Hamilton, ON.
Winnipeg, MB.
J Obstet Gynaecol Can. 2021 Jan;43(1):91-105.e1. doi: 10.1016/j.jogc.2020.03.001.
This guideline reviews the clinical evaluation and management of gestational trophoblastic diseases, including surgical and medical management of benign, premalignant, and malignant entities. The objective of this guideline is to assist health care providers in promptly diagnosing gestational trophoblastic diseases, to standardize treatment and follow-up, and to ensure early specialized care of patients with malignant or metastatic disease.
General gynaecologists, obstetricians, family physicians, midwives, emergency department physicians, anaesthesiologists, radiologists, pathologists, registered nurses, nurse practitioners, residents, gynaecologic oncologists, medical oncologists, radiation oncologists, surgeons, general practitioners in oncology, oncology nurses, pharmacists, physician assistants, and other health care providers who treat patients with gestational trophoblastic diseases. This guideline is also intended to provide information for interested parties who provide follow-up care for these patients following treatment.
Women of reproductive age with gestational trophoblastic diseases.
Women diagnosed with a gestational trophoblastic disease should be referred to a gynaecologist for initial evaluation and consideration for primary surgery (uterine evacuation or hysterectomy) and follow-up. Women diagnosed with gestational trophoblastic neoplasia should be referred to a gynaecologic oncologist for staging, risk scoring, and consideration for primary surgery or systemic therapy (single- or multi-agent chemotherapy) with the potential need for additional therapies. All cases of gestational trophoblastic neoplasia should be discussed at a multidisciplinary cancer case conference and registered in a centralized (regional and/or national) database.
Relevant studies from 2002 onwards were searched in Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and Cochrane Systematic Reviews using the following terms, either alone or in combination: trophoblastic neoplasms, choriocarcinoma, trophoblastic tumor, placental site, gestational trophoblastic disease, hydatidiform mole, drug therapy, surgical therapy, radiotherapy, cure, complications, recurrence, survival, prognosis, pregnancy outcome, disease outcome, treatment outcome, and remission. The initial search was performed in April 2017 and updated in May 2019. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional significant articles were identified through cross-referencing the identified reviews. The total number of studies identified was 673, with 79 studies cited in this review.
The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of Directors of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of Directors for the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework. See the online appendix tables for key to grading and interpretation of recommendations.
These guidelines will assist physicians in promptly diagnosing gestational trophoblastic diseases and urgently referring patients diagnosed with gestational trophoblastic neoplasia to gynaecologic oncology for specialized management. Treating gestational trophoblastic neoplasia in specialized centres with the use of centralized databases allows for capturing and comparing data on treatment outcomes of patients with these rare tumours and for optimizing patient care.
SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
本指南回顾了妊娠滋养细胞疾病的临床评估和管理，包括良性、癌前和恶性疾病的手术和药物治疗。本指南的目的是帮助医疗保健提供者及时诊断妊娠滋养细胞疾病，规范治疗和随访，并确保恶性或转移性疾病患者得到早期的专业治疗。
普通妇科医生、产科医生、家庭医生、助产士、急诊医生、麻醉师、放射科医生、病理学家、注册护士、执业护士、住院医师、妇科肿瘤学家、肿瘤内科医生、放射肿瘤学家、外科医生、肿瘤学全科医生、肿瘤护士、药剂师、医师助理以及其他治疗妊娠滋养细胞疾病的医疗保健提供者。本指南还旨在为接受这些患者治疗后提供随访护理的利益相关方提供信息。
患有妊娠滋养细胞疾病的育龄妇女。
诊断为妊娠滋养细胞疾病的妇女应转至妇科医生处进行初步评估，并考虑进行原发性手术（子宫排空或子宫切除术）和随访。诊断为妊娠滋养细胞肿瘤的妇女应转至妇科肿瘤科医生处进行分期、风险评分，并考虑进行原发性手术或全身治疗（单一或多药物化疗），可能需要额外的治疗。所有妊娠滋养细胞肿瘤病例均应在多学科癌症病例会议上讨论，并在集中（区域和/或国家）数据库中登记。
使用以下术语，单独或组合搜索 2002 年以来的 Embase、MEDLINE、Cochrane 对照试验中心注册库和 Cochrane 系统评价中的相关研究：滋养细胞肿瘤、绒毛膜癌、滋养细胞肿瘤、胎盘部位、妊娠滋养细胞疾病、葡萄胎、药物治疗、手术治疗、放射治疗、治愈、并发症、复发、生存、预后、妊娠结局、疾病结局、治疗结局和缓解。最初的搜索于 2017 年 4 月进行，并于 2019 年 5 月更新。按照以下顺序选择相关证据纳入：荟萃分析、系统评价、指南、随机对照试验、前瞻性队列研究、观察性研究、非系统评价、病例系列和报告。通过交叉引用已确定的综述，还确定了其他重要文章。总共确定了 673 项研究，本综述引用了 79 项研究。
内容和建议由作者起草并达成一致。加拿大妇科肿瘤学会的执行委员会和董事会审查了内容，并提交了意见供考虑，加拿大妇产科医生协会董事会批准了最终草案以供发布。使用 GRADE 方法框架中描述的标准对证据质量进行评级。请参见在线附录表中的关键评级和建议解释。
这些指南将帮助医生及时诊断妊娠滋养细胞疾病，并紧急将诊断为妊娠滋养细胞肿瘤的患者转介给妇科肿瘤医生进行专业管理。在专门的中心使用集中的数据库来治疗妊娠滋养细胞肿瘤，可以捕获和比较这些罕见肿瘤患者的治疗结果数据，并优化患者护理。
总结陈述（GRADE 评级在括号中）：建议（GRADE 评级在括号中）。
