Chemotherapy initiation with single-course methotrexate alone or combined with dactinomycin versus multi-course methotrexate for low-risk gestational trophoblastic neoplasia: a multi-centric randomized clinical trial / 医学前沿

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.

Evaluation and simplification of risk factors in FIGO 2000 scoring system for gestational trophoblastic neoplasia: a 19-year retrospective analysis / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

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.

Uterine rescue in high-risk gestational trophoblastic neoplasia treated with ema-co by uterine arteries embolization due to arteriovenous malformations / Resgate uterino em neoplasia trofoblástica gestacional de alto risco tratada com EMA-CO por embolização de artérias uterinas devido a malformações arteriovenosas

Abstract Complete hydatidiform mole (CHM) is a rare type of pregnancy, in which 15 to 20% of the cases may develop into gestational trophoblastic neoplasia (GTN). The diagnostic of GTN must be done as early as possible through weekly surveillance of serum hCG after uterine evacuation.We report the case of 23-year-old primigravida, with CHM but without surveillance of hCG after uterine evacuation. Two months later, the patient presented to the emergency with vaginal bleeding and was referred to the Centro de Doenças Trofoblásticas do Hospital São Paulo. She was diagnosed with high risk GTN stage/score III:7 as per The International Federation of Gynecology and Obstetrics/World Health Organization (FIGO/WHO). The sonographic examination revealed enlarged uterus with a heterogeneous mass constituted of multiple large vessels invading and causing disarrangement of the myometrium. The patient evolved with progressive worsening of vaginal bleeding after chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) regimen. She underwent blood transfusion and embolization of uterine arteries due to severe vaginal hemorrhage episodes, with complete control of bleeding. The hCG reached a negative value after the third cycle, and there was a complete regression of the anomalous vascularization of the uterus as well as full recovery of the uterine anatomy. The treatment in a reference center was essential for the appropriate management, especially regarding the uterine arteries embolization trough percutaneous femoral

Resumo Mola hidatiforme completa (MHC) é um tipo raro de gravidez, na qual 15 a 20% dos casos podem desenvolver neoplasia trofoblástica gestacional (NTG). O diagnóstico de NTG deve ser feito o mais cedo possível, pelo monitoramento semanal do hCG sérico após esvaziamento uterino. Relatamos o caso de uma paciente primigesta, de 23 anos de idade, com MHC, sem vigilância de hCG após esvaziamento uterino. Dois meses depois, a paciente compareceu na emergência com sangramento vaginal, sendo encaminhada ao Centro de Doenças Trofoblásticas do Hospital São Paulo, onde foi diagnosticada com NTG de alto risco, estádio e score de risco III:7 de acordo com a The International Federation of Gynecology and Obstetrics/Organização Mundial de Saúde (FIGO/OMS). O exame ultrassonográfico revelou útero aumentado com uma massa heterogênea constituída pormúltiplos vasos volumosos invadindo e desestruturando o miométrio. A paciente evoluiu com piora progressiva do sangramento vaginal após quimioterapia com o regime etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO). Ela foi submetida a transfusão de sangue e embolização das artérias uterinas devido aos episódios graves de hemorragia vaginal, com completo controle do sangramento. O hCG atingiu valor negativo após o terceiro ciclo, havendo regressão completa da vascularização uterina anômala, assim como recuperação da anatomia uterina. O tratamento em um centro de referência permitiu o manejo adequado, principalmente no que se refere à embolização das artérias uterinas através da punção percutânea da artéria femoral, que foi crucial para evitar a histerectomia, permitindo a cura da NTG e a manutenção da vida reprodutiva.

Tirotoxicosis por enfermedad trofoblástica gestacional: revisión a partir de 3 casos / Thyrotoxicosis due to gestational trophoblastic disease: clinical cases

La enfermedad trofoblástica gestacional (ETG) es una complicación del embarazo poco común. Corresponde a un espectro de lesiones proliferativas del tejido trofoblástico: Mola Hidatiforme (MH) en sus formas parcial y completa, Coriocarcinoma, Tumor Trofoblástico y Tumor Trofoblástico Epiteloide. Los distintos tipos de ETG presentan en común la hipersecreción de gonadotrofina coriónica humana (hCG). La hCG es una hormona glicoproteica con una estructura muy similar a la TSH, por lo cual puede estimular la función tiroidea en condiciones fisiológicas y en algunas condiciones patológicas. La ETG puede cursar con hipertiroidismo, el cual puede variar en intensidad, desde una presentación asintomática con alteración leve de hormonas tiroideas a un cuadro de hipertiroidismo manifiesto. Se presentan 3 casos clínicos de pacientes con ETG, específicamente MH que evolucionaron con tirotoxicosis transitoria. Los casos presentaron un cuadro leve de hipertiroidismo con pocos síntomas asociados. La taquicardia fue el único síntoma en la mayoría de los casos. En todas las pacientes las hormonas tiroideas se normalizaron después del tratamiento de la ETG. Conclusión: Se debe tener presente la posibilidad de hipertiroidismo en toda paciente con ETG. Un alto nivel de sospecha permitirá identificar a aquellas pacientes que cursen con hipertiroidismo, permitiendo así un diagnóstico y tratamiento oportuno.

Gestational trophoblastic disease (GTD) is a rare complication of pregnancy. GTD includes a group of proliferative lesions of trophoblastic tissue: partial and complete hydatidiform mole, choriocarcinoma, epithelioid trophoblastic tumor, and placental site trophoblastic tumor. The different types of GTD have in common the hypersecretion of human chorionic gonadotropin (hCG). HCG is a glycoprotein hormone with a similar structure to TSH. In physiological and pathological conditions hCG can stimulate thyroid function. GTD can present with hyperthyroidism, which can vary in intensity, from an asymptomatic presentation with mild alteration of thyroid hormones to a manifest hyperthyroidism. We present 3 clinical cases of patients with GTD thyrotoxicosis. All cases presented mild hyperthyroidism. Tachycardia was the only symptom in most cases. In all patients thyroid hormones return to normal after treatment of GTD. Conclusion: In patients with GTD the possibility of hyperthyroidism should be kept in mind. A high level of suspicion will allow to identifying patients with hyperthyroidism.

Mola invasiva. presentación de un caso / Mola invasiva. Apresentação de um caso / Invasive mole. Case presentation

Se presentó un caso de enfermedad trofoblástica tipo mola invasiva. El diagnóstico se sospechó con la ecografía del primer marcador genético, se realizaron dos legrados terapéuticos, el segundo de ellos, sugirió el diagnóstico de mola invasiva. Se realizó tratamiento quirúrgico (histerectomía total) con previa administración de quimioterapia con metotrexato sistémico. La biopsia confirmó el diagnóstico de mola invasiva. La mola invasiva es una de las formas de presentación de la enfermedad trofoblástica gestacional, es una condición infrecuente, en que la proliferación de células del trofoblasto y sincitiotrofoblasto penetran o incluso perforan la pared uterina, producen destrucción local pudiendo invadir el tejido parametrial y los vasos sanguíneos viajando dentro de estos, aunque no se han reportado verdaderas siembras metastásicas en otros órganos. La evolución clínica se realizó en consulta externa. Transcurrido dos años la evolución es satisfactoria, el tratamiento efectivo y bien tolerado por la paciente(AU).

A case of trophoblastic disease, of the invasive mole type was presented. The diagnosis was first suspected with the ultrasound of the first genetic marker. Two therapeutic curettages were performed, the second of which suggested the diagnosis of invasive mole. Surgical treatment (total hysterectomy) was performed with prior administration of chemotherapy with systemic methotrexate. The biopsy confirmed the diagnosis of invasive mole. Invasive mole is one of the forms of presentation of gestational trophoblastic disease. It is a rare condition in which the proliferation of trophoblast and syncytiotrophoblast cells penetrate or even perforate the uterine wall, produce local damage and can invade the parametrial tissue and blood vessels, traveling within these. True metastatic seeding in other organs has not been reported. The clinical evolution was carried out in an outpatient clinic. After two years the evolution is satisfactory, the treatment effective and well tolerated by the patient(AU).

Foi apresentado um caso de doença trofoblástica invasiva por mola. O diagnóstico foi suspeitado com a ultrassonografia do primeiro marcador genético, foram realizadas duas curetagens terapêuticas, sendo que a segunda sugeriu o diagnóstico de mola invasiva. O tratamento cirúrgico (histerectomia total) foi realizado com administração prévia de quimioterapia com metotrexato sistêmico. A biópsia confirmou o diagnóstico de mola invasiva. A mola invasiva é uma das formas de apresentação da doença trofoblástica gestacional, é uma condição infrequente, em que a proliferação de células trofoblásticas e sincitiotrofoblásticas penetram ou mesmo perfuram a parede uterina, produzem destruição local e podem invadir o tecido parametrial e vasos sanguíneos dos vasos. viajando dentro deles, embora verdadeira semeadura metastática em outros órgãos não tenha sido relatada. A evolução clínica foi realizada em ambulatório. Depois de dois anos, o a evolução é satisfatória, o tratamento é eficaz e bem tolerado pelo paciente(AU).

Pregnancy outcomes after chemotherapy for trophoblastic neoplasia / Futuro reprodutivo após tratamento quimioterápico da neoplasia trofoblástica

SUMMARY Introduction The successful development of chemotherapy enabled a fertilitysparing treatment for patients with trophoblastic neoplasia. After disease remission, the outcome of a subsequent pregnancy becomes a great concern for these women. Objective To analyze existing studies in the literature that describe the reproductive outcomes of patients with trophoblastic neoplasia treated with chemotherapy. Method Systematic review was performed searching for articles on Medline/ Pubmed, Lilacs and Cochrane Library databases, using the terms “gestational trophoblastic disease” and “pregnancy outcome”. Results A total of 18 articles were included. No evidence of decreased fertility after chemotherapy for trophoblastic neoplasia was observed. The abortion rates in patients who conceived within 6 months after chemotherapy was higher compared to those who waited longer. Some studies showed increased rates of stillbirth and repeat hydatidiform moles. Only one work showed increased congenital abnormalities. Conclusion The pregnancies conceived after chemotherapy for trophoblastic neoplasia should be followed with clinical surveillance due to higher rates of some pregnancy complications. However, studies in the literature provide reassuring data about reproductive outcomes of these patients.

RESUMO Introdução o sucesso do desenvolvimento da quimioterapia no tratamento da neoplasia trofoblástica proporcionou a possibilidade de conservação da fertilidade das pacientes, tornando o futuro reprodutivo uma nova preocupação após a remissão da doença Objetivo analisar os estudos existentes na literatura que descrevem o futuro reprodutivo de pacientes com neoplasia trofoblástica tratadas com quimioterapia. Método revisão sistemática que buscou artigos nas bases de dados Medline/Pubmed, Lilacs e Biblioteca Cochrane, utilizando as palavras-chave “gestational trophoblastic disease” e “pregnancy outcome”. Resultados foram selecionados 18 artigos de acordo com critérios de inclusão e exclusão. Não foi observada diminuição da fertilidade após a quimioterapia para neoplasia trofoblástica. Pacientes que engravidaram até 6 meses do término da quimioterapia apresentaram maiores taxas de abortamento quando comparadas às que esperaram mais de 6 meses. Alguns artigos encontraram maiores taxas de natimorto e nova mola hidatiforme. Apenas um estudo mostrou aumento da taxa de malformação. Conclusão as gestações subsequentes à neoplasia trofoblástica devem ser acompanhadas com vigilância clínica em decorrência da maior taxa de complicações na gestação, principalmente nas mulheres que engravidam até 6 meses após o término da quimioterapia. No entanto, os dados encontrados nos estudos tranquilizam quanto ao futuro reprodutivo dessas pacientes.

Is Doppler ultrasound useful for evaluating gestational trophoblastic disease?

Doppler ultrasound is a non-invasive method for evaluating vascularization and is widely used in clinical practice. Gestational trophoblastic neoplasia includes a group of highly vascularized malignancies derived from placental cells. This review summarizes data found in the literature regarding the applications of Doppler ultrasound in managing patients with gestational trophoblastic neoplasia. The PubMed/Medline, Web of Science, Cochrane and LILACS databases were searched for articles published in English until 2014 using the following keywords: “Gestational trophoblastic disease AND Ultrasonography, Doppler.” Twenty-eight articles met the inclusion criteria and were separated into the 4 following groups according to the aim of the study. (1) Doppler ultrasound does not seem to be capable of differentiating partial from complete moles, but it might be useful when evaluating pregnancies in which a complete mole coexists with a normal fetus. (2) There is controversy in the role of uterine artery Doppler velocimetry in the prediction of development of gestational trophoblastic neoplasia. (3) Doppler ultrasound is a useful tool in the diagnosis of gestational trophoblastic neoplasia because abnormal myometrial vascularization and lower uterine artery Doppler indices seem to be correlated with invasive disease. (4) Lower uterine artery Doppler indices in the diagnosis of gestational trophoblastic neoplasia are associated with methotrexate resistance and might play a role in prognosis. CONCLUSION: Several studies support the importance of Doppler ultrasound in the management of patients with gestational trophoblastic neoplasia, particularly the role of Doppler velocimetry in the prediction of trophoblastic neoplasia and the chemoresistance of trophoblastic tumors. Doppler findings should be used as ancillary tools, along with human chorionic gonadotropin assessment, in the diagnosis of gestational trophoblastic neoplasia.

Characterization and functional capacity in women with breast cancer, gynaecological cancer and gestational trophoblastic disease / Caracterización y capacidad funcional de mujeres con cáncer mamario, cáncer ginecológico y enfermedad trofoblástica gestacional / Caracterização e capacidade funcional de mulheres com câncer ginecológico, câncer mamário e doença trofoblástica gestacional

Objective: to describe the social, demographic and clinical profile, and functional capacity of women diagnosed with gynecological cancer, breast cancer and gestational trophoblastic disease during chemotherapy. Method: longitudinal retrospective study that evaluated the records of women treated in hospital clinics from January 2000 to December 2012. Results: they evaluated the records of 438 women. The analysis showed that were not able to perform their daily activities, limited to the activities of self-care. Older patients had greater functional impairment during therapy. Conclusions: the sample was women 41 to 50 years, diagnosed with breast cancer (50.9%) and made use of anthracycline based protocols (47%); the scores of the functional capacity of the sample fell from 78.22 to 73.57. It is evident that nursing care should focus on the control of signs and symptoms that impact the functional capacity of women under chemotherapy.

Objetivo: describir el perfil socio demográfico, clínico y capacidad funcional de mujeres diagnosticadas con cáncer ginecológico, mamario y enfermedad trofoblástica gestacional en tratamiento quimioterápico. Método: estudio longitudinal retrospectivo, que evaluó los registros de mujeres en tratamiento en un hospital de clínicas en el período de enero/2000-diciembre/2012. Resultados: fueron evaluados los registros de 438 mujeres. El análisis mostró que las pacientes no eran capaces de realizar sus actividades cotidianas, limitándose a las actividades del autocuidado. Las pacientes mayores sufrieron más comprometimiento funcional durante la terapéutica. Conclusiones: la muestra estudiada era de mujeres con 41-50 años, diagnosticadas con cáncer de mama (50,9%) y hacían uso de protocolos basados en antracíclicos (47%); los escores de la capacidad funcional de la muestra decayeron de 78,22 para 73,57. Se evidencia que los cuidados de enfermería deben centrarse en el control de señales y síntomas que causan impacto en la capacidad funcional de las mujeres en quimioterapia.

Objetivo: descrever o perfil sociodemográfico e clínico e a capacidade funcional de mulheres diagnosticadas com câncer ginecológico, câncer mamário e doença trofoblástica gestacional em tratamento quimioterápico. Método: estudo longitudinal retrospectivo, que avaliou os registros de mulheres em tratamento em um hospital de clínicas no período de janeiro de 2000 a dezembro de 2012. Resultados: foram avaliados os registros de 438 mulheres. A análise mostrou que as pacientes não eram capazes de realizar suas atividades cotidianas, limitando-se àquelas do autocuidado. As pacientes idosas sofreram maior comprometimento funcional durante a terapêutica. Conclusões: a amostra estudada era de mulheres com 41 a 50 anos, diagnosticadas com câncer de mama (50,9%), que faziam uso de protocolos baseados em antracíclicos (47%); os escores da capacidade funcional da amostra decaíram de 78,22 para 73,57. Evidencia-se que os cuidados de enfermagem devem centrar-se no controle de sinais e sintomas que causam impacto na capacidade funcional das mulheres sob quimioterapia.

Treatment of low-risk gestational trophoblastic neoplasia comparing biweekly eight-day Methotrexate with folinic acid versus bolus-dose Actinomycin-D, among Brazilian women / Tratamento da neoplasia trofoblástica gestacional de baixo-risco, comparando aplicação quinzenal de oito dias de Metotrexato com ácido folínico versus Actinomicina D em bolo, em mulheres brasileiras

PURPOSE: To compare two single-agent chemotherapy (ChT) regimens evaluating, in first-line treatment, response and side effects and, in final single-agent treatment, the outcomes, among Brazilian patients with low-risk gestational trophoblastic neoplasia (GTN), according to International Federation of Gynecology and Obstetrics (FIGO) 2002. METHODS: Retrospective analysis of two concurrent cohorts with 194 low-risk GTN patients: from 1992 to 2012, as first-line treatment, 115 patients received 4 intramuscular doses of methotrexate alternated with 4 oral doses of folinic acid (MTX/FA) repetead every 14 days and, since 1996, 79 patients received an endovenous bolus-dose of actinomycin D (Act-D), biweekly. At GTN diagnosis, patient opinion was taken into consideration when defining the initial single-agent ChT regimen, and when there was resistance or toxicity to one regimen, the other drug was used preferentially. This study was approved by the Irmandade da Santa Casa de Misericórdia de Porto Alegre Ethical Committee. RESULTS: Both groups were clinically similar (p>0.05). In first-line treatments, frequency of complete response was similar (75.7% with MTX/FA and 67.1% with bolus Act-D); the number of ChT courses -median 3 (range: 1-10) with MTX/FA and 2 (range: 1-6) with bolus Act-D - and the time to remission -median 9 weeks (range: 2-16) with MTX/FA and 10 weeks (range: 2-16) with bolus Act-D) - were not different between the groups. In both groups, first-line side effects frequency were high but intensity was low; stomatitis was higher with MTX/FA (p<0.01) and nausea and vomit with Act-D (p<0.01). Final single-agent ChT responses were high in both groups (94.8% with MTX/FA and 83.5% with bolus Act-D; p<0.01) and 13% higher in the group initially treated with MTX/FA. Rates of hysterectomy and of GTN recurrence were low and similar. No patient died due to GTN. CONCLUSION: The two regimens had similar first-line ChT response. ...

OBJETIVO: Em mulheres brasileiras com neoplasia trofoblástica gestacional (NTG) de baixo-risco, de acordo com a Federação Internacional de Ginecologia e Obstetrícia (FIGO) 2002, comparar dois regimes de quimioterapia (Qt) por agente único avaliando resposta e efeitos colaterais no tratamento de primeira linha, e a eficácia no tratamento final por agente único de Qt. MÉTODOS: Análise retrospectiva de duas coortes concorrentes com 194 pacientes com NTG de baixo risco: de 1992 a 2012; como primeira linha, 115 pacientes receberam 4 doses intramusculares de metotrexato alternado com 4 doses orais de ácido folínico (MTX/FA) repetidos a cada 14 dias e, desde 1996, 79 pacientes receberam quinzenalmente dose em bolo de actinomicina D (Act-D) por via endovenosa. No momento do diagnóstico da NTG, a opinião da paciente foi levada em consideração para definir o regime de Qt por agente único inicial e, quando havia resistência ou toxicidade a um regime, o outro fármaco era usado preferentemente. Este estudo foi aprovado pelo Comitê de Ética da Irmandade da Santa Casa de Misericórdia de Porto Alegre. RESULTADOS: Ambos os grupos eram clinicamente semelhantes (p>0,05). Nos tratamentos de primeira linha, a frequência de resposta completa foi semelhante (75,7% com MTX/FA e 67,1% com Act-D em bolo); não houve diferença entre os grupos quanto ao número de séries de Qt - mediana 3 (intervalo: 1-10) com MTX/FA e 2 (intervalo: 1-6) com Act-D em bolo - e ao tempo para remissão - mediana 9 semanas (intervalo: 2-16) com MTX/FA e 10 semanas (intervalo: 2-16) com Act-D em bolo. Em ambos os grupos, foi elevada a frequência de efeitos colaterais no tratamento de primeira linha, mas com intensidade baixa; estomatite foi mais frequente com MTX/FA (p<0.01) e náuseas e vômitos com Act-D (p<0.01). A resposta final à Qt por agente único foi alta nos dois grupos (94,8% com MTX/FA e 83,5% com Act-D em bolo; p<0,01) e 13% maior no grupo inicialmente tratado com ...

Mola hidatiforme parcial recorrente evoluindo para neoplasia trofoblástica gestacional / Recurrent partial hydatidiform mole evolving to gestational trophoblastic neoplasia

Mola hidatiforme parcial recorrente é evento em que há repetição da mola hidatiforme parcial. Há cerca de 100 casos relatados na literatura e dúvida se essa entidade pode evolver para neoplasia trofoblástica gestacional pós-molar. Apresenta-se relato de caso de paciente com recorrência de mola hidatiforme parcial em que houve aumento de embriopatia, bem como transformação maligna da mola parcial recorrente. Empregou-se quimioterapia com Methotrexate para induzir cura. Não obstante seja ocorrência rara, a importância deste relato encontra-se na evidência de neoplasia trofoblástica gestacional em recorrência de mola hidatiforme parcial, determinando vigilância hormonal rigorosa para detectar a malignização desses blastomas.

Recurrent partial hydatidiform mole is an event of repetitive partial hydatidiform mole. It has been reported around 100 cases in the literature and it is still unclear if this entity can evolve to postmolar gestational trophoblastic neoplasia. In this report, it is presented a case of recurrent partial hydatidiform mole with an increase in embriologic alterations, as well as malignization of recurrent partial hydatidiform mole. Chemotherapy with Methotrexate regimen was used to induce remission. Although rare, the importance of this report relies on the evidence of gestational trophoblastic neoplasia in recurrent partial hydatidiform mole, demanding straight hormonal surveillance to detect malignization of these tumors.

Response to initial treatment of low and intermediate risk gestational trophoblastic disease with methotrexate and folinic acid.

OBJECTIVES: To evaluate the response and toxicity of methotrexate and folinic acid given as primary treatment of low and intermediate risk gestational trophoblastic disease (GTD). MATERIAL AND METHOD: Medical records review was performed in patients who received methotrexate and folinic acid as a primary treatment of low and intermediate risk persistent GTD between January 1992 and December 2001. Response was defined as decline of beta human chorionic gonadotropin (hCG) to < or = 5 mlU/ml (remission) after methotrexate and folinic acid treatment. Response rate was estimated and factors associated with response were evaluated. RESULTS: Ninety four eligible patients were treated with intramuscular methotrexate and folinic acid. Complete remission was achieved in 64 cases (68%, 95% CI 58-78%). Mucositis (6.4%) and hepatotoxicity (6.4%) were the most common toxicity of methotrexate in the present study and none of these toxic effects was life threatening. Factors associated with response were initial serum hCG < or = 10,000 mlU/ml and stage I disease. CONCLUSION: Methotrexate with folinic acid is effective treatment for low and intermediate risk GTD with minimal severe toxicity.

Treatment results of methotrexate and folinic acid as primary chemotherapy for nonmetastatic gestational trophoblastic neoplasia.

OBJECTIVE: To evaluate the efficacy and toxicity of methotrexate and folinic acid (MTX-FA) chemotherapy in patients with nonmetastatic gestational trophoblastic neoplasia (NMGTN). MATERIAL AND METHOD: Between 1997 and 2003, a total of 67 patients with NMGTN received treatment at the Chiang Mai University Hospital. Of the 67 patients, 55 were initially treated with methotrexate 1.0 mg/kg intramuscularly (IM) on day 1, 3,5, and 7 and folinic acid 0.1 mg/kg IM on day 2, 4, 6 and 8. Treatment courses were repeated every 14 days. Clinical characteristics and outcomes were analyzed RESULTS: All 55 patients with NMGTN were cured. Of the 55 patients initially treated with MTX-FA, 49 (89%) achieved complete remission. Six (11%) patients developed methotrexate resistance, 3 were cured with actinomycin D, 1 were cured with 5-fluorouracil followed by etoposide, 2 required hystertectomy to attain remission. No serious toxicity was noted CONCLUSION: Methotrexate and folinic acid chemotherapy is highly effective and well-tolerated in treating patients with nonmetastatic gestational trophoblastic neoplasia.