Combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios for early prediction of postmolar gestational trophoblastic neoplasia.

PURPOSE: To investigate factors predicting postmolar gestational trophoblastic neoplasia (GTN) by combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios. METHODS: This retrospective study enrolled patients with histopathologically proven molar pregnancy. Patients lost to follow-up before remission or developing postmolar GTN were excluded. Demographic and clinical characteristics and hCG data obtained before and after molar evacuation were collected. Area under the receiver operating characteristic curve (AUC) analysis was used to identify the hCG and hCG ratio cutoff values that predict postmolar GTN. Multivariate analysis was employed to identify independent predictors of GTN. RESULTS: There were 113 complete moles, 11 partial moles, and 52 unspecified moles included in the final analysis. Of the 176 cases, 90 achieved remission and 86 developed post-molar GTN. The incidence of postmolar GTN was 48.9%, with a median time to GTN development of 5 weeks. Univariate analysis showed age, molar evacuation performed elsewhere, pre-evacuation hCG, hCG at 2nd week post-evacuation, and ratio of hCG at 2nd week post-evacuation to post-evacuation hCG significantly predict GTN. Multivariate analysis revealed an hCG value ≥ 1400 IU/L at 2nd week post-evacuation (AUC: 0.92, aOR: 6.51, 95% CI 1.28-33.16; p = 0.024) and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 (AUC: 0.88, aOR: 12.27, 95% CI 2.15-70.13; p = 0.005) to independently predict GTN. CONCLUSIONS: An hCG value ≥ 1400 IU/L at 2nd week post-evacuation and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 independently and reliably predict postmolar GTN.

The management of hydatidiform mole using prophylactic chemotherapy and hysterectomy for high-risk patients decreased the incidence of gestational trophoblastic neoplasia in Vietnam: a retrospective observational study.

The management of hydatidiform mole (HM) and the incidence of post-molar gestational trophoblastic neoplasia (GTN) in Vietnam has not been reported to date. This study aimed to study the incidence of HM and post-molar GTN and identify factors associated with post-molar GTN at a tertiary hospital in Vietnam. Five hundred and eighty-four patients who were treated for HM at Tu Du Hospital between January and December 2010 were included in this study. The mean age and gestational age at the first evacuation were 28.8 years old and 11.0 weeks, respectively. After the initial evacuation and pathological examination, 87 patients who were older than 40 or did not wish to have children underwent a hysterectomy, while the others underwent second curettage. All 472 patients who had human chorionic gonadotropin (hCG) ≥ 100,000 IU/L before treatment received one cycle of methotrexate with folinic acid as prophylactic chemotherapy. The incidence of HM was 11.1 per 1,000 deliveries; 47 patients (8.0%) developed post-molar GTN. Gestational week, hCG level at one week after the first evacuation, and pathological remnants were significantly associated with the development of post-molar GTN. The results of this study suggest that prophylactic chemotherapy and hysterectomy may be useful for high-risk HM patients to reduce post-molar GTN in settings in which the risk of post-molar GTN and loss to follow-up after HM are greater and hCG measurements and appropriate GTN treatments are unavailable. However, future studies on the long-term outcomes and side effects of prophylactic therapies on HM are required.

Multicenter analysis of gestational trophoblastic neoplasia in Turkey.

BACKGROUND: To evaluate the incidence, diagnosis and management of GTN among 28 centers in Turkey. MATERIALS AND METHODS: A retrospective study was designed to include GTN patients attending 28 centers in the 10-year period between January 2003 and May 2013. Demographical characteristics of the patients, histopathological diagnosis, the International Federation of Gynecology and Obstetrics (FIGO) anatomical and prognostic scores, use of single-agent and multi-agent chemotherapy, surgical interventions and prognosis were evaluated. RESULTS: From 2003-2013, there were 1,173,235 deliveries and 456 GTN cases at the 28 centers. The incidence was calculated to be 0.38 per 1,000 deliveries. According to the evaluated data of 364 patients, the median age at diagnosis was 31 years (range, 15-59 years). A histopathological diagnosis was present for 45.1% of the patients, and invasive mole, choriocarcinoma and PSTTs were diagnosed in 22.3% (n=81), 18.1% (n=66) and 4.7% (n=17) of the patients, respectively. Regarding final prognosis, 352 (96.7%) of the patients had remission, and 7 (1.9%) had persistence, whereas the disease was mortal for 5 (1.4%) of the patients. CONCLUSIONS: Because of the differences between countries, it is important to provide national registration systems and special clinics for the accurate diagnosis and treatment of GTN.

Gestational trophoblastic disease: experience at Nawabshah Hospital.

BACKGROUND: Gestational Trophoblastic Disease (GTD) is a heterogeneous group of diseases that includes partial and complete hydatidiform mole, invasive mole, choriocarcinoma and placental site trophoblastic tumour. The incidence of GTD varies in different parts of the world. The malignant potential of this disease is higher in South East Asia in comparison to western countries. Objectives of study were to determine the frequency, clinical presentation and management outcomes of GTD. This retrospective, descriptive case series was conducted in the Department of Obstetric and Gynaecology Nawabshah Medical College Hospital, from 1st Jan 2007 to 30th Dec 2007. METHODS: The case records of all the gestational trophoblastic cases during study period were analysed regarding their history, clinical examination, investigations, treatment and follow-up. The main outcomes were measured in terms of duration, antecedent pregnancy, investigations, treatment and the follow-up. RESULTS: There were a total of 1056 Obstetric admissions during the study period, which included 30 cases of trophoblastic disease with a frequency of GTD was 28 per 1000 live births. Of these 30 cases, 21 (70%) patients had hydatidiform mole, 7 (23.3%) patients had invasive disease and 2 (6.6%) patients had choriocarcinoma. Twenty three patients (76.6%) received chemotherapy while 25 (83.3%) patients had suction evacuation and 4 (13.3%) patients underwent hysterectomy. Among all patients, 29 (96.7%) fully recovered and 1 (3.3%) died because of extensive disease; metastasis extending up to brain. CONCLUSION: Frequency of GTD was higher compared to national and international studies. The disease was common in extremes of ages, low para and grand multiparous women. Hydatidiform mole was the commonest type of trophoblastic disease in these patients. Most common presenting complaint was bleeding per vagina followed by pain in lower abdomen.

[Sensitivity, specificity, predictive positive and negative value of the main clinical signs and symptoms of hydatiform mole]. / Sensibilità, specificità, valore predittivo positivo e negativo dei principali segni clinici e sintomi della mola idatidea.

AIM: Especially in the first weeks of pregnancy, complete and partial hydatiform moles are not easily detected by sonography, symptoms and clinical signs. Due to the rarity of moles, it is possible that they may be confused with abortive pregnancies until the pathological examination. The aim of this study is to identify the sensitivity, specificity, predictive positive and negative value of the main symptoms and clinical signs of molar pregnancies. METHODS: Thirteen molar pregnancies have been detected after pathological examination from January 2003 to July 2005 in Perugia. Their main clinical signs and symptoms are compared with those recorded in 288 abortive pregnancies, 56 ectopic pregnancies and 27 Hyperemesis gravidarum, observed in the same period. RESULTS: Vaginal bleeding and pelvic pain are the most sensitive symptoms and have the highest predictive negative values. The size of the uterus greater for date is the most specific sign. Pelvic pain with hyperemesis, and uterus size greater for date have the highest predictive positive values, but the lowest sensitivity. CONCLUSIONS: A mole should be excluded in patients with hyperemesis and pelvic pain, and in patients with uterus size greater for date. In the first case, a hyperemesis gravidarum may be diagnosed and, in the second one, a twin pregnancy may be confirmed with a sonographic scan.

Transient uterine myometrial contraction associated with moles.

PURPOSE: To examine the incidence of transient distortion of uterine central tissue and myometrial hypointense areas observed on MR images in women with clinically suspicious moles. MATERIALS AND METHODS: The study population consisted of six women aged 15-47 years with clinically suspicious moles (hydatidiform mole in four, invasive mole in one, and microscopic mole in one). The control study population was 105 reproductive-age women (18-52 years) without uterine malignancy, gestational trophoblastic disease, or pregnancy. MR images were analyzed to check for discrepancies of the uterine central tissue configuration. If a discrepancy was observed, the myometrial hypointense area, its diameter, and changes in its shape and location were analyzed. RESULTS: Differences in uterine central tissue configuration and hypointense areas were observed in all six patients. In the control study, only seven cases showed uterine endometrial distortion, and five exhibited hypointense areas. These areas disappeared, changed in shape, or other hypointense areas appeared on subsequent MR images. Significant differences (P < 0.01) in the incidence of uterine central tissue distortion and hypointense areas, and in their maximum diameter between the study and the control groups were observed. CONCLUSION: Uterine myometrial hypointense areas with central tissue distortion, most likely due to transient myometrial contraction, are frequently seen in women with clinically suspicious moles.

Epidemiology and time trends of gestational trophoblastic disease in Korea.

OBJECTIVES: For the purpose of determining the annual incidence and time trends of gestational trophoblastic disease (GTD), the medical records from 24 university hospitals, 13 private general hospitals and the Korean Research Institute of Gestational Trophoblastic Disease (KRI-TRD) were analyzed from 1971 to 1995. MATERIALS & RESULTS: From a total of 7198 GTD cases (H-mole=3831, Invasive mole=2163, Choriocarcinoma=1177, PSTr=27) among 838659 deliveries between 1971 and 1995, the hospital-based incidence of H-mole per 1000 deliveries declined from 40.2 during 1971-975, to 2.3 during 1991-995. The population-based incidence of H-mole, however, revealed an average of 2.05 per 1000 deliveries during 1991-995. Old age and gravidities as factors in GTD patients both decreased significantly during the study period. Time trends for the incidence of GTD in Korea revealed significant changes, not only a decrease in the incidence of GTD, but also an improvement in the annual remission rate. Korea's socio-eonomic improvement in recent decades also contributed to the decreased incidence of GTD and the increased survival rates.

Recent aspects of gestational trophoblastic disease in Japan.

The regional registration in 11 prefectures and one area covering 34% of total Japanese population started in 1974, increasing gradually to 21 prefectures and one area in 1993 covering 48.5% of total Japanese populations, by the Japan Trophoblastic Disease Committee under the auspices of Japan Society of Obstetrics and Gynecology. The results showed marked decreasing trend in incidence of molar pregnancy and choriocarcinoma in Japan. The most frequent antecedent pregnancies of choriocarcinoma has shifted from molar pregnancy in 1974 to term pregnancy in 1993. The Choriocarcinoma Risk Score Table that is in use and of practical significance, differentiating choriocarcinoma from invasive or metastatic mole by reference to simple 8 clinical items with the probability of more than 90% when compared with the histological diagnoses, is also presented.

Current approaches to diagnosis and treatment of gestational trophoblastic disease.

Diagnosis of molar pregnancy relies on serum and urine human chorionic gonadotropin estimations in addition to characteristic appearances on histology. Approximately 92% of hydatidiform moles resolve spontaneously after evacuation, and with careful human chorionic gonadotropin follow-up, the remainder can be successfully treated with a minimum of toxicity. Non-post-mole gestational choriocarcinoma is also highly curable with modern chemotherapy, and in the rare cases when drug resistance develops, surgery can be an effective salvage treatment. In cases when doubt exists as to whether a patient has a true gestational tumor or a human chorionic gonadotropin-producing carcinoma, the origin of the tumor can sometimes be determined by DNA analysis. This determination can help to avoid inappropriate chemotherapy for patients with nongestational tumors.

Under-registration of gestational trophoblastic disease in the Swedish Cancer Registry.

The paper presents a study of completeness of registration of hydatidiform mole and gestational trophoblastic neoplasia in the Swedish Cancer Registry. The study is based on patients treated in Stockholm County, Sweden from 1971 through 1986. Non-notified cases were identified through a computerized register covering nearly all hospital admissions in the region and local hospital patient register. The results show that 25% of the cases with a diagnosis of hydatidiform mole were not included in the cancer register. Of all patients treated for trophoblastic malignancy, 66% were not recorded in the Cancer Registry. The frequent absence of histopathological confirmation in cases with malignant trophoblastic disease was probably the main factor contributing to the observed under-registration. The study indicates that the Swedish Cancer Registry alone does not provide sufficient data for studies on the incidence of gestational trophoblastic disease.

Placental site trophoblastic tumor. Diagnosis, clinical behavior and treatment.

Placental site trophoblastic tumor is a rare trophoblastic neoplasm with the potential for metastatic disease and death. Difficulty diagnosing these tumors and predicting their biologic behavior has clouded attempts to successfully outline individual treatment plans. This review details current knowledge of the origin and clinical behavior of this rare form of trophoblastic disease. The use of various markers to predict clinically aggressive behavior is reviewed critically, and treatment is recommended on the basis of recently published clinical series.

Study and treatment of gestational trophoblastic diseases at the John I. Brewer Trophoblastic Disease Center, 1962-1990.

From 1962 through 1989, 5063 patients were referred to the John I. Brewer Trophoblastic Disease Center of the Northwestern University Medical School. Among these were 564 patients treated with chemotherapy for gestational trophoblastic tumors (choriocarcinoma and invasive mole). The overall cure rate was 94%, 100% for 323 patients without evidence of metastases and 85% for 241 patients with metastatic disease. Four factors were determined to significantly influence treatment response: (1) clinicopathologic diagnosis of choriocarcinoma, (2) metastases to sites other than the lung or vagina, (3) number of metastases, and (4) previous failed chemotherapy.

[Statistical analysis of trophoblastic disease in Kanagawa prefecture].

Two thousand one hundred and thirty-five cases of trophoblastic disease were registered in Kanagawa Prefecture in 7 years (from 1978 to 1984). The incidence of trophoblastic diseases, hydatidiform mole, partial mole, invasive mole, choriocarcinoma and persistent trophoblastic disease (PTD) was 3.22, 1.67, 1.20, 0.07, 0.06 and 0.20, respectively, per 1,000 live births. The incidence was constant for 7 years, and did not differ significantly from that of 16 prefectures in Japan. In Kanagawa, the incidence of hydatidiform mole was less and that of partial mole was more than those in the 16 prefectures. The incidence of invasive mole and choriocarcinoma was lower and that of PTD was higher than those in the 16 prefectures. Total incidence of invasive mole, choriocarcinoma and PTD was higher in the western part of Japan, and lower in the eastern and northern parts. Kanagawa Prefecture is between these two regions. The distribution by age of hydatidiform mole was high in 25-29 y.o. and over 40 y.o. The distribution by age of partial mole tended to be similar to that of hydatidiform mole, but less remarkable. The distribution by age of invasive mole and choriocarcinoma had 2 peaks of 30-34 y.o. and 45-49 y.o. The distribution by age of PTD was between that of hydatidiform mole and choriocarcinoma.

Registry and follow-up systems of trophoblastic disease in Japan.

With recent progress in chemotherapy, the prognosis of patients with trophoblastic disease has greatly improved, but the remission rate of patients with choriocarcinoma remains unfavorable. To improve the prognosis of these patients, early detection and early treatment are essential. Under the leadership of the Committee of Trophoblastic Disease of the Japan Society of Obstetrics and Gynecology, regional registries of trophoblastic disease were started in 1974. By 1982 14 prefectures with a total population of 46,893,620 were included in the registry. The early detection and treatment and follow-up made possible by the registry in addition to the introduction of advanced chemotherapy may be responsible for a rapidly decreasing trend in the death rate from this disease.

Repeat gestational trophoblastic disease.

During a ten-year period from 1969 through 1979, 22 of 1648 patients referred to the John I. Brewer Trophoblastic Disease Center of Northwestern University Medical School had repeat gestational trophoblastic disease, an incidence of 1.33%. A total of 52 trophoblastic disease episodes occurred in these 22 patients. Invasive mole or choriocarcinoma occurred as the first trophoblastic disease episode in only three patients (14%), whereas one of these sequelae was the second trophoblastic disease event in seven patients (32%). Seventeen patients (77%) had consecutive trophoblastic disease episodes. After a second trophoblastic disease episode, the risk for a subsequent event rose to 28%; however, 44% of these patients delivered viable infants. There was no difference in outcome of subsequent pregnancies with respect to previous chemotherapy.