ReCure: Second Uterine Evacuation for Low-risk Gestational Trophoblastic Neoplasia
To evaluate the efficacy and safety of second uterine curettage in patients with low-risk non-metastatic GTN.
|Condition or Disease||Intervention/Treatment||Phase|
This is a randomized, multicenter clinical trial including patients seen at one of 13 gestational trophoblastic disease reference centers in Brazil. Subjects are eligible if they have low-risk gestational trophoblastic neoplasia according to FIGO 2000 criteria and the FIGO/WHO prognostic risk score. The study includes two treatment arms: immediate treatment with single-agent chemotherapy (center choice of agent) or second uterine curettage. The primary outcome is the rate of primary remission. Secondary outcomes are the number of chemotherapy cycles required to achieve remission, rate of primary chemotherapy resistance, rate of relapse, and overall survival.
Arms and Interventions
|Active Comparator: Chemotherapy
Patients allocated to receive conventional chemotherapy will be treated with methotrexate (1 mg/kg intramuscular) with rescue of folinic acid (15mg orally). In cases of chemoresistance, second-line chemotherapy will be performed with actinomycin-D (Act-D) 1.25 mg intravenous pulse every 14 days. The third line of chemotherapy will be the EMA/CO regimen (reserving the EP / EMA regimen (E, cisplatin, MTX / Act-D) for the fourth line.
conventional chemotherapy will be treated with MTX (1 mg/kg intramuscular) with rescue of FA (15mg orally). In cases of chemoresistance, second-line chemotherapy will be performed with actinomycin-D (Act-D) 1.25 mg intravenous pulse every 14 days. The third line of chemotherapy will be the EMA/CO regimen (, reserving the EP / EMA regimen (E, cisplatin, MTX / Act-D) for the fourth line.
|Experimental: Uterine evacuation
Patients randomized to undergo a second curettage will undergo manual or electronic vacuum aspiration under ultrasound guidance. Following discharge after the second curettage patients will return to weekly hCG monitoring. If hCG levels are decreasing, patients will remain on weekly hCG follow-up until the first normal hCG (<5 IU/L) is achieved. Then they will have monthly hCG monitoring for 12 months. If patients do not attain remission and develop persistent GTN as established by FIGO 2000, the tumor will be re-staged and appropriate chemotherapy will be initiated.
Procedure: Uterine curettage
Manual or electric vacuum aspiration under ultrasound guidance.
Primary Outcome Measures
- Remission rate from primary therapy [3 years]
Undetectable hCG on weekly serum assay for at least three weeks
Secondary Outcome Measures
- Cycles to remission [3 years]
Total number of cycles of chemotherapy required to attain remission
- Time to remission [3 years]
Time in days from randomization to remission
- Need for multiagent chemotherapy [3 years]
Need for progression from single agent to multiagent chemotherapy
- Relapse [1 year]
Re-elevation of hCG after achieving remission
- Death [1 year]
Death from any cause
- Histopathological diagnosis of molar pegnancy according to the morphological criteria described by Sebire et al., who meet the diagnostic criteria for low-risk non-metastatic GTN according to FIGO 2000 criteria
High risk GTN (FIGO risk score ≥ 7) or metastatic disease at diagnosis of GTN (stage II, III or IV);
Histopathological diagnosis of choriocarcinoma, placental site trophoblastic or epithelioid trophoblastic tumor at the second curettage;
Previous chemotherapy treatment;
Level of hCG at the time of GTN diagnosis less than 20 IU/L (to minimize the risk of inclusion of patients with false positive hCG, either by cross-reaction with pituitary hormones or by the presence of circulating heterophilic antibodies);
Incomplete medical records.
Loss to follow-up;
Voluntary desire to stop participating in the study.
Contacts and Locations
|1||Paulista State University UNESP||Botucatu||Brazil|
|2||Campinas State University UNICAMP||Campinas||Brazil|
|3||University of Caxias do Sul||Caxias Do Sul||Brazil|
|4||Federal University of Ceará||Ceará||Brazil|
|5||Medical School of Santa Casa da Misericórdia de Porto Alegre||Porto Alegre||Brazil|
|6||Maternidade Escola da Universidade Federal do Rio de Janeiro||Rio de Janeiro||Brazil|
|7||Federal University of São Paulo UNIFESP||São Paulo||Brazil|
Sponsors and Collaborators
- Brigham and Women's Hospital
- Maternidade Escola da Universidade Federal do Rio de Janeiro
- Universidade Federal do Rio de Janeiro
- Federal University of Ceará
- Federal University of São Paulo UNIFESP
- Campinas State University UNICAMP
- Paulista State University UNESP BOTUCATU
- Medical School of Santa Casa da Misericórdia de Porto Alegr
- University of Caxias do Sul
- Study Director: Antonio Braga, MD, PhD, Maternidade Escola da Universidade Federal do Rio de Janeiro
Study Documents (Full-Text)None provided.
- Hemida R, Vos EL, El-Deek B, Arafa M, Toson E, Burger CW, van Doorn HC. Second Uterine Curettage and the Number of Chemotherapy Courses in Postmolar Gestational Trophoblastic Neoplasia: A Randomized Controlled Trial. Obstet Gynecol. 2019 May;133(5):1024-1031. doi: 10.1097/AOG.0000000000003232. Erratum in: Obstet Gynecol. 2019 Sep;134(3):652.
- Osborne RJ, Filiaci VL, Schink JC, Mannel RS, Behbakht K, Hoffman JS, Spirtos NM, Chan JK, Tidy JA, Miller DS. Second Curettage for Low-Risk Nonmetastatic Gestational Trophoblastic Neoplasia. Obstet Gynecol. 2016 Sep;128(3):535-542. doi: 10.1097/AOG.0000000000001554.