IL MONITORAGGIO NEI TUMORI DEL TROFOBLASTO DI ORIGINE GESTAZIONALE

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CARAVAGGIO 15-17 MAGGIO 2008 MANAGEMENT AND
FOLLOW-UP AFTER MOLAR PREGNANCY
G. Mangili, E. Garavaglia, S Montoli, C
Gentile, R Vigano, E Rabaiotti, P De Marzi, M
Petrone, F Pella, D. Spagnolo, L. Valsecchi, P.
Cavoretto A Ferrari
Dipartimento Materno Infantile , UF Ginecologia
Oncologica IRCCS San Raffaele Milano
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E Garavaglia, HSR, Milan
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SURGERY

• Suction curettage of the uterine cavity with
  ultrasonography
• Intravenous oxytocin once evacuation is complete
• Hysterectomy (in older patients?)
• Attention to evacuation of late gestational
  miscarriages

E Garavaglia, HSR, Milan
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FOLLOW UP

• After molar evacuation, patients with molar
  pregnancy must be followed carefully to rule out
  development of postmolar GTN, by expertized
  clinicians
• 5-30 persistent trophoblastic neoplasia (pGTN)
  (different observation times chosen by each
  center. (7 in our centre) Kohorn E et al. 1993.
  

E Garavaglia, HSR, Milan
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FOLLOW UP AND ßhCG

• in all gestational trophoblastic tumors from both
  the serum and the urine.
  
• excellent indicator for recognizing malignant
  trasformation, checking the effectiveness of the
  treatment, relapse or progression
• diagnosis of persistent trophoblastic disease is
  based traditionally upon serial ßhCG serum level
  measurements. Vaitukaitis
  JL et al. 1972

E Garavaglia, HSR, Milan
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OLD SURVEILLANCE PROTOCOL

• serial weekly hCG checks after 21 days after
  molar evacuation
• Once undetectable titer is attained for 3
  weeks, monthly follow up is continued
• for 6 months for partial moles
• for 12 months for complete moles,
• until 24 months for high risk patients (hCG
  negativization after 60 days or TVU positive)

E Garavaglia, HSR, Milan
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HOW LONG SHOULD PATIENTS BE FOLLOWED AFTER MOLAR
PREGNANCY?

• Questions
• Is this long follow up clinically necessary?
• Is still important differentiation between
  partial and complete mole for follow up?

E Garavaglia, HSR, Milan
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PROLONGED ßhcg MONITORING

• economic, social and emotional burden
• postponement of fertility in women over 35
• prematurely discontinuation of follow up
  (Schlaerth 19, Kim 27, Massad 81)

E Garavaglia, HSR, Milan
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PROPHYLACTIC CHEMOTHERAPY

• MOTIVATION reduction of incidence of pGTN
  (Goldstein from 20 to 8, Kim from 47 to 14)
• OBJECTIONS
• usefullness exposition to a chemotherapic agent
  (Hancock 1997)
• incomplete protection to pGTN
• false security
• CONCLUSION if poor thecnological and economical
  resorses for follow up or where women have a low
  compliance.

E Garavaglia, HSR, Milan
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IS PROLONGED MONITORING NECESSARY ?

• In New England Trophoblastic Disease Center no
  pGTN when hCG lt 5 mIU/ml
• in 1029 patients with CM
• in 238 patients with PM
• same result by Batorfi on 120 pts, Lavie on 74
• In our center 1 pGTN on 230 (0.4) patients 3
  months after marker normalization (Kerkmeijer
  1/265)

E Garavaglia, HSR, Milan
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CONCLUSIONS

• If undetectable hCG values, risk of pGTN
  extraordinary low for CM and PM
• gonadotropin follow up could be shortened for 97
  of patients.

E Garavaglia, HSR, Milan
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IS PROLONGED MONITORING NECESSARY ?

• In Trophoblastic Disease Unit in only one of the
  6701 women registered for hCG follow up the
  routine prolonged 2-year surveillance protocol
  detected pGTN
• the modified 6-month surveillance protocol wuold
  detect more than 99 of all case of postmolar
  pGTN, while minimising the lenght of surveillance
  for the majority of women.

E Garavaglia, HSR, Milan
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WHEN TO PROLONG FOLLOW UP

• Two important prognostic factors to select high
  risk patients
• - Ploidy
• - the myometrial nodule

E Garavaglia, HSR, Milan
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Risk of GTT

• 162 diploid mole
• 105 triploid
• 17.3 diploid GTT
• 0 triploid GTT

Niemann Obstet Gynecol 2006 1071006-11

• The risk of GTT after triploid mole is low (from
  0 to 0.001)

7.5
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TRANSVAGINAL ULTRASONOGRAPHY (TVU)

• .

Mangili, Am J Obstet Gynecol 19931691218-23
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PROGNOSTIC FACTORS
E.Garavaglia, HSR Milan
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TVU - CONCLUSION

• The risk of pGTN is increased in patients
  presenting myometrial invasions assessed by
  ultrasound after uterine evacuation.

E.Garavaglia, HSR Milan
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TVU

• At the beginning of follow-up
• 178 (94 ) TVU negative
• 189 pts
• 9 myometrial nodule.

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E.Garavaglia, HSR Milan
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NEGATIVE TVU GROUP (178)

• 7 (4 ) pGTN 6 non metastatic
• 1 lung metastatis
• after 8 weeks (range 7-16)
• myometrial nodule 8.4 weeks (range 4-20)
• ßhCG 13.533 (range 27 -55900)

E.Garavaglia, HSR Milan
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POSITIVE TVU GROUP

• 9 7 (78 ) pGTN
• 2 marker normalization
• (slow decline at the 72 and 91 day
  after evacuation)

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HSR, Milan
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HSR, Milan
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HSR, Milan
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CONCLUSIONS

• Follow up must be prolonged in the presence of
  myometrial nodules
• at the beginning of the follow up,
• during follow up
• normalization of myometrium is an indicator of
  disease resolution

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REVISED SURVEILLANCE PROTOCOL OF HYDATIFORM MOLE

• serial weekly hCG checks after 21 days after
  molar evacuation until return normal for 3
  consecutive weeks
• Triploid stop follow up
• HM until 6 months after evacuation
• For 6 months after hCG normalization
• - normal hCG gt 60 days after evacuation
• - myometrial nodule presence

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G. Mangili, E. Garavaglia, S Montoli, C
Gentile, R Vigano, E Rabaiotti, P De Marzi, M
Petrone, F Pella, D. Spagnolo, L. Valsecchi, P.
Cavoretto A Ferrari
Dipartimento Materno Infantile , UF Ginecologia
Oncologica IRCCS San Raffaele Milano