Inappropriate management of women with persistent low hCG results.

The USA hCG Reference Service is a consulting service with a specialized clinical laboratory aiding physicians in the interpretation of conflicting or nonrepresentative human chorionic gonadotropin (hCG) results. We have consulted on 189 cases with persistent low levels of hCG but no evidence of pregnancy or tumor. Quiescent gestational trophoblastic disease (GTD) was identified in 121 cases by the absence of invasive trophoblast antigen and nonresponse to chemotherapy (64 cases with a history of hydatidiform mole or gestational trophoblastic neoplasia (GTN) and 57 cases following antecedent pregnancy). Another 61 Reference Service cases hadfalse positive hCG, and we observed 7 cases with low levels of hCG of pituitary origin (hCG subsequently suppressed by estrogen-progesterone medication). Most disturbing is that the majority of these cases (68%) received needless therapy for assumed GTN/choriocarcinoma/placental site trophoblastic tumor before consultation with the Reference Service. One hundred twenty-eight of the 189 patients (77 of 121 with quiescent GTD, 48 of 61 withfalse positive hCG and 3 of 7 with pituitary hCG) underwent therapy ranging from single-agent chemotherapy (117 cases), to EMA-CO combination chemotherapy (etoposide, methotrexate, actinomycin D alternating with cyclophosphamide and vincristine) (16 cases), to hysterectomy and/or bilateral salpingo-oophorectomy (31 cases). False positive hCG and pituitary hCG would obviously not respond to these treatments, and no treated cases of quiescent GTD responded to chemotherapy orfully responded to hysterectomy. The continued needless treatment of patients with quiescent GTD, even after multiple publications, is entirely avoidable. Unfortunately, the number of needlessly treated cases referred to the Reference Service is increasing.