Total hysterectomy versus uterine evacuation for preventing post-molar gestational trophoblastic neoplasia in patients who are at least 40 years old: a systematic review and meta-analysis

Abstract

BackgroundThe clinical value of total hysterectomy for patients with hydatidiform mole (HM) being at least 40 years old remains highly controversial. Since the practice of hysterectomy has been applied globally for decades, there is an urgent need to perform a systematic review to assess its risks and benefits.MethodsSix electronic databases, including four English databases and one Chinese database, were searched from the inception of each database till October 6th 2017. Studies were included if they: 1) were human studies, 2) explicitly indicated exposure to hysterectomy, 3) explicitly indicated control to uterine evacuation, 4) explicitly indicated the participants were older patients with HM being at least 40 years in age, 5) compared the outcome of interest as the incidence of post-molar GTN. Two authors independently conducted the literature search, study selection, data extraction. Pooled odds ratios were analyzed using Review Manager 5.3.ResultsThe overall pooled effect size of total hysterectomy had a significant advantage in preventing post-molar gestational trophoblastic neoplasia over uterine evacuation with an OR of 0.19 (95% CI, 0.08–0.48; P = 0.0004) and a low heterogeneity (I2 = 21%, P = 0.28). Subgroup analysis and sensitivity analysis also showed similar results.ConclusionsTotal hysterectomy, as compared to uterine evacuation, is a better therapeutic method for patients with HM being at least 40 years old unless fertility is still desired.Electronic supplementary materialThe online version of this article (10.1186/s12885-018-5168-x) contains supplementary material, which is available to authorized users.

Gestational Trophoblastic Disease

“…Hysterectomy is an alternative to suction D&E for molar evacuation in selected patients who do not wish to preserve childbearing ( Box 2 ), especially in women older than the age of 40 years, because these patients have a higher risk of postmolar gestational trophoblastic neoplasia. 3 , 13 , 16 Usually the adnexa may be preserved, even if theca lutein cysts are present. Hysterectomy reduces the risk of malignant postmolar sequelae to approximately 3–5% compared with approximately 15–20% after evacuation by D&E. 3 , 13 , 16 Because hysterectomy does not eliminate the possibility of postmolar gestational trophoblastic neoplasia these patients should also be monitored postoperatively with serial hCG levels.…”

“… 3 , 13 , 16 Usually the adnexa may be preserved, even if theca lutein cysts are present. Hysterectomy reduces the risk of malignant postmolar sequelae to approximately 3–5% compared with approximately 15–20% after evacuation by D&E. 3 , 13 , 16 Because hysterectomy does not eliminate the possibility of postmolar gestational trophoblastic neoplasia these patients should also be monitored postoperatively with serial hCG levels. 3 , 13 , 16 …”

Epidemiology, diagnosis, and treatment of gestational trophoblastic disease: A Society of Gynecologic Oncology evidenced-based review and recommendation

“…For those who have completed childbearing and have a presumed molar pregnancy, hysterectomy provides an alternative method of management. In one study, compared to uterine evacuation, hysterectomy has a significant advantage in preventing post-molar GTN with an approximately 80% reduction in risk [29]. Although hysterectomy eliminates any locally invasive disease, some women will have occult metastases at the time of diagnosis and therefore hCG monitoring is still warranted after hysterectomy [29].…”

Perimenopausal giant hydatidiform mole complicated with preeclampsia and hyperthyroidism: A case report and literature review

“…Suction curettage is the preferred treatment for complete hydatidiform mole, especially for patients with fertility requirements [ 15 ]. However, total hysterectomy may be appropriate for perimenopausal patients who have already given birth.…”

“…In addition to the removal of the hydatidiform tissue, total hysterectomy can reduce the need for subsequent chemotherapy by eliminating the risk of local muscular layer infiltration [ 16 ]. Zhao et al [ 15 ] showed that the incidence of progression to GTN after suction curettage in high-risk hydatidiform mole patients above 40 years old was 44%. Total hysterectomy could reduce the possibility of GTN progression, but 13% of patients could still progress to GTN [ 16 ].…”