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Sun SY, Goldstein DP, Bernstein MR, Horowitz NS, Mattar R, Maestá I, Braga A, Berkowitz RS. Maternal Near Miss According to World Health Organization Classification Among Women with a Hydatidiform Mole: Experience at the New England Trophoblastic Disease Center, 1994-2013. J Reprod Med 2016; 61:210-214. [PMID: 27424360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To investigate the frequency of potentially life-threatening conditions (PLTCs) and maternal near misses (MNMs) at the New England Trophoblastic Disease Center (NETDC) in recent years, when there has been earlier diagnosis of molar pregnancy. STUDY DESIGN This study included patients with molar pregnancy at the NETDC between 1994 and 2013. Clinical and pathologic reports were reviewed. PLTC and MNM criteria and maternal deaths were searched in medical records using the World Health Organization criteria and classification. RESULTS We identified 375 patients with molar pregnancy and no patient developed a MNM or maternal death. Only 6 (1.6%) had PLTCs (hemorrhage with hemodynamic instability, severe preeclampsia, respiratory distress, blood transfusion, and ICU admission). CONCLUSION We observed a low rate of PLTC and no cases of MNMs or maternal deaths related to molar pregnancy, likely due to earlier diagnosis at the NETDC in recent years.
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Luckett R, Pena N, Vitonis A, Bernstein MR, Feldman S. Effect of patient navigator program on no-show rates at an academic referral colposcopy clinic. J Womens Health (Larchmt) 2015; 24:608-15. [PMID: 26173000 DOI: 10.1089/jwh.2014.5111] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patient navigators have been used successfully to guide vulnerable patients through barriers to cancer care and reduce disparities in cancer outcomes. This study evaluated the effect of a patient navigator program on no-show rates at a tertiary care referral colposcopy center and explored factors associated with missed appointments. METHODS No-show rates prior and subsequent to implementation of the intervention were compared by chi-square test. We compared patient demographic, lifestyle, and diagnostic characteristics between patients who had ever and never missed appointments. We described patient-reported barriers to care. RESULTS Of 4,199 women evaluated in our clinic from January 2006 to December 2013, 2,441 (58%) had at least one missed appointment. African American, Hispanic, and publicly insured women tended to miss appointments more frequently than did white and privately insured women (p<0.0001). Patients who missed appointments tended to have more abnormal cytology (p<0.0001), cervical pathology (p=0.007), and vulvar pathology (p=0.001). No-show rates declined from 49.7% to 29.5% after implementation of the patient navigator program (p<0.0001). We found that 45% of patient no-shows were anticipated or a result of patient misunderstanding and could be mediated with targeted education by the patient navigator. CONCLUSIONS Patient navigator programs at referral centers reduce no-show rates, thus improving patient follow-up, which may reduce disparities in cervical cancer screening and treatment.
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Affiliation(s)
- Rebecca Luckett
- 1 Department of Obstetrics and Gynecology, Brigham and Women's Hospital , Boston, Massachusetts
| | - Nancy Pena
- 2 Department of Gynecologic Oncology, Dana Farber Cancer Institute , Harvard Medical School, Boston, Massachusetts
| | - Allison Vitonis
- 1 Department of Obstetrics and Gynecology, Brigham and Women's Hospital , Boston, Massachusetts
| | - Marilyn R Bernstein
- 2 Department of Gynecologic Oncology, Dana Farber Cancer Institute , Harvard Medical School, Boston, Massachusetts
| | - Sarah Feldman
- 1 Department of Obstetrics and Gynecology, Brigham and Women's Hospital , Boston, Massachusetts
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Maestá I, Growdon WB, Goldstein DP, Bernstein MR, Horowitz NS, Rudge MVC, Berkowitz RS. Prognostic factors associated with time to hCG remission in patients with low-risk postmolar gestational trophoblastic neoplasia. Gynecol Oncol 2013; 130:312-6. [DOI: 10.1016/j.ygyno.2013.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 05/13/2013] [Accepted: 05/15/2013] [Indexed: 11/16/2022]
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Garner EIO, Lipson E, Bernstein MR, Goldstein DP, Berkowitz RS. Subsequent pregnancy experience in patients with molar pregnancy and gestational trophoblastic tumor. J Reprod Med 2002; 47:380-6. [PMID: 12063876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Modern therapy for molar pregnancy and gestational trophoblastic tumors has resulted in high cure rates and preservation of fertility, even in the setting of metastatic disease requiring chemotherapy. Patients and their partners facing future pregnancy after treatment for gestational trophoblastic disease express fear related to risk of disease recurrence and outcome of subsequent pregnancies. Data from the New England Trophoblastic Disease Center on later pregnancies following complete and partial mole as well as persistent gestational trophoblastic tumor show that patients, in general, can anticipate normal subsequent pregnancy outcomes.
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Affiliation(s)
- Elizabeth I O Garner
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Feltmate CM, Genest DR, Wise L, Bernstein MR, Goldstein DP, Berkowitz RS. Placental site trophoblastic tumor: a 17-year experience at the New England Trophoblastic Disease Center. Gynecol Oncol 2001; 82:415-9. [PMID: 11520134 DOI: 10.1006/gyno.2001.6265] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We reviewed cases of placental site trophoblastic tumors from the New England Trophoblastic Disease Center (NETDC) database from 1982-1999 in an effort to identify prognostic factors for recurrent disease. METHODS A chart review was performed utilizing patients identified from the NETDC database. Data obtained included patient age at diagnosis, antecedent pregnancy, duration and extent of disease, presenting symptoms, pre- and posttreatment hCG levels, diagnostic and therapeutic procedures, treatment and outcome of patients. Statistical analysis was performed using Student's t test and chi(2) test when appropriate. RESULTS Thirteen patients were identified. All ultimately underwent hysterectomy although initial treatment of 1 patient was uterine resection. There were 5 recurrences (43%)--3 among the 9 patients who had no metastases on presentation (33%) and 2 of 3 patients who presented with metastases (66%). The 5 patients who recurred were among 8 who had received peri- or postoperative chemotherapy (62.5%). Treatment of recurrences included continued or alternate chemotherapy, radiotherapy, and/or excision of locally recurrent disease. Follow up time averaged 56.2 months (range 12-182 months). One of the 4 patients receiving chemotherapy < or =1 week after hysterectomy recurred, whereas all 4 patients who received chemotherapy 3 weeks or more after hysterectomy recurred. Uterine tumor volume was significantly greater, 154.1 cm(3), in patients with initial metastases versus 42.3 cm(3) in patients without initial metastases (P = 0.04). Mitotic index (P = 0.04) was significantly increased in patients who developed recurrent disease. CONCLUSION High mitotic index appears to be an adverse prognostic indicator for recurrence. Hysterectomy remains the mainstay of treatment. Chemotherapy is indicated for patients with metastases and may be indicated when the mitotic index is >5 mitoses/10 HPF. Radiation treatment may play a role in recurrent disease but must be evaluated on a case-by-case basis.
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Affiliation(s)
- C M Feltmate
- Division of Gynecologic Oncology, Brigham and Womens Hospital, Boston, Massachusetts 02115, USA
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Berkowitz RS, Tuncer ZS, Bernstein MR, Goldstein DP. Management of gestational trophoblastic diseases: subsequent pregnancy experience. Semin Oncol 2000; 27:678-85. [PMID: 11130475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Patients with gestational trophoblastic disease (GTD) can usually achieve complete sustained remission while retaining their fertility even in the presence of wide-spread metastasis. Following complete and partial mole, our patients had 1,239 and 205 later pregnancies, respectively, which resulted in 68.6% and 74.1% term live births, respectively. Patients with either type of hydatidiform mole have, in general, a normal later pregnancy experience. After one molar pregnancy, the risk of a molar pregnancy in a later conception was about 1%. Our patients who received chemotherapy for persistent gestational trophoblastic tumor had 522 later pregnancies, which resulted in 358 (68.6%) term live births and only 10 (2.5%) major and minor congenital anomalies. Data from other centers involving 2,598 later pregnancies also indicate that after chemotherapy patients can generally anticipate a normal future reproductive outcome.
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Affiliation(s)
- R S Berkowitz
- New England Trophoblastic Disease Center, Department of Obstetrics and Gynecology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Schorge JO, Goldstein DP, Bernstein MR, Berkowitz RS. Recent advances in gestational trophoblastic disease. J Reprod Med 2000; 45:692-700. [PMID: 11027078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Recent advances have increased our understanding of gestational trophoblastic disease, and epidemiologic studies have demonstrated that there are important differences in risk factors for complete and partial mole. Complete moles are now increasingly being diagnosed in the first trimester, affecting their clinical presentation and pathologic characteristics. While important advances have been made in chemotherapy, it is now recognized that etoposide is associated with a risk of second tumors. Several studies have advanced understanding of the molecular biology of gestational trophoblastic disease, and this is important for the eventual development of new and innovative therapy.
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Affiliation(s)
- J O Schorge
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Benson CB, Genest DR, Bernstein MR, Soto-Wright V, Goldstein DP, Berkowitz RS. Sonographic appearance of first trimester complete hydatidiform moles. Ultrasound Obstet Gynecol 2000; 16:188-191. [PMID: 11117091 DOI: 10.1046/j.1469-0705.2000.00201.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Complete hydatidiform moles are now being diagnosed earlier in gestation, thus the clinical presentation and pathologic findings of complete molar pregnancy have changed. We studied the sonographic appearance of first trimester moles and the ability of ultrasound to detect them. METHODS We reviewed the sonographic interpretation and sonograms, when available, from all patients with first trimester complete moles diagnosed at our institution from January 1988 to March 1996. RESULTS Of the 24 patients in our study, the mean gestational age at time of the sonogram was 8.7 +/- 2.0 weeks (mean +/- SD) with a range of 5.7-12.3 weeks. The initial sonographic interpretation was a complete mole in 17 (71%) cases, partial mole versus failed pregnancy in two (8%), and failed pregnancy in five (21%) cases. Of the 22 patients with sonograms available for review, interpretation on review of the images was a complete mole in 18 (82%) cases, partial mole versus failed pregnancy in one (5%), and failed pregnancy in three (14%) cases. The typical sonographic appearance of a first trimester complete mole was a complex, echogenic, intra-uterine mass containing many small cystic spaces. CONCLUSION The majority of first trimester complete moles demonstrate a typical ultrasound appearance such that the diagnosis can be made with ultrasound in most cases.
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Affiliation(s)
- C B Benson
- Department of Radiology, New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Harvard Medical School and Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
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Abstract
Patients diagnosed with molar pregnancy are treated by either suction curettage or hysterectomy, depending on their desire to preserve fertility. We use single-agent chemotherapy, preferably methotrexate, to treat low- or moderate-risk persistent trophoblastic tumors. High-risk patients who have metastatic disease are treated primarily with combination chemotherapy and, as indicated, adjuvant radiotherapy or surgery. We perform a hysterectomy in all cases of placental-site trophoblastic tumors; combination chemotherapy is used if there is evidence of metastatic disease.
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Affiliation(s)
- J O Schorge
- Division of Gynecologic Oncology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Abstract
OBJECTIVE The aim of this study was to determine the role of parental factors that may relate to the pathogenesis of molar pregnancy. METHODS A retrospective review of six patients who had a molar pregnancy with at least two different partners at New England Trophoblastic Disease Center between 1965 and March 1999 was performed. RESULTS A total of 34 pregnancies with 20 different partners were observed in 6 patients. These pregnancies resulted in 15 (44.1%) hydatidiform moles, 8 (23.5%) term live births, 7 (20.6%) therapeutic abortions, 3 (8.8%) spontaneous abortions, and 1 preterm delivery. While 5 patients had a molar pregnancy with 2 different partners, 1 patient had a molar pregnancy with 3 different partners. Two patients developed persistent postmolar gestational trophoblastic tumor in 3 (20.0%) of the 15 episodes of molar pregnancy. Three of the male partners reported a total of 7 healthy children from prior relationships. CONCLUSION The experience in these six patients suggests that a primary oocyte problem may contribute to the development of molar pregnancy.
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Affiliation(s)
- Z S Tuncer
- Gillette Center for Women's Cancers, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts 02115, USA
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Abstract
OBJECTIVE To determine the outcome of subsequent pregnancies in patients with partial or complete molar pregnancy who conceive before completing the recommended hCG follow-up of at least 6 months. METHODS Retrospective record review of patients with partial or complete mole who conceived before the standard gonadotropin follow-up of 6 months was completed during 1980-1998. RESULTS Sixty-seven patients with molar pregnancy who conceived before completion of hCG follow-up were identified. Thirty-five (52.2%) patients had a prior partial mole, and 32 (47.8%) had a prior complete mole. The mean interval from first achieving undetectable hCG level to new pregnancy was 3.1 and 3.4 months in patients with partial and complete mole, respectively. Eleven patients underwent elective termination, and 12 were lost to follow-up. Of the remaining 44 patients, 33 (75.0%) had live births, 10 had spontaneous abortions, and one had an ectopic pregnancy. A viable pregnancy outcome was achieved in 20 (83.3%) of 24 patients with partial mole and 13 (65.0%) of 20 patients with complete mole. None of the patients developed any evidence of postmolar persistent gestational trophoblastic tumor. None of the live births had any detectable fetal anomalies. CONCLUSION The risk of persistent tumor is low and reproductive outcome is favorable once undetectable hCG levels are achieved. Pregnancies occurring before the completion of recommended hCG follow-up may be allowed to continue under careful surveillance.
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Affiliation(s)
- Z S Tuncer
- New England Trophoblastic Disease Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Tuncer ZS, Bernstein MR, Goldstein DP, Berkowitz RS. Outcome of pregnancies occurring before completion of human chorionic gonadotropin follow-up in patients with persistent gestational trophoblastic tumor. Gynecol Oncol 1999; 73:345-7. [PMID: 10366457 DOI: 10.1006/gyno.1999.5437] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the outcome of pregnancies occurring before completion of human chorionic gonadotropin follow-up in patients treated with chemotherapy for gestational trophoblastic tumor. METHODS Retrospective record review of patients with gestational trophoblastic tumor who conceived before standard hCG follow-up was completed during 1973-1998. RESULTS Forty-three patients treated for gestational trophoblastic tumors conceived before human chorionic gonadotropin follow-up was completed. The antecedent pregnancy was complete mole in 31 (72.1%) and partial mole in 12 (27. 9%) patients. Of the 43 patients, 39 (90.7%) had stage I, 1 had stage II, and 3 had stage III disease. The mean interval from human chorionic gonadotropin remission to new pregnancy was 6.3 months (range 1-11 months). Ten patients underwent elective termination and four patients were lost to follow-up. Of the remaining 29 patients, 22 (75.9%) had term live births, 3 (10.3%) had preterm delivery, 3 had spontaneous abortion, and 1 (3.5%) had a repeat mole. Two cases of fetal anomalies were detected; one was inherited polydactyly and the other was hydronephrosis. One patient developed choriocarcinoma with lung involvement and underwent cesarean section at 28 weeks; a normal fetus was delivered and no choriocarcinoma was detected in the placenta. CONCLUSION Pregnancies occurring in patients treated for gestational trophoblastic tumor before standard human chorionic gonadotropin follow-up is completed may continue under close clinical surveillance since the majority have a favorable outcome. However, patients should also be advised of the low but important risk of delayed diagnosis in case tumor relapse develops during early subsequent pregnancy.
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Affiliation(s)
- Z S Tuncer
- Gillette Center for Women's Cancers, Harvard Medical School, Boston, Massachusetts 02115, USA
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Rodabaugh KJ, Bernstein MR, Goldstein DP, Berkowitz RS. Natural history of postterm choriocarcinoma. J Reprod Med 1998; 43:75-80. [PMID: 9475153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To review the 32-year experience of the New England Trophoblastic Disease Center (NETDC) with choriocarcinoma occurring after a term gestation and to evaluate potential prognostic factors using the World Health Organization (WHO) prognostic score. STUDY DESIGN The charts of 44 women who were treated for postterm choriocarcinoma at the NETDC from August 1964 to January 1996 were retrospectively reviewed. Demographic data and details of the clinical course were determined. Potential risk factors, including disease duration, pretreatment human chorionic gonadotropin (hCG) level, sites of metastases and stage, as well as data regarding the infants and previous and subsequent pregnancies, were evaluated. RESULTS Five (11%) of the infants suffered significant complications secondary to maternal choriocarcinoma. The time interval from delivery to diagnosis, pretreatment hCG level and sites of metastatic disease were all significant risk factors in predicting outcome. All 31 patients with a WHO score < or = 8 survived, and 6/13 (46%) patients with a WHO score > 8 died. CONCLUSION Disease duration greater than four months from delivery, pretreatment hCG level > 100,000 mIU/mL, presence of liver or brain metastases, and a WHO score > 8 were all important predictors of outcome in patients with postterm choriocarcinoma.
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Affiliation(s)
- K J Rodabaugh
- New England Trophoblastic Disease Center, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Berkowitz RS, Im SS, Bernstein MR, Goldstein DP. Gestational trophoblastic disease. Subsequent pregnancy outcome, including repeat molar pregnancy. J Reprod Med 1998; 43:81-6. [PMID: 9475154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine subsequent reproductive outcomes in patients treated for partial molar pregnancy, complete molar pregnancy and persistent gestational trophoblastic tumors at the New England Trophoblastic Disease Center (NETDC) between June 1, 1965, and December 31, 1996. STUDY DESIGN Questionnaires were mailed to all patients followed at the NETDC to assess subsequent pregnancy experience. All patients and their referring physicians were also requested to inform the NETDC about later pregnancies. RESULTS Following partial mole, complete mole and persistent gestational trophoblastic tumor, our patients had 195, 1,234 and 504 later pregnancies, respectively. These patients had a later pregnancy experience comparable to that of the general population. However, after having one molar pregnancy, the risk of molar pregnancy in a later conception was about 1%. Twenty-nine of our patients had at least two episodes of molar pregnancy; following two episodes of molar pregnancy, 6 (23.1%) of 26 later conceptions resulted in another molar gestation. CONCLUSION Patients with partial mole, complete mole and persistent gestational trophoblastic tumor can be reassured that in general they can anticipate a normal future reproductive outcome.
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Affiliation(s)
- R S Berkowitz
- New England Trophoblastic Disease Center, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Goldstein DP, Zanten-Przybysz IV, Bernstein MR, Berkowitz RS. Revised FIGO staging system for gestational trophoblastic tumors. Recommendations regarding therapy. J Reprod Med 1998; 43:37-43. [PMID: 9475148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the revised International Federation of Gynecology and Obstetrics (FIGO) staging system for gestational trophoblastic tumors (GTT) and to recommend therapy. STUDY DESIGN Review of the literature regarding the development of the FIGO staging system, the World Health Organization (WHO) prognostic scoring system and Hammond's clinical classification for GTT plus analysis of response to single-agent chemotherapy in 546 patients treated at the New England Trophoblastic Disease Center. RESULTS The revised FIGO staging system appears to successfully combine anatomic staging and a prognostic clinical classification. The revised FIGO staging system reliably predicts treatment outcome and therefore can be used to help select optimal treatment protocols. CONCLUSION The revised FIGO staging system is capable of predicting patients who respond poorly to single-agent chemotherapy, appears to reliably predict outcome and therefore can be used to help select appropriate treatment protocols.
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Affiliation(s)
- D P Goldstein
- New England Trophoblastic Disease Center, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Abstract
A 45-year-old man presented with an incidentally discovered benign renal angiomyolipoma. This lesion initially demonstrated renal vein involvement. On referral to our institution 3 years later, there was interval progression of tumor thrombus to the intrahepatic inferior vena cava. Intravascular extension of benign angiomyolipoma, though rare, has been reported. We present a new example and review the literature concerning this unusual complication of a common renal neoplasm.
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Affiliation(s)
- M R Bernstein
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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Soto-Wright V, Goldstein DP, Bernstein MR, Berkowitz RS. The management of gestational trophoblastic tumors with etoposide, methotrexate, and actinomycin D. Gynecol Oncol 1997; 64:156-9. [PMID: 8995566 DOI: 10.1006/gyno.1996.4534] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of etoposide, methotrexate, and actinomycin D (EMA) as primary and secondary therapy for gestational trophoblastic tumor (GTT). METHODS In a retrospective study, the medical records of all patients with middle-risk metastatic GTT or nonmetastatic choriocarcinoma receiving primary EMA and patients with GTT resistant to single-agent regimens treated with secondary EMA were reviewed. Hematologic toxicity was graded using WHO criteria. RESULTS Seven patients received primary EMA with 5 (67%) achieving remission. Twenty-two patients with resistance to single-agent regimens received secondary EMA with 21 (95%) achieving remission. The most acute hematologic toxicity was grade 1 or 2. Only 2 of 90 EMA cycles were associated with grade 4 toxicity requiring hospital admission. CONCLUSION Although EMA effectively induces remission with minimal acute hematologic toxicity in the primary and secondary therapy of GTT, recently published data regarding secondary tumors associated with etoposide exposure should restrict its use to patients who absolutely require etoposide to achieve remission.
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Affiliation(s)
- V Soto-Wright
- New England Trophoblastic Disease Center, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Berkowitz RS, Bernstein MR, Harlow BL, Rice LW, Lage JM, Goldstein DP, Cramer DW. Case-control study of risk factors for partial molar pregnancy. Am J Obstet Gynecol 1995; 173:788-94. [PMID: 7573245 DOI: 10.1016/0002-9378(95)90342-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The purpose of our study was to identify risk factors for partial molar pregnancy from a woman's general, reproductive, and dietary history. STUDY DESIGN Sixty-five women with pathologically confirmed partial molar pregnancy were interviewed, and their experiences were compared with those of 130 age-matched control women who had successfully completed a pregnancy with delivery of a live infant at the same hospital during the same calendar period. RESULTS Multivariate analysis revealed that exposures which independently and significantly predicted increased risk for partial molar pregnancy included irregular cycles, pregnancy histories including only male infants among prior live births, and oral contraceptive use for > 4 years. Dietary factors previously postulated for complete molar pregnancy including protein, fat, vitamin A, or carotene were found not to be related to risk for partial molar pregnancy. CONCLUSION Epidemiologic patterns for complete and partial molar pregnancies appear to differ somewhat; risk for partial mole is associated with reproductive history but not dietary factors.
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Affiliation(s)
- R S Berkowitz
- New England Trophoblastic Disease Center, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
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Wenzel LB, Berkowitz RS, Robinson S, Goldstein DP, Bernstein MR. Psychological, social and sexual effects of gestational trophoblastic disease on patients and their partners. J Reprod Med 1994; 39:163-7. [PMID: 8035371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The psychological, social and sexual effects of gestational trophoblastic disease in both patients and their partners are reviewed. The results suggest that despite the favorable prognosis of this disease, mood disturbances, sexual disturbances and fertility concerns can persist in both patients and their partners. Recommendations are made concerning providing supportive care to meet the needs of patients and their partners.
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Affiliation(s)
- L B Wenzel
- Memorial Cancer Institute, Long Beach Memorial Medical Center, California
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Berkowitz RS, Bernstein MR, Laborde O, Goldstein DP. Subsequent pregnancy experience in patients with gestational trophoblastic disease. New England Trophoblastic Disease Center, 1965-1992. J Reprod Med 1994; 39:228-32. [PMID: 8035378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We reviewed the subsequent pregnancy outcome in patients with partial mole, complete mole and persistent gestational trophoblastic tumor treated at the New England Trophoblastic Disease Center from June 1, 1965, to December 31, 1992. Such patients can be assured that they can anticipate a normal future reproductive outcome. However, when a patient has had a molar pregnancy, she is at increased risk (1%) of developing molar disease in a subsequent conception.
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Affiliation(s)
- R S Berkowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Steller MA, Genest DR, Bernstein MR, Lage JM, Goldstein DP, Berkowitz RS. Clinical features of multiple conception with partial or complete molar pregnancy and coexisting fetuses. J Reprod Med 1994; 39:147-54. [PMID: 8035369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The estimated incidence of twin pregnancy consisting of hydatidiform mole and a coexisting fetus is 1 per 22,000-100,000 pregnancies. Since 1965, nine patients with this entity have been treated at the New England Trophoblastic Disease Center (NETDC), Boston. One patient had a partial hydatidiform mole coexisting with a normal placenta and fetus. The other eight patients had twin pregnancies with a complete hydatidiform mole (CHM) and coexisting fetus. We compared the clinical outcomes in these 8 patients and 14 additional published case reports of multiple gestations composed of CHM and coexisting fetuses with a group of 71 patients with singleton CHM treated at NETDC. Twelve of the 22 patients (55%) with CHM and coexisting fetuses developed persistent gestational trophoblastic tumor, requiring chemotherapy. Five of these patients developed metastases requiring multiple cycles of chemotherapy to achieve remission. The presenting symptoms of multiple conception with CHM and coexisting fetuses were similar to those in patients with a singleton conception and complete mole. However, as compared to singleton CHM, patients having a multiple conception with CHM and coexisting fetuses were diagnosed at a later gestational age, had higher preevacuation beta-human chorionic gonadotropin levels and had a greater propensity to develop persistent tumor. These data indicate that patients with multiple conceptions consisting of CHM and coexisting fetuses are at high risk of developing persistent gestational trophoblastic tumor.
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Affiliation(s)
- M A Steller
- New England Trophoblastic Disease Center, Brigham and Women's Hospital, Boston, Massachusetts 02115
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Steller MA, Genest DR, Bernstein MR, Lage JM, Goldstein DP, Berkowitz RS. Natural history of twin pregnancy with complete hydatidiform mole and coexisting fetus. Obstet Gynecol 1994; 83:35-42. [PMID: 8272304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To investigate the clinical features and natural history of twin conceptions consisting of complete hydatidiform mole and a coexisting fetus. METHODS Since 1973, eight well-documented cases of twin pregnancy with complete hydatidiform mole and coexisting fetus have been treated at the New England Trophoblastic Disease Center (NETDC). The clinical features of these eight patients were compared to 71 patients with singleton complete hydatidiform mole treated at the NETDC and with the published experience of other investigators. Flow cytometric analysis of DNA content was performed in addition to histologic inspection to assist in confirming the diagnosis of twin pregnancy with complete hydatidiform mole and coexisting fetus. RESULTS Five of the eight patients in this series developed persistent gestational trophoblastic tumor requiring chemotherapy. Three of these five patients developed metastases requiring multi-agent chemotherapy to achieve remission. The presenting symptoms of twin pregnancy with complete hydatidiform mole and coexisting fetus were similar to those in patients with a singleton complete mole. However, compared to singleton complete molar gestation, a twin pregnancy with complete mole and coexisting fetus was diagnosed at a later gestational age, had higher preevacuation beta-hCG levels, and had a greater propensity to develop persistent gestational trophoblastic tumor. CONCLUSION Our findings indicate that patients with complete hydatidiform mole and coexisting fetus are at high risk for developing persistent gestational trophoblastic tumor.
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Affiliation(s)
- M A Steller
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
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23
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Abstract
Hydropic placentas may be classified by histopathology into hydropic abortus, partial hydatidiform mole, and complete hydatidiform mole. We studied 142 hydropic placentas: 39% were complete hydatidiform moles, 35% partial hydatidiform moles, and 26% hydropic abortuses. Villous vesicle size was predictive of histologic diagnosis. We determined DNA ploidy in 137 cases. Seventy-three percent of hydropic abortuses were diploid and 11% were triploid. Ninety percent of partial moles were triploid or near-triploid; one partial mole was haploid and one diploid. Of the complete moles, 50% were diploid, 43% were tetraploid, 3.6% polyploid, and 1.7% triploid. Partial moles had lower pre-evacuation beta-hCG levels than complete moles. Persistent tumor followed 33% of complete moles and 12% of partial moles. Although the numbers were small, no patient with a diploid, tetraploid, aneuploid, or haploid partial mole developed persistent disease. Among complete moles, the pre-evacuation beta-hCG level was not predictive of persistence (P = .15). Subdividing complete moles by ploidy, we found that tetraploid moles were associated with higher pre-evacuation beta-hCG levels than were diploid moles. However, tetraploidy was not associated with increased persistent tumor among complete moles. Although most partial moles were triploid and most complete moles were diploid or tetraploid, there was wider DNA heterogeneity among molar gestations than previously reported. In this series, DNA ploidy was not an independent predictor of persistence in complete moles.
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Affiliation(s)
- J M Lage
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
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24
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Genest DR, Laborde O, Berkowitz RS, Goldstein DP, Bernstein MR, Lage J. A clinicopathologic study of 153 cases of complete hydatidiform mole (1980-1990): histologic grade lacks prognostic significance. Obstet Gynecol 1991; 78:402-9. [PMID: 1876374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Although the significance of histologic grading in hydatidiform mole has previously been investigated, most studies evaluated patients treated before 1975. Since 1975, many advances have been made in the understanding and treatment of hydatidiform mole, including the division of molar pregnancy into complete and partial hydatidiform mole. We retrospectively studied 153 cases of complete hydatidiform mole diagnosed and treated at the Brigham and Women's Hospital between 1980-1990 to determine the current prognostic significance of histologic grading in this disease. The histologic grade (based on the criteria of Hertig and Sheldon) was compared with the subsequent clinical course, including the rates of spontaneous remission, persistent gestational trophoblastic tumor, metastatic disease, "high-risk" metastatic disease, chemotherapy resistance, and survival. The histologic grade of the original complete hydatidiform mole did not correlate significantly with any index of clinical outcome evaluated.
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Affiliation(s)
- D R Genest
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
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25
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Dobkin GR, Berkowitz RS, Goldstein DP, Bernstein MR, Doubilet PM. Duplex ultrasonography for persistent gestational trophoblastic tumor. J Reprod Med 1991; 36:14-6. [PMID: 2008004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Duplex ultrasonography was performed on 17 consecutive patients being evaluated for persistent gestational trophoblastic tumor (GTT). All patients had had a prior molar pregnancy evacuated and presented with a rise or plateau in their beta-human chorionic gonadotropin levels. The ultrasonography was considered to be abnormal if the image demonstrated a focal area of altered echogenicity within the uterus or if Doppler scanning revealed a focal area of detectable intrauterine blood flow. The ultrasound findings were compared with the pathologic results from dilation and curettage specimens. Ten of the 17 patients had pathologically proven macroscopic tumor. Of those 10, 7 had an abnormal sonographic image (sensitivity, 70%), and 9 had an abnormal Doppler examination (sensitivity, 90%). In all 10 patients the image and/or Doppler examination was abnormal. Among four patients with microscopic disease, imaging was positive in one case, and the Doppler examination was positive in three. Imaging and Doppler ultrasonography are complementary modalities that can reliably detect persistent uterine GTT, and Doppler ultrasonography appears to be more sensitive than imaging in making this diagnosis.
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Affiliation(s)
- G R Dobkin
- Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115
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26
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Lage JM, Berkowitz RS, Rice LW, Goldstein DP, Bernstein MR, Weinberg DS. Flow cytometric analysis of DNA content in partial hydatidiform moles with persistent gestational trophoblastic tumor. Obstet Gynecol 1991; 77:111-5. [PMID: 1845777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Hydatidiform moles may be classified as partial or complete based on genetic and pathologic criteria. Between January 1979 and January 1990, 17 (5.5%) of 310 patients followed for partial mole developed persistent gestational trophoblastic tumor. Tissues from 14 partial moles were available for flow cytometric analysis of DNA content. Eleven partial moles (85%) were triploid, two (15%) were diploid, and one DNA histogram was uninterpretable. All patients with triploid partial moles achieved complete remission with one course of single-agent chemotherapy. The two with diploid partial mole required multiple courses of chemotherapy to achieve gonadotropin remission. Although the DNA content of most partial moles with persistent gestational trophoblastic tumor was triploid, diploid partial moles with persistent tumor were less sensitive to single-agent chemotherapy.
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Affiliation(s)
- J M Lage
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
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27
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Berkowitz RS, Goldstein DP, Bernstein MR. Evolving concepts of molar pregnancy. J Reprod Med 1991; 36:40-4. [PMID: 1848899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Molar pregnancy is composed of two distinct clinical and pathologic entities, complete and partial mole. Knowledge of the cytogenetic origin, natural history and treatment of complete and partial hydatidiform mole is evolving.
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Affiliation(s)
- R S Berkowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts 02115
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28
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Muto MG, Lage JM, Berkowitz RS, Goldstein DP, Bernstein MR. Gestational trophoblastic disease of the fallopian tube. J Reprod Med 1991; 36:57-60. [PMID: 1848902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Tubal gestational trophoblastic disease (GTD) was diagnosed in 16 (0.8%) of 2,100 women with GTD managed at the New England Trophoblastic Disease Center. Tubal partial mole, complete mole and choriocarcinoma were present in 5, 5 and 6 patients, respectively. Patients with tubal GTD were not clinically distinguishable from those with traditional tubal pregnancies. While only one patient with tubal mole developed metastases, four patients with tubal choriocarcinoma presented with metastases. All the patients achieved complete, sustained remission.
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Affiliation(s)
- M G Muto
- Department of Obstetrics and Gynecology Brigham and Women's Hospital, Boston Massachusetts 02115
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29
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Rice LW, Genest DR, Berkowitz RS, Goldstein DP, Bernstein MR, Redline RW. Pathologic features of sharp curettings in complete hydatidiform mole. Predictors of persistent gestational trophoblastic disease. J Reprod Med 1991; 36:17-20. [PMID: 1848894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The medical records and pathologic specimens were reviewed from 33 patients with complete molar pregnancy at Brigham and Women's Hospital between 1980 and 1989. Two pathologists (D.R.G. and R.W.R.) reviewed all slides from the original sharp curettage to identify pathologic features that may be associated with persistent gestational trophoblastic tumor (GTT). The pathologic features evaluated were implantation site, presence of myometrium, presence of villi, presence and degree of atypia in cytotrophoblast, syncytiotrophoblast and intermediate trophoblast, presence of fibrinoid, presence of implantation site inflammatory cells, volume of tissue and area of trophoblastic tissue. Only one pathologic feature, fibrinoid deposits, identified in sharp curettings was associated with the development of persistent GTT. While 12 (48%) of 25 patients who attained remission without chemotherapy had fibrinoid deposits, only 1 (12.5%) of 8 patients who developed persistent GTT had them (P less than .10).
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Affiliation(s)
- L W Rice
- Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA
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30
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Berkowitz RS, Goldstein DP, Bernstein MR. Reproductive experience after complete and partial molar pregnancy and gestational trophoblastic tumors. J Reprod Med 1991; 36:3-8. [PMID: 1848896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We reviewed the subsequent pregnancy experience in patients with complete and partial mole and gestational trophoblastic tumors who were managed at the New England Trophoblastic Disease Center between June 1965 and December 1989. Such patients should be reassured that they can anticipate a normal reproductive outcome in the future.
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Affiliation(s)
- R S Berkowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, MA 02115
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31
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DuBeshter B, Berkowitz RS, Goldstein DP, Bernstein MR. Management of low-risk metastatic gestational trophoblastic tumors. J Reprod Med 1991; 36:36-9. [PMID: 1848898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The clinical course of 48 patients with low-risk metastatic gestational trophoblastic tumors (GTTs) treated with primary single-agent chemotherapy was reviewed. All patients achieved sustained remission, although 25 (51%) required a second single-agent regimen, and 7 (14%) needed combination chemotherapy to achieve it. An average of 3.4 courses of chemotherapy were necessary to achieve remission, and 6 patients (12%) underwent resection of resistant tumor foci. Primary single-agent chemotherapy is a reasonable treatment option in patients with low-risk metastatic GTT.
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Affiliation(s)
- B DuBeshter
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine, Strong Memorial Hospital, NY
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32
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Abstract
The current study investigates the clinical characteristics of patients with partial molar pregnancy who developed persistent gestational trophoblastic tumor (GTT). Between January 1979 and January 1989, 16 of 240 (6.6%) patients, who were followed for partial mole, developed persistent GTT. Fifteen (94%) patients were diagnosed as having a missed abortion before evacuation and only 1 patient presented with excessive uterine size and theca lutein ovarian cysts and was felt to have molar disease. No patient presented with toxemia, hyperemesis, or hyperthyroidism. All 16 patients developed nonmetastatic GTT. Fifteen patients achieved complete remission with methotrexate-citrovorum factor and only 1 patient required combination chemotherapy to attain remission. None of the patients had histologic evidence of choriocarcinoma. Patients with partial mole who developed persistent GTT did not have clinical or pathological characteristics that distinguished them from other patients with partial mole. All patients with partial mole should be followed with measurement of hCG levels to assure gonadotropin remission.
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Affiliation(s)
- L W Rice
- New England Trophoblastic Disease Center, Boston, Massachusetts
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33
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Berkowitz RS, Goldstein DP, Bernstein MR. Methotrexate infusion and folinic acid in the primary therapy of nonmetastatic gestational trophoblastic tumors. Gynecol Oncol 1990; 36:56-9. [PMID: 2153091 DOI: 10.1016/0090-8258(90)90108-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Thirty-two patients with nonmetastatic gestational trophoblastic tumors were treated with methotrexate infusion and folinic acid and the results of this therapy were compared to our prior experience with the 8-day methotrexate-folinic acid regimen. Complete remission was achieved in 22 of 32 (68.7%) patients treated with methotrexate infusion and 147 of 163 (90.2%) patients treated with the 8-day regimen (P less than 0.01). One course of chemotherapy induced complete remission in 19 (86.3%) patients treated with methotrexate infusion and 121 (82.2%) patients treated with the 8-day regimen. All 10 patients resistant to methotrexate infusion later achieved remission with other chemotherapy. Following methotrexate infusion, no patient developed myelosuppression, hepatotoxicity, or alopecia. Efforts should continue to identify new chemotherapeutic protocols that maximize remission rates and minimize toxicity and hospitalization.
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Affiliation(s)
- R S Berkowitz
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
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34
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Rice LW, Lage JM, Berkowitz RS, Goldstein DP, Bernstein MR. Repetitive complete and partial hydatidiform mole. Obstet Gynecol 1989; 74:217-9. [PMID: 2748058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Fifteen patients with repetitive hydatidiform mole were followed at the New England Trophoblastic Disease Center between 1965-1988. The medical records were examined to determine the patients' age, gravidity, parity, clinical presentation, development of post-molar tumor, and subsequent pregnancy experience. Each molar tissue was reviewed pathologically. Seven patients had repetitive complete hydatidiform mole and three developed persistent post-molar disease after their later mole. Five patients had an initial complete hydatidiform mole followed by a partial hydatidiform mole; two developed persistent post-molar disease after the partial mole. One patient had an initial partial hydatidiform mole followed by a complete hydatidiform mole and required chemotherapy after her complete mole. Two patients had repetitive partial hydatidiform mole, and neither developed post-molar disease. Four of the patients with repetitive mole later achieved a normal viable pregnancy. Molar pregnancies must be categorized as either complete or partial to provide meaningful data concerning repetitive hydatidiform mole.
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Affiliation(s)
- L W Rice
- Department of Obstetrics and Gynecology, New England Trophoblastic Disease Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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35
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Finkler NJ, Berkowitz RS, Driscoll SG, Goldstein DP, Bernstein MR. Clinical experience with placental site trophoblastic tumors at the New England Trophoblastic Disease Center. Obstet Gynecol 1988; 71:854-7. [PMID: 2835717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
From 1982-1986, seven patients with pathologically confirmed placental site trophoblastic tumors underwent treatment at the New England Trophoblastic Disease Center. All seven patients presented with nonmetastatic disease; the presenting symptom was vaginal bleeding in six patients and amenorrhea in one patient. Mitotic counts of the tumor may vary among endometrial curettings, hysterectomy specimens, and metastatic lesions. When placental site trophoblastic tumor is diagnosed on endometrial curettage, a thorough metastatic workup should be undertaken. Because of this tumor's poor response to chemotherapy, a diagnosis of nonmetastatic placental site trophoblastic tumor should be followed by prompt hysterectomy.
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Affiliation(s)
- N J Finkler
- Department of Obstetrics and Gynecology, Harvard Medical School, Boston, Massachusetts
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36
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Abstract
The course of 51 patients with high-risk metastatic gestational trophoblastic tumor was reviewed. The clinical characteristics and therapy of patients who died were compared to patients who attained remission to identify parameters that are associated with treatment failure. The presence of liver, brain, or intestinal metastases and the failure of prior chemotherapy were found to portend a poor prognosis (P less than 0.001, P less than 0.05). Other high-risk factors such as markedly elevated HCG levels, time interval greater than 4 months from the antecedent pregnancy to treatment, and post-term choriocarcinoma were not independently associated with treatment failure. The mean prognostic score and the mean number of high-risk factors for patients who died were 13 and 3, as compared to 7 and 2, respectively, for patients who achieved remission (P less than 0.001, P less than 0.001). Alternative intensive chemotherapy regimens need to be developed to improve remission rates in patients with liver, brain, or intestinal metastases, failed prior chemotherapy, or a high prognostic score.
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Affiliation(s)
- B DuBeshter
- New England Trophoblastic Disease Center, Brigham & Women's Hospital, Department of Obstetrics and Gynecology, Harvard Medical School, Boston, Massachusetts 02115
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37
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Berkowitz RS, Goldstein DP, Bernstein MR, Sablinska B. Subsequent pregnancy outcome in patients with molar pregnancy and gestational trophoblastic tumors. J Reprod Med 1987; 32:680-4. [PMID: 2822923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Subsequent pregnancy outcome was reviewed in patients with complete and partial mole and persistent gestational trophoblastic tumors who were treated at the New England Trophoblastic Disease Center between Jun 1, 1965, and Dec 31, 1986. In general, these patients can be reassured that they can anticipate a normal reproductive outcome in the future.
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Affiliation(s)
- R S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Brigham and Women's Hospital, Boston, MA 02115
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38
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Berkowitz RS, Goldstein DP, DuBeshter B, Bernstein MR. Management of complete molar pregnancy. J Reprod Med 1987; 32:634-9. [PMID: 3312599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This review of the current management of complete molar pregnancy is based upon the clinical experience at the New England Trophoblastic Disease Center. Suction curettage is the preferred method of molar evacuation regardless of uterine size in patients who desire to preserve fertility. Prophylactic chemotherapy may be useful in the management of high-risk molar pregnancy, especially when hormonal follow-up is either unavailable or unreliable. All patients must be followed with serial human chorionic gonadotropin levels to ensure that remission has occurred.
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Affiliation(s)
- R S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Brigham and Women's Hospital, Boston, MA 02115
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39
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DuBeshter B, Berkowitz RS, Goldstein DP, Cramer DW, Bernstein MR. Metastatic gestational trophoblastic disease: experience at the New England Trophoblastic Disease Center, 1965 to 1985. Obstet Gynecol 1987; 69:390-5. [PMID: 3029641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This report reviews the results of therapy in 93 patients with metastatic gestational trophoblastic tumor treated from 1965-1985. Complete remission was achieved in all 42 patients with low-risk metastatic disease and in 34 of 51 patients (67%) with high-risk metastatic disease. Single-agent chemotherapy induced complete remission in 38 of 42 patients (91%) with low-risk metastatic disease. Survival of high-risk patients has improved markedly over the past two decades; complete remission was attained in 13 of 24 high-risk patients (54%) from 1965-1975, and in 21 of 27 (78%) from 1976-1985. Survival correlated with the number of high-risk factors, the prognostic score, and the type of treatment. From 1965-1975, 54% (13 of 24) of high-risk patients were treated with single-agent chemotherapy alone, while in the last decade only 7% (two of 27) were so treated. Twenty-one patients with traditional high-risk factors had a prognostic score of 7 or less, and all achieved remission, with 67% (14 of 21) treated with primary single-agent chemotherapy. The prognostic scoring system was more effective than traditional high-risk criteria at predicting which patients require intensive combination chemotherapy to attain remission.
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40
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Berkowitz RS, Goldstein DP, Bernstein MR. Ten year's experience with methotrexate and folinic acid as primary therapy for gestational trophoblastic disease. Gynecol Oncol 1986; 23:111-8. [PMID: 3002916 DOI: 10.1016/0090-8258(86)90123-x] [Citation(s) in RCA: 109] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Methotrexate and folinic acid was administered as primary therapy in 185 patients with gestational trophoblastic disease between 1974 and 1984. Methotrexate and folinic acid induced complete remission in 147 (90.2%) of 163 patients with nonmetastatic disease and in 15 (68.2%) of 22 patients with low-risk metastatic disease. Sustained remission was achieved in 132 (81.5%) patients following only one course of chemotherapy. All patients with methotrexate resistance subsequently achieved remission with Actinomycin D or combination chemotherapy. Methotrexate when administered with folinic acid was associated with granulocytopenia, thrombocytopenia, and hepatotoxicity in 11 (5.9%), 3 (1.6%), and 26 (14.1%) patients, respectively. The human chorionic gonadotropin (hCG) regression curve served as a reliable guide for the administration of chemotherapy and enabled the attainment of a high remission rate while limiting chemotherapy exposure. Methotrexate and folinic acid achieves an excellent therapeutic outcome with limited chemotherapy exposure and effectively limits systemic toxicity.
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41
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Berkowitz RS, Goldstein DP, Bernstein MR. Natural history of partial molar pregnancy. Obstet Gynecol 1985; 66:677-81. [PMID: 2414703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Between January 1979 and August 1984, 81 patients with partial molar pregnancy were observed at the New England Trophoblastic Disease Center. The preevacuation clinical diagnosis in 74 (91.3%) patients was either missed or incomplete abortion. The uterine size was either small or appropriate for gestational age in 78 (96.3%) patients. Only five (6.2%) patients presented with excessive uterine size or toxemia and were thought to have a molar pregnancy. Preevacuation human chorionic gonadotropin (hCG) levels exceeded 100,000 mIU/mL in only two (6.6%) of 30 patients. No patient had prominent theca lutein cysts. After evacuation, eight (9.9%) patients developed nonmetastatic gestational trophoblastic disease. Patients with partial moles usually do not present with the clinical features that are characteristic of complete molar pregnancy. The diagnosis of partial mole is generally only considered after histologic review of curettage specimens.
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Berkowitz RS, Cramer DW, Bernstein MR, Cassells S, Driscoll SG, Goldstein DP. Risk factors for complete molar pregnancy from a case-control study. Am J Obstet Gynecol 1985; 152:1016-20. [PMID: 4025447 DOI: 10.1016/0002-9378(85)90550-2] [Citation(s) in RCA: 88] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Demographic, reproductive, and dietary histories for 90 white women with complete molar pregnancy were compared in a multivariate analysis with those of 90 parous controls matched to cases by residence, birth year, and race. Women with molar pregnancy were more likely to have been born outside North America (relative risk = 1.9, p = 0.05), were more likely to have been past age 30 at time of their molar pregnancy (relative risk = 1.6, p = 0.05), and were more likely to have diets deficient in the vitamin A precursor carotene. Women with dietary scores for carotene above the control median had a relative risk for molar pregnancy of 0.6 (p = 0.02). In addition, there was a significant trend for decreasing risk for molar pregnancy with increasing consumption of carotene. Although other nutritional deficiencies in patients with complete molar pregnancy may exist, carotene is a biologically plausible candidate for a nutritional risk factor that could explain the geographic distribution of molar pregnancy.
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Berkowitz RS, Goldstein DP, Bernstein MR. Modified triple chemotherapy in the management of high-risk metastatic gestational trophoblastic tumors. Gynecol Oncol 1984; 19:173-81. [PMID: 6208089 DOI: 10.1016/0090-8258(84)90177-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Modified triple chemotherapy (MAC III: methotrexate with citrovorum factor, actinomycin D, and cyclophosphamide) was administered as primary treatment to 14 patients with high-risk metastatic gestational trophoblastic tumors (GTT). Ten (71.4%) patients attained complete remission with 1 to 4 courses of MAC III (mean = 2.7 courses). Three of the remaining patients subsequently achieved remission with the modified Bagshawe regimen or vinblastine, bleomycin, and cis-platinum. Following 38 courses of MAC III, moderate hepatotoxicity (SGOT greater than or equal to 150 U) developed after 1 (2.6%) course. Marked thrombocytopenia (platelets less than 50,000/mm3) and marked granulocytopenia (granulocytes less than 500/mm3) developed after 7 (18.4%) and 19 (50%) of the courses, respectively. Platelet transfusions were administered after 4 (10.5%) courses of MAC III and no patient required granulocyte transfusions. MAC III is an effective alternative treatment for patients with high-risk metastatic GTT.
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Abstract
The current study reviews post-term choriocarcinoma at the New England Trophoblastic Disease Center (NETDC) in order to expand knowledge of its clinical features. Between June 1965 and June 1981, 366 patients with persistent gestational trophoblastic disease were managed at the NETDC and 15 (4.1%) of these patients had choriocarcinoma following term pregnancy. Post-term choriocarcinoma has a propensity for early metastasis with frequent involvement of the liver and brain. Metastases were detected in 13 (86.7%) patients with post-term choriocarcinoma at the time of diagnosis. Seven patients (53.8%) with metastatic post-term choriocarcinoma had hepatic and/or cerebral involvement. Complete remission was achieved in both patients with nonmetastatic disease and in 8 (61.5%) patients with metastatic disease. When the time interval from the antecedent term delivery to diagnosis was less than 4 months, 7 (87.5%) of 8 patients achieved complete remission. The 5 patients who died from post-term choriocarcinoma all had hepatic and/or cerebral involvement. Patients with post-term choriocarcinoma should undergo a meticulous metastatic evaluation and if metastases are detected these patients should be treated with primary combination chemotherapy and with the selective use of irradiation and surgical therapy.
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Abstract
Pelvic ultrasonography was performed in 33 patients with persistent gestational trophoblastic disease (GTD) and the sonographic findings were compared in all patients with laparoscopic findings and histologic material from endometrial curettage and/or hysterectomy. Ultrasonography indicated trophoblastic uterine involvement in 17 patients (51.5%) and the ultrasound interpretation was histologically confirmed in all 17 patients by endometrial curettage and/or hysterectomy. Among the 16 patients in whom the uterus appeared normal by ultrasound, endometrial curettings demonstrated scanty fragments of trophoblastic tumor in 6 patients (37.5%). Furthermore, in all 16 patients in whom the uterus appeared normal by ultrasound, laparoscopy also revealed no uterine abnormalities. Ultrasonography appears to be accurate in detecting extensive trophoblastic uterine involvement and helpful in identifying resistant uterine foci. Pelvic ultrasonography should be an integral part of the pretreatment assessment of patients with persistent GTD.
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Abstract
Methotrexate with citrovorum rescue (MTX-CF) was administered as primary treatment in 106 patients with gestational trophoblastic disease (GTD). Ninety-six patients (90.6%) achieved complete remission with MTX-CF and 77 of these patients (80.2%) required only one course of MTX-CF to attain remission. MTX-CF induced sustained remission in 89 (94.7%) of 94 patients with nonmetastatic GTD and in seven (59.3%) of 12 patients with low-risk metastatic GTD. Resistance to MTX-CF was more common in patients with disseminated disease and with pretreatment hCG titers greater than or equal to 50,000 milliIU/ml. Following MTX-CF, granulocytopenia, thrombocytopenia and hepatotoxicity was observed in only seven (6.6%), three (2.8%), and ten (9.4%) patients, respectively. MTX-CF should be the preferred primary treatment in nonmetastatic and low-risk metastatic GTD.
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Berkowitz RS, Goldstein DP, Bernstein MR. Horizons in the management of gestational trophoblastic neoplasia: analysis of treatment failure. J Reprod Med 1981; 26:227-9. [PMID: 6260938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Berkowitz RS, Goldstein DP, Bernstein MR. Management of nonmetastatic trophoblastic tumors. J Reprod Med 1981; 26:219-22. [PMID: 6260936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Goldstein DP, Berkowitz RS, Bernstein MR. Management of molar pregnancy. J Reprod Med 1981; 26:208-12. [PMID: 7218227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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