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OBJECTIVE: To describe the clinical characteristics of malignant gestational trophoblastic tumor after medical abortion used by mifepristone combined with misoprostol and its diagnosis and differential diagnosis from incomplete abortion. METHODS: Four cases with malignant gestational trophoblast tumor after medical abortion were presented focusing on the clinical manifestation and the methods of diagnosis and differential diagnosis. RESULTS: Irregular vaginal bleeding and abnormal high level of beta-human chorionic gonadotropin (hCG) in plasma were the common manifestation of the gestational trophoblast tumour and incomplete abortion after medical abortion. However, beta-hCG of the former after curettage was still higher by dynamic monitoring. Malignant gestational trophoblast tumor showed rich blood flow signal and low blood flow resistance index (RI, RI < 0.5) in uterus in color doppler echography, digital subtraction angiography (DSA) with abnormal enlargement of the arteria of uterine, arteriovenous fistula beside the uterine were the main characteristics of malignant gestational trophoblast tumour. CONCLUSIONS: Pay attention to the early stage malignant gestational trophoblast tumour among patients with abnormal vaginal bleeding after medical abortion. beta-hCG and DSA were the most effective methods to diagnose and differentially diagnose choriocarcinoma from the incomplete abortion among the patients with abnormal vaginal bleeding after medical abortion.

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BACKGROUND: Gestational trophoblastic disease refers to a spectrum of rare benign and malignant gynecologic disorders whose pathogenesis is not well understood. Recent studies from China and the United States have raised the hypothesis that long-term use of oral contraceptives before conception may increase the risk of gestational trophoblastic tumors. A multicenter case-control study of gestational trophoblastic tumors was undertaken to test this hypothesis. METHODS: Telephone interviews were conducted with 235 case patients, including 50 with gestational choriocarcinoma, and 413 control subjects matched on recentness of pregnancy, age at pregnancy, and area of residence. Relative risks (odds ratios) were computed by conditional logistic regression. Reported P values are two-sided. RESULTS: The relative risk estimate for ever having used oral contraceptives before the index pregnancy was 1.9 (95% confidence interval [CI] = 1.2-3.0), and the risk increased with duration of use (P for trend = .05). The estimate was highest for women who used oral contraceptives during the cycle in which they became pregnant (relative risk = 4.0; 95% CI=1.6-10), but there was no consistent pattern according to the time interval since last use. Separate analyses of choriocarcinoma and persistent mole yielded similar results, i.e., the relative risk estimates for oral contraceptive use were 2.2 (95% CI=0.8-6.4) and 1.8 (95% CI=1.0-3.0), respectively. Control for the number of sexual partners, which was independently associated with risk (P for trend = .05), did not materially change the results. CONCLUSIONS: This study, the largest to date, indicates that long duration of oral contraceptive use before conception increases the risk of gestational trophoblastic tumors. These findings may provide clues to the pathogenesis of this rare disease. Changes in use of oral contraceptives are not warranted, however, because the incidence attributable to oral contraceptive use is very low.

PIP: Recent studies in the US and China have suggested that long-term use of oral contraceptives (OCs) before conception increases the risk of gestational trophoblastic tumors. This association was investigated further in a study conducted at 8 US medical centers that specialize in the treatment of this gynecologic disorder. 235 cases, including 50 women with gestational choriocarcinoma, were matched with 413 controls on recentness of pregnancy, age at pregnancy, and area of residence. The relative risk estimate for ever-use of OCs before the index pregnancy was 1.9 (95% confidence interval [CI], 1.2-3.0) and the risk increased with duration of OC use. The relative risk was highest (4.0; 95% CI, 1.6-10.0) for women who used OCs during the cycle in which they became pregnant, but there was no consistent pattern according to the time interval since last OC use. The relative risks for choriocarcinoma and persistent mole associated with OC use were 2.2 (95% CI, 0.8-6.4) and 1.8 (95% CI, 1.0-3.0), respectively. This study, the largest to date, suggests that a long duration of OC use before conception does, indeed, increase the risk of gestational trophoblastic tumors.

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There have been claims of an increased risk for gestational trophoblastic disease (i.e., hydatidiform mole and choriocarcinoma) in Vietnam since the period of Agent Orange sprayings. In 1990, we conducted a case-control study in Ho Chi Minh City to investigate risk factors for gestational trophoblastic disease in Vietnam. Eighty-seven married women, all of whom had a recent pathologic diagnosis of gestational trophoblastic disease, identified in the Obstetrical and Gynecological Hospital, were included in the study. Eighty-seven married women who were admitted mainly in the surgery departments of the same hospital were the controls, and they were matched to cases for age and area of residence. Odds ratios (ORs), adjusted for matching variables and other potential confounders, were estimated with unconditional logistic regression. A statistically significant trend in risk was observed with previous live births (p = .01). Cases were found to eat less meat per wk (OR = 0.4, 95% confidence interval [95% CI] = 0.2-0.9 for > or = five meat dishes) and to own fewer consumer goods than controls. An increase in risk was associated with the breeding of pigs (OR = 5.7, 95% CI = 1.2-27.6 for raising three or more pigs). A cumulative Agent Orange exposure index was constructed, using the patient's complete residence history. No significant difference was found between cases and controls for this index (OR = 0.7, 95% CI = 0.2-1.8 for high-exposure category), nor was such a difference noted for the agricultural use of pesticides.

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PIP: This paper considers the debate over the risks of developing cancer from using various contraceptive methods. Claiming that the debate provokes unfair publicity and misinterpretation, various risks of cancer due to the oral pill, long-acting contraceptives, and IUDs are discussed. The oral pill is examined in the context of its potential relationship in causing breast cancer, endometrial cancer, ovarian cancer, cervical cancer, vaginal and fallopian tube neoplasms, and trophoblastic disease. Long-acting contraceptives are discussed in the context of genital tract neoplasia, while IUDs are examined in regard to gynecologic malignancies. The paper finds that no conclusive evidence exists indicating that IUDs cause gynecological cancers. Low-dose oral contraceptive pills are currently being used, and no clear evidence exists that they cause or increase the chance of developing cancer in the genital tract and the breast. Oral contraceptives do, however, have beneficial effects in preventing endometrial and ovarian cancer. The low-dose combined oral contraceptive should be considered safe where cancer, cardiovascular, and thrombotic risks are concerned.^ieng

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A case-control study involving 331 patients with complete hydatidiform mole and 662 community controls matched to the cases on age and timing of pregnancy was conducted in Beijing, China. A history of a term birth was associated with reduced risk (odds ratio = 0.6, 95% confidence interval 0.4 to 0.9), with some evidence of further decrease with multiple births. Previous spontaneous abortions were not related to risk, although those with a prior induced abortion were at elevated risk, particularly if two or more abortions were involved (odds ratio = 2.8, 95% confidence interval 1.4 to 5.7). A history of having sought medical advice for infertility was associated with reduced risk (odds ratio = 0.5, 95% confidence interval 0.2 to 0.8), but those who reported use of herbal medicines during a first trimester of a previous pregnancy were at excess risk (odds ratio = 2.2, 95% confidence interval 1.3 to 3.6). In addition, a statistically significant trend in risk was observed with years of oral contraceptive use (odds ratio = 2.6, 95% confidence interval 0.9 to 6.9 for greater than or equal to 4 years of use). Dietary habits and family histories of cancer or trophoblastic disease were not related to risk in this study.

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PIP: The use of (OC) oral contraceptives after molar evacuation has been reported to increase the incidence of proliferative trophoblastic sequelae. At Charing Cross Hospital, London, locally invasive or metatastic trophoblastic disease developed in 16 of 65 patients (25%) who used OCs after molar evacuation. In contrast, only 43 of 464 patients (9.3%) not using OCs required chemotherapy after molar evacuation. The Charing Cross workers speculated that exogenous steroids may provide a tumor-stimulating effect when they are administered before gonadotropin remission. This report from Britain prompted us to review our experience at the New England Trophoblastic Disease Center. 50 patients, who had been treated for molar pregnancy, were selected at random from the files of the trophoblastic tumor registry. 23 patients used barrier methods of contraception (diaphragm, condom, and/or spermicidal jelly) and 27 used OCs after molar evacuation. The 2 groups of patients were comparable in parity, age, pretreatment hCG titers, and histological grade of molar tissue. The frequency of locally invasive or metastatic trophoblastic disease was 13% (3/23) in patients using barrier methods and 11% (3/27) in patients using OCs. We therefore believe that OCs do not increase the risk for proliferative trophoblastic sequelae following molar evacuation. OCs may be safely prescribed to patients during the interval of hormonal follow-up after molar evacuation.^ieng

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The need for chemotherapy for trophoblastic tumour after evacuation of a hydatidiform mole was found to be significantly increased in patients taking oral contraceptives before normal human chorionic gonadotrophin (HCG) values were obtained. Oral contraception was also found to delay the fall in HDG excretion in patients not requiring treatment with cytotoxic drugs.

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