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Cavalari CAA, Mehrtash H, Brizuela V, Baguiya A, Adu-Bonsaffoh K, Cecatti JG, Bahamondes L, Charles CM, Govule P, Dossou JP, Souza RT, Leão LH, Filippi V, Tunçalp Ö, Baccaro LF. Prevalence and management of ectopic and molar pregnancies in 17 countries in Africa and Latin America and the Caribbean: a secondary analysis of the WHO multi-country cross-sectional survey on abortion. BMJ Open 2024; 14:e086723. [PMID: 39401964 PMCID: PMC11474897 DOI: 10.1136/bmjopen-2024-086723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 09/16/2024] [Indexed: 10/17/2024] Open
Abstract
INTRODUCTION There are limited global data on ectopic pregnancy (EP) and molar pregnancy (MP), making it important to understand their epidemiology and management across different regions. Our study aimed to describe their prevalence for both conditions, severity of their complications and management among women in selected health facilities across 17 countries in Africa and Latin America and the Caribbean (LAC). METHODS This is a secondary analysis of the WHO multi-country survey on abortion. Data were collected from 280 healthcare facilities across 11 countries in Africa and 6 in LAC. Sociodemographic information, signs and symptoms, management and clinical outcomes were extracted from medical records. Facility-level data on post-abortion care (PAC) capabilities were also collected, and facilities were classified accordingly. χ2 or Fisher's exact tests were used to compare categorical data. RESULTS The total number of women with EP and MP across both regions was 9.9% (2 415/24 424) where EP accounted for 7.8% (1 904/24 424) and MP for 2.1% (511/24 424). EP presented a higher severity of complications than MP. At admission, 49.8% of EP had signs of peritoneal irritation. The most common surgical management for EP was laparotomy (87.2%) and for MP, uterine evacuation (89.8%). Facilities with higher scores in infrastructure and capability to provide PAC more frequently provided minimal invasive management using methotrexate/other medical treatment (34.9%) and laparoscopy (5.1%). CONCLUSION In Africa and LAC, EP and MP cause significant maternal morbidity and mortality. The disparity in the provision of good quality care highlights the need to strengthen the implementation of evidence-based recommendations in the clinical and surgical management of EP and MP.
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Affiliation(s)
- Camila Ayume Amano Cavalari
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Hedieh Mehrtash
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Vanessa Brizuela
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Adama Baguiya
- Kaya Health and Demographic Surveillance System (Kaya-HDSS), Ouagadougou, Burkina Faso
| | - Kwame Adu-Bonsaffoh
- Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Greater Accra, Ghana
| | - Jose Guilherme Cecatti
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Luis Bahamondes
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Charles M'poca Charles
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Philip Govule
- Epidemiology and Disease Control, University of Ghana College of Health Sciences, Accra, Greater Accra, Ghana
- Health Sciences, Uganda Martyrs University Faculty of Health Sciences, Kampala, Uganda
| | - Jean-Paul Dossou
- CNHU-HKM Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
- Public Health, Instituut voor Tropische Geneeskunde, Antwerpen, Flanders, Belgium
| | - Renato T Souza
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Luis Henrique Leão
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | | | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Luiz Francisco Baccaro
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
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Altalib A, Al Qahtani N, Alosaimi SS, Al Hashem MS, Almowallad R, Al-Rufiei M, Alhumaid LI. Changing Trends in the Clinical Presentation and Incidence of Molar Pregnancy in Saudi Arabia: A 30-Year Retrospective Analysis. Cureus 2023; 15:e50936. [PMID: 38259393 PMCID: PMC10801279 DOI: 10.7759/cureus.50936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
Background Molar pregnancy (MP) incidence and clinical presentation vary significantly worldwide. Recent trends show changes in its clinical representation and incidence, particularly with the adoption of early diagnosis using first-trimester ultrasonography, which has reduced the prevalence of classical second-trimester presentations. This study aimed to analyze the changes in clinical presentation and incidence of MP among the Saudi population over the past 30 years. Methods In this retrospective study at King Fahad University Hospital, 121 complete mole (CM) pregnancy cases diagnosed and pathologically confirmed were reviewed. This included 87 cases from 2007 to 2022 (recent group) and 34 cases from 1992 to 2006 (older group). Cases of CM diagnosed before January 1992 and other diagnoses such as PM, invasive mole, or choriocarcinoma were excluded; thus, this study is focused on CM in particular. We compared patient age, gravidity, parity, abortion history, gestational age at diagnosis, hyperemesis gravidarum symptoms, anemia symptoms, and hemoglobin levels. Classical symptoms and signs related to CM were also reviewed. Data were analyzed using Microsoft Excel 2021 (Microsoft Corporation, Redmond, Washington, United States) and presented as mean, frequency, and percentage, with chi-squared tests for categorical variables; p<0.05 was considered statistically significant. Results The incidence of CM declined from 2.1 per 1,000 deliveries to 0.9 per 1,000 deliveries. Vaginal bleeding was the most common presentation in both the older (91.9%) and recent (67.6%) groups. Hyperemesis gravidarum prevalence was similar in both groups. Theca-lutein cysts were more frequent in the older group (27.5%) than the recent group (8.8%). A significant difference was observed in the occurrence of a large-for-date uterus between the older (63.20%) and recent (23.5%) groups. Notably, 14.7% of patients in the recent group were asymptomatic at diagnosis. Anemia was present in 46 cases (52.8%) of the older group but absent in the recent group, and preeclampsia occurred in 10 cases (11.4%) of the older group but not in the recent group. Conclusions Advancements in ultrasound technology, including transvaginal probes with Doppler capabilities, have enabled earlier pregnancy diagnosis, as early as five to six weeks of gestation. Many MP are now diagnosed in the first trimester without the classic clinical symptoms or "snow-storm" ultrasound appearance. The availability of sensitive beta-human chorionic gonadotropin assays has led to the early termination of these pregnancies, marking a significant shift in the management of MP.
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Affiliation(s)
- Ayman Altalib
- Obstetrics and Gynaecology, Imam Abdulrahman Bin Faisal University, Khobar, SAU
| | - Noura Al Qahtani
- Obstetrics and Gynaecology, Imam Abdulrahman Bin Faisal University, Khobar, SAU
| | - Shrouq S Alosaimi
- Obstetrics and Gynaecology, Imam Abdulrahman Bin Faisal University, Khobar, SAU
| | - Mariam S Al Hashem
- Obstetrics and Gynaecology, Imam Abdulrahman Bin Faisal University, Khobar, SAU
| | - Roaa Almowallad
- Obstetrics and Gynaecology, Imam Abdulrahman Bin Faisal University, Khobar, SAU
| | - Maryam Al-Rufiei
- Obstetrics and Gynaecology, Imam Abdulrahman Bin Faisal University, Khobar, SAU
| | - Lujain I Alhumaid
- Obstetrics and Gynaecology, Imam Abdulrahman Bin Faisal University, Khobar, SAU
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Braga A, Andrade T, do Carmo Borges de Souza M, Campos V, Freitas F, Maestá I, Sun SY, Pedrotti LG, Bessel M, Junior JA, Filho JR, Elias KM, Horowitz NS, Berkowitz RS. Presentation, medical complications and development of gestational trophoblastic neoplasia of hydatidiform mole after intracytoplasmic sperm injection as compared to hydatidiform mole after spontaneous conception - a retrospective cohort study and literature review. Gynecol Oncol 2023; 170:179-185. [PMID: 36706644 DOI: 10.1016/j.ygyno.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/11/2023] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To describe the natural history of hydatidiform mole (HM) after intracytoplasmic sperm injection (ICSI), emphasizing the clinical and oncological outcomes, as compared to patients who had HM after spontaneous conception (SC). STUDY DESIGN Retrospective historical cohort study of patients with HM followed at the Rio de Janeiro Federal University, from January 1st 2000-December 31st 2020. RESULTS Comparing singleton HM after SC to those following ICSI there were differences in terms of maternal age (24 vs 34 years, p < 0.01), gestational age at diagnosis (10 vs 7 weeks, p < 0.01), preevacuation human chorionic gonadotropin levels (200,000 vs 99,000 IU/L, p < 0.01), occurrence of genital bleeding (60.5 vs 26.9%, p < 0.01) and hyperemesis (23 vs 3.9%, p = 0.02) at presentation, and time to remission (12 vs 5 weeks, p < 0.01), respectively. There were no differences observed in the cases of twin mole, regardless of the form of fertilization that gave rise to HM, except molar histology with greater occurrence of partial hydatidiform mole (10.7 vs 40.0%, p = 0.01) following ICSI. Univariate logistic regression for occurrence of postmolar GTN after ICSI identified no predictor variable for this outcome. However, after adjusting for maternal age and complete hydatidiform mole histology, multivariable logistic regression showed the risk of GTN with HM after ICSI had an adjusted odds ratio of 0.22 (95%CI:0.05-0.93, p = 0.04), suggesting a possible protective effect when compared to HM after SC. CONCLUSIONS Singleton HM after ICSI are diagnosed earlier in gestation, present with fewer medical complications, and may be less likely to develop GTN when compared with HM after SC.
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Affiliation(s)
- Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil; Postgraduate Program in Applied Health Sciences, Vassouras University, Rio de Janeiro, RJ, Brazil; National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, RJ, Brazil.
| | - Taiane Andrade
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - Maria do Carmo Borges de Souza
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - Vanessa Campos
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil
| | - Fernanda Freitas
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil
| | - Izildinha Maestá
- Botucatu Trophoblastic Disease Center of the Clinical Hospital of Botucatu Medical School, Department of Gynecology and Obstetrics, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Sue Yazaki Sun
- Departament of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | | | - Joffre Amim Junior
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - Jorge Rezende Filho
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Braga A, Paiva G, Cattai CJ, Elias KM, Horowitz NS, Berkowitz RS. Current chemotherapeutic options for the treatment of gestational trophoblastic disease. Expert Opin Pharmacother 2023; 24:245-258. [PMID: 36399723 DOI: 10.1080/14656566.2022.2150075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Gestational trophoblastic neoplasia (GTN) is a rare tumor that arises from trophoblastic tissues with high remission rates after chemotherapy treatment. GTN can develop from any gestational events, such as miscarriage, ectopic pregnancy, and preterm/term pregnancy, but is more frequent after hydatidiform mole. The sensitivity of this tumor to chemotherapy and the presence of an exceptional tumor marker allow high remission rates, especially when patients are treated in referral centers. AREAS COVERED Observational, retrospective, prospective, systematic reviews, and meta-analysis studies focusing on GTN treatment. We searched PubMed, Medline, and the Library of Congress from January 1965 to May 2022. EXPERT OPINION Early GTN diagnosis allows low-toxic and highly effective treatment. Even multimetastatic disease has high rates of remission with multiagent regimen chemotherapy. Surgery is reserved for uterine disease in patients who have completed childbearing, in cases of chemoresistance to multiagent regimens or in the rare cases of placental site trophoblastic tumor or epithelioid trophoblastic tumor. While resistance is managed by salvage chemotherapy, cases with limited clinical response to sequential regimens have been successfully treated with immunotherapy.
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Affiliation(s)
- Antonio Braga
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil.,Department of Medicine, Vassouras Medical School, Postgraduate Program in Applied Health Sciences, Vassouras University, Vassouras, RJ, Brazil.,National Academy of Medicine, Young Leadership Physician Program, Rio de Janeiro, RJ, Brazil
| | - Gabriela Paiva
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil
| | - Cassia Juliana Cattai
- , Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Campos V, Paiva G, Padron L, Freitas F, Pedrotti LG, Sun SY, Viggiano M, Oliveira L, Rohr L, Madi JM, Arrym TP, Oliveira P, Dos Santos Esteves APV, Junior JA, Filho JR, Elias KM, Horowitz NS, Braga A, Berkowitz RS. Influence of COVID-19 pandemic on molar pregnancy and postmolar gestational trophoblastic neoplasia: An observational study. BJOG 2023; 130:292-302. [PMID: 36209485 DOI: 10.1111/1471-0528.17313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 09/11/2022] [Accepted: 09/23/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To assess whether the incidence and aggressiveness of molar pregnancy (MP) and postmolar gestational trophoblastic neoplasia (GTN) changed during the COVID-19 pandemic. DESIGN Observational study with two separate designs: retrospective multicentre cohort of patients with MP/postmolar GTN and a cross-sectional analysis, with application of a questionnaire. SETTING Six Brazilian Reference Centres on gestational trophoblastic disease. POPULATION 2662 patients with MP/postmolar GTN treated from March-December/2015-2020 were retrospectively evaluated and 528 of these patients answered a questionnaire. METHODS Longitudinal retrospective multicentre study of patients diagnosed with MP/ postmolar GTN at presentation and a cross-sectional analysis, with application of a questionnaire, exclusive to patients treated during the period of study, to assess living and health conditions during the COVID-19 pandemic compared with previous years. MAIN OUTCOME MEASURES The incidence of MP/postmolar GTN. RESULTS Compared with the last 5 pre-pandemic years, MP/postmolar GTN incidence remained stable during 2020 (COVID-19 pandemic). Multivariable logistic regression, adjusted for the patient age, showed that during 2020, presentation with MP was more likely to be >10 weeks of gestation (adjusted odds ratio [aOR] 2.50, 95% confidence interval [CI] 1.90-3.29, P < 0.001), have a pre-evacuation hCG level ≥100 000 iu/l (aOR 1.77, 95% CI 1.38-2.28, P < 0.001) and time to the initiation of chemotherapy ≥7 months (aOR 1.86, 95% CI 1.01-3.43, P = 0.047) when compared with 2015-2019. CONCLUSIONS Although the incidence of MP/postmolar GTN remained stable during the COVID-19 pandemic in Brazil, the pandemic was associated with greater gestational age at MP diagnosis and more protracted delays in initiation of chemotherapy for postmolar GTN.
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Affiliation(s)
- Vanessa Campos
- Department of Maternal Child, Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, Brazil.,Department of Obstetrics and Gynaecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Gabriela Paiva
- Department of Obstetrics and Gynaecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Lilian Padron
- Department of Obstetrics and Gynaecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Fernanda Freitas
- Department of Obstetrics and Gynaecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | | | - Sue Yazaki Sun
- Department of Obstetrics, Paulista School of Medicine, São Paulo Federal University, São Paulo, Brazil
| | - Maurício Viggiano
- Department of Obstetrics and Gynecology, Goiania Trophoblastic Disease Center (Clinics Hospital of Goias Federal University), Goiania, Brazil
| | - Larissa Oliveira
- Division of Recife Trophoblastic Disease Center (Clinics Hospital of Pernambuco Federal University), Recife, Brazil
| | - Lucia Rohr
- Division of Recife Trophoblastic Disease Center (Clinics Hospital of Pernambuco Federal University), Recife, Brazil
| | - José Mauro Madi
- Division of Caxias do Sul Trophoblastic Disease Center, General Hospital of Caxias do Sul, School of Medicine, Center for Biological and Health Sciences, Caxias do Sul University, Caxias do Sul, Brazil
| | - Tiago Pedromônico Arrym
- Department of Obstetrics and Gynecology, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Priscila Oliveira
- Department of Obstetrics and Gynaecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Ana Paula Vieira Dos Santos Esteves
- Department of Obstetrics and Gynaecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Joffre Amim Junior
- Department of Obstetrics and Gynaecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Jorge Rezende Filho
- Department of Obstetrics and Gynaecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Antônio Braga
- Department of Maternal Child, Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, Brazil.,Department of Obstetrics and Gynaecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil.,Postgraduate Program in Applied Health Sciences, Vassouras University, Rio de Janeiro, Brazil
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Liu Y, Ye Y, Cheng X, Lu W, Xie X, Wang X, Li X. The effect of prophylactic chemotherapy on treatment outcome of postmolar gestational trophoblastic neoplasia. BMC Womens Health 2023; 23:1. [PMID: 36593459 PMCID: PMC9806869 DOI: 10.1186/s12905-022-02134-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/16/2022] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To evaluate whether prophylactic chemotherapy (P-chem) increased the drug resistance rate of postmolar GTN and whether the first-line chemotherapy should be different from P-chem. METHODS Postmolar GTN received P-Chem was defined as P-Chem group. Postmolar GTN without P-chem was randomly selected as control group according to the ratio of 1:3 (P-chem:control) and matched by age for low risk and high risk GTN separately. RESULTS Totally 455 low-risk and 32 high-risk postmolar GTN patients were included. WHO risk score, chemotherapy cycles to achieve hCG normalization and resistant rate were similar between P-chem (27 cases) and control (81 cases) group. Among low-risk GTN patients, interval from hydatidiform mole to GTN was significantly longer in P-chem group than control (44 vs 69 days, P = 0.001). Total chemotherapy cycles and resistant rate were similar between low-risk GTN treated with same agent as P-chem (group A) and alternative agent (group B). But group A needed more chemotherapy cycles to achieve hCG normalization than group B. CONCLUSIONS P-chem delayed the time to GTN diagnosis, but didn't increase risk score or lead to drug resistance of postmolar GTN. Alternative agent different from P-chem had the potential of enhancing chemotherapy response in low- risk postmolar GTN.
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Affiliation(s)
- Yuanyuan Liu
- grid.13402.340000 0004 1759 700XDepartment of Gynecologic Oncology, Women’s Hospital, Zhejiang University School of Medicine, No. 1 Xueshi Road, Hangzhou, 310006 Zhejiang China ,grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang China ,grid.13402.340000 0004 1759 700XCancer Research Institute of Zhejiang University, Hangzhou, Zhejiang China
| | - Yaqiong Ye
- grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang China ,Ninghai Second People’s Hospital, Ninghai, 315600 Zhejiang China
| | - Xiaodong Cheng
- grid.13402.340000 0004 1759 700XDepartment of Gynecologic Oncology, Women’s Hospital, Zhejiang University School of Medicine, No. 1 Xueshi Road, Hangzhou, 310006 Zhejiang China ,grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang China ,grid.13402.340000 0004 1759 700XCancer Research Institute of Zhejiang University, Hangzhou, Zhejiang China
| | - Weiguo Lu
- grid.13402.340000 0004 1759 700XDepartment of Gynecologic Oncology, Women’s Hospital, Zhejiang University School of Medicine, No. 1 Xueshi Road, Hangzhou, 310006 Zhejiang China ,grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang China ,grid.13402.340000 0004 1759 700XCancer Research Institute of Zhejiang University, Hangzhou, Zhejiang China ,Center for Uterine Cancer Diagnosis and Therapy Research of Zhejiang Province, Hangzhou, 310006 Zhejiang China
| | - Xing Xie
- grid.13402.340000 0004 1759 700XDepartment of Gynecologic Oncology, Women’s Hospital, Zhejiang University School of Medicine, No. 1 Xueshi Road, Hangzhou, 310006 Zhejiang China ,grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang China ,grid.13402.340000 0004 1759 700XCancer Research Institute of Zhejiang University, Hangzhou, Zhejiang China
| | - Xinyu Wang
- grid.13402.340000 0004 1759 700XDepartment of Gynecologic Oncology, Women’s Hospital, Zhejiang University School of Medicine, No. 1 Xueshi Road, Hangzhou, 310006 Zhejiang China ,grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang China ,grid.13402.340000 0004 1759 700XCancer Research Institute of Zhejiang University, Hangzhou, Zhejiang China
| | - Xiao Li
- grid.13402.340000 0004 1759 700XDepartment of Gynecologic Oncology, Women’s Hospital, Zhejiang University School of Medicine, No. 1 Xueshi Road, Hangzhou, 310006 Zhejiang China ,grid.13402.340000 0004 1759 700XZhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang China ,grid.13402.340000 0004 1759 700XCancer Research Institute of Zhejiang University, Hangzhou, Zhejiang China
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Braga A, Canelas AC, Torres B, Maesta I, Giongo Pedrotti L, Bessel M, Vieira dos Santos Esteves AP, Amim Junior J, Rezende Filho J, Elias KM, Horowitz NS, Berkowitz RS. Neutrophil/lymphocyte ratio and other blood cell component counts are not associated with the development of postmolar gestational trophoblastic neoplasia. PLoS One 2022; 17:e0277892. [PMID: 36454778 PMCID: PMC9714693 DOI: 10.1371/journal.pone.0277892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/06/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To relate preevacuation platelet count and leukogram findings, especially neutrophil/lymphocyte ratios (NLR) and platelet/lymphocyte ratios with the occurrence of gestational trophoblastic neoplasia (GTN) after complete hydatidiform mole (CHM) among Brazilian women. METHODS Retrospective cohort study of patients with CHM followed at Rio de Janeiro Federal University, from January/2015-December/2020. Before molar evacuation, all patients underwent a medical evaluation, complete blood count and hCG measurement, in addition to other routine preoperative tests. The primary outcome was the occurrence of postmolar GTN. RESULTS From 827 cases of CHM treated initially at the Reference Center, 696 (84.15%) had spontaneous remission and 131 (15.85%) developed postmolar GTN. Using optimal cut-offs from receiver operating characteristic curves and multivariable logistic regression adjusted for the possible confounding variables of age and preevacuation hCG level (already known to be associated with the development of GTN) we found that ≥2 medical complications at presentation (aOR: 1.96, CI 95%: 1.29-2.98, p<0.001) and preevacuation hCG ≥100,000 IU/L (aOR: 2.16, CI 95%: 1.32-3.52, p<0.001) were significantly associated with postmolar GTN after CHM. However, no blood count profile findings were able to predict progression from CHM to GTN. CONCLUSION Although blood count is a widely available test, being a low-cost test and mandatory before molar evacuation, and prognostic for outcome in other neoplasms, its findings were not able to predict the occurrence of GTN after CHM. In contrast, the occurrence of medical complications at presentation and higher preevacuation hCG levels were significantly associated with postmolar GTN and may be useful to guide individualized clinical decisions in post-molar follow-up and treatment of these patients.
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Affiliation(s)
- Antonio Braga
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Maternal Child Health, Postgraduate Program in Medical Sciences, Faculty of Medicine of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
- National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, Rio de Janeiro, Brazil
- Postgraduate Program in Applied Health Sciences, Vassouras University, Rio de Janeiro, Rio de Janeiro, Brazil
- * E-mail:
| | - Ana Clara Canelas
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Berenice Torres
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Izildinha Maesta
- Department of Gynecology and Obstetrics, Botucatu Trophoblastic Disease Center of the Clinical Hospital of Botucatu Medical School, São Paulo State University - UNESP, Botucatu, São Paulo, Brazil
| | | | - Marina Bessel
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ana Paula Vieira dos Santos Esteves
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Joffre Amim Junior
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jorge Rezende Filho
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Kevin M. Elias
- Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Neil S. Horowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ross S. Berkowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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8
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Aiob A, Naskovica K, Amdur Zilberfarb I, Sharon A, Bornstein J, Lowenstein L. Changes in diagnostic sensitivity, incidence and presentation of complete and partial hydatidiform mole over the years. Eur J Obstet Gynecol Reprod Biol 2022; 274:136-141. [PMID: 35640442 DOI: 10.1016/j.ejogrb.2022.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/04/2022] [Accepted: 05/22/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Molar pregnancy is the most common type of gestational trophoblastic disease. Several recent reports have described changes in the clinical representation, the incidence and the diagnostic sensitivity of molar pregnancy. These changes could be due to widespread use of transvaginal ultrasound and beta-hCG testing in the management of routine first-trimester investigations. STUDY DESIGN This is a retrospective study of 144 women diagnosed with partial or complete mole at a regional medical center during 2007-2020. Incidence, demographics, clinical features and diagnostic sensitivity were compared between 2007 and 2014 and 2015-2020, and attempts were made to understand the bases of the changes between the time periods. RESULTS Sixty-two moles were diagnosed during 2007-2014 and 82 during 2015-2020. The proportions of complete moles in the respective periods were 65% (40) and 18% (15). From the earlier to the later period, the incidence and proportion of complete moles decreased, and of partial moles, increased. The median gestational age at diagnosis of molar pregnancy was 9.3 weeks. In the later period, women presented less frequently with vaginal bleeding, though this remained the most common presenting symptom. The proportion of women who underwent surgical evacuation of the uterus due to suspected molar pregnancy decreased, as did the proportion of moles that was suspected in ultrasound evaluation (P < 0.001). CONCLUSION The proportion of complete moles decreased between the periods examined. Gestational age at diagnosis was similar to data from 1994 to 2013. Some typical presenting symptoms of molar pregnancy decreased. However, earlier diagnosis of missed abortion can miss diagnoses of molar pregnancy.
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Affiliation(s)
- Ala Aiob
- Department of Obstetrics and Gynecology, Galilee Medical Cente, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel.
| | - Karina Naskovica
- Department of Obstetrics and Gynecology, Galilee Medical Cente, Israel
| | | | - Avishalom Sharon
- Department of Obstetrics and Gynecology, Galilee Medical Cente, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Jacob Bornstein
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Lior Lowenstein
- Department of Obstetrics and Gynecology, Galilee Medical Cente, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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Ramos MM, Maesta I, de Araújo Costa RA, Mazeto GM, Horowitz NS, Elias KM, Braga A, Berkowitz RS. Clinical characteristics and thyroid function in complete hydatidiform mole complicated by hyperthyroidism. Gynecol Oncol 2022; 165:137-142. [DOI: 10.1016/j.ygyno.2022.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/25/2022] [Accepted: 01/31/2022] [Indexed: 11/25/2022]
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Braga A, Padrón L, Rezende-Filho J, Elias K, Horowitz N, Berkowitz R. Treatment of hydatidiform mole using manual vacuum aspiration: technical and tactical aspects. Int J Gynecol Cancer 2021; 31:1299-1300. [PMID: 34049976 DOI: 10.1136/ijgc-2021-002631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Antonio Braga
- Department of Obstetrics and Gynecology, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
- Department Maternal Child, Federal Fluminense University, Niteroi, Rio de Janeiro, Brazil
| | - Lilian Padrón
- Gynecology Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jorge Rezende-Filho
- Department of Obstetrics and Gynecology, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Kevin Elias
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology. Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Neil Horowitz
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology. Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ross Berkowitz
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology. Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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11
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De Guzman E, Shakeel H, Jain R. Thyrotoxicosis: a rare presentation of molar pregnancy. BMJ Case Rep 2021; 14:14/7/e242131. [PMID: 34226253 DOI: 10.1136/bcr-2021-242131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 49-year-old woman, G8P7, presented with 1 week of worsening vaginal bleeding and abdominal cramps in the setting of a recently discovered unplanned pregnancy. Vaginal ultrasound findings and a significantly elevated human chorionic gonadotropin (hCG) level were concerning for molar pregnancy. She developed signs of hyperthyroidism on the night of admission, for which the endocrinology team was consulted. Laboratory data were consistent with hyperthyroidism. The patient was believed to have thyrotoxicosis secondary to molar pregnancy with concern for impending thyroid storm. Her mental health disorder and bacteraemia made taking care of her further challenging. She was started on a beta-blocker, antithyroid agent and intravenous corticosteroids. She underwent an uncomplicated suction dilation and curettage (D&C), with resolution of her symptoms a few days after. At a follow-up appointment, the patient continued to be asymptomatic and was feeling well.
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Affiliation(s)
- Eison De Guzman
- Department of Internal Medicine, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Hira Shakeel
- Department of Endocrinology and Metabolism, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Rohit Jain
- Department of Endocrinology and Metabolism, The George Washington University Hospital, Washington, District of Columbia, USA
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12
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Distinct microRNA profiles for complete hydatidiform moles at risk of malignant progression. Am J Obstet Gynecol 2021; 224:372.e1-372.e30. [PMID: 33031755 DOI: 10.1016/j.ajog.2020.09.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/24/2020] [Accepted: 09/29/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND MicroRNAs are small noncoding RNAs with important regulatory functions. Although well-studied in cancer, little is known about the role of microRNAs in premalignant disease. Complete hydatidiform moles are benign forms of gestational trophoblastic disease that progress to gestational trophoblastic neoplasia in up to 20% of cases; however, there is no well-established biomarker that can predict the development of gestational trophoblastic neoplasia. OBJECTIVE This study aimed to investigate possible differences in microRNA expression between complete moles progressing to gestational trophoblastic neoplasia and those regressing after surgical evacuation. STUDY DESIGN Total RNA was extracted from fresh frozen tissues from 39 complete moles collected at the time of uterine evacuation in Brazil. In the study, 39 cases achieved human chorionic gonadotropin normalization without further therapy, and 9 cases developed gestational trophoblastic neoplasia requiring chemotherapy. Total RNA was also extracted from 2 choriocarcinoma cell lines, JEG-3 and JAR, and an immortalized normal placenta cell line, 3A-subE. MicroRNA expression in all samples was quantified using microRNA sequencing. Hits from the sequencing data were validated using a quantitative probe-based assay. Significantly altered microRNAs were then subjected to target prediction and gene ontology analyses to search for alterations in key signaling pathways. Expression of potential microRNA targets was assessed by quantitative real-time polymerase chain reaction and western blot. Finally, potential prognostic protein biomarkers were validated in an independent set of formalin-fixed paraffin-embedded patient samples from the United States (15 complete moles progressing to gestational trophoblastic neoplasia and 12 that spontaneously regressed) using quantitative immunohistochemistry. RESULTS In total, 462 microRNAs were identified in all samples at a threshold of <1 tag per million. MicroRNA sequencing revealed a distinct set of microRNAs associated with gestational trophoblastic neoplasia. Gene ontology analysis of the most altered transcripts showed that the leading pathway was related to response to ischemia (P<.001). Here, 2 of the top 3 most significantly altered microRNAs were mir-181b-5p (1.65-fold; adjusted P=.014) and mir-181d-5p (1.85-fold; adjusted P=.014), both of which have been shown to regulate expression of BCL2. By quantitative real-time polymerase chain reaction, BCL2 messenger RNA expression was significantly lower in the complete moles progressing to gestational trophoblastic neoplasia than the regressing complete moles (-4.69-fold; P=.018). Reduced expression of BCL2 was confirmed in tissue samples by western blot. Immunohistochemistry in the independent patient samples revealed significantly lower cytoplasmic expression of BCL2 in the villous trophoblasts from cases destined for progression to gestational trophoblastic neoplasia compared with those that regressed, both with respect to staining intensity (optic density 0.110±0.102 vs 0.212±0.036; P<.001) and to the percentage of positive cells (16%±28% vs 49.4%±28.05%; P=.003). CONCLUSION Complete moles progressing to gestational trophoblastic neoplasia are associated with a distinct microRNA profile. miR-181 family members and BCL2 may be prognostic biomarkers for predicting gestational trophoblastic neoplasia risk.
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13
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Pereira JVB, Lim T. Hyperthyroidism in gestational trophoblastic disease - a literature review. Thyroid Res 2021; 14:1. [PMID: 33446242 PMCID: PMC7807451 DOI: 10.1186/s13044-021-00092-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/04/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Gestational trophoblastic disease (GTD) is a group of pregnancy-related disorders that arise from abnormal proliferation of placental trophoblast. Some patients with GTD develop hyperthyroidism, a rare but potentially life-threatening complication requiring early detection and management. Existing literature on hyperthyroidism in GTD is scant. This review aims to analyse the epidemiology, pathophysiology and management of this phenomenon. METHODS A comprehensive search of MEDLINE, EMBASE and Cochrane Library was performed to obtain articles that explored hyperthyroidism in GTD. A total of 405 articles were screened and 228 articles were considered for full-text review. We selected articles that explored epidemiology, pathophysiology and outcomes/management of hyperthyroidism in GTD. RESULTS The pathophysiology of hyperthyroidism in GTD is well-investigated. Placental trophoblastic tissue secretes excessive hCG, which is structurally similar to thyroid stimulating hormone and also has enhanced thyrotropic activity compared to normal hCG. The incidence and prevalence of hyperthyroidism in GTD varies worldwide, with lower rates associated with high uptake of early antenatal screening and early GTD detection. No clear risk factors for hyperthyroidism in GTD were identified. While hyperthyroidism can be definitively managed with surgical evacuation of the uterus, severe complications associated with hyperthyroidism in GTD have been reported, including thyroid storm-induced multi-organ failure, ARDS, and pulmonary hypertension. CONCLUSION Early detection of GTD is critical to prevent development of hyperthyroidism and its associated complications. Hyperthyroidism should be recognised as an important perioperative consideration for women undergoing surgery for GTD, and requires appropriate management. Future studies should explore risk factors for hyperthyroidism in GTD, which may facilitate earlier identification of high-risk women.
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Affiliation(s)
- Jarett Vanz-Brian Pereira
- Faculty of Medicine, University of New South Wales, Wallace Wurth Building - UNSW Sydney, 18 High St, Kensington NSW, Sydney, 2052, Australia.
| | - Taylor Lim
- Faculty of Medicine, University of New South Wales, Wallace Wurth Building - UNSW Sydney, 18 High St, Kensington NSW, Sydney, 2052, Australia
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Lin LH, Polizio R, Fushida K, Francisco RPV. Imaging in Gestational Trophoblastic Disease. Semin Ultrasound CT MR 2019; 40:332-349. [PMID: 31375173 DOI: 10.1053/j.sult.2019.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Gestational trophoblastic disease (GTD) is a spectrum of disorders characterized by abnormal trophoblastic proliferation. GTD includes benign conditions such as hydatidiform moles and malignant diseases that are referred as gestational trophoblastic neoplasia (GTN). Ultrasound plays a central role in the diagnosis of patients with hydatidiform mole. Other imaging modalities are useful in molar pregnancy, mainly for evaluating pulmonary complications and atypical presentation of hydatidiform mole. GTN typically arises after 20% of molar pregnancies but can uncommonly occur after nonmolar gestations. After uterine evacuation, serial human chorionic gonadotropin levels are evaluated in patients for early detection of GTN. Once GTN is suspected, Doppler ultrasound is the primary tool to confirm the diagnosis; however, magnetic resonance imaging can also help in selected cases. Metastatic disease workup can involve various modalities, including ultrasound, X-ray, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. In this article, we review the main imaging modalities used to evaluate patients with GTD.
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Affiliation(s)
- Lawrence Hsu Lin
- University of Sao Paulo Trophoblastic Disease Center, Department of Obstetrics and Gynecology, University of Sao Paulo Medical School, Sao Paulo, Brazil.
| | - Rodrigo Polizio
- Sao Paulo State Cancer Center, Department of Oncology and Radiology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Koji Fushida
- University of Sao Paulo Trophoblastic Disease Center, Department of Obstetrics and Gynecology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Rossana Pulcineli Vieira Francisco
- University of Sao Paulo Trophoblastic Disease Center, Department of Obstetrics and Gynecology, University of Sao Paulo Medical School, Sao Paulo, Brazil
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Braga A, Mora P, de Melo AC, Nogueira-Rodrigues A, Amim-Junior J, Rezende-Filho J, Seckl MJ. Challenges in the diagnosis and treatment of gestational trophoblastic neoplasia worldwide. World J Clin Oncol 2019; 10:28-37. [PMID: 30815369 PMCID: PMC6390119 DOI: 10.5306/wjco.v10.i2.28] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/12/2018] [Accepted: 01/01/2019] [Indexed: 02/06/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) is a rare tumor that originates from pregnancy that includes invasive mole, choriocarcinoma (CCA), placental site trophoblastic tumor and epithelioid trophoblastic tumor (PSTT/ETT). GTN presents different degrees of proliferation, invasion and dissemination, but, if treated in reference centers, has high cure rates, even in multi-metastatic cases. The diagnosis of GTN following a hydatidiform molar pregnancy is made according to the International Federation of Gynecology and Obstetrics (FIGO) 2000 criteria: four or more plateaued human chorionic gonadotropin (hCG) concentrations over three weeks; rise in hCG for three consecutive weekly measurements over at least a period of 2 weeks or more; and an elevated but falling hCG concentrations six or more months after molar evacuation. However, the latter reason for treatment is no longer used by many centers. In addition, GTN is diagnosed with a pathological diagnosis of CCA or PSTT/ETT. For staging after a molar pregnancy, FIGO recommends pelvic-transvaginal Doppler ultrasound and chest X-ray. In cases of pulmonary metastases with more than 1 cm, the screening should be complemented with chest computed tomography and brain magnetic resonance image. Single agent chemotherapy, usually Methotrexate (MTX) or Actinomycin-D (Act-D), can cure about 70% of patients with FIGO/World Health Organization (WHO) prognosis risk score ≤ 6 (low risk), reserving multiple agent chemotherapy, such as EMA/CO (Etoposide, MTX, Act-D, Cyclophosphamide and Oncovin) for cases with FIGO/WHO prognosis risk score ≥ 7 (high risk) that is often metastatic. Best overall cure rates for low and high risk disease is close to 100% and > 95%, respectively. The management of PSTT/ETT differs and cure rates tend to be a bit lower. The early diagnosis of this disease and the appropriate treatment avoid maternal death, allow the healing and maintenance of the reproductive potential of these women.
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Affiliation(s)
- Antonio Braga
- Postgraduate Program of Medical Sciences, Fluminense Federal University, Niterói 24033-900, Brazil
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Paulo Mora
- Postgraduate Program of Medical Sciences, Fluminense Federal University, Niterói 24033-900, Brazil
- Brazilian National Cancer, Hospital do Câncer 2, Rio de Janeiro 20220-410, Brazil
| | | | - Angélica Nogueira-Rodrigues
- Department of Internal Medicine, Faculty of Medicine, Minas Gerais Federal University, Belo Horizonte 30130-100, Brazil
| | - Joffre Amim-Junior
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Jorge Rezende-Filho
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, United Kingdom
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Barut MU, Sak S, Sak ME. Kliniğimize Başvuran Mol Gebelik Olgularının Retrospektif İncelenmesi. DICLE MEDICAL JOURNAL 2018. [DOI: 10.5798/dicletip.474185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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18
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Braga A, Obeica B, Werner H, Sun SY, Amim Júnior J, Filho JR, Araujo Júnior E. A twin pregnancy with a hydatidiform mole and a coexisting live fetus: prenatal diagnosis, treatment, and follow-up. J Ultrason 2017; 17:299-305. [PMID: 29375907 PMCID: PMC5769672 DOI: 10.15557/jou.2017.0044] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 11/25/2022] Open
Abstract
Twin molar pregnancy with a hydatidiform mole and a coexisting live fetus is a rare form of gestational trophoblastic disease associated with an increased risk of obstetric complications and poor perinatal outcome. Prenatal diagnosis is essential for couple counseling and follow-up in Tertiary Reference Centers. Magnetic resonance imaging is important for the diagnostic differentiation of placental mesenchymal dysplasia and exclusion of myometrial invasion. Here we present a case of twin molar pregnancy with a hydatidiform mole and a coexisting live fetus diagnosed at gestational week 14 using two-dimensional (2D) and three-dimensional (3D) ultrasound and magnetic resonance imaging. We also describe the obstetric management and postmolar follow-up.
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Affiliation(s)
- Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Bruna Obeica
- Rio de Janeiro Trophoblastic Disease Center, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Heron Werner
- Department of Radiology, Clínica de Diagnóstico por Imagem, Rio de Janeiro, Brazil
| | - Sue Yazaki Sun
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo, São Paulo, Brazil
| | - Joffre Amim Júnior
- Rio de Janeiro Trophoblastic Disease Center, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jorge Rezende Filho
- Rio de Janeiro Trophoblastic Disease Center, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo, São Paulo, Brazil
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Shaaban AM, Rezvani M, Haroun RR, Kennedy AM, Elsayes KM, Olpin JD, Salama ME, Foster BR, Menias CO. Gestational Trophoblastic Disease: Clinical and Imaging Features. Radiographics 2017; 37:681-700. [PMID: 28287945 DOI: 10.1148/rg.2017160140] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gestational trophoblastic disease (GTD) is a spectrum of both benign and malignant gestational tumors, including hydatidiform mole (complete and partial), invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. The latter four entities are referred to as gestational trophoblastic neoplasia (GTN). These conditions are aggressive with a propensity to widely metastasize. GTN can result in significant morbidity and mortality if left untreated. Early diagnosis of GTD is essential for prompt and successful management while preserving fertility. Initial diagnosis of GTD is based on a multifactorial approach consisting of clinical features, serial quantitative human chorionic gonadotropin (β-hCG) titers, and imaging findings. Ultrasonography (US) is the modality of choice for initial diagnosis of complete hydatidiform mole and can provide an invaluable means of local surveillance after treatment. The performance of US in diagnosing all molar pregnancies is surprisingly poor, predominantly due to the difficulty in differentiating partial hydatidiform mole from nonmolar abortion and retained products of conception. While GTN after a molar pregnancy is usually diagnosed with serial β-hCG titers, imaging plays an important role in evaluation of local extent of disease and systemic surveillance. Imaging also plays a crucial role in detection and management of complications, such as uterine and pulmonary arteriovenous fistulas. Familiarity with the pathogenesis, classification, imaging features, and treatment of these tumors can aid in radiologic diagnosis and guide appropriate management. ©RSNA, 2017.
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Affiliation(s)
- Akram M Shaaban
- From the Department of Radiology and Imaging Sciences (A.M.S., M.R., R.R.H., A.M.K., J.D.O.) and Department of Pathology (M.E.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.); Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Ore (B.R.F.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Maryam Rezvani
- From the Department of Radiology and Imaging Sciences (A.M.S., M.R., R.R.H., A.M.K., J.D.O.) and Department of Pathology (M.E.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.); Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Ore (B.R.F.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Reham R Haroun
- From the Department of Radiology and Imaging Sciences (A.M.S., M.R., R.R.H., A.M.K., J.D.O.) and Department of Pathology (M.E.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.); Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Ore (B.R.F.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Anne M Kennedy
- From the Department of Radiology and Imaging Sciences (A.M.S., M.R., R.R.H., A.M.K., J.D.O.) and Department of Pathology (M.E.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.); Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Ore (B.R.F.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Khaled M Elsayes
- From the Department of Radiology and Imaging Sciences (A.M.S., M.R., R.R.H., A.M.K., J.D.O.) and Department of Pathology (M.E.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.); Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Ore (B.R.F.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Jeffrey D Olpin
- From the Department of Radiology and Imaging Sciences (A.M.S., M.R., R.R.H., A.M.K., J.D.O.) and Department of Pathology (M.E.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.); Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Ore (B.R.F.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Mohamed E Salama
- From the Department of Radiology and Imaging Sciences (A.M.S., M.R., R.R.H., A.M.K., J.D.O.) and Department of Pathology (M.E.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.); Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Ore (B.R.F.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Bryan R Foster
- From the Department of Radiology and Imaging Sciences (A.M.S., M.R., R.R.H., A.M.K., J.D.O.) and Department of Pathology (M.E.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.); Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Ore (B.R.F.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
| | - Christine O Menias
- From the Department of Radiology and Imaging Sciences (A.M.S., M.R., R.R.H., A.M.K., J.D.O.) and Department of Pathology (M.E.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.); Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Ore (B.R.F.); and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.)
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Dantas PRS, Maestá I, Filho JR, Junior JA, Elias KM, Howoritz N, Braga A, Berkowitz RS. Does hormonal contraception during molar pregnancy follow-up influence the risk and clinical aggressiveness of gestational trophoblastic neoplasia after controlling for risk factors? Gynecol Oncol 2017; 147:364-370. [PMID: 28927899 DOI: 10.1016/j.ygyno.2017.09.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/07/2017] [Accepted: 09/09/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Patrícia Rangel Sobral Dantas
- Department of Gynecology and Obstetrics, Botucatu Medical School, Postgraduate Program of Gynecology, Obstetrics and Mastology of São Paulo State University. Rubião Júnior District, Botucatu, São Paulo, Brazil; Rio de Janeiro Trophoblastic Disease Center, Brazilian Association of Gestational Trophoblastic Disease, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil
| | - Izildinha Maestá
- Department of Gynecology and Obstetrics, Botucatu Medical School, Postgraduate Program of Gynecology, Obstetrics and Mastology of São Paulo State University. Rubião Júnior District, Botucatu, São Paulo, Brazil
| | - Jorge Rezende Filho
- Rio de Janeiro Trophoblastic Disease Center, Brazilian Association of Gestational Trophoblastic Disease, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil; Department of Gynecology and Obstetrics, Maternity School, Postgraduate Program of Perinatal Health of Rio de Janeiro Federal University, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil
| | - Joffre Amin Junior
- Rio de Janeiro Trophoblastic Disease Center, Brazilian Association of Gestational Trophoblastic Disease, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil; Department of Gynecology and Obstetrics, Maternity School, Postgraduate Program of Perinatal Health of Rio de Janeiro Federal University, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil
| | - Kevin M Elias
- Department of Obstetrics and Gynecology and Reproductive Biology, Division of Gynecologic Oncology, New England Trophoblastic Disease Center, Donald P. Goldstein MD Trophoblastic Tumor Registry, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis St, Boston, MA, USA
| | - Neil Howoritz
- Department of Obstetrics and Gynecology and Reproductive Biology, Division of Gynecologic Oncology, New England Trophoblastic Disease Center, Donald P. Goldstein MD Trophoblastic Tumor Registry, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis St, Boston, MA, USA
| | - Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center, Brazilian Association of Gestational Trophoblastic Disease, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil; Department of Gynecology and Obstetrics, Maternity School, Postgraduate Program of Perinatal Health of Rio de Janeiro Federal University, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil; Department of Maternal-Child, Antonio Pedro University Hospital, Postgraduate Program of Medical Sciences of Fluminense Federal University, 303 Marquês do Paraná St, Centro, Niterói, Rio de Janeiro, Brazil.
| | - Ross S Berkowitz
- Department of Obstetrics and Gynecology and Reproductive Biology, Division of Gynecologic Oncology, New England Trophoblastic Disease Center, Donald P. Goldstein MD Trophoblastic Tumor Registry, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis St, Boston, MA, USA
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Elias KM, Harvey RA, Hasselblatt KT, Seckl MJ, Berkowitz RS. Type I interferons modulate methotrexate resistance in gestational trophoblastic neoplasia. Am J Reprod Immunol 2017; 77. [DOI: 10.1111/aji.12666] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/17/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- Kevin M. Elias
- New England Trophoblastic Disease Center; Division of Gynecologic Oncology; Department of Obstetrics, Gynecology and Reproductive Biology; Dana-Farber Cancer Institute; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
| | - Richard A. Harvey
- Charing Cross Gestational Trophoblastic Disease Centre; Charing Cross Campus of Imperial College Healthcare NHS Trust; London UK
| | - Kathleen T. Hasselblatt
- New England Trophoblastic Disease Center; Division of Gynecologic Oncology; Department of Obstetrics, Gynecology and Reproductive Biology; Dana-Farber Cancer Institute; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
| | - Michael J. Seckl
- Charing Cross Gestational Trophoblastic Disease Centre; Charing Cross Campus of Imperial College Healthcare NHS Trust; London UK
- Lung Cancer Biology Group; Division of Medicine; Hammersmith Campus of Imperial College School of Medicine; London UK
| | - Ross S. Berkowitz
- New England Trophoblastic Disease Center; Division of Gynecologic Oncology; Department of Obstetrics, Gynecology and Reproductive Biology; Dana-Farber Cancer Institute; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
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Complete molar pregnancy in adolescents from North and South America: Clinical presentation and risk of gestational trophoblastic neoplasia. Gynecol Oncol 2016; 142:496-500. [DOI: 10.1016/j.ygyno.2016.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/18/2016] [Accepted: 07/01/2016] [Indexed: 11/22/2022]
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