Is chemotherapy necessary for patients with molar pregnancy and human chorionic gonadotropin serum levels raised but falling at 6 months after uterine evacuation?

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 6 months 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 6 months 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 8 monthsp = 0.001), had a greater interval between uterine evacuation and initiating chemotherapy (8 versus 6 monthsp < 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. Conclusion. 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 6 months after evacuation. Instead, we pursue close hormonal and radiological surveillance as the best strategy for these patients. (C) 2016 Elsevier Inc. All rights reserved.Carlos Chagas Filho Foundation under the Brazilian Ministry of Science and TechnologyDonald P. Goldstein MD Trophoblastic Tumor Registry EndowmentDyett Family Trophoblastic Disease Research and Registry EndowmentUniv Fed Fluminense, Rio de Janeiro Trophoblast Dis Ctr, Antonio Pedro Univ Hosp, Matern Sch,Matern Ward Santa Casa Misericordia Ri, Rio De Janeiro, RJ, BrazilUniv Fed Fluminense, Postgrad Program Med Sci, Niteroi, RJ, BrazilUniv Fed Rio de Janeiro, Matern Sch, Postgrad Program Perinatal Hlth, Fac Med, Rio De Janeiro, RJ, BrazilSao Paulo State Univ, Trophoblast Dis Ctr, Clin Hosp, Botucatu Med Sch,Dept Gynecol & Obstet, Botucatu, SP, BrazilUniv Fed Sao Paulo, Paulista Sch Med, Sao Paulo Hosp, Trophoblast Dis Ctr, Sao Paulo, SP, BrazilUniv Sao Paulo, Sao Paulo Clin Hosp, Trophoblast Dis Ctr, Sao Paulo, SP, BrazilCaxias Do Sul Univ, Caxias Do Sul Trophoblast Dis Ctr, Gen Hosp Caxias Do Sul, Sch Med,Ctr Biol & Hlth Sci, Caxias Do Sul, MS USAIrmandade Santa Casa Misericordia Hosp, Porto Alegre Trophoblast Dis Ctr, Mario Totta Matern Ward, Porto Alegre, RS, BrazilGoias Fed Univ, Goias Trophoblast Dis Ctr, Clin Hosp Goias, Goiania, Go, BrazilHarvard Med Sch, Brigham & Womens Hosp, New England Trophoblast Dis Ctr, Div Gynecol Oncol,Dept Obstet & Gynecol & Reprod, Boston, MA USASão Paulo Hospital Trophoblastic Disease Center, Paulista School of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, São Paulo, BrazilWeb of Scienc