molar pregnancy treatment
TRANSCRIPT
SECOND EVACUATION BENEFITIN TROPHOBLASTIC DISEASE
Istituto Istituto Nazionale per Nazionale per lo lo StudioStudioee la la Cura dei Tumori Cura dei Tumori - - MilanoMilano
Flavia Zanaboni
U.O. Oncologia Ginecologica
SECOND EVACUATION IN GTD
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Molar pregnancy treatment
Suction curettage is the preferred method of evacuation, regardless of uterine size, but up to 30% of patients will require further treatment
SECOND EVACUATION IN GTD
The role of second evacuation
is still controversial
Molar pregnancy treatment
SECOND EVACUATION IN GTD
Chemotherapy results in persistent Gestational Trophoblastic Disease are generally excellent.
Repeated uterine evacuation has been
recommended by some Groups in order to minimize the number of patients exposed to potentially toxic therapy.
Molar pregnancy treatment
SECOND EVACUATION IN GTD
Pro Data
Trophoblastic Tumor Service Boston Hosp. (USA) 1975-1978
37 molar pts with second curettage34 nonmetastatic GTD
Berkowitz RS, Gynecol Oncol 1980
SECOND EVACUATION BENEFIT IN GTD
Trophoblastic Tumor Service Boston Hosp. (USA) 1975-1978
Main indications for further evacuation were :
raised or plateaued hCG levels, vaginal bleeding and orabnormal ultrasounds
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Berkowitz RS, Gynecol Oncol 1980
Trophoblastic Tumor Service Boston Hosp. (USA) 1975-1978
Histological findings :
20 pts (54%) had no residual trophoblastic tissue10 pts (27%) had unchanged histology7 cases were recognized as worsened histology
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Berkowitz RS, Gynecol Oncol 1980
Trophoblastic Tumor Service Boston Hosp. (USA) 1975-1978
Chemotherapy treatment:
All the pts were treated with MTX –FA im chemotherapy
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Berkowitz RS, Gynecol Oncol 1980
Trophoblastic Tumor Service Boston Hosp. (USA) 1975-1978
Considering histological findings at repeated evacuations :
19/20 pts (95%) with no trophoblastic tissue required only one course of CHT6/10 pts (60%) with unchanged histology required only one CHT6/7 pts (86%) with worsened histology needed multiple courses of CHT
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Berkowitz RS, Gynecol Oncol 1980
Trophoblastic Tumor Service Boston Hosp. (USA) 1975-1978
Considering hCG values before repeated evacuations :
the optimum cut-point for “aggressive” GTD was 50.000 mIU/L(only 3/7 pts with worsened histology had greater titers)(p < 0.05)
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Berkowitz RS, Gynecol Oncol 1980
Trophoblastic Tumor Service Boston Hosp. (USA) 1975-1978
Repeated evacuation (2nd) provides histological prognostically important data regarding chemosensitivity and remain integral part of the management of GTD
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Berkowitz RS, Gynecol Oncol 1980
Sheffield Trophoblastic Disease Center (UK) 1991-2000
4075 registered pts544 (13%) second evacuation60 (1.4%) third evacuation
Pezeshki M, Gynecol Oncol 2004
Pro Data
SECOND EVACUATION BENEFIT IN GTD
Sheffield Trophoblastic Disease Center (UK) 1991-2000
Main indications for further evacuation were :
raised hCG (22%), vaginal bleeding (48%) or abnormal ultrasound (7%),mostly associated to raised HCG
Pezeshki M, Gynecol Oncol 2004
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Sheffield Trophoblastic Disease Center (UK) 1991-2000
Histological findings :
251 pts (47%) had histological evidence of persistent GTD21 cases were recognized as GTD only at 2nd evacuation5 pts showed choriocarcinoma
Pezeshki M, Gynecol Oncol 2004
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Sheffield Trophoblastic Disease Center (UK) 1991-2000
Chemotherapy treatment:
116 pts (21%) after 2nd evacuation and 28 pts (46%) after 3rd curettage needed chemotherapy
It means that the remaining 66% of cases completed f-up without problems
Pezeshki M, Gynecol Oncol 2004
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Sheffield Trophoblastic Disease Center (UK) 1991-2000
Considering histological findings at repeated evacuations :
38% of pts with histological persistent GTD required CHT,compared to only 18% of those with no molar tissue
Pezeshki M, Gynaecol Oncol 2004
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Sheffield Trophoblastic Disease Center (UK) 1991-2000
Considering urinary hCG values before repeated evacuations :
the optimum cut-point for the prevalence of CHT is between1400 and 1500 IU/L (less than the original value of 5000 estimated from a pilot study by Lorigan)
Pezeshki M, Gynaecol Oncol 2004
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Sheffield Trophoblastic Disease Center (UK) 1991-2000
Repeated evacuation (2nd) is more useful in deciding who are not likely to need CHT than in deciding who is likely to need it
Pezeshki M, Gynecol Oncol 2004
SECOND EVACUATION BENEFIT IN GTD
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Dutch Central Registry for Hydatidiform Moles (NL) 1987-2003
2122 registered pts103 (30%) second evacuation85 low-risk GTD eligible for case-control study (controls : 209)
van Trommel NE, Gynecol Oncol 2005
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Dutch Central Registry for Hydatidiform Moles (NL) 1987-2003
Main indications for further evacuation were :
vaginal bleeding (60%) or abnormal ultrasound with rise or plateau in hCG levels (40%)
van Trommel NE, Gynecol Oncol 2005
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Dutch Central Registry for Hydatidiform Moles (NL) 1987-2003
After 2nd evacuation 8 out of 85 pts (9.4%) did not need further CHT (p < 0.001)
Debulking effect : median number of courses of first-line MTX-FA CHT was significantly lower in study group (5 vs 6, p 0.036)
“Dark side of the moon” : 2.4% of uterine perforation!
van Trommel NE, Gynecol Oncol 2005
SECOND EVACUATION BENEFIT IN GTD
Pro Data
SECOND EVACUATION BENEFIT IN GTD
Pro Data
Repeated curettage could be reasonable in in incompletely evacuated cases or in symptomatic patients (bleeding) in hCG f-up, particularly when levels are < 1500 IU/L and there is no evidence of extra-uterine lesions
Grazie per l’attenzione!
SECOND EVACUATION IN GTD Pro