Is there uniformity in definitions and treatment of gestational trophoblastic disease in Europe?

Abstract

ObjectivesBecause gestational trophoblastic disease is rare, little evidence is available from randomized controlled trials on optimal treatment and follow-up. Treatment protocols vary within Europe, and even between different centers within countries. One of the goals of the European Organization for Treatment of Trophoblastic Diseases (EOTTD) is to harmonize treatment in Europe. To provide a basis for international standardization of definitions, treatment and follow-up protocols in gestational trophoblastic disease, we evaluated differences and similarities between protocols in EOTTD countries.MethodsMembers from each EOTTD country were asked to complete an online structured questionnaire comprising multiple-choice and multiple-answer questions. The following themes were discussed: incidence of gestational trophoblastic disease and gestational trophoblastic neoplasia, definitions, guidelines, classification system, treatment, recurrence, and follow-up.ResultsForty-four respondents from 17 countries participated in this study. Guidelines were present in 80% of the countries and the FIGO (Fédération Internationale de Gynécologie et d'Obstétrique) staging and risk classification was often used to estimate risks. Agreement about when to start chemotherapy for post-molar gestational trophoblastic neoplasia was present among 66% of the respondents. Preferred first-line treatments in low- and high-risk gestational trophoblastic neoplasia were methotrexate (81%) and EMA-CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine) (93%), respectively. The definition of human chorionic gonadotropin normalization after hydatidiform mole evacuation was two consecutive normal values for nine countries. The FIGO definition of post-molar gestational trophoblastic neoplasia based on human chorionic gonadotropin plateau or rise was agreed on by 69% of respondents, and only 69% and 74% defined low-risk and high-risk disease, respectively, using FIGO criteria. There were major differences in definitions of recurrence, chemotherapy resistance and follow-up protocols among countries, despite EOTTD consensus statements.ConclusionsThis questionnaire provides a good overview of current clinical practices in different countries. Based on the survey results, it is clear that there are several gestationaltrophoblastic disease-related topics that need urgent attention within the EOTTD community to create more uniformity and to aid the development of uniform guidelines in Europe.

Computed tomography chest imaging offers no advantage over chest X-ray in the initial assessment of gestational trophoblastic neoplasia

“…Metastases detected on CXR, were found to be associated with an extended TNhCG, supporting the literature in low-risk patients, suggesting that pulmonary metastases present at the start of treatment are associated with higher rates of TR 7,13,15,18 and disease recurrence. 16,18 Metastases detected on CT were not associated with a longer TNhCG.…”

“…Unfortunately, previously published literature comparing CXR and CT did not study these outcome measures. 7,9,13 Frijstein et al 18 demonstrated higher rates of disease recurrence amongst low-risk patients with pulmonary metastases, compared to those without pulmonary metastases. However, as our study included both low-and high-risk patients, the two studies cannot be compared.…”

“…Relapse was defined as ≥2 rising serial serum hCG levels in the absence of a new pregnancy or alternative explanation, following ≥6 weeks of normal serum hCG levels following the completion of chemotherapy to initially achieve CR. 18 Treatment decisions were entirely based upon CXR derived assessment of GTN. Selection and details of chemotherapy regimens can be found in Supplementary Table S1.…”

Sonographic characteristics of post‐molar gestational trophoblastic neoplasia at diagnosis and during follow‐up, and relationship with methotrexate resistance

“…The FIGO 2000 risk-scoring system, including eight clinical variables, is the accepted model for stratification of women with GTN into low vs high risk of resistance to first-line single agent chemotherapy, and thereby for treatment selection 1,2 . In Europe, MTX is used widely as first-line treatment for low risk GTN 16 . Although useful, the risk-scoring system will stratify incorrectly more than one-third of all patients who will become resistant to single-agent MTX 17 , and studies have aimed at improving risk prediction in women with GTN 7,18,19 .…”

Evaluation of a Web-Based Intervention for Patients with Gestational Trophoblastic Disease: A Randomized Controlled Trial

“…In the Netherlands, GTD has an incidence of 1.67 per 1,000 deliveries [3]. Given the rarity of GTD, high-level evidence is limited, and treatment protocols vary between and within countries [5]. Healthcare professionals are often unfamiliar with the management of GTD, especially in countries with limited access to specialized care.…”