European Journal of Obstetrics & Gynecology and Reproductive Biology 180 (2014) 8–11
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Gestational trophoblastic disease in the western region of Saudi Arabia (single-institute experience) Nisrin Anfinan, Khalid Sait *, Hesham Sait Scientific chair of prof. Abdullah Hussain Basalamah for Gynecological Cancer, Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 December 2013 Received in revised form 11 April 2014 Accepted 4 June 2014
Objective: To estimate the prevalence of gestational trophoblastic disease (GTD) in the western region of Saudi Arabia, and to evaluate the success of treatment and the effect of age and risk group on survival. Methods: Between January 2001 and December 2010, all patients treated for GTD were identified from the King Abdulaziz University Hospital database. Patients with persistent disease were evaluated according to their clinical treatment outcomes. Results: In total, 122 cases of GTD were identified in the database. Of these, 77 (63%) cases were diagnosed and received initial treatment at the study centre, resulting in an incidence of 1.26 cases per 1000 deliveries. The mean (standard deviation) age of the study participants was 31.52 10.8 years, mean gestational age at diagnosis was 12.42 3.2 weeks, and mean follow-up for each patient was 24 months. There were 20 cases (26%) of persistent GTD after treatment. The majority of patients with low-risk disease were treated with single-agent methotrexate, with an overall success rate of 83%. The overall 5year survival rate for all patients was 98%. Using the Wilcoxon (Gehan) test, risk group and age (cut-off 40 years) were not found to be significantly associated with survival (p = 0.69). Conclusions: This single-institute study reports the first survival data for GTD for Saudi Arabia. However, the overall incidence of GTD in Saudi Arabia will be defined by establishment of a GTD registry. ã 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Trophoblastic disease Incidence Survival rate
Introduction Gestational trophoblastic disease (GTD) represents a heterogeneous group of disorders characterized by abnormally formed placentas and neoplasms, elevated human chorionic gonadotropin (hCG), and a constellation of clinical symptoms. The World Health Organization (WHO) classification of GTD includes hydatidiform mole (HM), complete mole, partial mole, invasive mole, choriocarcinoma, placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour [1,2]. The classic presenting symptoms and clinical findings of HM include vaginal bleeding, passage of vesicles, anaemia, excessive uterine enlargement, toxaemia of pregnancy, hyperemesis gravidarum, hyperthyroidism, trophoblastic emboli and theca lutein cysts associated with an extremely high level of hCG [3]. Occasionally, the clinical presentation is incomplete or missed abortion [4]. Factors that have been associated with increased risk for HM include maternal age, previous molar pregnancy, parity, ethnicity, socioeconomic status and environmental exposure [1,5,6].
* Corresponding author. E-mail address: [email protected] (K. Sait). http://dx.doi.org/10.1016/j.ejogrb.2014.06.005 0301-2115/ ã 2014 Elsevier Ireland Ltd. All rights reserved.
Gestational trophoblastic neoplasia (GTN) (which may represent invasive mole, choriocarcinoma and PSTT) may be diagnosed after evacuation of a complete or partial molar pregnancy. It can also be diagnosed following abortion, ectopic pregnancy or normal pregnancy, typically based on plateauing of hCG level over at least 3 weeks, an increase of 10% in hCG level for three or more values over at least 2 weeks or persistent hCG 6 months after molar evacuation [7]. According to the prognostic scoring index of the modified WHO scoring system [8], the majority of women diagnosed with low-risk GTN can be treated with single-agent methotrexate (MTX) and folinic acid. Women with high-risk GTN require multi-agent chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) [5,9–11]. The reported incidence of GTD varies widely in different regions of the world at different times. In North America and Europe, HM occurs in approximately 0.5–1 per 1000 pregnancies [1]. Higher frequencies have been reported in some areas of Asia and the Middle East, with rates ranging from 1 to 12 per 1000 pregnancies [12,13]. In Saudi Arabia, studies have reported prevalence rates of HM of 0.94 per 1000 deliveries [14] and 2.2 per 1000 deliveries [15]. Felemban et al. reported that the prevalence of complete HM is 1
N. Anfinan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 180 (2014) 8–11 Table 1 Demographic data of patients (n = 122).
Table 3 Characteristics of patients with persistent and non-persistent gestational trophoblastic disease.
Variable
n
Age (years) Mean SD Range
31.52 10.8 15–56
Parity Median Range
3 0–7
Gestational age (weeks) Mean SD Range
12.42 3.2 4–22
Pre-evacuation level of hCG 100,000 u/ml
30 (25%) 92 (75%)
Nationality Saudi Non-Saudi
53 (43%) 69 (57%)
Median follow-up (months) Range
24 12–72
Odds ratio
Persistent (n = 65) n (%)
Non-persistent (n = 57) n (%)
p-value
Age (years) 40
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Gestational trophoblastic disease in the western region of Saudi Arabia (single-institute experience) Nisrin Anfinan, Khalid Sait *, Hesham Sait Scientific chair of prof. Abdullah Hussain Basalamah for Gynecological Cancer, Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 December 2013 Received in revised form 11 April 2014 Accepted 4 June 2014
Objective: To estimate the prevalence of gestational trophoblastic disease (GTD) in the western region of Saudi Arabia, and to evaluate the success of treatment and the effect of age and risk group on survival. Methods: Between January 2001 and December 2010, all patients treated for GTD were identified from the King Abdulaziz University Hospital database. Patients with persistent disease were evaluated according to their clinical treatment outcomes. Results: In total, 122 cases of GTD were identified in the database. Of these, 77 (63%) cases were diagnosed and received initial treatment at the study centre, resulting in an incidence of 1.26 cases per 1000 deliveries. The mean (standard deviation) age of the study participants was 31.52 10.8 years, mean gestational age at diagnosis was 12.42 3.2 weeks, and mean follow-up for each patient was 24 months. There were 20 cases (26%) of persistent GTD after treatment. The majority of patients with low-risk disease were treated with single-agent methotrexate, with an overall success rate of 83%. The overall 5year survival rate for all patients was 98%. Using the Wilcoxon (Gehan) test, risk group and age (cut-off 40 years) were not found to be significantly associated with survival (p = 0.69). Conclusions: This single-institute study reports the first survival data for GTD for Saudi Arabia. However, the overall incidence of GTD in Saudi Arabia will be defined by establishment of a GTD registry. ã 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Trophoblastic disease Incidence Survival rate
Introduction Gestational trophoblastic disease (GTD) represents a heterogeneous group of disorders characterized by abnormally formed placentas and neoplasms, elevated human chorionic gonadotropin (hCG), and a constellation of clinical symptoms. The World Health Organization (WHO) classification of GTD includes hydatidiform mole (HM), complete mole, partial mole, invasive mole, choriocarcinoma, placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour [1,2]. The classic presenting symptoms and clinical findings of HM include vaginal bleeding, passage of vesicles, anaemia, excessive uterine enlargement, toxaemia of pregnancy, hyperemesis gravidarum, hyperthyroidism, trophoblastic emboli and theca lutein cysts associated with an extremely high level of hCG [3]. Occasionally, the clinical presentation is incomplete or missed abortion [4]. Factors that have been associated with increased risk for HM include maternal age, previous molar pregnancy, parity, ethnicity, socioeconomic status and environmental exposure [1,5,6].
* Corresponding author. E-mail address: [email protected] (K. Sait). http://dx.doi.org/10.1016/j.ejogrb.2014.06.005 0301-2115/ ã 2014 Elsevier Ireland Ltd. All rights reserved.
Gestational trophoblastic neoplasia (GTN) (which may represent invasive mole, choriocarcinoma and PSTT) may be diagnosed after evacuation of a complete or partial molar pregnancy. It can also be diagnosed following abortion, ectopic pregnancy or normal pregnancy, typically based on plateauing of hCG level over at least 3 weeks, an increase of 10% in hCG level for three or more values over at least 2 weeks or persistent hCG 6 months after molar evacuation [7]. According to the prognostic scoring index of the modified WHO scoring system [8], the majority of women diagnosed with low-risk GTN can be treated with single-agent methotrexate (MTX) and folinic acid. Women with high-risk GTN require multi-agent chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) [5,9–11]. The reported incidence of GTD varies widely in different regions of the world at different times. In North America and Europe, HM occurs in approximately 0.5–1 per 1000 pregnancies [1]. Higher frequencies have been reported in some areas of Asia and the Middle East, with rates ranging from 1 to 12 per 1000 pregnancies [12,13]. In Saudi Arabia, studies have reported prevalence rates of HM of 0.94 per 1000 deliveries [14] and 2.2 per 1000 deliveries [15]. Felemban et al. reported that the prevalence of complete HM is 1
N. Anfinan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 180 (2014) 8–11 Table 1 Demographic data of patients (n = 122).
Table 3 Characteristics of patients with persistent and non-persistent gestational trophoblastic disease.
Variable
n
Age (years) Mean SD Range
31.52 10.8 15–56
Parity Median Range
3 0–7
Gestational age (weeks) Mean SD Range
12.42 3.2 4–22
Pre-evacuation level of hCG 100,000 u/ml
30 (25%) 92 (75%)
Nationality Saudi Non-Saudi
53 (43%) 69 (57%)
Median follow-up (months) Range
24 12–72
Odds ratio
Persistent (n = 65) n (%)
Non-persistent (n = 57) n (%)
p-value
Age (years) 40
