Postmolar Gestational Trophoblastic Neoplasia Research Articles

Second Uterine Curettage and the Number of Chemotherapy Courses in Postmolar Gestational Trophoblastic Neoplasia: A Randomized Controlled Trial

Second Uterine Curettage and the Number of Chemotherapy Courses in Postmolar Gestational Trophoblastic Neoplasia: A Randomized Controlled Trial

Clinical Outcome and Survival of Post-molar GTN Versus Non-molar GTN Patients

Background: Gestational trophoblastic neoplasia (GTN) can derive either from molar or non-molar pregnancy. Our primary objective is to compare clinical presentation and outcome of treatment of non-molar and post-molar GTN. Our secondary outcome is to evaluate and compare the prognostic factors of non-molar GTN compare to post-molar GTN in subgroup classification of GTN patients by stage and by low-risk and high-risk groups.Methods: Retrospective chart review of GTN patients treated from 2007 to 2016 was done. General characteristics, clinical data, treatment options and treatment outcomes were collected. The cases with missing significant data were excluded. Statistics analysis of the data was performed with SPSS version 22.0. Mean, mode, median and percent were used to present the data. Student t-test, Mann Whitney-U test and Kaplan Meier were used to analyze the data. The results were presented in Tables or graphs where appropriate. Results: Total of 71 GTN patients were recruited into the study. Fifty-one patients were post-molar GTN and 20 were non-molar GTN patients. The mean age of the patients was not different (p=0.25). Median duration from previous pregnancy and time to achieve remission were longer in non-molar GTN (292 days vs. 42 days and 163 vs. 64 days, respectively). Mortality rate of the non-molar GTN is higher that of the post-molar GTN (15% vs. 1.9%). Comparison of stage to stage showed no differences between the post-molar and the non-molar GTN. According to previous pregnancy type, post-abortion had higher resistant to treatment rate than post-term delivery.Conclusion: Non-molar GTN is different form post-molar GTN in several aspects, such as the duration from previous pregnancy, stage and score at diagnosis, treatment resistance and mortality rate. Comparison between the non-molar and post-molar GTN stage by stage and risk scores could not identify the difference between the two groups.

Total hysterectomy versus uterine evacuation for preventing post-molar gestational trophoblastic neoplasia in patients who are at least 40\u2009years old: a systematic review and meta-analysis

BackgroundThe clinical value of total hysterectomy for patients with hydatidiform mole (HM) being at least 40 years old remains highly controversial. Since the practice of hysterectomy has been applied globally for decades, there is an urgent need to perform a systematic review to assess its risks and benefits.MethodsSix electronic databases, including four English databases and one Chinese database, were searched from the inception of each database till October 6th 2017. Studies were included if they: 1) were human studies, 2) explicitly indicated exposure to hysterectomy, 3) explicitly indicated control to uterine evacuation, 4) explicitly indicated the participants were older patients with HM being at least 40 years in age, 5) compared the outcome of interest as the incidence of post-molar GTN. Two authors independently conducted the literature search, study selection, data extraction. Pooled odds ratios were analyzed using Review Manager 5.3.ResultsThe overall pooled effect size of total hysterectomy had a significant advantage in preventing post-molar gestational trophoblastic neoplasia over uterine evacuation with an OR of 0.19 (95% CI, 0.08–0.48; P = 0.0004) and a low heterogeneity (I2 = 21%, P = 0.28). Subgroup analysis and sensitivity analysis also showed similar results.ConclusionsTotal hysterectomy, as compared to uterine evacuation, is a better therapeutic method for patients with HM being at least 40 years old unless fertility is still desired.

Is there uniformity in definitions and treatment of gestational trophoblastic disease in Europe?

Because gestational trophoblastic disease is rare, little evidence is available from randomized controlled trials on optimal treatment and follow-up. Treatment protocols vary within Europe, and even between different centers within countries. One of the goals of the European Organization for Treatment of Trophoblastic Diseases (EOTTD) is to harmonize treatment in Europe. To provide a basis for international standardization of definitions, treatment and follow-up protocols in gestational trophoblastic disease, we evaluated differences and similarities between protocols in EOTTD countries. Members from each EOTTD country were asked to complete an online structured questionnaire comprising multiple-choice and multiple-answer questions. The following themes were discussed: incidence of gestational trophoblastic disease and gestational trophoblastic neoplasia, definitions, guidelines, classification system, treatment, recurrence, and follow-up. Forty-four respondents from 17 countries participated in this study. Guidelines were present in 80% of the countries and the FIGO (Fédération Internationale de Gynécologie et d'Obstétrique) staging and risk classification was often used to estimate risks. Agreement about when to start chemotherapy for post-molar gestational trophoblastic neoplasia was present among 66% of the respondents. Preferred first-line treatments in low- and high-risk gestational trophoblastic neoplasia were methotrexate (81%) and EMA-CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine) (93%), respectively. The definition of human chorionic gonadotropin normalization after hydatidiform mole evacuation was two consecutive normal values for nine countries. The FIGO definition of post-molar gestational trophoblastic neoplasia based on human chorionic gonadotropin plateau or rise was agreed on by 69% of respondents, and only 69% and 74% defined low-risk and high-risk disease, respectively, using FIGO criteria. There were major differences in definitions of recurrence, chemotherapy resistance and follow-up protocols among countries, despite EOTTD consensus statements. This questionnaire provides a good overview of current clinical practices in different countries. Based on the survey results, it is clear that there are several gestationaltrophoblastic disease-related topics that need urgent attention within the EOTTD community to create more uniformity and to aid the development of uniform guidelines in Europe.

OP16.03: Sonographic characteristics of postmolar gestational trophoblastic neoplasia (GTN) at diagnosis and during follow‐up

OP16.03: Sonographic characteristics of postmolar gestational trophoblastic neoplasia (GTN) at diagnosis and during follow‐up

OC19.08: Sonographic characteristics of postmolar gestational trophoblastic neoplasia (GTN) in relation to chemo‐resistant disease

OC19.08: Sonographic characteristics of postmolar gestational trophoblastic neoplasia (GTN) in relation to chemo‐resistant disease

Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD) represents a group of disorders that derive from placental trophoblastic tissue, including hydatidiform moles, postmolar gestational trophoblastic neoplasia (GTN), and gestational choriocarcinoma. GTN is the most curable gynecologic malignancy and tends to be more common after a complete molar pregnancy than a partial mole. Human chorionic gonadotropin (β-hCG) represents a marker for GTD and should be followed for 6 months after molar pregnancy evacuation to rule out the development of postmolar GTN. GTN is defined by a plateaued, rising, or prolonged elevated β-hCG value after molar evacuation; histologic diagnosis of choriocarcinoma, invasive mole, placental site trophoblastic tumor, or epithelioid trophoblastic tumor; or identification of metastasis after molar pregnancy evacuation. Classification for GTN as low (score ≤ 6) or high risk (score > 7) is based on the World Health Organization prognostic score. This scoring system helps select treatment, which usually entails actinomycin D or methotrexate for low-risk disease and EMA/CO (etoposide, methotrexate, actinomycin D/cyclophosphamide, vincristine) for high-risk disease. These regimens can achieve cure rates approaching 100% and over 90% for low- and high-risk disease, respectively. This review contains 5 figures, 8 tables and 49 references Key words: choriocarcinoma, gestational trophoblastic disease, gestational trophoblastic neoplasia, human chorionic gonadotropin, hydatidiform mole, invasive mole

The impact of uterine re-curettage on the number of chemotherapy courses in treatment of post molar gestational trophoblastic neoplasia: A randomized controlled study

The impact of uterine re-curettage on the number of chemotherapy courses in treatment of post molar gestational trophoblastic neoplasia: A randomized controlled study

Decentralized treatment for post-molar gestational trophoblastic neoplasia (PMGTN) is associated with increased lines of chemotherapy and longer time to remission

Decentralized treatment for post-molar gestational trophoblastic neoplasia (PMGTN) is associated with increased lines of chemotherapy and longer time to remission

Pulse actinomycin D as first-line treatment of low-risk post-molar non-choriocarcinoma gestational trophoblastic neoplasia

BackgroundLittle data exists predicting the resistance to actinomycin D (Act-D) single-agent for gestational trophoblastic neoplasia (GTN). The objective was to determine the overall success of pulse Act-D and the factors predictive of resistance to pulse Act-D in the treatment of low-risk, non-choriocarcinoma post-molar GTN.MethodsFrom January 2013 to October 2016, according to the FIGO criteria for the diagnosis of post-molar disease and the FIGO risk-factor scoring system for GTN, a total of 135 patients with post-molar non-choriocarcinoma GTN who were chemotherapy-naive with a FIGO score < 7 were treated with single-agent pulse Act-D as a first-line regimen, in Peking Union Medical College Hospital. The pulse Act-D regimen is defined as 1.25 mg/m2 (max 2 mg) IV push every other week. All patients were followed until May 2017. Epidemiological and clinical data were compared between patients with remission and resistance to Act-D to determine predictive factors by univariate and multivariate analysis.ResultsNinety-six of 135 patients (71.1%) achieved complete remission after first-line chemotherapy of pulse Act-D. In multivariate analysis, existing invasive uterine lesions observed by pre-chemotherapy transvaginal ultrasound (odds ratio [OR] 7.5, 95% confidence intervals [CI] 2.7–20.8), FIGO score ≥ 5 (OR 15.2, 95% CI 1.5–156.1) and pre-chemotherapy levels of β-hCG ≥ 4000 IU/L (OR 3.1, 95% CI 1.2–8.3) were independent high-risk factors predicting resistance to pulse Act-D as single-agent chemotherapy. During follow-up, no relapse, treatment-associated serious adverse events, or death occurred.ConclusionsAs first-line chemotherapy, pulse Act-D was effective and tolerable for patients with low-risk post-molar non-choriocarcinoma. Existing invasive uterine lesions observed by pre-chemotherapy transvaginal ultrasound, a FIGO score ≥ 5, and pre-chemotherapy levels of β-hCG ≥ 4000 IU/L were independent factors for resistance to pulse Act-D.

Temporal trends in incidence and outcome of hydatidiform mole: a retrospective cohort study

Background: Reported incidence rates of hydatidiform mole (HM) show wide geographic and temporal variations, making reliable international comparisons difficult. The aim of the current study was to examine temporal trends in the incidence of HM and post-molar gestational trophoblastic neoplasia (GTN) in Stockholm County.Material and methods: Data of all women with a diagnosis of HM in Stockholm County 1991–2010 was collected. The incidence of HM was assessed both in relation to number of births and viable conceptions (births and pregnancy terminations). The risk of post-molar GTN was analysed for all HM, as well as for the subtypes complete (CHM) and partial hydatidiform mole (PHM). Temporal trends were analysed by stratifying the study period into five-year intervals.Results: The overall incidence rate of HM was 2.08/1000 deliveries and 1.48/1000 viable conceptions. A significant temporal increase in the incidence rate of HM, as well as in the total number and proportion of PHM, was seen. Among 956 women with HM, 77 (8%) progressed into post-molar GTN. There was evidence of a slight, but non-significant increase in the risk of malignancy in the two last five-year periods under study.Conclusions: We found evidence of a significant temporal increase in the incidence rate of HM, which could not fully be explained by an increase in maternal age over time. Changes in diagnostic methods probably contributed to the increased incidence rate of PHM. The risk of post-molar GTN remained constant over time.

Does a human chorionic gonadotropin level of over 20,000 IU/L four weeks after uterine evacuation for complete hydatidiform mole constitute an indication for chemotherapy for gestational trophoblastic neoplasia?

ObjectiveTo evaluate whether a human chorionic gonadotropin (hCG) level ≥20,000 IU/L four weeks after uterine evacuation for complete hydatidiform mole (CHM) is an appropriate indicator for initiating chemotherapy for the treatment of gestational trophoblastic neoplasia (GTN). Study designHistorical database review of 1228 women with CHM who received treatment and follow-up between January 2000 and June 2013 at four Brazilian trophoblastic disease centers. The primary outcome measure was the progression from CHM to GTN. The secondary outcomes were the occurrence of uterine perforation, staging of GTN, WHO/FIGO risk score, and treatment (use of single- or multiagent chemotherapy). ResultsAn hCG level ≥20,000 IU/L four weeks after uterine evacuation for CHM, while occurring in only 6.1% of women, was the most important risk factor for the development of postmolar GTN (adjusted RR = 5.83; p < 0.01; CI: 3.47–9.79), with a sensitivity of 36.8%, a specificity of 98.6%, a positive predictive value of 80%, and a negative predictive value of 91.1%. On the other hand, there were no differences in postmolar GTN stage, prognostic score, or need for multiagent chemotherapy relative to hCG level ≥20,000 IU/L versus <20,000 IU/L. ConclusionsAlthough hCG level ≥20,000 IU/L four weeks after uterine evacuation for CHM was very predictive of development of post-molar GTN, delay in treatment until hCG plateau or increase did not affect outcomes, with no uterine perforations or treatment failures.

What is the optimal duration of human chorionic gonadotrophin surveillance following evacuation of a molar pregnancy? A retrospective analysis on over 20,000 consecutive patients

ObjectiveTo quantify the risk of developing post-molar gestational trophoblastic neoplasia (pGTN) beyond the first normal human chorionic gonadotrophin (hCG) in women who have had a complete (CHM) or partial molar pregnancy (PHM) and to re-evaluate the current UK Hydatidiform mole hCG surveillance guidelines. MethodsThe Charing Cross Hospital Trophoblast Disease Centre database was screened to identify all registered cases of hydatidiform mole (HM) between 1980 and 2009. ResultsWe identified 20,144 cases of HM, comprising 8400 CHM, 9586 PHM, and 2158 cases of unclassified hydatidiform mole (UHM). Twenty-nine cases (20 CHM, 3 PHM and 6 UHM) developed pGTN after the first normal hCG. For CHM the risk of pGTN at the point of hCG normalisation was 1 in 406, and fell rapidly in the first six months of monitoring. For PHM the risk of pGTN at the point of hCG normalisation was 1 in 3195. Women with CHM where hCG normalisation occurred beyond 56days after uterine evacuation of molar tissue were found to have a 3.8-fold higher risk of pGTN. ConclusionsOur results show that pGTN can occur after hCG normalisation following PHM but the risk is extremely low. Women with CHM have a comparatively higher risk of pGTN after hCG normalisation. Those with CHM where hCG normalises within 56days have a lower risk of pGTN. We have revised the current UK hCG surveillance protocol for PHM to a single additional confirmatory normal urine hCG measurement one month after first normalisation. The protocol for CHM remains unchanged.

Comparison of different therapeutic strategies for complete hydatidiform mole in women at least 40\xa0years old: a retrospective cohort study

BackgroundThere are three main therapeutic strategies, namely expectant management (dilation and curettage only), prophylactic chemotherapy and prophylactic total hysterectomy for treating older women with complete hydatidiform mole (CHM). However, the scientific community has so far, not unanimously accepted the above-mentioned methods. The objective of this study was to evaluate the effectiveness of these therapeutic strategies in preventing post-molar gestational trophoblastic neoplasia (GTN) pertaining to patients with CHM who were at least 40 years old.MethodsHundred and seventy-one patients from our hospital who had histologically been diagnosed of CHM and underwent treatment from January 2004 to December 2013 were included. All patients were followed continuously for a minimum of 2 years after which relevant clinical data were extracted and analysed.ResultsAll patients were divided to three groups. Group 1 consisted of 124 patients, treated by expectant management, and the incidence of post-molar GTN was 37.1%. Group 2 included 12 patients who received prophylactic chemotherapy, with an incidence of 41.7%. The remaining 35 patients, Group 3, underwent prophylactic total hysterectomy, with the lowest incidence of 11.4%. A significantly lower incidence was noted in group 3 as compared to group 1 (P = 0.004). GTN patients who received prophylactic chemotherapy required, on average, longer time to be diagnosed of GTN and had higher probability of chemotherapy resistance (P = 0.031 and P = 0.024).ConclusionsThis retrospective analysis showed that prophylactic total hysterectomy was the most effective therapeutic strategy for treating CHM in women at least 40 years old of age.

Effectiveness and toxicity of first-line methotrexate chemotherapy in low-risk postmolar gestational trophoblastic neoplasia: The New England Trophoblastic Disease Center experience

ObjectivesTo assess the outcomes and toxicity of first-line methotrexate (MTX) chemotherapy in low-risk postmolar gestational trophoblastic neoplasia (GTN) patients receiving 8-day methotrexate or one-day methotrexate infusion regimens. MethodsThis retrospective cohort study was conducted at the New England Trophoblastic Disease Center (NETDC), between 1974 and 2014, and included 325 patients with FIGO-defined low-risk postmolar GTN receiving first-line 8-day MTX/folinic acid (FA) or one-day MTX infusion and FA. Demographics, disease presentation, initial treatment plan, treatment outcome, and treatment-related adverse events were assessed. ResultsSustained remission (84% vs 62%, p<0.001) and need to switch to second-line therapy due to treatment-related adverse events (5.3% vs 0%, p=0.001) were higher for 8-day MTX/FA compared to one-day MTX infusion. MTX resistance, however, was more frequent with one-day MTX (34.5%) than with 8-day MTX/FA (7.3%, p<0.001). Relapse rates were similar with both regimens (3.0%). Compared to one-day MTX infusion, 8-day MTX/FA was associated with significantly higher gastrointestinal disorders (48% vs 24%), abnormal laboratory findings (48% vs 28%), eye disorders (37% vs 19%) and general disorders (22% vs 5%) (p<0.001). Only infection frequency did not differ between 8-day MTX/FA and one-day MTX infusion (20% vs 12%, p=0.083). ConclusionsThis is one of the largest studies to comprehensively catalogue toxicities associated with 8-day MTX/FA and one-day MTX infusion. Although treatment-related adverse events were more frequent with 8-day MTX/FA, these were all self-limited and resolved with no long-term sequelae. Given this and its higher effectiveness, 8-day MTX/FA remains the treatment of choice at NETDC for patients with low-risk postmolar GTN.

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

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. 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. 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. 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.

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

The aim of this study was to comparatively study a novel model and existing models of predicting postmolar gestational trophoblastic neoplasia (GTN). Two hundred twenty-two patients with complete hydatidiform moles were enrolled retrospectively. A natural regression was noted in 195 patients (spontaneous regression group), whereas the remaining 27 patients entered postmolar GTN (postmolar GTN group). The upper limits of the 95% confidence interval of human chorionic gonadotropin (hCG) values and hCG regression rates were calculated aggregately from the spontaneous regression group. The 4 prediction models (weekly hCG regression curve and weekly hCG regression rate curve reported by previous studies; daily hCG regression curve and daily hCG regression rate curve pioneered by us) were then plotted. The individual hCG curve of the postmolar GTN group was plotted and compared with the prediction models, respectively. The individual hCG curve superimposing the prediction curve was considered showing an elevated risk of GTN. All patients with postmolar GTN were preidentified by daily hCG regression rate curve. The other 3 prediction models had a considerable rate of failure in identification. Mean diagnosis time of daily hCG regression rate curve was significantly lower (P = 0.008), with an average of 15.3 days gained compared with International Federation of Gynecology and Obstetrics criteria. Cochran Q test showed that daily hCG regression rate curve produced a significantly better performance in predicting postmolar GTN than weekly hCG regression curve (P = 0.01). Our data showed that daily hCG regression rate curve gives a better prediction of postmolar GTN and might potentially enhance the monitoring of patients with molar pregnancy, especially those who could not adhere to International Federation of Gynecology and Obstetrics protocols. However, this preliminary research should not change current clinical practice until further validation is carried out.

The added value of hysterectomy in the management of gestational trophoblastic neoplasia

BackgroundDespite the undoubted effectiveness of chemotherapeutic treatment in gestational trophoblastic neoplasia (GTN), problems related to toxicity of chemotherapy and chemo-resistant disease have led to reconsideration of the use of hysterectomy. Aim of the present study was to evaluate indications for and outcome of hysterectomy in patients with GTN in a nation-wide cohort. MethodsBetween 1977 and 2012, we identified all patients diagnosed with GTN and treated with hysterectomy from the Dutch national databases. Demographics, clinical characteristics and follow-up were recorded retrospectively. ResultsOne hundred and nine patients (16.5% of all registered patients with GTN) underwent hysterectomy as part of their management for GTN. The majority of patients was classified as low-risk disease (74.3%), post-molar GTN (73.5%) and disease confined to the uterus (65.1%). After hysterectomy, complete remission was achieved in 66.2% of patients with localized disease and in 15.8% of patients with metastatic disease. For patients with localized disease, treated with primary hysterectomy, treatment duration was significantly shorter (mean 3.2weeks and 8.0weeks respectively, p=0.01) with lower number of administered chemotherapy cycles (mean 1.5 and 5.8 respectively, p<0.01) than patients in a matched control group. ConclusionIn selected cases, a hysterectomy may be an effective means to either reduce or eliminate tumor bulk. Primary hysterectomy should mainly be considered in older patients with localized disease and no desire to preserve fertility, whereas patients with chemotherapy-resistant disease may benefit from additional hysterectomy, especially when disease is localized. For patients with widespread metastatic disease, the benefit of hysterectomy lies in the removal of chemotherapy-resistant tumor bulk with subsequent effect on survival.

Uterine artery Doppler flow velocimetry parameters for predicting gestational trophoblastic neoplasia after complete hydatidiform mole, a prospective cohort study

OBJECTIVES:Doppler ultrasonography can be used to assess neoangiogenesis, a characteristic feature of postmolar gestational trophoblastic neoplasia. However, there is limited information on whether uterine artery Doppler flow velocimetry parameters can predict gestational trophoblastic neoplasia following a complete hydatidiform mole. The purpose of this study was as follows: 1) to compare uterine blood flow before and after complete mole evacuation between women who developed postmolar gestational trophoblastic neoplasia and those who achieved spontaneous remission, 2) to assess the usefulness of uterine Doppler parameters as predictors of postmolar gestational trophoblastic neoplasia and to determine the best parameters and cutoff values for predicting postmolar gestational trophoblastic neoplasia.METHODS:This prospective cohort study included 246 patients with a complete mole who were treated at three different trophoblastic diseases centers between 2013 and 2014. The pulsatility index, resistivity index, and systolic/diastolic ratio were measured by Doppler flow velocimetry before and 4-6 weeks after molar evacuation. Statistical analysis was performed using Wilcoxon’s test, logistic regression, and ROC analysis.RESULTS:No differences in pre- and post-evacuation Doppler measurements were observed in patients who developed postmolar gestational trophoblastic neoplasia. In those with spontaneous remission, the pulsatility index and systolic/diastolic ratio were increased after evacuation. The pre- and post-evacuation pulsatility indices were significantly lower in patients with gestational trophoblastic neoplasia (odds ratio of 13.9-30.5). A pre-evacuation pulsatility index ≤1.38 (77% sensitivity and 82% specificity) and post-evacuation pulsatility index ≤1.77 (79% sensitivity and 86% specificity) were significantly predictive of gestational trophoblastic neoplasia.CONCLUSIONS:Uterine Doppler flow velocimetry measurements, particularly pre- and post-molar evacuation pulsatility indices, can be useful for predicting postmolar gestational trophoblastic neoplasia.

Is chemotherapy necessary for patients with molar pregnancy and human chorionic gonadotropin serum levels raised but falling at 6 months after uterine evacuation?

ObjectiveTo compare the outcomes of Brazilian patients with molar pregnancy who continue human chorionic gonadotropin (hCG) surveillance with those treated with chemotherapy when hCG was still positive, but falling at 6months after uterine evacuation. MethodsRetrospective chart review of 12,526 patients with hydatidiform mole treated at one of nine Brazilian reference centers from January 1990 to May 2016. ResultsAt 6months from uterine evacuation, 96 (0.8%) patients had hCG levels raised but falling. In 15/96 (15.6%) patients, chemotherapy was initiated immediately per FIGO 2000 criteria, while 81/96 (84.4%) patients were managed expectantly. Among the latter, 65/81 (80.2%) achieved spontaneous remission and 16 (19.8%) developed postmolar gestational trophoblastic neoplasia (GTN). Patients who received chemotherapy following expectant management required more time for remission (11 versus 8months; p=0.001), had a greater interval between uterine evacuation and initiating chemotherapy (8 versus 6months; p<0.001), and presented with a median WHO/FIGO risk score higher than women treated according to FIGO 2000 criteria (4 versus 2, p=0.04), but there were no significant differences in the need for multiagent treatment regimens (1/15 versus 3/16 patients, p=0.60). None of the women relapsed, and no deaths occurred in either group. ConclusionIn order to avoid unnecessary exposure of women to chemotherapy, we no longer follow the FIGO 2000 recommendation to treat all patients with molar pregnancy and hCG raised but falling at 6months after evacuation. Instead, we pursue close hormonal and radiological surveillance as the best strategy for these patients.