title: The evolving role of hysterectomy in gestational trophoblastic neoplasia at the New England Trophoblastic Disease Center.
abstract: OBJECTIVE
  To identify indications for hysterectomy in patients with gestational trophoblastic neoplasia (GTN) and to evaluate outcomes of hysterectomy in those patients.
  
  
  METHODS
  Patients who underwent hysterectomy were identified utilizing hospital medical records and the New England Trophoblastic Disease Center (NETDC) database from January 1, 1959-January 1, 2009. Demographic data as well as indication for hysterectomy, stage, World Health Organization score, chemotherapeutic regimens and outcomes were recorded. We further stratified our population into patients with hysterectomies before and after 1980 to assess how indications for and outcomes after hysterectomy may have changed at our institution over time.
  
  
  RESULTS
  A total of 98 patients were identified to have undergone hysterectomy for GTN. In the entire cohort 85% (n = 83) achieved remission and 48% (n = 47) required chemotherapy after hysterectomy. Among the patients in the early cohort (n = 49), indications for hysterectomy included 15 (31%) for primary definitive management, 14 (29%) for chemotherapy resistant disease, 14 (29%) for bleeding and 6 (11%) for other reasons. Of the patients with hysterectomy for chemotherapy resistance, 9 (64%) achieved remission. In the more recent cohort (n = 49) indications for hysterectomy included 24 (49%) for primary definitive management, 19 (39%) for drug-resistant disease, 4 (8%) for bleeding and 2 (4%) for other reasons. Of the patients with hysterectomy for chemotherapy resistance, 16 (84%) achieved remission. There was a statistically significant decline in the number of hysterectomies performed for bleeding. Hysterectomy was performed for bleeding in the early cohort (1959-1980) in 14 (29%) of 49 patients but in only 4 (8%) of 49 patients in the later cohort (1981-2009) (p = 0.02).
  
  
  CONCLUSIONS
  During the years 1959-2009 the number of hysterectomies performed for GTN at the NETDC has remained stable. However, at our center there has been a decline in the incidence of hysterectomy for life-threatening hemorrhage. Overall 83 (84.7%) patients with hysterectomy for GTN obtained remission. In patients who underwent hysterectomy to treat chemotherapy-resistant disease, 25 of 33 (75.8%) subsequently achieved complete remission. Hysterectomy continues to play an important role in the management of selected patients with GTN.
authors.affiliation: Division of Gynecologic Oncology, New England Trophoblastic Disease Center, Boston, Massachusetts, USA.
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Clark
authors.forename: Nicole S
authors.initials: NS
authors.lastname: Nevadunsky
authors.forename: Sue
authors.initials: S
authors.lastname: Ghosh
authors.forename: Donald P
authors.initials: DP
authors.lastname: Goldstein
authors.forename: Ross S
authors.initials: RS
authors.lastname: Berkowitz
mesh_terms: D000328:Adult; D000970:Antineoplastic Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D005260:Female; D031901:Gestational Trophoblastic Disease / Q000150:complications / Q000188:drug therapy / Q000601:surgery*; D006801:Humans; D007044:Hysterectomy; D008796:Metrorrhagia / Q000209:etiology / Q000601:surgery*; D009511:New England; D010298:Parity; D011247:Pregnancy; D012017:Referral and Consultation; D012074:Remission Induction; D012189:Retrospective Studies; D014594:Uterine Neoplasms / Q000150:complications / Q000188:drug therapy / Q000601:surgery*
chemical_list: D000970:Antineoplastic Agents