الفهرس 
GESTATIIONAL TROPHOBLASTIIC NEOPLASIIAOnly 14 pages are availabe for public view
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Abstract
Gestational trophoblastic disease (GTD) is a spectrum of trophoblastic diseases that encompass the hydatidiform mole (both complete and partial), as well as the potentially-malignant and malignant forms: invasive mole, choriocarcinoma and placental site trophoblastic tumor. Gestational trophoblastic neoplasia (GTN) refers to persistent elevation of serum levels of human chorionic gonadotropin (hCG).
The subsequent management of GTD after evacuation of the uterus relies on serial surveillance of serum hCG levels. When serum hCG levels plateau or rise, chemotherapy should promptly be initiated.
A sonographically detectable intrauterine lesion, however, may indicate either remnants of incomplete evacuation or invasive disease. Subjecting women who have invasive disease to re-evacuation, due to misdiagnosis of incomplete evacuation, may provoke severe bleeding, due to disturbance of the highly-vascularized invasive lesion.
Meticulous 2D gray-scale real-time ultrasound as well as color Doppler ultrasound scanning should differentiate between remnants of incomplete evacuation and invasive disease (the latter should be highly vascular and invading the myometrium; while the former should be avascular and intra-cavitary). Both modalities are, however, highly dependable upon the sonographer and the equipment.
A very useful tool for differentiating between intra-cavitary remnants and invasive disease is the office hysteroscopy. It has been a common practice over the past few years at Gynecologic Oncology Unit in Ain Shams University Maternity Hospital to do office hysteroscopy for women with plateauing serum hCG levels and sonographic evidence of intrauterine lesion. This approach did save many women unnecessary chemotherapy for misdiagnosis of persistent GTN, and did save other women from undergoing re-evacuation for a misdiagnosis of remnants of incomplete evacuation, as well.
This study was conducted at Gynecologic Oncology Unit and Early Cancer Detection Unit at Ain Shams University Maternity Hospital during the period between January 2016 and June 2018. A total of 45 women with persistently elevated post-evacuation serum hCG level were included A written informed consent was obtained from all patients before participation.
The aim of the current study was to evaluate the value of office hysteroscopy in women with hydatidiform mole and had persistent post-evacuation elevated serum hCG level and sonographic criteria of invasive disease.
All recruited women were subjected to
- Thorough history revision.
- General abdominal and pelvic examination.
- Pelvic ultrasound examination.
- Diagnostic hysteroscopy.Algorithm showing Study Course
Women with Plateauing or Rising Serum hCG Level
Transvaginal Ultrasonography
No Sonographically Detectable Intrauterine or intramural Lesions Sonographically Detectable Intramural Lesion
Office Hysteroscopy
Intracavitary Lesion
(Incomplete Evacuation) No Lesion
or
Invasive Lesion
Re-evacuation
Histopathological Assessment
plus
Post-evacuation Serum hCG Surveillance
Plateauing or Rising Serum hCG Level
or
Choriocarcinoma Declining Serum hCG Level
Follow-up
Chemotherapy
In this study the results were:
- Of the included 45 women, 18 (40%) had a sonographic finding of ‘invasive mole’, 16 (35.6%) had ‘vascular myometrial area’, while 11 (24.4%) had ‘intracavitary lesion invading the myometrium.
- Of the included 45 women, 25 (55.6%) had a hysteroscopic finding of ‘remnants’, 1 (2.2%) had ‘vascular mass’, and 19 (42.2%) had empty cavity.
- For the 19/44 (43.2%) cases who had a hysteroscopic finding of an empty cavity’ were diagnosed as persistent GTN and received chemotherapy according to the protocol.
- The remaining 25/44 (56.8%) cases, who had a hysteroscopic finding of ‘remnants’, underwent re-evacuation. Postoperative serum hCG surveillance showed persistently elevated levels in 9/44 (20.5%) cases, who, therefore, received chemotherapy according to the protocol; and adequately declining levels in 16/44 (36.4%) cases, who, accordingly, did not receive chemotherapy.
Figure-8Flow-Chart showing Main Study Outcomes
Sonographic Finding
(n=45)
Office Hysteroscopy
(n=45)
Remnants of Conception
(n=25; 55.6%) Empty Cavity
(n=19; 42.2%) Vascular Mass
(n=1; 2.2%)
Re-evacuation
(n=25/44)
(56.8%) No Re-evacuation
(n=19/44)
(43.2%) 44 years old Patient, underwent TAH
Pathology showed Molar Pregnancy Pathology of TAH showed Invasive Mole
hCG Surveillance Post—TAH hCG Surveillance showed no persistent Disease
Post-Re-Evacuation Falling hCG
(n=16/44)
(36.4%) Persistently Elevated hCG Levels
(n=9/44)
(20.5%)
Did not Receive Chemotherapy
(n=16/44)
(36.4%) Diagnosed as Persistent GTN and Received Chemotherapy
(n=28/44)
(63.6%)
- According to the results of included women, hysteroscopy significantly reduced the risk of receiving chemotherapy almost 2-folds [RR 0.57, 95% CI (0.44 to 0.74), p<0.001]; the number needed to treat [NNT] was 2.32.
- Hysteroscopy significantly reduced the risk of chemotherapy only in women with a sonographic finding of ‘invasive mole’ [almost 4-folds: RR 0.28, 95% CI (0.13 to 0.59), p<0.001]; NNT = 1.38.
- In women with a sonographic finding of ‘vascular myometrial lesion’, the value of hysteroscopy in reducing the risk of receiving chemotherapy was slight and insignificant [RR 0.81, 95% CI (0.64 to 1.03), p=0.225]; NNT = 5.33.
- In women with a sonographic finding of ‘intracavitary lesion invading the myometrium’, there was a nil risk reduction.