens and outcomes were recorded. We further stratified our population into patients with hysterectomies before and after 1980 to assess how indications for and outcomes after hysterectomy may have changed at our institution over time.

RESULTS

A total of 98 patients were identified to have undergone hysterectomy for GTN. In the entire cohort 85% (n = 83) achieved remission and 48% (n = 47) required chemotherapy after hysterectomy. Among the patients in the early cohort (n = 49), indications for hysterectomy included 15 (31%) for primary definitive management, 14 (29%) for chemotherapy resistant disease, 14 (29%) for bleeding and 6 (11%) for other reasons. Of the patients with hysterectomy for chemotherapy resistance, 9 (64%) achieved remission. In the more recent cohort (n = 49) indications for hysterectomy included 24 (49%) for primary definitive management, 19 (39%) for drug-resistant disease, 4 (8%) for bleeding and 2 (4%) for other reasons. Of the patients with hysterectomy for chemotherapy resistance, 16 (84%) achieved remission. There was a statistically significant decline in the number of hysterectomies performed for bleeding. Hysterectomy was performed for bleeding in the early cohort (1959-1980) in 14 (29%) of 49 patients but in only 4 (8%) of 49 patients in the later cohort (1981-2009) (p = 0.02).

CONCLUSION

During the years 1959-2009 the number of hysterectomies performed for GTN at the NETDC has remained stable. However, at our center there has been a decline in the incidence of hysterectomy for life-threatening hemorrhage. Overall 83 (84.7%) patients with hysterectomy for GTN obtained remission. In patients who underwent hysterectomy to treat chemotherapy-resistant disease, 25 of 33 (75.8%) subsequently achieved complete remission. Hysterectomy continues to play an important role in the management of selected patients with GTN.

Hysterectomy in gestational trophoblastic neoplasia: Chiang Mai University Hospital's experience

Indications and outcomes of hysterectomy in women with gestational trophoblastic neoplasia (GTN) were reviewed at Chiang Mai University Hospital, Chiang Mai, Thailand. From January 1998 through December 2008, 18 women underwent simple transabdominal hysterectomy (TAH). Indications for TAH included suspicious lesions confined to the uterus (5), chemoresistant lesions confined to the uterus (7), hemoperitonium (4), and other diagnoses of gynecologic diseases (2). The final histology reports included choriocarcinoma (9), invasive mole (6), placental site trophoblastic tumor or PSTT (1), uterine fibroid without residual GTN (1), and unknown (1). Two women experienced massive blood loss (4700 ml and 7500 ml, respectively). Postoperatively, only one woman with diagnosis of PSTT did not receive other adjuvant treatment. One woman failed to survive. In conclusion, hysterectomy continues to be an important treatment strategy for selected women with GTN. The common indications include drug-insensitive disease, PSTT, and hemorrhagic complications.

[Pulmonary resection in the management of gestational trophoblastic neoplasia: a clinical study]

OBJECTIVE

To investigate the effect of surgical resection in the management of gestational trophoblastic neoplasia (GTN) patients with pulmonary metastases.

METHODS

A retrospective review of the medical records of 62 GTN patients who underwent pulmonary resection was carried out. The cases were divided into recurrent group (group A, n = 10), drug-resistant group (group B, n = 28), and the group with satisfactory response to chemotherapy but residual pulmonary lesion (s) (group C, n = 25). One patient underwent lobectomy twice, and she was allocated simultaneously to groups A and B. The patients' median age, antecedent pregnancy, International Federation of Gynecology and Obstetrics (FIGO) risk score, number of preoperative chemotherapy courses, preoperative beta-human chorionic gonadotrophin (beta-hCG) titer, lesion size, number of lobes affected, positive rate of histology, follow-ups and prognosis were compared between the three groups.

RESULTS

The proportion of high-risk patients in the three groups was 90%, 82% and 44%, respectively. The complete remission rates of the three groups were 90%, 79% and 100%, with relapse rates of 2/8, 15% and zero, respectively. Positive histology of the resected specimen was more frequently recognized in recurrent and drug-resistant groups (A 60%, B 36%, C 12%). In the drug-resistant group there were more preoperative chemotherapy sessions (A 3, B 7, C 5) and more patients with abnormal preoperative beta-hCG titer (A 50%, B 61%, C 12%).

CONCLUSIONS

Surgical resection is effective in the treatment of pulmonary metastases of GTN. Surgery is indicated when clinical evidence suggests that pulmonary metastatic disease causes relapse or drug-resistance and the lesions are relatively localized. Surgical resection is not recommended for patients with satisfactory response to chemotherapy but residual pulmonary lesions.

[Efficacy of surgical management combined with chemotherapy in the treatment of drug-resistant gestational trophoblastic neoplasm]

OBJECTIVE

To evaluate the efficacy of surgical management combined with chemotherapy in the treatment of drug-resistant gestational trophoblastic neoplasm (GTN) patients, and investigate factors influencing the outcome of the surgery combined with chemotherapy.

METHODS

Medical records of 42 patents with drug-resistant GTN who were treated by chemotherapy combined with surgical management at Peking Union Medical College Hospital from Jan 1996 to Jan 2006 were reviewed.

RESULTS

Among 42 patients, 32 achieved serologically complete remission (SCR) with an SCR rate of 76%, and 10 patients had a treatment failure. Treatment failure was more frequently seen in patients who also had metastasis of other sites except for lungs and vagina and patients with antecedent non-molar pregnancy (P = 0.023 and 0.017, respectively). Preoperative human chorionic gonadotropin-beta subunit (beta-hCG) titer > 10 U/L (P = 0.020), failure to reach normal serum titers of beta-hCG during treatment (P = 0.003), age > or = 35 years (OR: 12.6, 95% CI: 2.4 - 66.0, P = 0.002) and preoperative chemotherapy regimens > or = 4 (OR: 4.5, 95% CI: 1.0 - 20.1, P = 0.059) were also correlated with treatment failure. All the 10 patients with treatment failure had at least 3 of 6 above mentioned predictors of treatment failure.

CONCLUSIONS

Surgical management combined with chemotherapy is effective in the treatment of drug-resistant GTN. Age > or = 35 years, antecedent non-molar pregnancy, metastasis of other sites except for lungs and vagina, preoperative beta-hCG titer > 10 U/L, failure to reach normal serum titers of beta-hCG during treatment, and preoperative chemotherapy regimens > or = 4 are significant predictors of treatment failure. Patients with 3 or more predictors of treatment failure usually have poor prognosis. Therefore, surgical management should not be performed for these patients.

Sexual dysfunction as a complication of treatment of gestational trophoblastic neoplasia

OBJECTIVE

To examine the impact of gestational trophoblastic neoplasia (GTN) therapy on women's sexuality.

STUDY DESIGN

A questionnaire concerning various sexual problems experienced by patients treated with chemotherapy and/or surgery for GTN and in remission for 1 year or more was completed by 47 women in the outpatient clinic of the Trophoblastic Disease Section of our institution from January to June 2007.

RESULTS

Ninety-five percent of the subjects continued sexual activity after treatment, but there was an increase in the incidence of sexual problems, which resulted in a slight reduction in the quality of their sex lives. Seventy percent of the women experienced absent or low sexual desire, while 42% had dyspareunia and 45% had lubrication problems. Fifty-three percent experienced changes in the relationship with their partner within the first year after remission.

CONCLUSION

Sexual dysfunction is a common complication of treatment of GTN yet is given little attention as compared to other complications. Patient education and reassurance, with early diagnosis and intervention, are essential for a better quality of life for survivors.

[Imaging of gestational trophoblastic disease]

INTRODUCTION

Trophoblastic diseases correspond to a very heterogeneous group.

OBJECTIVE

To establish the importance of imaging in the management of trophoblastic diseases.

PATIENTS AND METHODS

Retrospective study from 1995 to 2008, including all patients with a gestational throphoblastic disease in our department.

RESULTS

Seventy-four cases were identified with 58 molar pregnancies, 14 trophoblastic tumors and two cases of hydatiform mole coexistent with a twin live fetus. Ultrasound's sensibility in case of hydatiform moles was 75.86%. It was sharply more important in case of a complete mole with a detection rate of 96.15% against 28% in case of partial mole. In trophoblastic tumors, ultrasound coupled with Doppler had shown signs of invasion in half of the cases. Four patients presented with lung metastases. Magnetic resonance imaging was performed in two cases.

DISCUSSION AND CONCLUSION

Ultrasound is of high-performance in the positive diagnosis of complete moles. Furthermore, it shows signs of invasion in case of trophoblastic tumors. In those cases, a radiological assessment guides the management even in the absence of histological proofs.

The changing role of thoracotomy in gestational trophoblastic neoplasia at the New England Trophoblastic Disease Center

OBJECTIVE

To review our experience with thoracotomy in gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

Nineteen thoracotomy patients from our database were identified. Thoracotomy was performed for therapeutic reasons in 11 patients and to clarify the diagnosis in eight.

RESULTS

Among the 11 patients with chemotherapy-resistant pulmonary tumors, 10 of 11 (90.9%) achieved remission with thoracotomy. Thoracotomy was more likely to be done to clarify diagnosis before 1980 (83%) than after 1980 (23%) (p = 0.04), when it became more likely to be done for therapeutic indications. Ten patients had solitary lung lesions and 9 had multiple lesions. Four patients died (21%), with an average survival after thoracotomy of 149 days; patients had bilateral or multiple lung lesions, median preoperative hCG was 58,000 mIU/mL and all were stage IV. Survivors had lower stage disease, were more likely to have solitary lesions and had lower preoperative hCG levels.

CONCLUSION

There have been several temporal changes in the indications for thoracotomy for GTN. In general, the optimal patient to achieve remission with thoracotomy will have stage III disease, a preoperative hCG of < 1,500 mIU/mL, and a solitary lung nodule resistant to chemotherapy. Likelihood of remission after thoracotomy is high in properly selected patients.

The role of adjuvant surgery in the management of gestational trophoblastic neoplasia

OBJECTIVE

To evaluate the role of different surgical procedures combined with chemotherapy in the management of gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

A retrospective descriptive analysis of data was done using charts of diagnosed cases of GTN from 1996 to 2006. The patients were classified according to FIGO staging and WHO prognostic scoring. Surgical procedures were evaluated as to indications, hospital stay, remission rate and number of chemotherapy cycles needed to achieve remission.

RESULTS

One hundred thirty-four patients underwent at least 1 major surgery in the form of hysterectomy, with uterine perforation and profuse vaginal bleeding as an indication for surgery. Common indications for adjuvant surgery are completed family size and resistance to chemotherapy. Two patients had excision of liver metastases, and 3 patients had lung resection.

CONCLUSION

With the increasing use of early surgical intervention combined with chemotherapy, we feel that we are maximizing the benefit that can be derived by our patients from our treatment protocol. We are decreasing the number of chemotherapeutic cycles needed to attain remission and in effect decreasing the exposure of the patients to toxicity from the chemotherapy.

Role of hysterectomy in managing persistent gestational trophoblastic disease

OBJECTIVE

To evaluate incidence, indications and outcomes of hysterectomy for gestational trophoblastic disease (GTD) and compare outcomes for patients who underwent primary hysterectomy with outcomes for those who underwent adjuvant hysterectomy.

STUDY DESIGN

Using the Sheffield Trophoblastic Tumour Centre database (January 1, 1986, until June 30, 2007), patients who underwent hysterectomy were identified, along with age, antecedent pregnancy, diagnosis date, hysterectomy date and chemotherapy and pathologic findings.

RESULTS

A total of 8,860 patients were registered at Weston Park Hospital, Sheffield. Of them, 627 (7.1%) needed chemotherapy and 62 (0.71%) underwent hysterectomy. The most frequent indication was resistance to chemotherapy in 22 of 62 (35.5%), followed by major hemorrhage in 21 of 62 (33.9%). Emergent hysterectomy was performed in 22 (35.5%). Mean International Federation of Gynecology and Obstetrics risk score was 6.5. Choriocarcinoma was the most frequent pathology (23), followed by invasive mole (10) and placental site trophoblastic tumor (9). Thirty-one patients needed chemotherapy after hysterectomy, 93.5% are in remission, 7 relapsed, 3 were cured and 4 died of disease.

CONCLUSION

Incidence of hysterectomy for GTD was 1 in 140. Patients who underwent hysterectomy represent a high-risk group, often having more aggressive pathology. Hysterectomy is valuable as primary and adjuvant treatments.

[Placental site trophoblastic tumor: case report and review of literature]

A 32-year-old para 3 patient is presented having suffered from a silent uterine rupture on the occasion of her second and third Caesarean sections. After the third Caesarean section, there was light uterine bleeding whilst the patient breastfed for five months. Amenorrhoea then ensued due to oral contraception. Regular clinical and ultrasound checks revealed negative serum beta-HCG values and retrovesicular resistance, which increased in size after 18 months and became symptomatic. Because the patient's family was complete, abdominal hysterectomy without adnexectomy was performed. Histology revealed a placental site trophoblastic tumour (PSTT). This is a rare tumour with malignant potential, whose prognosis depends on the stage of the primary tumour, the period of time between the last pregnancy and onset of disease, the patient's age, and the rate of mitosis, and whose progress cannot be assessed using the WHO Prognostic Index Score for Gestational Trophoblastic Disease. In therapeutic terms, hysterectomy is recommended. Chemosensitivity is low and, due to the infrequency of the tumours, the most suitable chemotherapy scheme is unknown. In the case of metastasising or recurrent PSTT, the EP/EMA regime has proved to be most effective.

Short communication: A review of the management by hysterectomy of 25 cases of gestational trophoblastic tumours from March 1993 to January 2006

We reviewed 25 cases of gestational trophoblastic tumours referred for surgical management from Charing Cross Hospital (the London centre for gestational trophoblastic disease [GTD]) over a 13-year period. The operation performed was total abdominal hysterectomy, with lymph node sampling in 9/25 (36%) women and bilateral salpingo-oophorectomy in 11/25 (44%) women. Radical hysterectomy and unilateral parametrectomy was required in 3/25 (12%) women. Three of 25 (12%) women failed to survive, i.e. the overall rate of survival was 88%. Management by hysterectomy of primary drug-resistant and relapse cases of GTD is a useful and safe adjunct to chemotherapy.

Fertility-sparing surgery for persistent gestational trophoblastic neoplasia in the myometrium: a case report

BACKGROUND

Persistently low-level "real" serum human chorionic gonadotropin (hCG) after treatment for gestational trophoblastic neoplasia (GTN) in patients desirous of preserving fertility is a diagnostic and management challenge. Among the possible explanations is the presence of false positive ("phantom") hCG or of trophoblasts in a myometrial sanctuary.

CASE

An 18-year-old woman had persistent low-level hCG values in her serum after treatment for nonmetastatic GTN. Her only child had died, and she wanted to preserve her fertility potential. Phantom hCG was excluded. Positron emission tomography (PET) showed increased uptake in an area of the uterus in which magnetic resonance imaging had shown an ill-defined, ovoid lesion. Removal of the lesion with preservation of the uterus followed by 2 courses of multiagent chemotherapy (methotrexate, dactinomycin and cyclophosphamide) resuited in clinical remission.

CONCLUSION

PET can prove useful in detecting persistent disease in a myometrial sanctuary in patients with resistant, nonmetastatic GTN. Conservative surgical excision with uterine preservation is possible and can be of value in achieving remission.