The Role Of Hysterectomy In Gestational Trophoblastic Disease

Öz

Objective: To evaluate indications and role of hysterectomy in women presenting with gestational trophoblastic disease. Material and Methods: 320 women attended to Women’s Health Research and Education Hospital Oncology Department with a diagnosis of gestational trophoblastic disease during the period 1996-2004 were screened. Thirty patients had hysterectomy and chemotherapy regarded as study grup (group I) and the patients followed only with chemotherapy without hysterectomy according to the treatment protocol in our hospital were regarded as control group (group II). The pretreatment risk score , remission period after hysterectomy, the amount of given chemotherapy were evaluated from the reports retrospectively. Chi-square and Mann-Whitney U tests were used for statistical analysis. Results: Significant difference was observed between two groups according to the age. The median age in group I was 23.5 y(15-50), in group II was 45y(19-58)(p<0.001). According to the pretreatment risk score , given chemotherapy amount, remission period(month) in group I respectively 4.5, 1,1. In group II respectively 3,4.5,3 (p<0.001). Hysterectomy indications were; women who completed fertility, patient choice, heavy vaginal bleeding, chemoresistant disease, plasental site tumor pathology limited to uterus. Post molar gestational trophoblastic disease after dilatation and curettage was 18.7%. After hysterectomy in the following period (1-9 years), there were no invasive or metastatic disease detected. Discussion: Chemotherapy amount that were given to get remission and remission period in the patients with low-risk potential and who had chemoresistant disease and plasental site tumor pathology limited to the uterus were lower. Hysterectomy can be an option in these patients with completed fertility period.

Anahtar Kelimeler

• Gestational Trophoblastic Disease,Hysterectomy

Gestasyonel Trofoblastik Hastalıklarda Histerektominin Rolü

Öz

Amaç: Gestasyonel trofoblastik hastalık tanısı ile başvuran hastalarda histerektomi endikasyonları ve histerektominin hastalığın takibindeki rolünü araştırmayı planladık. Materyal Metot: Kadın Hastalıkları ve Doğum Eğitim ve Araştırma Hastanesi’ne 1996-2004 yılları arasında gestasyonel trofoblasik hastalık tanısı ile başvuran 320 hasta retrospektif olarak tarandı. Çalışmaya takibinde kemoterapi ve histerektomi uygulanan 30 hastamız çalışma grubu olarak (grup I), yine takibinde sadece kemoterapi uygulanan 68 hastamız kontrol grubu olarak oluşturuldu ( grupII). Hastaların patolojik tanıları, yaşları , tedavi öncesi ve sonrası uygulanan tetkikler , histerektomi nedenleri, remisyon süreleri ve aldıkları tedaviler gibi bilgiler dosyalardan taranarak incelendi. Ki-kare ve Mann Whitney U testleri istatistik analiz için kullanıldı. Sonuçlar: Her iki grupta yaşlar arasında istatistiksel fark saptandı. Grup I’ in ortalama yaşı 23.5 (15-50) saptanırken, grup II‘nin ortalam yaşı 45(19-58) idi (p<0.001). Tedavi öncesi risk skorları, verilen kemoterapi kür sayısı, ve remisyon periotlarına bakıldığında ayrı ayrı Grup I ‘de 4.5, 1, 1 bulunurken, Grup II ‘de 3,4.5, 3 olarak saptanmış ve istatistik fark saptanmıştır(p<0.001). Histerektomi endikasyonları fertilitesini tamamlamış hastalar, hastanın isteği, yoğun vaginal kanama , kemorezistan hastalık, uterusa sınırlı plasental bölge tümörü olarak sınıflandırılmıştır. Dilatasyon ve küretaj sonrası post molar gestasyonal trofoblastik hastalık gelişme insidansı %18.7 olarak bulunmuştur, ancak histerektomi sonrası takip sürelerinde (1-9 yıl) herhangi bir invasive mol veya metastatik hastalık görülmemiştir. Tartışma: Histerektomi sonrası düşük riskli gestasyonel trofoblastik neoplazisi olup uterusa sınırlı plasental bölge tümorü ve ve kemorezistan olan hastaların kemoterapi ihtiyacı ve remisyon sürelerinin daha düşük olduğu saptanmıştır. Fertilite isteği olmayan bu grup hastalarda histerektomi önerilebilir.

Anahtar Kelimeler

• Gestasyonel trofoblastik hastalıklar,histerektomi

Kaynakça

1. 1. Ozalp SS, Yalçin OT, Tanir HM. Hydatidiform mole in Turkey from 1932 to 2000.. Int J Gynaecol Obstet. 2001 Jun;73(3):257-8.
2. 2. Ozalp SS, Telli E, Oge T, et al. Multicenter analysis of gestational trophoblastic neoplasia in Turkey. Asian Pac J Cancer Prev. 2014;15(8):3625-8.
3. 3. Zhao P, Chen Q, Lu W. Comparison of different therapeutic strategies for complete hydatidiform mole in women at least 40 years old: a retrospective cohort study. BMC Cancer. 2017 Nov 9;17(1):733.
4. 4. Eysbouts YK, Massuger LFAG, IntHout J, et al. The added value of hysterectomy in the management of gestational trophoblastic neoplasia. Gynecol Oncol. 2017 Jun;145(3):536-542.
5. 5. Doll KM, Soper JT. The role of surgery in the management of gestational trophoblastic neoplasia. Obstet Gynecol Surv. 2013 Jul;68(7):533-42. Review.
6. 6. Fang J, Wang S, Han X, et al. Role of adjuvant hysterectomy in management of high-risk gestational trophoblastic neoplasia. Int J Gynecol Cancer. 2012 Mar;22(3):509- 14.
7. 7. İbrahim Egemen Ertaş, Aşkın Doğan, Volkan Emirdar, ve ark. Gestasyonel Trofoblastik Neoplazilerin Tedavisinde Histerektominin Rolü: Tek Merkezin 17 Yıllık Deneyimi. Türk Jinekoloji ve Obstetrik Derneği Dergisi, 2012; Cilt: 9 Say›: 2 Sayfa: 110- 5
8. 8. Hanna RK, Soper JT. The role of surgery and radiation therapy in the management of gestational trophoblastic disease. Oncologist. 2010;15(6):593-600.Review.

9. 9. Fülöp V, Szigetvári I, Szepesi J, et al. The Role of Surgery in the Management of Gestational Trophoblastic Neoplasia The Hungarian Experience. J Reprod Med. 2016 May-Jun;61(5-6):197-204.
10. 10. Eoh KJ, Chung YS, Yim GW, et al. Role of surgical therapy in the management of gestational trophoblastic neoplasia. Obstet Gynecol Sci. 2015 Jul;58(4):277-83.
11. 11. Giorgione V, Bergamini A, Cioffi R, et al. Role of Surgery in the Management of Hydatidiform Mole in Elderly Patients: A Single-Center Clinical Experience.Int J Gynecol Cancer. 2017 Mar;27(3):550-553.
12. 12. Sun SY, Melamed A, Joseph NT, et al. Clinical presentation of complete Hydatidiform mole and partial Hydatidiform mole at a regional Trophoblastic disease Center in the United States over the past 2 decades. Int J Gynecol Cancer. 2016;26(2):367–70. 13. Curry SL, Hammond CB, Tyrey L, et al. Hydatidiform mole: diagnosis, management, and long-term followup of 347 patients. Obstet Gynecol. 1975;45(1):1–8.
13. 14. Savage PM, Sita-Lumsden A, Dickson S, et al. The relationship of maternal age to molar pregnancy incidence, risks for chemotherapy and subsequent pregnancy outcome. J Obstet Gynaecol.2013;33(4):406–11. 15. Pisal N, North C, Tidy J, Hancock B. Role of hysterectomy in management of gestational trophoblastic disease. Gynecol Oncol. 2002 Nov;87(2):190-2.
14. 16. Soper JT. Role of surgery and radiation therapy in the management of gestational trophoblastic disease. Best Pract Res Clin Obstet Gynaecol. 2003 Dec;17(6):943- 57.
15. 17. Lang JF, Childers JM, Surwit EA. Laparoscopic hysterectomy for persistent gestational trophoblastic neoplasia. J Am Assoc Gynecol Laparosc. 1995 Aug;2(4):475-7.
16. 18. Riley K, Newell J, Zaino R, Kesterson J. Robotic-assisted Laparoscopic Management of Chemoresistant Myoinvasive Complete Molar Pregnancy. J Minim Invasive Gynecol. 2015 Sep-Oct;22(6):1100-3
17. 19. Wang Q, Fu J, Hu L, et al. Prophylactic chemotherapy for hydatidiform mole to prevent gestational trophoblastic neoplasia. Cochrane Database Syst Rev. 2017 Sep 11;9:CD007289.
18. 20. Horowitz NS, Goldstein DP, Berkowitz RS. Placental site trophoblastic tumors and epithelioid trophoblastic tumors: Biology, natural history, and treatment modalities. Gynecol Oncol. 2017 Jan;144(1):208-214