LAWRENCE HSU LIN
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Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/57 - Laboratório de Fisiologia Obstétrica, Hospital das Clínicas, Faculdade de Medicina
LIM/57 - Laboratório de Fisiologia Obstétrica, Hospital das Clínicas, Faculdade de Medicina
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article 3 Citação(ões) na Scopus Management of Symptomatic Uterine Arteriovenous Malformations After Gestational Trophoblastic Disease The Brazilian Experience and Possible Role for Depot Medroxyprogesterone Acetate and Tranexamic Acid Treatment(2018) BRAGA, Antonio; LIMA, Lana; PARENTE, Raphael Camara Medeiros; CELESTE, Roger Keller; REZENDE FILHO, Jorge de; AMIM JUNIOR, Joffre; MAESTA, Izildinha; SUN, Sue Yazaki; UBERTI, Elza; LIN, Lawrence; MADI, Jose Mauro; VIGGIANO, Mauricio; ELIAS, Kevin M.; HOROWITZ, Neil S.; BERKOWITZ, Ross S.OBJECTIVE: To identify predictive variables of heavy vaginal bleeding from uterine arteriovenous malformation (uAVM) after gestational trophoblastic disease (GTD) and review outcomes with different treatment strategies. STUDY DESIGN: This is a retrospective study of patients with uAVM presenting with vaginal bleeding after postmolar follow-up or treatment for postmolar gestational trophoblastic neoplasia, with normal hCG levels for at least 6 or 12 months, respectively, followed at 9 Brazilian GTD reference centers, from January 2004-January 2016. Patients were treated preferentially with uterine artery embolization (UAE), but when UAE was not available, depot medroxyprogesterone acetate and tranexamic acid (DMPA + TA) was offered. RESULTS: The incidence of symptomatic uAVM after GTD was 0.6% (39/6,129). Risk factors associated with class III-IV hemorrhage included number of previous curettages (aRR 4.23, 95% CI 1.36-13.1, p=0.013), uterine artery index of resistance <= 0.32 (aRR 35.2, 95% CI 3.58-347.5, p=0.002), and uterine artery peak systolic velocity >= 78.7 cm/s (aRR 10.7, 95% CI 1.15-100.6, p=0.037). Patients with class I-II hemorrhage treated with DMPA + TA had a higher rate of uAVM resolution (N=14/16 [87.5%]) versus UAE (N=4/8 [50%], p=0.033). Patients with class III-IV hemorrhage were 87% less likely to have successful treatment with DMPA + TA compared to class I-II hemorrhage (cRR 0.13, 95% CI 0.02-0.83, p=0.013). CONCLUSION: Although UAE is preferred for cases of heavy vaginal bleeding, there may be a role for DMPA + TA in the management of less severe bleeding complications.- Is chemotherapy always necessary for patients with nonmetastatic gestational trophoblastic neoplasia with histopathological diagnosis of choriocarcinoma?(2018) BRAGA, Antonio; CAMPOS, Vanessa; REZENDE FILHO, Jorge; LIN, Lawrence H.; SUN, Sue Yazaki; SOUZA, Christiani Bisinoto de; SILVA, Rita de Cassia Alves Ferreira da; LEAL, Elaine Azevedo Soares; SILVEIRA, Eduardo; MAESTA, Izildinha; MADI, Jose Mauro; UBERTI, Elza H.; VIGGIANO, Mauricio; ELIAS, Kevin M.; HOROWITZ, Neil; BERKOWITZ, Ross S.Objective. To evaluate expectant management versus immediate chemotherapy following pathological diagnosis of gestational choriocarcinoma (GCC) in patients with nonmetastatic disease. Methods. Multicenter retrospective cohort that included patients with histological diagnosis of GCC with nonmetastatic disease followed at one of thirteen Brazilian referral centers for gestational trophoblastic disease from January 2000 to December 2016. Results. Among 3191 patients with gestational trophoblastic neoplasia, 199 patients with nonmetastatic GCC were identified. Chemotherapy was initiated immediately in 152 (76.4%) patients per FIGO 2000 guideline, while 47 (23.6%) were managed expectantly. Both groups presented with similar characteristics and outcomes. All patients (n = 12) who had normal human chorionic gonadotropin (hCG) in the first 2-3 weeks of expectant management achieved complete sustained remission with no chemotherapy. Only 44.7% (21 patients) of patients who were expectantly managed needed to receive chemotherapy due to plateauing or rising hCG level in the first 2-3 weeks of follow up. The outcome of patients receiving chemotherapy after initial expectant management was similar to those who received chemotherapy immediately after the diagnosis in terms of need for multi-agent chemotherapy or number of cycles of chemotherapy. There was no case of relapse or death in either group. Logistic regression analysis showed that age >= 40 years and hCG >= 92,428 IU/L at GCC diagnosis were risk factors for needing chemotherapy after initial expectant management of nonmetastatic GCC. Conclusion. In order to avoid exposing patients unnecessarily to chemotherapy, close surveillance of women with pathological diagnosis of nonmetastatic GCC seems to be a safe practice, particularly for those who have a normal hCG at the time of diagnosis. If confirmed by other studies, the FIGO guidelines may need to be revised.
article 2 Citação(ões) na Scopus Single-Center Experience in Managing Epithelioid Trophoblastic Tumors(2018) LIN, Lawrence H.; FUSHIDA, Koji; OKUMURA, Maria; SCHULTZ, Regina; FRANCISCO, Rossana P. V.; ZUGAIB, MarceloOBJECTIVE: To describe the experience in managing patients with epithelioid trophoblastic tumor (ETT) in a single institution. STUDY DESIGN: This is a retrospective case series of patients diagnosed with ETT at the University of Sao Paulo Trophoblastic Disease Center from January 2001 to December 2016. RESULTS: During the study period, 8 patients with ETT were identified. Patient characteristics were as follows: all patients were of reproductive age, the last gestation in 75% was a hydatidiform mole, the interval from the last pregnancy ranged from 3-48 months, and the median human chorionic gonadotropin (hCG) level was 119 mIU/mL. Six patients presented with stage I disease; 5 of them were treated with hysterectomy and chemotherapy and 1 was treated with hysterectomy alone. One patient presented with a lung nodule and was treated with pulmonary resection and chemotherapy. These 7 patients were followed and had no recurrence. The only patient who died presented with stage IV disease, which did not respond to chemotherapy. CONCLUSION: ETT is a rare form of trophoblastic tumor which presents with low levels of hCG for tumor volume. This case series highlights the importance of surgical management of confined diseases, since ETT is poorly responsive to chemotherapy.