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How Should Early Gestational Trophoblastic Disease Be Managed?

  • Linda G. W. Kerkmeijer
  • Julian C. Schink
Chapter

Abstract

Gestational trophoblastic disease refers to benign (complete and partial hydatidiform mole) and malignant (invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor) subtypes of abnormal proliferation of the placental trophoblast. Complete and (less often) partial hydatidiform moles may progress into persistent trophoblastic disease, which is indicated by a plateau or rise in hCG levels. Hydatidiform mole is best managed by suction curettage and careful follow-up of hCG levels. With a sensitive hCG assay, hCG follow-up after molar evacuation can be discontinued after normal levels have been achieved. The use of prophylactic chemotherapy for prevention of persistent trophoblastic disease and second curettage for low-risk persistent disease after hydatidiform mole remains controversial. Methotrexate chemotherapy is most frequently used in the treatment of low-risk persistent trophoblastic disease; a trial that compares methotrexate versus actinomycin D chemotherapy is ongoing. Women should wait until 12 months after completing chemotherapy and have consistently normalized hCG levels before attempting another pregnancy. Hysterectomy and lymph node dissection is the preferred treatment for localized placental site trophoblastic tumors. Due to its rare occurrence, centralization of the management of trophoblastic disease is recommended and leads to improved survival.

Keywords

Human Chorionic Gonadotropin Gestational Trophoblastic Disease Molar Pregnancy Complete Hydatidiform Mole Placental Site Trophoblastic Tumor 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Lurain JR. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. Am J Obstet Gynecol. 2010;203:531–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Wells M. The pathology of gestational trophoblastic disease: recent advances. Pathology. 2007;39:88–96.PubMedCrossRefGoogle Scholar
  3. 3.
    Smith HO. Gestational trophoblastic disease epidemiology and trends. Clin Obstet Gynecol. 2003;46:541–56.PubMedCrossRefGoogle Scholar
  4. 4.
    Smith HO, Qualls CR, Prairie BA, Padilla LA, Rayburn WF, Key CR. Trends in gestational choriocarcinoma: a 27-year perspective. Obstet Gynecol. 2003;102:978–87.PubMedCrossRefGoogle Scholar
  5. 5.
    Schmid P, Nagai Y, Agarwal R, Hancock B, Savage PM, Sebire NJ, Lindsay I, Wells M, Fisher RA, Short D, Newlands ES, Wischnewsky MB, Seckl MJ. Prognostic markers and long-term outcome of placental-site trophoblastic tumours: a retrospective observational study. Lancet. 2009;374:48–55.PubMedCrossRefGoogle Scholar
  6. 6.
    FIGO Oncology Committee. FIGO staging for gestational trophoblastic neoplasia 2000. FIGO Oncology Committee. Int J Gynaecol Obstet. 2002;77:285–7.CrossRefGoogle Scholar
  7. 7.
    Mitchell H, Seckl MJ. Discrepancies between commercially available immunoassays in the detection of tumour-derived hCG. Mol Cell Endocrinol. 2007;260–262:310–3.PubMedCrossRefGoogle Scholar
  8. 8.
    Soto-Wright V, Bernstein M, Goldstein DP, Berkowitz RS. The changing clinical presentation of complete molar pregnancy. Obstet Gynecol. 1995;86:775–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Kerkmeijer LG, Massuger LF, Ten Kate-Booij MJ, Sweep FC, Thomas CM. Earlier diagnosis and serum human chorionic gonadotropin regression in complete hydatidiform moles. Obstet Gynecol. 2009;113:326–31.PubMedGoogle Scholar
  10. 10.
    Paradinas FJ, Browne P, Fisher RA, Foskett M, Bagshawe KD, Newlands E. A clinical, histopathological and flow cytometric study of 149 complete moles, 146 partial moles and 107 non-molar hydropic abortions. Histopathology. 1996;28:101–10.PubMedCrossRefGoogle Scholar
  11. 11.
    Genest DR, Dorfman DM, Castrillon DH. Ploidy and imprinting in hydatidiform moles. Complementary use of flow cytometry and immunohistochemistry of the imprinted gene product p57KIP2 to assist molar classification. J Reprod Med. 2002;47:342–6.PubMedGoogle Scholar
  12. 12.
    Tidy JA, Gillespie AM, Bright N, Radstone CR, Coleman RE, Hancock BW. Gestational trophoblastic disease: a study of mode of evacuation and subsequent need for treatment with chemotherapy. Gynecol Oncol. 2000;78:309–12.PubMedCrossRefGoogle Scholar
  13. 13.
    Garrett LA, Garner EI, Feltmate CM, Goldstein DP, Berkowitz RS. Subsequent pregnancy outcomes in patients with molar pregnancy and persistent gestational trophoblastic neoplasia. J Reprod Med. 2008;53:481–6.PubMedGoogle Scholar
  14. 14.
    Stone M, Dent J, Kardana A, Bagshawe KD. Relationship of oral contraception to development of trophoblastic tumour after evacuation of a hydatidiform mole. Br J Obstet Gynaecol. 1976;83:913–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Berkowitz RS, Goldstein DP, Marean AR, Bernstein M. Oral contraceptives and postmolar trophoblastic disease. Obstet Gynecol. 1981;58:474–7.PubMedGoogle Scholar
  16. 16.
    Curry SL, Schlaerth JB, Kohorn EI, Boyce JB, Gore H, Twiggs LB, Blessing JA. Hormonal contraception and trophoblastic sequelae after hydatidiform mole (a Gynecologic Oncology Group Study). Am J Obstet Gynecol. 1989;160:805–9; discussion 809–11.PubMedCrossRefGoogle Scholar
  17. 17.
    Ho Yuen B, Burch P. Relationship of oral contraceptives and the intrauterine contraceptive devices to the regression of concentrations of the beta subunit of human chorionic gonadotropin and invasive complications after molar pregnancy. Am J Obstet Gynecol. 1983;145:214–7.PubMedGoogle Scholar
  18. 18.
    Kohorn EI. Persistent low-level “real” human chorionic gonadotropin: a clinical challenge and a therapeutic dilemma. Gynecol Oncol. 2002;85:315–20.PubMedCrossRefGoogle Scholar
  19. 19.
    Khanlian SA, Smith HO, Cole LA. Persistent low levels of human chorionic gonadotropin: a premalignant gestational trophoblastic disease. Am J Obstet Gynecol. 2003;188:1254–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Kohorn EI. What we know about low-level hCG: definition, classification and management. J Reprod Med. 2004;49:433–7.PubMedGoogle Scholar
  21. 21.
    Cole LA, Khanlian SA, Giddings A, Butler SA, Muller CY, Hammond C, Kohorn E. Gestational trophoblastic diseases: 4. Presentation with persistent low positive human chorionic gonadotropin test results. Gynecol Oncol. 2006;102:165–72.PubMedCrossRefGoogle Scholar
  22. 22.
    Seckl MJ, Newlands ES. Management of gestational trophoblastic disease. In: Gershenson D et al., editors. Gynecologic cancer – controversies in management. London: Churchill Livingstone; 2004.Google Scholar
  23. 23.
    Palmieri C, Dhillon T, Fisher RA, Young AM, Short D, Mitchell H, Aghajanian C, Savage PM, Newlands ES, Hancock BW, Seckl MJ. Management and outcome of healthy women with a persistently elevated beta-hCG. Gynecol Oncol. 2007;106:35–43.PubMedCrossRefGoogle Scholar
  24. 24.
    Cole LA, Muller CY. Hyperglycosylated hCG in the management of quiescent and chemorefractory gestational trophoblastic diseases. Gynecol Oncol. 2010;116:3–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Cole LA, Butler SA, Khanlian SA, Giddings A, Muller CY, Seckl MJ, Kohorn EI. Gestational trophoblastic diseases: 2. Hyperglycosylated hCG as a reliable marker of active neoplasia. Gynecol Oncol. 2006;102:151–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Soper JT, Mutch DG, Schink JC, American College of Obstetricians Gynecologists. Diagnosis and treatment of gestational trophoblastic disease: ACOG practice bulletin no. 53. Gynecol Oncol. 2004;93:575–85.PubMedCrossRefGoogle Scholar
  27. 27.
    Sebire NJ, Foskett M, Short D, Savage P, Stewart W, Thomson M, Seckl MJ. Shortened duration of human chorionic gonadotrophin surveillance following complete or partial hydatidiform mole: evidence for revised protocol of a UK regional trophoblastic disease unit. Br J Obstet Gynaecol. 2007;114:760–2.CrossRefGoogle Scholar
  28. 28.
    Kerkmeijer L, Wielsma S, Bekkers R, Pyman J, Tan J, Quinn M. Guidelines following hydatidiform mole: a reappraisal. Aust N Z J Obstet Gynaecol. 2006;46:112–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Wielsma S, Kerkmeijer L, Bekkers R, Pyman J, Tan J, Quinn M. Persistent trophoblast disease following partial molar pregnancy. Aust N Z J Obstet Gynaecol. 2006;46:119–23.PubMedCrossRefGoogle Scholar
  30. 30.
    Kerkmeijer LG, Wielsma S, Massuger LF, Sweep FC, Thomas CM. Recurrent gestational trophoblastic disease after hCG normalization following hydatidiform mole in the Netherlands. Gynecol Oncol. 2007;106:142–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Massad LS, Abu-Rustum NR, Lee SS, Renta V. Poor compliance with postmolar surveillance and treatment protocols by indigent women. Obstet Gynecol. 2000;96:940–4.PubMedCrossRefGoogle Scholar
  32. 32.
    Wenzel L, Berkowitz RS, Newlands E, Hancock B, Goldstein DP, Seckl MJ, Habbal R, Bernstein M, Kluhsman B, Kulchak-Rahm A, Strickland S, Higgins J. Quality of life after gestational trophoblastic disease. J Reprod Med. 2002;47:387–94.PubMedGoogle Scholar
  33. 33.
    Feltmate CM, Batorfi J, Fulop V, Goldstein DP, Doszpod J, Berkowitz RS. Human chorionic gonadotropin follow-up in patients with molar pregnancy: a time for reevaluation. Obstet Gynecol. 2003;101:732–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Bagshawe KD, Wilson H, Dublon P, Smith A, Baldwin M, Kardana A. Follow-up after hydatidiform mole: studies using radioimmunoassay for urinary human chorionic gonadotrophin (HCG). J Obstet Gynaecol Br Commonw. 1973;80:461–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Curry SL, Hammond CB, Tyrey L, Creasman WT, Parker RT. Hydatidiform mole: diagnosis, management, and long-term followup of 347 patients. Obstet Gynecol. 1975;45:1–8.PubMedGoogle Scholar
  36. 36.
    Batorfi J, Vegh G, Szepesi J, Szigetvari I, Doszpod J, Fulop V. How long should patients be followed after molar pregnancy? Analysis of serum hCG follow-up data. Eur J Obstet Gynecol Reprod Biol. 2004;112:95–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Wolfberg AJ, Growdon WB, Feltmate CM, Goldstein DP, Genest DR, Chinchilla ME, Berkowitz RS, Lieberman EL. Low risk of relapse after achieving undetectable hCG levels in women with partial molar pregnancy. Obstet Gynecol. 2006;108:393–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Lurain JR, Hoekstra AV, Schink JC. Results of treatment of patients with gestational trophoblastic neoplasia referred to the Brewer Trophoblastic Disease Center after failure of treatment elsewhere (1979–2006). J Reprod Med. 2008;53:535–40.PubMedGoogle Scholar
  39. 39.
    Bagshawe KD, Dent J, Webb J. Hydatidiform mole in England and Wales 1973–83. Lancet. 1986;2:673–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Wolfberg AJ, Feltmate C, Goldstein DP, Berkowitz RS, Lieberman E. Low risk of relapse after achieving undetectable HCG levels in women with complete molar pregnancy. Obstet Gynecol. 2004;104:551–4.PubMedCrossRefGoogle Scholar
  41. 41.
    Kim DS, Moon H, Kim KT, Moon YJ, Hwang YY. Effects of prophylactic chemotherapy for persistent trophoblastic disease in patients with complete hydatidiform mole. Obstet Gynecol. 1986;67:690–4.PubMedCrossRefGoogle Scholar
  42. 42.
    Growdon WB, Wolfberg AJ, Goldstein DP, Feltmate CM, Chinchilla ME, Lieberman ES, Berkowitz RS. Evaluating methotrexate treatment in patients with low-risk postmolar gestational trophoblastic neoplasia. Gynecol Oncol. 2009;112:353–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Limpongsanurak S. Prophylactic actinomycin D for high-risk complete hydatidiform mole. J Reprod Med. 2001;46:110–6.PubMedGoogle Scholar
  44. 44.
    Kashimura Y, Kashimura M, Sugimori H, Tsukamoto N, Matsuyama T, Matsukuma K, Kamura T, Saito T, Kawano H, Nose R, et al. Prophylactic chemotherapy for hydatidiform mole. Five to 15 years follow-up. Cancer. 1986;58:624–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Uberti EM, Fajardo Mdo C, da Cunha AG, Rosa MW, Ayub AC, Graudenz Mda S, Schmid H. Prevention of postmolar gestational trophoblastic neoplasia using prophylactic single bolus dose of actinomycin D in high-risk hydatidiform mole: a simple, effective, secure and low-cost approach without adverse effects on compliance to general follow-up or subsequent treatment. Gynecol Oncol. 2009;114:299–305.PubMedCrossRefGoogle Scholar
  46. 46.
    Alazzam M, Young T, Coleman R, Hancock B, Drew D, Wilson P, Tidy J. Predicting gestational trophoblastic neoplasia (GTN): is urine hCG the answer? Gynecol Oncol. 2011;122:595–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Brewer JI, Eckman TR, Dolkart RE, Torok EE, Webster A. Gestational trophoblastic disease. A comparative study of the results of therapy in patients with invasive mole and with choriocarcinoma. Am J Obstet Gynecol. 1971;109:335–40.PubMedGoogle Scholar
  48. 48.
    Hoekstra AV, Lurain JR, Rademaker AW, Schink JC. Gestational trophoblastic neoplasia: treatment outcomes. Obstet Gynecol. 2008;112:251–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Kohorn EI. Abstract. Proceedings of the international society for the study of trophoblastic disease world congress Cochin, India; 2009.Google Scholar
  50. 50.
    Paradinas FJ. The diagnosis and prognosis of molar pregnancy: the experience of the National Referral Centre in London. Int J Gynaecol Obstet. 1998;60 Suppl 1:S57–64.PubMedCrossRefGoogle Scholar
  51. 51.
    Golfier F, Clerc J, Hajri T, Massardier J, Frappart L, Duvillard P, Rabreau M, Patrier S, Devisme L, Carles D, Pelluard F, Gasser B, Tarranger-Charpin C, Schott AM, Raudrant D. Contribution of referent pathologists to the quality of trophoblastic diseases diagnosis. Hum Reprod. 2011;26:2651–7.PubMedCrossRefGoogle Scholar
  52. 52.
    Seckl MJ, Fisher RA, Salerno G, Rees H, Paradinas FJ, Foskett M, Newlands ES. Choriocarcinoma and partial hydatidiform moles. Lancet. 2000;356:36–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Matsui H, Suzuka K, Yamazawa K, Tanaka N, Mitsuhashi A, Seki K, Sekiya S. Relapse rate of patients with low-risk gestational trophoblastic tumor initially treated with single-agent chemotherapy. Gynecol Oncol. 2005;96:616–20.PubMedCrossRefGoogle Scholar
  54. 54.
    Kohorn EI. Imaging practices in the diagnosis and management of gestational trophoblastic disease: an assessment. J Reprod Med. 2012;57:207–10.PubMedGoogle Scholar
  55. 55.
    Alazzam M, Tidy J, Hancock BW, Osborne R. First line chemotherapy in low risk gestational trophoblastic neoplasia. Cochrane Database Syst Rev. 2009;(1):CD007102.Google Scholar
  56. 56.
    Hammond CB, Hertz R, Ross GT, Lipsett MB, Odell WD. Primary chemotherapy for nonmetastatic gestational trophoblastic neoplasms. Am J Obstet Gynecol. 1967;98:71–8.PubMedGoogle Scholar
  57. 57.
    Hammond CB, Borchert LG, Tyrey L, Creasman WT, Parker RT. Treatment of metastatic trophoblastic disease: good and poor prognosis. Am J Obstet Gynecol. 1973;115:451–7.PubMedGoogle Scholar
  58. 58.
    Lurain JR, Elfstrand EP. Single-agent methotrexate chemotherapy for the treatment of nonmetastatic gestational trophoblastic tumors. Am J Obstet Gynecol. 1995;172:574–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Garrett AP, Garner EO, Goldstein DP, Berkowitz RS. Methotrexate infusion and folinic acid as primary therapy for nonmetastatic and low-risk metastatic gestational trophoblastic tumors. 15 years of experience. J Reprod Med. 2002;47:355–62.PubMedGoogle Scholar
  60. 60.
    McNeish IA, Strickland S, Holden L, Rustin GJ, Foskett M, Seckl MJ, Newlands ES. Low-risk persistent gestational trophoblastic disease: outcome after initial treatment with low-dose methotrexate and folinic acid from 1992 to 2000. J Clin Oncol. 2002;20:1838–44.PubMedCrossRefGoogle Scholar
  61. 61.
    Osborne RJ, Filiaci V, Schink JC, Mannel RS, Alvarez Secord A, Kelley JL, Provencher D, Scott Miller D, Covens AL, Lage JM. Phase III trial of weekly methotrexate or pulsed actinomycin for low-risk gestational trophoblastic neoplasia: a gynecologic oncology group study. J Clin Oncol. 2011;29:825–31.PubMedCentralPubMedCrossRefGoogle Scholar
  62. 62.
    Rustin GJ, Newlands ES, Lutz JM, Holden L, Bagshawe KD, Hiscox JG, Foskett M, Fuller S, Short D. Combination but not single-agent methotrexate chemotherapy for gestational trophoblastic tumors increases the incidence of second tumors. J Clin Oncol. 1996;14:2769–73.PubMedGoogle Scholar
  63. 63.
    Gilani MM, Yarandi F, Eftekhar Z, Hanjani P. Comparison of pulse methotrexate and pulse dactinomycin in the treatment of low-risk gestational trophoblastic neoplasia. Aust N Z J Obstet Gynaecol. 2005;45:161–4.PubMedCrossRefGoogle Scholar
  64. 64.
    Yarandi F, Eftekhar Z, Shojaei H, Kanani S, Sharifi A, Hanjani P. Pulse methotrexate versus pulse actinomycin D in the treatment of low-risk gestational trophoblastic neoplasia. Int J Gynaecol Obstet. 2008;103:33–7.PubMedCrossRefGoogle Scholar
  65. 65.
    Lertkhachonsuk AA, Israngura N, Wilailak S, Tangtrakul S. Actinomycin d versus methotrexate-folinic acid as the treatment of stage I, low-risk gestational trophoblastic neoplasia: a randomized controlled trial. Int J Gynecol Cancer. 2009;19:985–8.PubMedCrossRefGoogle Scholar
  66. 66.
    Mousavi A, Cheraghi F, Yarandi F, Gilani MM, Shojaei H. Comparison of pulsed actinomycin D versus 5-day methotrexate for the treatment of low-risk gestational trophoblastic disease. Int J Gynaecol Obstet. 2012;116:39–42.PubMedCrossRefGoogle Scholar
  67. 67.
    Lybol C, Sweep FC, Harvey R, Mitchell H, Short D, Thomas CM, Ottevanger PB, Savage PM, Massuger LF, Seckl MJ. Relapse rates after two versus three consolidation courses of methotrexate in the treatment of low-risk gestational trophoblastic neoplasia. Gynecol Oncol. 2012;125:576–9.PubMedCrossRefGoogle Scholar
  68. 68.
    Dobson LS, Lorigan PC, Coleman RE, Hancock BW. Persistent gestational trophoblastic disease: results of MEA (methotrexate, etoposide and dactinomycin) as first-line chemotherapy in high risk disease and EA (etoposide and dactinomycin) as second-line therapy for low risk disease. Br J Cancer. 2000;82:1547–52.PubMedCentralPubMedCrossRefGoogle Scholar
  69. 69.
    Feng F, Xiang Y, Wan X, Zhou Y. Prognosis of patients with relapsed and chemoresistant gestational trophoblastic neoplasia transferred to the Peking Union Medical College Hospital. Br J Obstet Gynaecol. 2010;117:47–52.CrossRefGoogle Scholar
  70. 70.
    Rotmensch J, Rosenshein NB, Block BS. Comparison of human chorionic gonadotropin regression in molar pregnancies and post-molar nonmetastatic gestational trophoblastic neoplasia. Gynecol Oncol. 1988;29:82–6.PubMedCrossRefGoogle Scholar
  71. 71.
    Shigematsu T, Hirakawa T, Yahata H, Sonoda T, Kinukawa N, Nakano H. Identification of chemotherapeutic refractory cases based on human chorionic gonadotropin values among patients with low-risk persistent trophoblastic disease treated with 8-day methotrexate-folinic acid. Eur J Gynaecol Oncol. 2003;24:113–6.PubMedGoogle Scholar
  72. 72.
    van Trommel NE, Massuger LF, Schijf CP, ten Kate-Booij MJ, Sweep FC, Thomas CM. Early identification of resistance to first-line single-agent methotrexate in patients with persistent trophoblastic disease. J Clin Oncol. 2006;24:52–8.PubMedCrossRefGoogle Scholar
  73. 73.
    Kerkmeijer LG, Thomas CM, Harvey R, Sweep FC, Mitchell H, Massuger LF, Seckl MJ. External validation of serum hCG cutoff levels for prediction of resistance to single-agent chemotherapy in patients with persistent trophoblastic disease. Br J Cancer. 2009;100:979–84.PubMedCentralPubMedCrossRefGoogle Scholar
  74. 74.
    You B, Pollet-Villard M, Fronton L, Labrousse C, Schott AM, Hajri T, Girard P, Freyer G, Tod M, Tranchand B, Colomban O, Ribba B, Raudrant D, Massardier J, Chabaud S, Golfier F. Predictive values of hCG clearance for risk of methotrexate resistance in low-risk gestational trophoblastic neoplasias. Ann Oncol. 2010;21: 1643–50.PubMedCrossRefGoogle Scholar
  75. 75.
    Garner EI, Lipson E, Bernstein MR, Goldstein DP, Berkowitz RS. Subsequent pregnancy experience in patients with molar pregnancy and gestational trophoblastic tumor. J Reprod Med. 2002;47: 380–6.PubMedGoogle Scholar
  76. 76.
    Woolas RP, Bower M, Newlands ES, Seckl M, Short D, Holden L. Influence of chemotherapy for gestational trophoblastic disease on subsequent pregnancy outcome. Br J Obstet Gynaecol. 1998;105: 1032–5.PubMedCrossRefGoogle Scholar
  77. 77.
    Berkowitz RS, Goldstein DP. Molar pregnancy and gestational trophoblastic neoplasms. In: Barakat R et al., editors. Principles and practice of gynecologic oncology. 5th ed. Baltimore: Lippincott Williams and Wilkins; 2009.Google Scholar
  78. 78.
    Matsui H, Iitsuka Y, Suzuka K, Yamazawa K, Tanaka N, Mitsuhashi A, Sekiya S. Early pregnancy outcomes after chemotherapy for gestational trophoblastic tumor. J Reprod Med. 2004;49:531–4.PubMedGoogle Scholar
  79. 79.
    Pezeshki M, Hancock BW, Silcocks P, Everard JE, Coleman J, Gillespie AM, Tidy J, Coleman RE. The role of repeat uterine evacuation in the management of persistent gestational trophoblastic disease. Gynecol Oncol. 2004;95:423–9.PubMedCrossRefGoogle Scholar
  80. 80.
    van Trommel NE, Massuger LF, Verheijen RH, Sweep FC, Thomas CM. The curative effect of a second curettage in persistent trophoblastic disease: a retrospective cohort survey. Gynecol Oncol. 2005;99:6–13.PubMedCrossRefGoogle Scholar
  81. 81.
    Garner EI, Feltmate CM, Goldstein DP, Berkowitz RS. The curative effect of a second curettage in persistent trophoblastic disease: a retrospective cohort survey. Gynecol Oncol. 2005;99:3–5.PubMedCrossRefGoogle Scholar
  82. 82.
    van Trommel NE, Thomas CM, Massuger LF, Sweep FC. Second curettage in persistent trophoblastic disease (PTD): the need for univocal definition of PTD. Gynecol Oncol. 2005;99:250–1; author reply 251.PubMedCrossRefGoogle Scholar
  83. 83.
    Papadopoulos AJ, Foskett M, Seckl MJ, McNeish I, Paradinas FJ, Rees H, Newlands ES. Twenty-five years’ clinical experience with placental site trophoblastic tumors. J Reprod Med. 2002;47:460–4.PubMedGoogle Scholar
  84. 84.
    Cole LA, Khanlian SA, Muller CY, Giddings A, Kohorn E, Berkowitz R. Gestational trophoblastic diseases: 3. Human chorionic gonadotropin-free beta-subunit, a reliable marker of placental site trophoblastic tumors. Gynecol Oncol. 2006;102:160–4.PubMedCrossRefGoogle Scholar
  85. 85.
    Feltmate CM, Genest DR, Wise L, Bernstein MR, Goldstein DP, Berkowitz RS. Placental site trophoblastic tumor: a 17-year experience at the New England Trophoblastic Disease Center. Gynecol Oncol. 2001;82:415–9.PubMedCrossRefGoogle Scholar
  86. 86.
    Hoekstra AV, Keh P, Lurain JR. Placental site trophoblastic tumor: a review of 7 cases and their implications for prognosis and treatment. J Reprod Med. 2004;49:447–52.PubMedGoogle Scholar
  87. 87.
    Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. Lancet. 2010;376:717–29.PubMedCrossRefGoogle Scholar
  88. 88.
    Brandt KR, Coakley KJ. MR appearance of placental site trophoblastic tumor: a report of three cases. AJR Am J Roentgenol. 1998;170:485–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  1. 1.Radiation OncologyUniversity Medical Center UtrechtUtrechtThe Netherlands
  2. 2.Obstetrics and GynecologyNorthwestern University Feinberg School of MedicineChicagoUSA

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