[Effects of prophylactic chemotherapy on outcomes and prognosis of patients older than 40 years with invasive mole].

Objective: To discuss the effects of prophylactic chemotherapy on the outcomes and prognosis of invasive mole patients. Methods: One hundred and fifteen invasive mole (IM) patients older than 40 years were registered in Peking Union Medical Collage Hospital.Eleven of them were treated with prophylactic chemotherapy before diagnosed as IM prophylactic chemotherapy group, while the other 104 cases received therapeutic chemotherapy after diagnosed as IM (non-prophylactic chemotherapy group). The general clinical data (including age, clinical stage, risk factor score), treatment, outcomes and relapse of patients were retrospectively compared between two groups. Results: (1) The age of prophylactic chemotherapy group and non-prophylactic chemotherapy group were (47±5) versus (46±4) years old. Ratio of clinical stageⅠ-Ⅱ were 3/11 versus 29.8% (31/104), clinical stage Ⅲ-Ⅳ were 8/11 versus 70.2% (73/104). Ratio of risk factor score 0-6 were 11/11 versus 84.6% (88/104), risk factor score >6 were 0 versus 15.4% (16/104). There were no significant statistical differences between two groups in age, clinical stage or risk factor score (all P>0.05). (2) Treatment: the total chemotherapy courses between prophylactic chemotherapy group and non-prophylactic chemotherapy group (median 7 versus 5) were significantly different (Z=3.071,P=0.002). There were no significant statistical differences between two groups in the chemotherapy courses until negative conversion of ß-hCG, consolidation chemotherapy courses, total therapeutic chemotherapy courses or ratio of hysterectomy (all P>0.05). (3) Outcomes and relapse: between the prophylactic chemotherapy group and the non-prophylactic chemotherapy group, the complete remission rate were 11/11 versus 98.1%(102/104), the relapse rate were 0 versus 1.0%(1/102). There were no significant difference between the two groups in outcomes or relapse rate (P>0.05). Conclusions: Prophylactic chemotherapy does not substantially benefit the IM patients older than 40 years. Prophylactic chemotherapy may not significantly improve patients' prognosis, in which increased sample size is required in further study.

Spontaneous renal hemorrhage caused by invasive mole: a case report.

CASE: The authors report a case with spontaneous renal hemorrhage caused by invasive mole. The diagnosis was gestational trophoblastic disease (GTD), with metastasis to brain, kidneys, and lungs at Stage IV. The patient was given etoposide-methotrexate-actinomycin D plus cyclophosphamide-vincristine (EMACO) treatment regimen for 11 times including three times with consolidation chemotherapies. Laparoscopically-assisted vaginal hysterectomy (LAVH) + laparoscopic-assisted left renal excision + evacuation of the left perirenal hematoma were performed during the eighth chemotherapy. CONCLUSION: Post-operational pathological examination revealed trophoblasts within the lesions present in uterine fundus and the residue images of a few trophoblasts present in the left renal mass.

Methotrexate and actinomycin D chemotherapy in a patient with porphyria: a case report.

BACKGROUND: Despite their broadly recommended use as chemotherapeutic agents, the porphyrogenicity of methotrexate and actinomycin D have not been confirmed. Accordingly, it is not known whether these agents are safe for use in patients with porphyria. CASE PRESENTATION: In this report, we present a case of an invasive mole with lung metastasis in a 49-year-old Japanese woman who had previously been diagnosed with acute intermittent porphyria at 27 years of age but had no recent history of acute intermittent porphyria attacks. Her serum human chorionic gonadotropin level was elevated 1 month after hysterectomy, and she was referred to our center for chemotherapy. After she received 100 mg of methotrexate, drug eruptions were observed starting on day 3 and grew progressively worse. Erythema and mucosal erosion spread throughout her body, whereupon she was administered prednisolone. In addition, our patient experienced febrile neutropenia and required granulocyte colony- stimulating factor treatment. No changes in our patient's urinary coproporphyrin or uroporphyrin levels were detected during this entire episode. Methotrexate was replaced by actinomycin D (0.5 mg/body intravenously on days 1-5 every 2 weeks). After five uneventful cycles of actinomycin D, our patient achieved and maintained a normal serum human chorionic gonadotropin level for 3 years. CONCLUSIONS: Methotrexate and actinomycin D did not induce acute porphyric attacks in this patient with acute intermittent porphyria; however, severe adverse effects were noted with methotrexate. Although further investigation is required, our data suggest that these agents are nonporphyrinogenic and can therefore be used to treat patients with comorbid porphyria.

Hypotensive Response Magnitude and Duration in Hypertensives: Continuous and Interval Exercise / Magnitude e Duração da Resposta Hipotensora em Hipertensos: Exercício Contínuo e Intervalado

Background: Although exercise training is known to promote post-exercise hypotension, there is currently no consistent argument about the effects of manipulating its various components (intensity, duration, rest periods, types of exercise, training methods) on the magnitude and duration of hypotensive response. Objective: To compare the effect of continuous and interval exercises on hypotensive response magnitude and duration in hypertensive patients by using ambulatory blood pressure monitoring (ABPM). Methods: The sample consisted of 20 elderly hypertensives. Each participant underwent three ABPM sessions: one control ABPM, without exercise; one ABPM after continuous exercise; and one ABPM after interval exercise. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and double product (DP) were monitored to check post-exercise hypotension and for comparison between each ABPM. Results: ABPM after continuous exercise and after interval exercise showed post-exercise hypotension and a significant reduction (p < 0.05) in SBP, DBP, MAP and DP for 20 hours as compared with control ABPM. Comparing ABPM after continuous and ABPM after interval exercise, a significant reduction (p < 0.05) in SBP, DBP, MAP and DP was observed in the latter. Conclusion: Continuous and interval exercise trainings promote post-exercise hypotension with reduction in SBP, DBP, MAP and DP in the 20 hours following exercise. Interval exercise training causes greater post-exercise hypotension and lower cardiovascular overload as compared with continuous exercise. .

Fundamento: Embora se saiba que o exercício promova hipotensão pós-exercício, até o momento não há argumentações consistentes sobre os efeitos da manipulação de seus diversos componentes (intensidade, duração, intervalos de descanso, tipos de exercício, métodos de treinamento) na magnitude e duração da resposta hipotensora. Objetivo: Comparar os efeitos dos exercícios dinâmicos, contínuo e intervalado, sobre a magnitude e duração da resposta hipotensora em hipertensos por meio da monitorização ambulatorial da pressão arterial (MAPA). Métodos: A amostra foi composta por 20 idosos hipertensos. Cada participante realizou três sessões de MAPA, sendo uma controle (sem exercício), uma após exercício contínuo e uma após exercício intervalado. O monitoramento de pressão arterial sistólica (PAS), pressão arterial diastólica (PAD), pressão arterial média (PAM), frequência cardíaca (FC) e duplo produto (DP) foi realizado para verificação da hipotensão pós-exercício e comparação entre cada MAPA. Resultados: As MAPAs após exercício contínuo e intervalado demonstraram hipotensão pós-exercício e redução significativa (p < 0,05) de PAS, PAD, PAM e DP por 20 horas, na comparação com a MAPA controle. Na comparação entre as MAPAs após exercício contínuo e intervalado, verificou-se redução significativa (p < 0,05) de PAS, PAD, PAM e DP após exercício intervalado. Conclusão: Os exercícios contínuo e intervalado promovem hipotensão pós-exercício, com redução significativa de PAS, PAD, PAM e DP ao longo das 20 horas subsequentes à atividade. O exercício intervalado gera maior magnitude de hipotensão pós-exercício e menor sobrecarga cardiovascular, medida por menor DP. .

Invasive mole of the uterus- a rare case diagnosed by ultrasound: a case report.

Gestational trophoblastic neoplasias (GTN) are rare tumours that constitute less than 1% of all gynecological malignancies. Invasive mole is a distinct subgroup of GTN, which if not diagnosed and treated early, can result in serious complications like uterine perforation and haemoperitoneum. We present a rare case of an invasive mole of the uterus, which developed following the evacuation of a molar pregnancy. It was accurately diagnosed by transvaginal ultrasound and color Doppler, and successfully treated before any major complications could arise.

Ovarian hyperstimulation syndrome in a spontaneous pregnancy with invasive mole: report of a case.

It is known that most cases of Ovarian Hyperstimulation Syndrome (OHSS) are associated with the therapies for ovulation induction. However, OHSS may rarely be associated with a spontaneous ovulatory cycle, usually in the case of multiple gestations, hypothyroidism or polycystic ovary syndrome. We report a case of severe OHSS in spontaneous pregnancy with invasive mole in a 34 years old woman. The clinical picture showed abdominal pain, massive ascites, nausea, dyspnea and amenorrhea. After imaging examinations and laboratory tests, the diagnosis was established. The patient was managed expectantly with no complications. Although spontaneous ovarian hyperstimulation is a rare entity, it is important that the physician recognizes this condition. Prompt diagnosis and successful management is likely to avoid serious complications, which may develop rapidly.

Prognosis of malignant gestational trophoblastic neoplasia: 20 years of experience.

OBJECTIVE: To analyze retrospectively the management and prognosis of malignant gestational trophoblastic neoplasia (GTN) patients treated at Peking Union Medical College (PUMC) Hospital from 1985 to 2005. STUDY DESIGN: From 1985 to 2005 1,130 GTN patients were treated at PUMC Hospital. Management and prognosis were analyzed retrospectively. The analyses of prognostic factors were performed by using univariate and multivariate analyses. RESULTS: Among the 1,130 patients 903 (80.0%) achieved complete remission (CR), 187 (16.5%) partial remission (PR) and 40 (3.5%) died of progress of the disease (PD). Among the CR patients, 31 (3.4%) relapsed later. Of the 187 PR patients, 155 (82.0%) had normal beta-hCG titer but with residual tumor in the lung or other organs. Among them, 6 patients with choriocarcinoma experienced PD after treatment. One hundred thirty-nine patients became pregnant during follow-up, with a total of 159 pregnancies. Among them, abnormal pregnancy rate was 16.4%, molar rate was 3.1% and fetal abnormality rate was 1.6%. CONCLUSION: Most GTN patients can be cured completely with timely and appropriate chemotherapy treatment. In select cases, surgery should be performed to obtain a better curative outcome. Patients whose residual metastatic tumors remain unchanged after beta-hCG returns to normal are assumed to have CR. We recommend that patients postpone pregnancy for at least 12 months after chemotherapy.

Gestational trophoblastic disease: experience at a tertiary care hospital of Sindh.

OBJECTIVE: To determine the frequency, clinical presentation and management outcomes of Gestational Trophoblastic Disease (GTD). STUDY DESIGN: Descriptive case series. PLACE AND DURATION: Department of Gynaecology and Obstetrics, Liaquat University of Medical and Health Sciences, Jamshoro, from March 2003 to March 2004. PATIENTS AND METHODS: The case records of all the gestational trophoblastic cases during study period were analyzed regarding their illness 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 1030 obstetric admissions during the study period, which included 23 cases of trophoblastic disease. Hence, frequency of GTD was 1 per 45 live births. Of these 23 cases, 19 (82.6%) patients had hydatidiform mole and 4 patients had malignant trophoblastic disease. Eight patients (34.7%) received chemotherapy while rest of the patients had suction evacuation and follow-up. Among all patients, 21 (91.3%) fully recovered and 2 (8.69%) died because of extensive disease; metastasis extending upto brain. CONCLUSION: Frequency of trophoblastic disease was high in this series compared to world and national literature. Therefore, emphasis should be on the early diagnosis of disease as proper management in the early stages strongly influences the outcome of disease. Suction evacuation and follow-up are ideal treatments for benign trophoblastic disease.

[Study on the indication of surgical resection of pulmonary metastasis of malignant trophoblastic tumor].

OBJECTIVE: To investigate the indication of lung lobectomy in patients of malignant trophoblastic tumor with lung metastasis. METHODS: Data on a total of 629 cases of malignant trophoblastic tumor of stage III-IV in Peking Union Medical College Hospital from 1990 to 2003 were reviewed. Ninety-five cases including those that underwent lung lobectomy and cases with normal level of serum human chorionic gonadotropin-beta subunit (beta-hCG, < 2 IU/L) and residual pulmonary nodules after chemotherapy were selected and studied. RESULTS: Lung lobectomies were performed on six cases of invasive mole with lung metastasis and the pathological results were all necrotic nodules;another 35 cases of invasive mole with normal level of serum beta-hCG but residual pulmonary nodules after chemotherapy have been followed up for 6 months to 11 years and all were stable of diseases (SD). Lung lobectomies were performed on 29 cases of choriocarcinoma with lung metastasis. Among them, there were 17 cases whose pathological results were hemorrhage and necrotic tissue without trophoblastic cells (negative pathological results), while trophoblastic cells could still be detected in 12 cases of resected lung specimens (positive pathological results). Twenty-five cases of choriocarcinoma with normal serum beta-hCG but residual pulmonary nodules after chemotherapy were followed up, five cases had progress of disease (PD) and 20 were SD. There were no significant differences of age, stage and the last pregnancy between the positive and negative pathological results, SD and PD groups, respectively. However, the number of chemotherapeutic courses for decreasing beta-hCG from 10 IU/L to 2 IU/L and the total courses in the group of positive pathological results and PD group were significantly more than that of negative pathological results group and SD group (P = 0.01, P = 0.001). CONCLUSIONS: For invasive mole, lung metastasis can be successfully treated by chemotherapy alone. Patients with residual pulmonary nodules but normal serum beta-hCG after chemotherapy can be followed up and spared lung lobectomy. For choriocarcinoma, slowly decreasing of beta-hCG from 10 IU/L to 2 IU/L is a high risk for chemoresistance, and it is an indication for thoracotomy. Progression of disease after multiple chemotherapy courses should be treated with lung lobectomy.

[Assessment of staging and prognostic scoring system for malignant trophoblastic neoplasia].

OBJECTIVE: To assess malignant trophoblastic neoplasia with the standards of the clinical stage and prognostic factor scoring system. METHODS: Through assessing the high-risk factors except clinical stages for 223 patients before treatment according to International Federation of Gynecology and Obstetrics (FIGO) scoring system published in 2000, appropriate treatments were selected for the different patients. RESULTS: Forty-three of 78 cases of choriocarcinomas were with high-risk factors, the other 35 cases were with low-risk factors; 7 of 145 cases of invasive moles were with high-risk factors and the others were with low-risk factors. The primary chemotherapy principle was that one agent was used for those patients with low-risk factors and two or multiple-agents were used for those patients with high-risk factors. Among all patients, the one-year, three-year and five-year survival rates were 98.6%, 98.1% and 97.1% respectively. No patient died of drug toxicity or complication. CONCLUSION: Selection of treatment approaches according to the prognostic assessment of malignant trophoblastic neoplasia could lead to promising survival rate with no uncurable complication and toxic effects.

Partial hydatidiform mole.

A case of partial hydatidiform mole is presented, occurring in a young primiparous woman after natural conception. She presented with incomplete miscarriage. Histological diagnosis of partial mole was made. Failure of beta HCG to fall resulted in the start of chemotherapy. WHO scoring placed her in low risk group. In spite of the low risk, she required third line chemotherapy for complete eradication of disease.

[Floxuridine-containing regime in the treatment of gestational trophoblastic tumor].

OBJECTIVE: To analyse the efficacy of the floxuridine (FUDR)-containing regime (single agent or in combination) in the treatment of gestational trophoblastic tumor. METHODS: Seventy-four patients with gestational trophoblastic tumors (GTT), 47 invasive mole and 27 choriocarcinoma, were treated with FUDR-containing regime. The clinical staging of the disease were: 33 cases of stage I, 3 cases of stage II, 31 cases of stage IIIa, 6 cases of stage IIIb, and 1 case of stage IV. RESULTS: The cure rate of FUDR-containing regime in the treatment of GTT was 91.9% (68 out of 74 cases). Twenty-one out of these 74 patients showed drug resistant to 5-FU-containing or MTX-containing regime and were cured after they changed to the FUDR-containing regime. All 7 patients of advanced stage (> or = III b) got cured. The major adverse event of FUDR-containing regime was myelodepression and gastrointestinal toxicity: III-IV degree granulopenia 26%, III-IV thrombopenia 6.2%, III degree vomiting 57.1%, and III degree diarrhea 4.3%. CONCLUSION: FUDR-containing regime is efficient for the treatment of GTT, even for those with advanced stage or drug-resistant disease.

The role of hysterectomy in the therapy of gestational trophoblastic tumor.

OBJECTIVE: To evaluate the role of hysterectomy for patients with gestational trophoblastic tumor. METHODS: We retrospectively analyzed 68 cases of gestational trophoblastic neoplasia treated by hysterectomy from 1985 to approximately 1997 at PUMC hospital. Thirty-eight cases were diagnosed of choriocarcinoma and 30 were invasive mole. RESULTS: Twenty-three elder patients who didn't desire to preserve fertility were selected for hysterectomy after shorter courses of chemotherapy, 22 of them had a complete remission (95.6%), the total average courses of chemotherapy was 4.2. Of twenty-seven chemorefractory cases who were suspected of a refractory isolated lesion in the uterus, delayed hysterectomy as an adjunct to chemotherapy was performed, 20 of them got a complete remission (71.1%), the total average courses of chemotherapy were 9.4. Emergency hysterectomy is indicated in 18 patients with uterine perforation or life-threatening hemorrhage, 17 cases had a complete remission (94.4%), the total average courses of chemotherapy were 7.6. CONCLUSION: Although the development of effective chemotherapy has resulted in improved survival of patients with gestational trophoblastic tumor, hysterectomy remains an important adjuncts in the treatment of a selected subset of patients; in order to operate more completely and prevent recurrence, it's better to perform extended hysterectomy for the indicated patients.

Malignant trophoblastic disease following a twin pregnancy consisting of a complete hydatiform mole and a normal fetus and placenta. A case report.

We report an unusual pregnancy with a complete hydatiform mole coexisting with a normal fetus and placenta. This report stresses the importance of a correct diagnosis and the dilemmas the clinician is faced with when managing such a case. Malignant trophoblastic disease occurs in 55% of complete hydatiform mole and fetus. Two-thirds require combination chemotherapy.

Diagnosis and treatment of the malignant gestational trophoblastic tumor with pulmonary metastasis complicated with pulmonary tuberculosis.

OBJECTIVE: To evaluate the diagnosis and treatment for malignant gestational trophoblastic tumor (MGTT) with pulmonary metastasis complicated with pulmonary tuberculosis. METHODS: To analyze ten cases of MGTT with pulmonary metastasis complicated with pulmonary tuberculosis in our hospital from 1980 to 1997 retrospectively. RESULTS: From the x-ray film, there are great resemblances between MGTT with pulmonary metastasis and pulmonary tuberculosis. Of 10 patients, 7 of them were examined out pulmonary tuberculosis during the chemotherapy of MGTT. Pulmonary tuberculosis appeared six months before chemotherapy in three cases. All of the patients were treated with multiagent chemotherapy. Seven patients achiceved a complete remission, 2 patients developed drug resistance and died of cerebral haemorrhage and cerebral herniation, 1 woman who had achieved a complete remission from MGTT for 14 months died of miliary tuberculosis. CONCLUSION: It is very important to make differential diagnosis of the MGTT with pulmonary metastasis complicated with pulmonary tuberculosis. Trying to avoid excessive anti-tumor treatment owing to mistake pulmonary tuberculosis for pulmonary metastasis, and avoiding missing an opportunity of anti-tuberculosis treatment because of missed diagnosis should be emphasized.

[Pregnancy of patients conceived within one year after chemotherapy for gestational trophoblastic tumor].

OBJECTIVE: To explore the risk of pregnancy in patients conceived within one year after successful chemotherapy for gestational trophoblastic tumor. METHODS: 22 patients conceived within one year after chemotherapy were followed up and analysed about abnormal pregnant result, wastage rate and the time of interval between chemotherapy and pregnancy. RESULTS: Among 22 cases, 9 cases were full term birth, 6 cases were wastage. The wastage rate was 27.3%. The wastage rate of these patients conceived within half a year was higher than one year (P < 0.05). 1 repeated hydatidiform mole and one post term choriocarcinoma occurred in 22 patients. They both were conceived within 5 months after chemotherapy. CONCLUSIONS: Preservation of fertility is feasible in patients suffering from choriocarcimona and invasive mole. But these patients should practise contraception at least half a year after chemotherapy, and it's better to advise patients to take contraception for one year.

[Methotrexate combined chemotherapy for chemorefractory gestational trophoblastic tumour].

OBJECTIVE: To evaluate the response rate and toxicity of etopside, methotrexate, kengshengmycin, cyclophosphamide and vincristine (EMA/CO) regimen for women with chemorefractory gestational trophoblastic tumour. METHODS: Fifty-one patients with chemorefractory gestational trophoblastic tumour were treated by EMA/CO regimen. Operative excision and (or) selective arterial infusion as adjuncts to chemotherapy were performed in a selected subset of patients. The response and toxicity were assessed after treatment. RESULTS: Fifty-one patients received 352 cycles of the study regimen. The median number of courses for each patient was 6.9. Thirty-three cases (64.7%) achieved a complete remission while 14 patients (27.5%) had a partial remission, 4 cases showed nonresponse. Two (6.7%) of 30 complete responders developed recurrences. The main complications for EMA/CO chemotherapy were myelosuppression and gastrointestinal symptoms. CONCLUSION: The EMA/CO regimen is an effective treatment for chemorefractory gestational trophoblastic tumour, and the chemotherapeutic results can be further improved while combined with arterial infusion chemotherapy and surgery in the selected patients.

Forty-five year's experience of the treatment of choriocarcinoma and invasive mole.

Our work was begun in 1949. through many yera's effort, several chemicals (such as 6 MP, 5 FU and others) were found to be effective for the treatment of choriocarcinoma (C.C.) and invasive mole (I.M.). From 1959 through 1985, 1500 patients were consecutively treated. The mortality rate of CC was reduced from > 90% to < 20%. No more death occurred in IM. All Survivors followed up for 10-38 years showed no evidence of residual disease. 80% of the young patients treated with chemotherapy alone conceived after recovery. The pregnancy outcome showed no deviation from that of the general population. All children are growing up normally many married and gave birth to normal third generations. The results indicated that chemotherapy with 5 FU achieves not only a complete remission, but also a cure, even with wide-spread metastases. The results of choriocarcinoma and invasive mole treated with mainly 5 FU were reported. The clinical experience in the management of metastases at different sites were also summarized.