ABSTRACT
Abstract Objective To assess the potential relationship of clinical status upon admission and distance traveled from geographical health district in women with gestational trophoblastic disease (GTD). Methods This is a cross-sectional study including women with GTD from the 17 health districts from the São Paulo state (I-XVII), Brazil, referred to the Botucatu Trophoblastic Disease Center (specialized center, district VI), between 1990 and 2018. At admission, hydatidiform mole was assessed according to the risk score system of Berkowitz et al. Gestational trophoblastic neoplasia was evaluated using the International Federation of Gynecology and Obstetrics / World Health Organization (FIGO/WHO) staging/risk score. Data on demographics, clinical status and distance traveled were collected. Multiple regression analyses were performed. Results This study included 366 women (335 hydatidiform mole, 31 gestational trophoblastic neoplasia). The clinical status at admission and distance traveled significantly differed between the specialized center district and other districts. Patients referred from health districts IX (β = 2.38 [0.87-3.88], p = 0.002) and XVI (β = 0.78 [0.02-1.55], p = 0.045) had higher hydatidiform mole scores than those from the specialized center district. Gestational trophoblastic neoplasia patients from district XVI showed a 3.32 increase in FIGO risk scores compared with those from the specialized center area (β = 3.32, 95% CI = 0.78-5.87, p = 0.010). Distance traveled by patients from districts IX (200km) and XVI (203.5km) was significantly longer than that traveled by patients from the specialized center district (76km). Conclusion Patients from health districts outside the specialized center area had higher risk scores for both hydatidiform mole and gestational trophoblastic neoplasia at admission. Long distances (>80 km) seemed to adversely influence gestational trophoblastic disease clinical status at admission, indicating barriers to accessing specialized centers.
Resumo Objetivo Avaliar a possível relação entre estado clínico na apresentação e distância percorrida a partir do distrito de saúde em mulheres com doença trofoblástica gestacional. Métodos Estudo transversal incluindo mulheres com doença trofoblástica gestacional dos 17 distritos de saúde do estado de São Paulo (I-XVII), Brasil, encaminhadas ao Centro de Doenças Trofoblásticas de Botucatu (distrito VI), entre 1990 e 2018. Na admissão, avaliaram-se mola hidatiforme pelo sistema de pontuação de risco de Berkowitz et al. e neoplasia trofoblástica gestacional pelo escore de risco/estadiamento Federação Internacional de Ginecologia e Obstetrícia / Organização Mundial da Saúde (FIGO/OMS). Coletaram-se dados demográficos, clínicos e distância percorrida e análises de regressão múltipla foram realizadas. Resultados Este estudo incluiu 366 mulheres (335 mola hidatiforme, 31 neoplasia trofoblástica gestacional). O estado clínico na apresentação e distância percorrida diferiram significativamente entre o centro especializado e demais distritos. Nas pacientes encaminhadas pelos distritos IX (β = 2,38 [0,87-3,88], p = 0,002) e XVI (β = 0,78 [0,02-1,55], p = 0,045), os escores de mola hidatiforme foram maiores que no centro especializado. As pacientes com neoplasia trofoblástica gestacional do distrito XVI apresentaram escores FIGO 3,32 vezes maior que no centro especializado (β = 3,32, 95% CI = 0,78-5,87, p = 0,010). A distância percorrida pelas pacientes dos distritos IX (200km) e XVI (203,5km) foi significativamente maior do que a percorrida pelas pacientes do centro especializado (76km). Conclusão Pacientes de distritos de saúde fora da cobertura do centro especializado apresentaram escores de risco mais alto para mola hidatiforme e para neoplasia trofoblástica gestacional na admissão. Longas distâncias (>80 km) pareceram influenciar negativamente o estado clínico da doença trofoblástica gestacional na apresentação, indicando barreiras no acesso a centros especializados.
Subject(s)
Humans , Female , Pregnancy , Gestational Trophoblastic Disease , Tertiary Care CentersABSTRACT
Objetivo: Analisar a trajetória das mulheres com doença trofoblástica gestacional (DTG) até o Centro de Referência de Doença Trofoblástica Gestacional do Hospital São Paulo (CRDTG-HSP), identificando as portas de entrada ao serviço e as dificuldades que elas enfrentaram desde o diagnóstico. Métodos: Estudo de caso transversal exploratório, descritivo-analítico, com abordagem quali-quantitativa, que incluiu pacientes atendidas no período de 2015 a 2018. A coleta dos dados se deu por meio de um questionário on-line e de uma entrevista com roteiro semiestruturado. Resultados: Entre 96 pacientes, 40,63% (n = 39) tiveram acesso ao CRDTG-HSP por encaminhamento entre médicos, 31,25% (n = 30), pela página do Facebook da Associação Brasileira de Doença Trofoblástica Gestacional e 10,42% (n = 10), por meio da central de regulação de vagas do estado de São Paulo (CROSS), das quais 28,2%, 73% e 30%, respectivamente, possuíam assistência privada, na qual receberam tratamento inicial. As 12 entrevistadas relataram dificuldades, tais como a percepção da falta de preparo médico no manejo e comunicação da doença, o desconhecimento da sua situação de saúde mesmo após procedimentos cirúrgicos, a exposição a conversas inapropriadas entre médicos sobre o seu caso e o recebimento de encaminhamento sem explicação esclarecedora sobre seu quadro clínico. Por fim, as pacientes avaliaram positivamente a utilização de e-mail e WhatsApp como facilitadores no atendimento no CRDTG-HSP. Conclusão: O acesso ao CRDTG-HSP ocorreu minoritariamente pela CROSS e, mesmo tendo assistência privada, pacientes migraram para atendimento no centro especializado. Além disso, as pacientes tiveram percepção de falta de preparo médico no atendimento da DTG fora do CRDTG.(AU)
Objective: To understand and elaborate the trajectories of women with gestational trophoblastic disease from the initial entry to the healthcare system to follow-up at a public tertiary reference center. Methods: This exploratory, descriptive-analytical, cross-sectional case study included patients from 2015 to 2018. The data collected through online questionnaires and semi-structured interviews were analyzed via quantitative and qualitative approaches. Statistical analysis was performed using Pearson's chi-square test at 5% significance using software R version 4.0.2. The test power for the sample was calculated using G*power software version 3.1.9.6. Results: Overall, 96 patients completed the questionnaire. Only 10(10.42%) patients reached the reference center through the official channel, Sao Paulo State Vacancy Regulation Center, while 39(40.63%) patients through referral from physicians, and 30(31.25%) patients through the Brazilian Association of Gestational Trophoblastic Disease's Facebook fan page. Overall, 36 patients (37.5%) had private insurance and 73% of patients who reached the reference center via Facebook had private insurance. Twelve participants were interviewed and reported barriers, such as difficulties in understanding their health issues prior to arrival at the reference center, lack of professional knowledge about the disease, poor communication, and exposure to inappropriate conversations. They positively evaluated the reference center, the interaction was facilitated using email and WhatsApp. Conclusion: Although appropriate public care for these women exists, the flow from the diagnosis to specialized treatment remains unclear for both professionals and patients. The participants perceived that communication and physicians' expertise were inadequate.(AU)
Subject(s)
Humans , Female , Pregnancy , Gestational Trophoblastic Disease , Health Services Accessibility/statistics & numerical data , Social Perception , Unified Health System , Brazil , Cross-Sectional Studies , Women's Health , Telemedicine , Biomedical Technology , Integrality in HealthABSTRACT
@#Gestational trophoblastic diseases (GTDs) represent a unique group of lesions with an abnormal proliferation of trophoblasts. GTD can be divided into molar lesions and nonmolar lesions. Partial and complete hydatidiform moles and invasive moles are under molar lesions, whereas non‑molar lesions include choriocarcinomas and lesions that are derived from intermediate trophoblasts (ITs). These IT can be from the implantation site (exaggerated placental site [EPS] and placental site trophoblastic tumor) or from the chorionic type (placental site nodule and epithelioid trophoblastic tumor). EPS is a relatively uncommon form of GTD. It is a challenging condition for clinicians to diagnose because of the limited number of reported cases. From 1990 to April 2022, there were only 25 case reports published internationally, and this is the first local case report. Implantation site ITs (ISITs) are difficult to distinguish histologically. Immunohistochemical staining such as Ki‑67 can improve diagnostic accuracy by differentiating ISIT. Ki 67 will show staining of <1% in EPS. This is the case of a 25‑year‑old patient, G6P5 (5005), who experienced vaginal bleeding associated with pelvic and hypogastric pain after 13 weeks of missed menses. She was diagnosed with a molar pregnancy and underwent an emergency total abdominal hysterectomy with bilateral salpingectomy due to severe uterine bleeding. Histopathologic studies in this case showed diffuse and infiltrative growth of atypical monomorphic ITs arranged in sheets and cords, infiltrating and separating myometrial fibers. The uterine blood vessel wall was replaced with fibrinoid deposition, with areas of hemorrhages and necrosis. There were also chorionic villi. The histopathological findings revealed GTD arising from ITs, specifically EPS. This article describes the clinical presentation, diagnostic procedure, and management, together with histopathological observations and a review of related literature, of this rare GTD.
Subject(s)
Gestational Trophoblastic DiseaseABSTRACT
@#Gestational trophoblastic neoplasia (GTN) with a concurrent cervical malignancy is very rare, making the case both a diagnostic dilemma and a therapeutic challenge. Currently, there has only been one reported case worldwide. We present a case of GTN Stage I:11 with non‑keratinizing squamous cell carcinoma of the cervix Stage II‑B. Initial treatment, in the form of chemotherapy, was directed toward the GTN, as this appeared to be the more aggressive disease. Surgery was not feasible during diagnosis due to the cervical carcinoma. However, the GTN proved resistant to chemotherapy due to the increasing beta human chorionic gonadotropin titers. An attempt to decrease the size of the cervix for surgery to be possible through chemoradiation was instituted, but due to complications and tumor progression to the lungs, she succumbed to the malignancy.
Subject(s)
Uterine Cervical Neoplasms , Gestational Trophoblastic DiseaseABSTRACT
@#Choriocarcinoma is a malignant subtype of gestational trophoblastic disease that follows any type of pregnancy. It is characterized by rapid hematogenous spread to multiple organs, associated with high human chorionic gonadotropin levels with good response to chemotherapy. We present the case of a 31‑year‑old Filipina who initially presented with severe headaches and blurring of vision 3 years after an unremarkable term pregnancy. The transvaginal ultrasound was normal. After a series of diagnostic tests, the initial working impression was a primary brain tumor with metastases to the lungs, adrenal, kidney, and vulva. Emergency craniotomy was done due to deteriorating status secondary to an intracranial hemorrhage. The histopathology report showed choriocarcinoma. Chemotherapy using Etoposide‑Methotrexate‑Actinomycin D‑Cyclophosphamide‑Vincristine with high‑dose methotrexate and concomitant whole‑brain irradiation was then instituted with good response. This case highlights the importance of having a high index of suspicion for gestational trophoblastic neoplasia to prevent the performance of unnecessary procedures, leading to a delay in diagnosis and the institution of the appropriate treatment.
Subject(s)
Gestational Trophoblastic DiseaseABSTRACT
Background@#Gestational trophoblastic neoplasia (GTN) presents as vascular mass of varying morphology on ultrasound and confirmed through quantitative serum β subunit human chorionic gonadotrophin (β‑hCG). In regions with limited access to β‑hCG, ultrasound plays a crucial role in the initial diagnosis for timely management.@*Objectives@#This study aimed to investigate the associations between ultrasound vascular morphologic features, serum β‑hCG levels, and histopathology in GTN cases.@*Methodology@#A cross‑sectional review was conducted on 113 cases with ultrasound impression of GTN over an 8‑year period. The patient data were extracted from case records, and ultrasound images were categorized based on the distinct features. Associations with β‑hCG levels and histopathology were analyzed using the Chi‑square test and Mann–Whitney U‑test. Statistical significance was set at P < 0.05.@*Results@#A significant association was observed between ultrasound category and serum β‑hCG (P < 0.0001). The compact and diffuse types were more prevalent with β‑hCG levels between 104 to <105 mIU/mL, while the lacunar type was common among patients with ≥105 mIU/mL. However, there was no significant association between ultrasound categories and mean β‑hCG levels. Regarding histopathology, the lacunar type was more common in invasive moles, whereas the compact and diffuse types tended to be seen with choriocarcinoma, although these were not statistically significant (P = 0.182).@*Conclusions@#Morphologic types of GTN by gray scale and Doppler ultrasound vary across the different levels of serum β‑hCG and may suggest the histopathological diagnosis. This study provides valuable insights into the ultrasonographic characteristics of GTN, which can aid in its diagnosis and management.
Subject(s)
Gestational Trophoblastic Disease , Ultrasonography, DopplerABSTRACT
Background@#Gestational trophoblastic neoplasia (GTN) is considered one of the most curable malignancies, especially when diagnosis and treatment are commenced early. Identifying predictors for the development of GTN will enable prompt management equating to an excellent prognosis.@*Objectives@#The objectives of this study were to determine the validity of uterine artery Doppler parameters (UADPs) as predictors for postmolar GTN, compare UADP values before and after evacuation, determine cutoff values and relationship with beta‑human chorionic gonadotropin (hCG) levels.@*Materials and methods@#This was a prospective cohort study, which included histopathologically confirmed hydatidiform mole (HM) patients who underwent suction curettage. UADPs (pulsatility index (PI), resistive index, and systolic/diastolic [S/D] ratio) were measured preevacuation, 4 weeks postevacuation, and 6 weeks postevacuation. Patients were followed up to determine whether they will develop postmolar GTN or not.@*Results@#A total of 31 HM patients were admitted during the study period, 84% (26/31) of whom underwent suction curettage. Of these, 92% (24/26) had histopathology of complete HM and were recruited. However, only 17 patients followed up and completed the study. Results showed that there was an increasing trend of the UADP from preevacuation to 6 weeks postevacuation and the trend between those with and without postmolar GTN was statistically significant. There was also an inverse relationship between the UADP and baseline β‑hCG values. UADP showed lower values among patients who developed postmolar GTN compared to those who did not. The cutoff values recommended by the area under curve (AUC) that can be a possible predictor were 4th‑week right PI of 2.14 (AUC = 0.71) and right S/D ratio of 2.60 (AUC = 0.73) and 6th‑week left PI of 2.80 (AUC = 0.70) and right PI of 2.53 (AUC = 0.74).@*Conclusion@#Neoangiogenesis, a hallmark of malignancy, is correlated with invasive disease and will show increased myometrial vascularization with lower uterine artery indices. Doppler ultrasound may be a useful tool for postmolar follow‑up and GTN diagnosis. However, the small sample size in this study is a limitation and a larger multicenter study is recommended.
Subject(s)
Gestational Trophoblastic Disease , Hydatidiform MoleABSTRACT
Objective@#Despite the widespread use and measurement of beta‑human chorionic gonadotropin (β‑HCG) among hydatidiform mole (HM) patients, models derived from this biomarker to predict the remission or postmolar gestational trophoblastic neoplasia (GTN) rarely perform well. The study aimed to generate cutoff points for postevacuation β‑HCG levels and evaluate their performance among women with complete molar pregnancies@*Methods@#A retrospective cohort study composed of women with complete HM underwent bivariate procedures comparing characteristics between the comparison groups. Cut points using Liu’s and Youden’s indices were estimated, and their performance was evaluated using receiver operating characteristic curve analysis. Cox regression to compare time‑to‑progression across these proposed β‑HCG cutoffs was also performed.@*Results@#The incidence of postmolar GTN among the 155 women in the study was 15.5% (95% confidence interval: 10.2%–22.2%). Postevacuation HCG levels had a better prediction of disease status than preevacuation and HCG ratio models (χ2 : 163.07, P < 0.01). A cutoff at 508 mIU/mL the 3rd‑week postevacuation (area under the curve [AUC]: 0.89, sensitivity: 87.5%, specificity: 90.1%) was comparable with the 185 mIU/mL cutoff at the 5th‑week postevacuation (AUC: 0.89, sensitivity: 91.7%, specificity: 87%). The hazards ratio of postmolar GTN was 29.74 (8.53–103.71) and 39.89 (8.82–180.38) for the 3rd and 5th weeks HCG after evacuation adjusting for clinically relevant variables@*Conclusion@#The first 3rd‑ and 5th‑week postevacuation levels of β‑HCG demonstrated potential in predicting postmolar GTN. However, further refinement and adjustment for clinically relevant risk factors are still needed.
Subject(s)
Choriocarcinoma , Gestational Trophoblastic Disease , PrognosisABSTRACT
@#Precision medicine is a form of medicine that utilizes information about a person’s own genes to prevent, diagnose, or treat disease. In trophoblastic disease, precision medicine is important for accurate diagnosis, risk stratification, prognostication, and management. Immunohistochemistry, particularly p57kip2, has become an important ancillary procedure for the accurate identification of complete hydatidiform mole (HM). Molecular genotyping, on the other hand, is now considered the gold standard for the accurate classification of HM. Both tests are important for prognostication and the determination of the appropriate follow‑up plan. For gestational trophoblastic neoplasia, immunohistochemical markers can confirm the histologic diagnosis of its various types. Molecular genotyping differentiates gestational from nongestational tumors with overlapping histology and allows for precise identification of the index or causative pregnancy of a choriocarcinoma.
Subject(s)
Gestational Trophoblastic Disease , Hydatidiform Mole , Precision MedicineABSTRACT
@#Placental site trophoblastic tumor (PSTT) with uterine arteriovenous malformation (AVM) is a rare and potentially catastrophic occurrence. A high index of suspicion and immunohistochemistry secured the diagnosis. The use of appropriate imaging modalities led to the identification of the extent of the disease. Sequential planned management from neoadjuvant intensive chemotherapy, bilateral uterine artery embolization, and laparotomy, and coordinated among different medical disciplines resulted to a successful definitive treatment. Due to its relatively chemoresistant nature, hysterectomy is the mainstay of treatment. Adjuvant platinum-based intensive chemotherapy has been shown to improve overall survival in patients with metastatic disease and those with poor prognostic factors. This case of PSTT with a typical clinical profile was noteworthy due to the development of a significant AVM, a rare complication of PSTT. This case report included a review of treatment experiences as well as peculiarities that set PSTT apart from the more common gestational trophoblastic diseases.
Subject(s)
Gestational Trophoblastic Disease , Trophoblastic Tumor, Placental SiteABSTRACT
A doença trofoblástica gestacional (DTG) agrupa um conjunto de anomalias do desenvolvimento trofoblástico, que incluem formas clínicas benignas como a mola hidatiforme completa e parcial, o nódulo do sítio placentário atípico e o sítio trofoblástico exagerado, e malignas, caracterizando a neoplasia trofoblástica gestacional (NTG). De modo geral, seu diagnóstico precoce antecipa complicações clínicas que podem estar associadas a near miss obstétrico. Diante da suspeição clínica, é a ultrassonografia (US) precoce o exame de escolha pa ra o diagnóstico, associado à dosagem sérica de gonadotrofina coriônica humana, capaz de minimizar a ocorrência de complicações clínicas associadas à gravidez molar. Nos casos de NTG, é a US também de grande valia para estadiamento, avaliação de prognóstico e acompanhamento da mulher tratada para DTG. Este estudo faz uma revisão sobre o papel da US na DTG, sendo importante para familiarizar os tocoginecologistas com essa doença e salientar o papel da US consoante as melhores práticas clínicas.(AU)
Gestational trophoblastic disease (GTD) includes a set of trophoblastic developmental anomalies, which include benign forms such as complete and partial hydatidiform mole, atypical placental site nodule and exaggerated trophoblastic site, and malignant forms, characterizing gestational trophoblastic neoplasia (GTN). In general, its early diagnosis anticipates clinical complications that could be associated with obstetric near miss. In view of clinical suspicion, early ultrasonography (US) and serum levels of human chorionic gonadotropin are the best diagnostic screening techniques, able to minimizing the occurrence of medical complications associated with molar pregnancy. In cases of GTN, US is also of great value for staging, assessment of prognosis and follow-up of women treated for GTN. This study reviews the role of US in GTD, being important to familiarize tocogynecologists with this disease and highlight the role of US according to best clinical practices to minimize the morbidity of these patients and maximize the remission rates of this disease.(AU)
Subject(s)
Humans , Female , Pregnancy , Ultrasonography, Prenatal , Ultrasonography, Interventional/methods , Gestational Trophoblastic Disease/diagnostic imaging , Arteriovenous Malformations/diagnostic imaging , Choriocarcinoma/congenital , Hydatidiform Mole/congenital , Databases, Bibliographic , Trophoblastic Tumor, Placental Site/congenital , Hydatidiform Mole, Invasive/congenital , Trophoblastic Neoplasms/congenital , Early DiagnosisABSTRACT
Abstract Objective There are few multinational studies on gestational trophoblastic neoplasia (GTN) treatment outcomes in South America. The purpose of this study was to assess the clinical presentation, treatment outcomes, and factors associated with chemoresistance in low-risk postmolar GTN treated with first-line single-agent chemotherapy in three South American centers. Methods Multicentric, historical cohort study including women with International Federation of Gynecology and Obstetrics (FIGO)-staged low-risk postmolar GTN attending centers in Argentina, Brazil, and Colombia between 1990 and 2014. Data were obtained on patient characteristics, disease presentation, and treatment response. Logistic regression was used to assess the relationship between clinical factors and resistance to first-line single-agent treatment. A multivariate analysis of the clinical factors significant in univariate analysis was performed. Results A total of 163 women with low-risk GTN were included in the analysis. The overall rate of complete response to first-line chemotherapy was 80% (130/163). The rates of complete response to methotrexate or actinomycin-D as first-line treatment, and actinomycin-D as second-line treatment postmethotrexate failure were 79% (125/157), 83% (⅚), and 70% (23/33), respectively. Switching to second-line treatment due to chemoresistance occurred in 20.2% of cases (33/163). The multivariate analysis demonstrated that patients with a 5 to 6 FIGO risk score were 4.2-fold more likely to develop resistance to first-line single-agent treatment (p= 0.019). Conclusion 1) At presentation, most women showed clinical characteristics favorable to a good outcome, 2) the overall rate of sustained complete remission after first-line single-agent treatment was comparable to that observed in developed countries, 3) a FIGO risk score of 5 or 6 is associated with development of resistance to first-line single-agent chemotherapy.
Resumo Objetivo Existem poucos estudos multinacionais sobre os resultados do tratamento da neoplasia trofoblástica gestacional (NTG) na América do Sul. O objetivo deste estudo foi avaliar a apresentação clínica, os resultados do tratamento e os fatores associados a casos de quimiorresistência em NTG pós-molar de baixo risco tratados com quimioterapia de agente único de primeira linha em três centros sul-americanos. Métodos Estudo multicêntrico de coorte histórica incluindo mulheres com NTG pós-molar de baixo risco com estadiamento International Federation of Gynecology and Obstetrics (FIGO) em centros de atendimento na Argentina, Brasil e Colômbia entre 1990 e 2014. Foram obtidos dados sobre as características do paciente, apresentação da doença e resposta ao tratamento. A regressão logística foi usada para avaliar a relação entre fatores clínicos e resistência ao tratamento de primeira linha com agente único. Foi realizada uma análise multivariada dos fatores clínicos significativos na análise univariada. Resultados Cento e sessenta e três mulheres com NTG de baixo risco foram incluídas na análise. A taxa global de resposta completa à quimioterapia de primeira linha foi de 80% (130/163). As taxas de resposta completa ao metotrexato ou actinomicina-D como tratamento de primeira linha e actinomicina-D como tratamento de segunda linha após falha do metotrexato foram 79% (125/157), 83% (⅚) e 70% (23/33), respectivamente. A mudança para o tratamento de segunda linha por quimiorresistência ocorreu em 20,2% dos casos (33/163). A análise multivariada demonstrou que pacientes com pontuação de risco FIGO de 5 a 6 foram 4,2 vezes mais propensos a desenvolver resistência ao tratamento com agente único de primeira linha (p= 0,019). Conclusão 1) Na apresentação, a maioria das mulheres demonstrou características clínicas favoráveis a um bom resultado, 2) a taxa geral de remissão completa sustentada após o tratamento de primeira linha com agente único foi comparável à de países desenvolvidos, 3) um escore de risco FIGO de 5 ou 6 está associado ao desenvolvimento de resistência à quimioterapia de agente único de primeira linha.
Subject(s)
Humans , Female , Pregnancy , South America , Hydatidiform Mole , Gestational Trophoblastic Disease/therapy , Drug TherapyABSTRACT
Abstract Objective To evaluate the emotional and clinical aspects observed in women with gestational trophoblastic disease (GTD) followed-up in a reference center (RC) by a multidisciplinary team. Methods Retrospective cohort study of the clinical records of 186 women with GTD and of the emotional aspects (EA) observed in these women by a teamof psychologists and reported by the 389 support groups conducted from 2014 to 2018. Results The women were young (mean age: 31.2 years), 47% had no living child, 60% had planned the pregnancy, and 50% participated in two or more SG. Most women (n=137; 73.6%) reached spontaneous remission ofmolar gestation in a median time of 10 weeks and had a total follow-up time of seven months. In the group of 49 women (26.3%) who progressed to gestational trophoblastic neoplasia (GTN), time to remission after chemotherapy was 18 weeks, and total follow-up time was 36 months. EA included different levels of anxiety and depression,more evident in 9.1% of the women; these symptoms tended to occur more frequently in women older than 40 years (p=0.067), less educated (p=0.054), and whose disease progressed to GTN (p=0.018), as well as in those who had to undergo multi-agent chemotherapy (p=0.028) or hysterectomy (p=0.001) adjuvant to clinical treatment. Conclusion This study found several EA in association with all types of GTD. It also highlights the importance of specialized care only found in a RC, essential to support the recovery of the mental health of these women.
Resumo Objetivo Avaliar aspectos emocionais e clínicos observados em mulheres com doença trofoblástica gestacional (DTG) acompanhadas em um centro de referência (CR), por equipe multiprofissional. Método Estudo de coorte retrospectivo nos prontuários clínicos de 186 mulheres comDTG, e dos aspectos emocionais (AE) observados nessas mulheres pela equipe de psicólogas e registrados nos 389 grupos de apoio (GAs), ocorridos de 2014 a 2018. Resultados As pacientes eram jovens (idade média 31,2 anos), 47% sem filhos vivos, 60% tinham desejado ou planejado esta gravidez e 50% delas participaram de dois ou mais GAs. A maioria (n=137-73,6%) apresentou remissão espontânea da gestação molar com mediana de 10 semanas e um tempo total de seguimento de 7 meses. Quarenta e nove mulheres (26,3%) evoluíram para neoplasia trofoblástica gestacional (NTG); amediana para atingir a remissão após tratamento comquimioterapia foi de 19 semanas e o tempo total de seguimento foi de 36 meses. Os AE incluíram variados graus de ansiedade e depressão, mais evidentes em 9,1% das nossas pacientes; tais AE tenderam a ocorrer mais em mulheres com idade acima de 40 anos (p=0,067), com menor escolaridade (p=0,054), com evolução para NTG (p=0,018), e nas que necessitaram de tratamento quimioterápico com regime de múltiplos agentes (p=0,028), ou de histerectomia complementar ao tratamento clínico (p=0,001). Conclusão Este estudo mostrou presença de vários AE associados em todos os tipos de DTG. Destaca tambéma importância de umatendimento psicológico especializado, somente encontrado nos CR, que é essencial para ajudar na recuperação da saúde mental dessas mulheres.
Subject(s)
Humans , Female , Pregnancy , Self-Help Groups , Mental Health , Gestational Trophoblastic DiseaseABSTRACT
@#We present a rare case of a 23‑year‑old female with intraperitoneal hemorrhage from uterine rupture as an uncommon presentation of placental site trophoblastic tumor (PSTT) after spontaneous abortion. A high index of suspicion with this clinical presentation and the use of appropriate diagnostic tools to arrive at a diagnosis can go a long way in decreasing the adverse outcome of this disease. The histopathological findings and immunohistochemical staining were helpful armamentaria for the confirmation of PSTT. The patient was successfully managed with primary hysterectomy and postoperative chemotherapy.
Subject(s)
Gestational Trophoblastic Disease , Trophoblastic Tumor, Placental Site , Abortion, SpontaneousABSTRACT
Background@#Telemedicine has the potential of bridging the gap and achieving equity in receiving healthcare services. The department of health encouraged telemedicine using cell phones or consultations through social media platforms to decongest hospitals and reduce possible exposure to COVID‑19.@*Objectives@#This study aimed to describe the effectiveness of telemedicine in increasing the self‑efficacy of patients with gestational trophoblastic neoplasia (GTN) in a tertiary hospital in Davao City.@*Materials and Methods@#This research was a mixed method pre‑post‑test exploratory design with two main phases: a quantitative phase of assessing the effectiveness of telemedicine in increasing self‑efficacy to patients with GTN using Strategies Used by People to Promote Health‑29, and a qualitative phase of online focus group discussions of patients and health‑care workers. Thematic analysis was applied to contextualize the experience of the participants in engaging in telemedicine in the delivery of medical services.@*Results@#Total subscale of self‑efficacy of the patients during the first consultation was high. The respondents had a high level of confidence in stress reduction and in making decisions. The respondents had a very high positive attitude. After 6 months of telemedicine, the total subscale of self‑efficacy was very high. The respondents had a high level of confidence in stress reduction and very high levels of confidence in making decision and positive attitude. The respondents had improved self‑efficacy and verbalized that telemedicine was easy and readily accessible.@*Conclusions@#Telemedicine helped the respondents improve their self‑efficacy. There was a significant difference between the baseline stress reduction and making decisions subscales after 6 months of utilizing telemedicine.
Subject(s)
Gestational Trophoblastic Disease , TelemedicineABSTRACT
Objective@#To describe the experience of the Division of Trophoblastic Diseases of the Philippine General Hospital with the various third‑line chemotherapeutic regimens among high‑risk gestational trophoblastic neoplasia (GTN) patients who experienced resistance after receiving the etoposide, cisplatin–etoposide, methotrexate, actinomycin (EP‑EMA) regimen@*Materials and Methods@#This was a 17‑year descriptive study that included all patients who used various salvage chemotherapy after resistance to EP‑EMA as treatment for metastatic, high‑risk GTN at the Philippine General Hospital from January 2002 to December 2018. The medical records of eligible patients were retrieved and assessed. All abstracted data were analyzed retrospectively. Descriptive statistics were used to compute for percentages for the various demographic characteristics of the sample population@*Results@#From January 2002 to December 2018, a total of 291 patients with metastatic, high‑risk gestational GTN were treated at the Philippine General Hospital. Of these, only seven patients received various third‑line chemotherapy regimens after resistance to EP‑EMA. One patient was excluded due to incomplete data. Among the third‑line chemotherapeutic regimens used, 3 patients received paclitaxel/carboplatin, two of whom went into remission while one expired. One patient had vincristine, bleomycin, and cisplatin (VBP) with two adjunctive surgeries in the form of hysterectomy and thoracotomy. She also went into remission. Two patients received paclitaxel–cisplatin/paclitaxeletoposide (TP/TE) as third line of treatment. The first was shifted back to EP‑EMA and eventually developed chemoresistance to EP‑EMA and had multiple toxicities. After multidisciplinary conference with the patient and family, they decided to go home and refused further chemotherapy. The other patient had TP/TE followed by bleomycin–etoposide–cisplatin, with adjunctive hysterectomy. Despite multiple cycles of chemotherapy, the disease persisted. She was offered palliative care and the family decided to bring her home. Both patients eventually expired at home@*Conclusion@#No conclusion can be made about the most effective third line chemotherapy for resistant high‑risk GTN because of the limited cases included in this study. An individualized approach is still recommended. Physicians and centers for patients caring for such patients are encouraged to report their experience to improve the management of future patients
Subject(s)
Gestational Trophoblastic DiseaseABSTRACT
Objective@#This study aimed to determine the clinical characteristics, management, and outcome of gestational trophoblastic neoplasia (GTN) patients with brain metastasis.@*Materials and Methods@#This was a 10‑year descriptive study that included all patients with brain metastasis from GTN. Patients’ sociodemographic and clinicopathological profiles were described. Using Kaplan–Meier survival curve, the survival time was determined@*Results@#From January 1, 2010, to December 31, 2019, there were 33 GTN patients with brain metastasis. Four were excluded from the study due to incomplete records. Twenty‑nine patients were included in the study. Nineteen (65.51%) patients presented with neurologic symptoms upon diagnosis and one (3.44%) during treatment. All received etoposide, methotrexate, actinomycin, oncovin (EMACO) as first‑line treatment. Five (17.24%) patients were given induction chemotherapy with low‑dose etoposide–cisplatin. Seventeen (58.62%) patients underwent whole‑brain radiation and two (6.89%) were given intrathecal methotrexate. Thirteen patients (44.82%) achieved biochemical remission with EMACO chemotherapy. Four patients (13.79%) had resistance to EMACO and were given Etoposide Cisplatin Etoposide Methotrexate Actinomycin (EP EMA). Four patients (13.79%) underwent an adjunctive hysterectomy. Four patients (13.79%) died during treatment. One patient (3.44%) was unable to continue her chemotherapy because she got pregnant before her first consolidation course. There were eight early deaths (<4 weeks of admission) and hence were excluded in the analysis. Three patients who went into biochemical remission relapsed on the 1st, 2nd, and 3rd months after their last consolidation course, respectively. The median follow‑up time was 27 months. After excluding early deaths, the survival rate between 3 and 7 years after treatment is at 61.9%. The mean survival time was 5.43 years. Six surviving patients were contacted. Five (17.24%) of them had resumed their everyday life, and one is currently undergoing chemotherapy.@*Conclusion@#The study was able to document brain metastasis from GTN to be 14.28% (29/203) among metastatic high‑risk admissions. The biochemical remission rate from first‑line treatment was of 61.90% (13/21) and resistance rate was 19.04% (4/21). Lost to follow up after achieving biochemical remission was a challenge encountered
Subject(s)
Gestational Trophoblastic DiseaseABSTRACT
OBJECTIVES@#The International Federation of Gynecology and Obstetrics (FIGO) 2000 scoring system classifies gestational trophoblastic neoplasia (GTN) patients into low- and high-risk groups, so that single- or multi-agent chemotherapy can be administered accordingly. However, a number of FIGO-defined low-risk patients still exhibit resistance to single-agent regimens, and the risk factors currently adopted in the FIGO scoring system possess inequable values for predicting single-agent chemoresistance. The purpose of this study is therefore to evaluate the efficacy of risk factors in predicting single-agent chemoresistance and explore the feasibility of simplifying the FIGO 2000 scoring system for GTN.@*METHODS@#The clinical data of 578 GTN patients who received chemotherapy between January 2000 and December 2018 were retrospectively reviewed. Univariate and multivariate logistic regression analyses were carried out to identify risk factors associated with single-agent chemoresistance in low-risk GTN patients. Then, simplified models were built and compared with the original FIGO 2000 scoring system.@*RESULTS@#Among the eight FIGO risk factors, the univariate and multivariate analyses identified that pretreatment serum human chorionic gonadotropin (hCG) level and interval from antecedent pregnancy were consistently independent predictors for both first-line and subsequent single-agent chemoresistance. The simplified model with two independent factors showed a better performance in predicting single-agent chemoresistance than the model with the other four non-independent factors. However, the addition of other co-factors did improve the efficiency. Overall, simplified models can achieve favorable performance, but the original FIGO 2000 prognostic system still features the highest discrimination.@*CONCLUSIONS@#Pretreatment serum hCG level and interval from antecedent pregnancy were independent predictors for both first-line and subsequent single-agent chemoresistance, and they had greater weight than other non-independent factors in predicting single-agent chemoresistance. The simplified model composed of certain selected factors is a promising alternative to the original FIGO 2000 prognostic system, and it shows comparable performance.
Subject(s)
Female , Humans , Pregnancy , Gestational Trophoblastic Disease/drug therapy , Multivariate Analysis , Retrospective Studies , Risk FactorsABSTRACT
We aimed to evaluate the effectiveness and safety of single-course initial regimens in patients with low-risk gestational trophoblastic neoplasia (GTN). In this trial (NCT01823315), 276 patients were analyzed. Patients were allocated to three initiated regimens: single-course methotrexate (MTX), single-course MTX + dactinomycin (ACTD), and multi-course MTX (control arm). The primary endpoint was the complete remission (CR) rate by initial drug(s). The primary CR rate was 64.4% with multi-course MTX in the control arm. For the single-course MTX arm, the CR rate was 35.8% by one course; it increased to 59.3% after subsequent multi-course MTX, with non-inferiority to the control (difference -5.1%,95% confidence interval (CI) -19.4% to 9.2%, P = 0.014). After further treatment with multi-course ACTD, the CR rate (93.3%) was similar to that of the control (95.2%, P = 0.577). For the single-course MTX + ACTD arm, the CR rate was 46.7% by one course, which increased to 89.1% after subsequent multi-course, with non-inferiority (difference 24.7%, 95% CI 12.8%-36.6%, P < 0.001) to the control. It was similar to the CR rate by MTX and further ACTD in the control arm (89.1% vs. 95.2%, P =0.135). Four patients experienced recurrence, with no death, during the 2-year follow-up. We demonstrated that chemotherapy initiation with single-course MTX may be an alternative regimen for patients with low-risk GTN.