Diagnostic and therapeutic curettage in gestational trophoblastic disease John B. Schlaerth, MD, C. Paul Morrow, MD, and Maria Rodriguez, RN Los Angeles, California From June 1976 through June 1989, 37 nonconsecutive patients underwent uterine curettage during the course of their gestational trophoblastic disease. In 22 patients (59%) trophoblastic tissue was obtained. Three (8.1 %) patients sustained a uterine perforation during the procedure. In six patients curettage was performed for bleeding. There were six patients curetted during assessment for metastatic trophoblastic disease. Twenty-eight patients underwent curettage for the presumed diagnosis of non metastatic gestational trophoblastic disease. In retrospect, four of these women (14.3%) had insufficient criteria for the diagnosis of gestational trophoblastic disease. Of the remaining 23 patients, four (17.4%) went into clinical remission without further treatment. Ten patients (43.5%) had a transitory decline in serum ~-human chorionic gonadotropin levels that subsequently rose or plateaued. Six patients (26.1 %) showed no effect from the curettage on their serum ~-human chorionic gonadotropin trend during a short period of observation. Three patients (13.0%) with nonmetastatic gestational trophoblastic disease were not observed for a possible therapeutic effect after curettage. Thus, in only 4/20 (20%) women with nonmetastatic trophoblastic disease was a therapeutic effect from curettage shown. (AM J OBSTET GVNECOL 1990;162:1465-71.)

Key words: Curettage, gestational trophoblastic disease, effectiveness, risks

Uterine curettage has traditionally been regarded as important for diagnostic and therapeutic reasons in the assessment of women with gestational trophoblastic disease. I -3 In fact repeated curettages have been a common practice! Yet there has been little critical evaluation of curettage in this setting!-6 For this reason a retrospective review of the uterine curettages performed in women presumed to have gestational trophoblastic disease at our institution was undertaken. The purpose of this study is to examine the advantages and disadvantages of curettage in women with gestational trophoblastic disease.

Material and methods The medical records of all patients who underwent uterine curettage during follow-up for hydatidiform mole or suspected gestational trophoblastic disease at Los Angeles County-University of Southern California Women's Hospital were reviewed. Twenty women were curetted during the 46-month period from June 1976 through March 1980. Two of these women had a gesFrom the Division of Gynecologic Oncology. Department of Obstetrics and Gynecology, University of Southern California School of Medicine. Presented at the Fifty-sixth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Coronado, California, September 17-21,1989. Reprint requests: John B. Schlaerth, MD, Los Angeles CountyUniversity of Sou/hem Califomia Women's Hospital, 1240 North Mission Road, Room L903, Los Angeles, CA 90033. 6/6/20739

Table I. Uterine curettage results and serum R>-hCG levels in patients with nonmetastatic trophoblastic disease Curettage specimen

No. of patients

Gestational trophoblastic disease Trophoblastic cells Chorionic villi Normal endometrial tissue

6

Serum {3-hCG (mIV/ml) Mean

11,292

I

Range

1,220-16,362

6

4,716.5

259-15,947

3

2,396.7

140-4,500

9

7,019.3

14-20,900

tational choriocarcinoma not preceded by a hydatidiform mole. Interest in curettage for such patients waned during the next 7 years. Another 17 women underwent curettage during follow-up for hydatidiform mole in the 20-month period from November 1987 through June 1989. During these two time periods a repeat curettage was performed during the follow-up for hydatidiform mole if (1) R>-human chorionic gonadotropin serum (R>-hCG) levels plateaued or rose or (2) excessive uterine bleeding occurred. The clinical records were reviewed for initial management of the hydatidiform mole, the presence of bleeding, the size of the uterus, the trend of serum R>hCG levels before the curettage, the level of serum R>1465

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June 1990 Am J Obstet Gynecol

Table II. Uterine curettage performed for excessive bleeding from gestational trophoblastic disease Serum f3-hCG Patient

mIUlml

I

Pathologic histology

Trend curettage

Uterine size

Gm

18

P. C.

1080

Falling

Normalt

D.D.

6200

Falling

Large:j:

M.H.

1800

None*

L. M.

77800

A.P.

278

I

Days after mole-pregnancy

Tissue

Outcome

Atypical trophoblasts

32

Lost to follow-up

200

Decidua, blood

31

Large

30

Hydatidiform mole

16

Spontaneous remIssIon

None*

Large

230

Hydatidiform mole

7

Falling

Normal

3

Endometrium

31

Spontaneous remission Spontaneous remIssIon Chemother~p.y;

P. F.

Normal

None*

3880

9

Choriocarinoma

remIssIon Chemotherapy; hysterecto~~; remIssIon

197

Other

Blood transfusion

Lung metastasis Perforation

*Single value (?). t8 weeks' gestational size. Persistent gestational trophoblastic disease was diagnosed by a rise or plateau in serum (3liCG levels or by the appearance of metastasis. A rising trend in serum (3-hCG levels was defined as doubling in value over a 2-week period. A plateau in hCG levels was generally considered to be present when no decrease in serum (3-hCG level was apparent during 3 weeks of observation and any increase was insufficient to qualify as a rising trend. Assessment for metastasis included history and physical examination, liver func-

tion tests, chest roentgenogram, pelvic ultrasonographic examination, and computerized tomography of the chest, abdomen, brain and pelvis. Earlier patients underwent radioisotope scans of the brain and liver and pelvic angiography. The uterine curettage specimen was considered positive if a histologic diagnosis of'a gestational trophoblastic disease or trophoblastic cells were detected, otherwise it was considered negative for diagnostic purposes. Last, the details in management and clinical outcome were determined for all patients. Results

General observations. The yield from the curettages were analyzed for the 24 women with non metastatic

Curettage in gestational trophoblastic disease

Volume 162 Number 6

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Table IV. Uterine curettage in patients with unsubstantiated trophoblastic disease in retrospect (immediate precurettage titer hCG showed decline*) Serum {3-hCG Patient

mIUlml

I

Pathologic histology

Trend at curettage

Uterine sIze

Tissue

Days after mole-pregnancy

5

Trophoblastic

45

Atypical trophoblastic Chorionic villi

32

Endometrium

49

I

Gm

E. C.

1400

Plateau

Larget

P. C.

1080

Plateau

Normal:j:

18

R. F.

133

Plateau

Normal

3

K. B.

1640

Rise

Normal

76

Outcome

Hysterectomy for performation. remission Lost to follow-up Spontaneous remission Spont~neous remiSSion

*Value not received until after curettage. t>8 Weeks' gestational size. :j:8 Weeks' gestational size.

trophoblastic disease (Table I). Fifteen of 24 (62.5%) of those patients exhibited some aspect of trophoblastic histology. The uterine sizes were analyzed in reference to the diagnostic yield on the curettages. The curettings from eight of 12 (66.7%) large uteri contained trophoblastic elements. The curettings from 25 normal-sized uteri showed trophoblastic tissue in 13 (52%). Bleeding. Six patients underwent uterine curettage because of significant bleeding (Table II). Four of these women were clinically considered to have retention of molar tissue after evacuation. Two of these patients were evacuated at our institution. one (P. C.) by suction and sharp curettage to complete spontaneous abortion of the hydatidiform mole and the other (L. M.) underwent elective suction and sharp curettage for an intact hydatidiform mole. No details of primary management are known for the other two women (M. H., D. D.). One woman with metastatic postmolar trophoblastic disease and one woman with postabortal choriocarcinoma also underwent curettage. It should be noted

that this last patient sustained a uterine performation that led to laparotomy and hysterectomy. Persistent trophoblastic disease Metastatic. Six patients underwent uterine curettage as part of their assessment for metastatic trophoblastic disease (Table III). The preceding gestation in five patients was a hydatidiform mole and a tubal pregnancy in one (G. A.). One patient (A. P.) with metastasis was first seen with bleeding and is included under both groups of patients. N onrnetastatic. A total of 28 women underwent uterine curettage for presumed nonmetastatic postmolar trophoblastic disease on the basis of the trend of serum hCG levels. Two women with serum hCG trends suggesting postmolar trophoblastic disease also were first seen with bleeding and are included in Table II. :I'li . Despite a trend of serum l3-hCG levels to substantIate the diagnosis of non metastatic postmolar trophoblastic disease. four patients had a significant drop in l3-hCG level in the serum specimen drawn immediately before curettage (Table IV). Therefore. in retrospect the di-

1468 Schlaerth, Morrow, and Rodriguez

June 1990 Am J Obstet Gynecol

Table VI. Uterine curettage followed by a nonsustained fall in serum j3-hCG levels in patients wIth non metastatic trophoblastic disease Serum f3-hCG Patient

mIU I ml

I Trend at

Pathologic histology

curettage

Uterine size

I

Gm

S.W. T. C.

140 1170

Plateau Rise

Normal* Normal

M.M.

5340

Plateau

Larget

15

H. S.

16362

Rise

Large

225

T. D.

15700

Rise

Normal

3

S. J.

V. M. E. S.

3380 20900 2550 1270

Plateau Plateau Rise Plateau

Normal Normal Normal Normal

24 1 2 4

L.R.

15947

Plateau

Large

A.A.

5 3

Serum f3-hCG (mIUlml) Day after mole-pregnancy

Tissue

Chorionic villi Necrotic trophoblasts Hydatidiform mole Hydatidiform mole Hydatidiform mole Trophoblasts Endometrium Chorionic villi Hydatidiform mole Trophoblasts

730

At nadir

I

At start of treatment

I

Trend

32 29

18 273

37 648

Plateau Rise

29

520

645

Plateau

26

2130

7100

Rise

39

378

915

Rise

42 57 37 34

638 8933 2300 834

1190 11900 6900 930

Plateau Plateau Plateau Plateau

26

15100

16600

Plateau

*