title: Is chemotherapy necessary for patients with molar pregnancy and human chorionic gonadotropin serum levels raised but falling at 6months after uterine evacuation?
abstract: OBJECTIVE
  To compare the outcomes of Brazilian patients with molar pregnancy who continue human chorionic gonadotropin (hCG) surveillance with those treated with chemotherapy when hCG was still positive, but falling at 6months after uterine evacuation.
  
  
  METHODS
  Retrospective chart review of 12,526 patients with hydatidiform mole treated at one of nine Brazilian reference centers from January 1990 to May 2016.
  
  
  RESULTS
  At 6months from uterine evacuation, 96 (0.8%) patients had hCG levels raised but falling. In 15/96 (15.6%) patients, chemotherapy was initiated immediately per FIGO 2000 criteria, while 81/96 (84.4%) patients were managed expectantly. Among the latter, 65/81 (80.2%) achieved spontaneous remission and 16 (19.8%) developed postmolar gestational trophoblastic neoplasia (GTN). Patients who received chemotherapy following expectant management required more time for remission (11 versus 8months; p=0.001), had a greater interval between uterine evacuation and initiating chemotherapy (8 versus 6months; p<0.001), and presented with a median WHO/FIGO risk score higher than women treated according to FIGO 2000 criteria (4 versus 2, p=0.04), but there were no significant differences in the need for multiagent treatment regimens (1/15 versus 3/16 patients, p=0.60). None of the women relapsed, and no deaths occurred in either group.
  
  
  CONCLUSIONS
  In order to avoid unnecessary exposure of women to chemotherapy, we no longer follow the FIGO 2000 recommendation to treat all patients with molar pregnancy and hCG raised but falling at 6months after evacuation. Instead, we pursue close hormonal and radiological surveillance as the best strategy for these patients.
authors.affiliation: Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Maternity Ward of Santa Casa da Misericórdia do Rio de Janeiro), Rio de Janeiro, Rio de Janeiro, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Brazil. Electronic address: bragamed@yahoo.com.br.
authors.forename: Antonio
authors.initials: A
authors.lastname: Braga
authors.affiliation: Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Maternity Ward of Santa Casa da Misericórdia do Rio de Janeiro), Rio de Janeiro, Rio de Janeiro, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Brazil.
authors.forename: Berenice
authors.initials: B
authors.lastname: Torres
authors.affiliation: Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Maternity Ward of Santa Casa da Misericórdia do Rio de Janeiro), Rio de Janeiro, Rio de Janeiro, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Burlá
authors.affiliation: Trophoblastic Diseases Center of the Clinical Hospital of Botucatu Medical School, Department of Gynecology and Obstetrics, São Paulo State University, Botucatu, São Paulo, Brazil.
authors.forename: Izildinha
authors.initials: I
authors.lastname: Maestá
authors.affiliation: São Paulo Hospital Trophoblastic Disease Center, Paulista School of Medicine, São Paulo Federal University, São Paulo, São Paulo, Brazil.
authors.forename: Sue Yazaki
authors.initials: SY
authors.lastname: Sun
authors.affiliation: São Paulo Clinics Hospital Trophoblastic Disease Center, University of São Paulo, São Paulo, São Paulo, Brazil.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Lin
authors.affiliation: Caxias do Sul Trophoblastic Disease Center, General Hospital of Caxias do Sul, School of Medicine, Center for Biological and Health Sciences, Caxias do Sul University, Caxias do Sul, Rio Grande do Sul, Brazil.
authors.forename: José Mauro
authors.initials: JM
authors.lastname: Madi
authors.affiliation: Porto Alegre Trophoblastic Disease Center, Mario Totta Maternity Ward, Irmandade da Santa Casa de Misericórdia Hospital, Porto Alegre, Rio Grande do Sul, Brazil.
authors.forename: Elza
authors.initials: E
authors.lastname: Uberti
authors.affiliation: Goiás Trophoblastic Disease Center, Clinical Hospital of Goiás, Goiás Federal University, Goiânia, Goiás, Brazil.
authors.forename: Maurício
authors.initials: M
authors.lastname: Viggiano
authors.affiliation: New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Elias
authors.affiliation: New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Ross S
authors.initials: RS
authors.lastname: Berkowitz
mesh_terms: D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001938:Brazil; D016022:Case-Control Studies; D017024:Chemotherapy, Adjuvant; D006063:Chorionic Gonadotropin / Q000097:blood*; D015331:Cohort Studies; D003520:Cyclophosphamide / Q000008:administration & dosage; D003609:Dactinomycin / Q000008:administration & dosage; D005047:Etoposide / Q000008:administration & dosage; D005260:Female; D031901:Gestational Trophoblastic Disease; D006801:Humans; D006828:Hydatidiform Mole / Q000097:blood / Q000188:drug therapy* / Q000473:pathology; D002955:Leucovorin / Q000008:administration & dosage; D008727:Methotrexate / Q000008:administration & dosage; D008875:Middle Aged; D009367:Neoplasm Staging; D011247:Pregnancy; D012189:Retrospective Studies; D016896:Treatment Outcome; D014594:Uterine Neoplasms / Q000097:blood / Q000188:drug therapy* / Q000473:pathology; D014619:Vacuum Curettage; D014750:Vincristine / Q000008:administration & dosage; D057832:Watchful Waiting; D055815:Young Adult
chemical_list: D006063:Chorionic Gonadotropin; D003609:Dactinomycin; D014750:Vincristine; D005047:Etoposide; D003520:Cyclophosphamide; D002955:Leucovorin; D008727:Methotrexate
keywords: Chemotherapy; Human chorionic gonadotropin; Molar pregnancy