Abstract Objective To evaluate the efficacy of immunotherapy for GTN treatment after methotrexate-resistance or in cases of multiresistant disease, through a systematic review, as well as to present the first 4 Brazilian cases of immunotherapy for GTN treatment. Methods Three independent researchers searched five electronic databases (EMBASE, LILACS, Medline, CENTRAL and Web of Science), for relevant articles up to February/2023 (PROSPERO CRD42023401453). The quality assessment was performed using the Newcastle Ottawa scale for case series and case reports. The primary outcome of this study was the occurrence of complete remission. The presentation of the case reports was approved by the Institutional Review Board. Results Of the 4 cases presented, the first was a low-risk GTN with methotrexate resistance unsuccessfully treated with avelumab, which achieved remission with sequential multiagent chemotherapy. The remaining 3 cases were high-risk multiagent-resistant GTN that were successfully treated with pembrolizumab, among which there were two subsequent gestations, one of them with normal pregnancy and healthy conceptus. Regarding the systematic review, 12 studies were included, only one of them on avelumab, showing a 46.7% complete remission rate. The remaining 11 studies were on pembrolizumab, showing an 86.7% complete remission rate, regardless of tumor histology. Both immunotherapies showed good tolerability, with two healthy pregnancies being recorded: one after avelumb and another after pembrolizumab. Conclusion Immunotherapy showed effectiveness for GTN treatment and may be especially useful in cases of high-risk disease, where pembrolizumab achieves a high therapeutic response, regardless of the histological type, and despite prior chemoresistance to multiple lines of treatment.

Resumo Doença trofoblástica gestacional é anomalia da gravidez que engloba um grupo de doenças derivadas do trofoblasto, diferentes entre si na propensão para regressão, invasão, metástase e recidiva. No passado, era comum a paciente portadora de gravidez molar apresentar sintomas exuberantes: hemorragia copiosa, cistos tecaluteínicos, útero aumentado para a idade gestacional, pré-eclâmpsia precoce, hiperêmese e hipertireoidismo. Atualmente, com o diagnóstico precoce feito pela ultrassonografia, a maioria das pacientes é diagnosticada ainda na fase assintomática. Nos casos em que há progressão para neoplasia trofoblástica gestacional, o estadiamento feito com a dopplerfluxometria pélvica e a radiografia de tórax, eventualmente com a tomografia computadorizada e a ressonância magnética, é fundamental na avaliação da escolha do tratamento antineoplásico. Por ser uma doença incomum e grave, que acomete mulheres no menacme, mas cujo tratamento adequado determina elevadas taxas de cura, é fundamental que os radiologistas estejam familiarizados com essa entidade clínica, a fim de auxiliar no diagnóstico precoce e promover seu correto acompanhamento imaginológico.

Abstract Gestational trophoblastic disease is an abnormality of pregnancy that encompasses a group of diseases that differ from each other in their propensity for regression, invasion, metastasis, and recurrence. In the past, it was common for patients with molar pregnancy to present with marked symptoms: copious bleeding; theca lutein cysts; uterus larger than appropriate for gestational age; early preeclampsia; hyperemesis gravidarum; and hyperthyroidism. Currently, with early diagnosis made by ultrasound, most patients are diagnosed while the disease is still in the asymptomatic phase. In cases of progression to trophoblastic neoplasia, staging-typically with Doppler flow studies of the pelvis and chest X-ray, although occasionally with computed tomography or magnetic resonance imaging-is critical to the choice of an appropriate antineoplastic therapy regimen. Because it is an unusual and serious disease that affects women of reproductive age, as well as because its appropriate treatment results in high cure rates, it is crucial that radiologists be familiar with gestational trophoblastic disease, in order to facilitate its early diagnosis and to ensure appropriate follow-up imaging.

RESUMO A cesariana a pedido materno é aquela realizada em uma gestante sem indicações médicas e sem contraindicação para tentativa do parto vaginal. Existe grande controvérsia sobre a realização da cesariana a pedido. Riscos potenciais da cesariana a pedido incluem complicações em gravidezes subsequentes, tais como: rotura uterina, placenta prévia e acretismo. Potenciais benefícios da cesariana a pedido englobam um menor risco de hemorragia pós-parto na primeira cesariana e menos complicações cirúrgicas quando comparada ao parto vaginal. A cesariana a pedido jamais deve ser realizada antes de 39 semanas.

ABSTRACT Cesarean section by maternal request is the one performed on a pregnant woman without medical indication and without contraindication to vaginal delivery. There is great controversy over requested cesarean section. Potential risks include complications in subsequent pregnancies, such as uterine rupture, placenta previa and accreta. Potential benefits of requested cesareans include a lower risk of postpartum hemorrhage in the first cesarean and fewer surgical complications compared with vaginal delivery. Cesarean section by request should never be performed before 39 weeks.

Neste relato, é apresentado um caso de neoplasia trofoblástica gestacional após normalização espontânea de gonadotrofina coriônica humana em paciente com mola hidatiforme parcial. Trata-se da segunda ocorrência publicada desse evento e a primeira em que há comprovação imuno-histoquímica. No bojo dessa apresentação, ademais de mostrar o tratamento para essa intercorrência da gravidez, discute-se a possibilidade de redução da duração do seguimento pós-molar, assim como estratégias para o precoce reconhecimento da neoplasia trofoblástica gestacional após a remissão espontânea da gravidez molar.

We report here a case of gestational trophoblastic neoplasia after spontaneous normalization of human chorionic gonadotropin in a patient with a partial hydatidiform mole. This is the second occurrence of this event to be reported and the first one with proven immunohistochemical evidence. Besides showing the treatment for this pregnancy complication, this case report discusses the possibility of reducing the duration of post-molar follow-up, as well as strategies for early recognition of gestational trophoblastic neoplasia after spontaneous remission of molar pregnancy.

A contaminação de solos é um problema atual que requer investigação detalhada no sentido de estabelecer critérios para a distinção entre anomalias naturais e contribuição antrópica. O trabalho foi desenvolvido com o objetivo de avaliar a distribuição e as formas de ocorrência de Zn para identificar a origem de valores anômalos em solos adjacentes a áreas de mineração no município de Vazante-MG. Foram coletadas amostras de perfis de solos em remanescentes sobre a área minerada e em posições a jusante e a montante desta, nas camadas de 0-2, 2-5, 5-10, 10-20, 20-50, 50-100, e 100-150 cm. Um estudo de extração seqüencial avaliou os teores de Zn nas formas: (a) solúvel; (b) trocável; (c) associada a carbonatos; (d) associada a óxidos amorfos; (e) associada a óxidos cristalinos; (f) associada à matéria orgânica; (g) residual; e (h) total. Verificou-se que os teores de Zn, de modo geral, são mais elevados nas áreas localizadas sobre a zona de mineralização, com solos mais jovens (Cambissolos e Neossolos), em relação aos solos mais intemperizados (Latossolos e Argissolos), localizados tanto a montante quanto a jusante da área minerada. Os teores totais foram muito altos. Mesmo considerando apenas as formas solúvel e trocável, mais lábeis, em alguns perfis os valores foram superiores aos teores totais encontrados naturalmente em solos. Verificou-se um padrão decrescente dos teores com a profundidade nos perfis localizados fora da área minerada. Por outro lado, os teores de Zn aumentaram com a profundidade em um Cambissolo localizado na área minerada. Não houve diferença significativa entre os teores de Zn das áreas a montante e a jusante em todas as formas químicas avaliadas, sugerindo que não se pode presumir efeito antrópico na dispersão do Zn em áreas adjacentes à zona de mineralização.

Soil contamination is nowadays a problem that requires detailed investigation in order to set up criteria for distinction between natural anomalies and antropogenic contribution. This work was carried out to evaluate zinc distribution and fractions, aiming to identify the origin of high Zn content in soils around mining areas in the Vazante county -MG (Brazil). Soil profiles were sampled in mined areas, and in upslope and downslope positions at depths of 0-2, 2-5, 5-10, 10-20, 20-50, 50-100 and 100-150 cm. A sequential extraction method was employed to evaluate zinc concentrations in the following fractions: (a) soluble; (b) exchangeable; (c) carbonate-associated; (d) associated with amorphous oxides; (e) associated with crystalline oxides; (f) organically bound; (g) residual and (h) total. In general, Zn levels were higher in the younger soils (Inceptisols) of the mined than in highly weathered soils (Oxisols and Ultisols) both up and downslope from the mine. Total zinc levels were extremely high. Even when only the soluble and exchangeable Zn forms are considered, the values in some profiles are higher than those reported for naturally occurring total soil contents. A decreasing trend in the contents with soil depth was verified outside the mineralized area (in both up and downslope positions). On the other hand, the Zn contents increased with depth in the Cambisol within the mined area. There was no significant difference between mean Zn contents in upslope and downslope soils for all extracted Zn fractions. Anthropogenic contribution to the high Zn content in soils in areas surrounding the mined zone is therefore not supported.