Gestational Trophoblastic Disease: Current Evaluation and Management

The efficacy evaluation of initial chemotherapy for high-risk gestational trophoblastic neoplasm

In clinical practice, a large number of patients have failed to receive chemotherapy or combination therapy because of drug resistance, recurrence and metastasis of specific sites. Therefore, how to choose the initial chemotherapy individually and reduce the occurrence of drug resistance is the key to cure high-risk GTN. This study investigated the efficacy of chemotherapy based on 5-fluorouracil (5-FU) regimen and EMA/CO regimen as the initial chemotherapy regimen in the treatment of high-risk gestational trophoblastic neoplasms (high-risk GTN). The treatment status of high-risk GTN patients who received primary chemotherapy using 5-Fu regimens (FAV and FA regimens) or EMA/CO regimens at Cancer Hospital of China Medical University from 2002 to 2019 was retrospective analyzed. Regular follow-up was conducted to evaluate its efficacy and to analyze prognostic factors. There were a total of 87 high-risk patients, 75 in the 5-FU-based group and 12 in the EMA/CO group. The clinical characteristics of patients in both groups were not statistically significant (P > 0.05). The overall survival rate of all patients was 87.4%, the rate of serological complete remission (SCR) was 87.4%, the SCR rate of initial treatment was 75.9%, the recurrence rate was 7.9%, and the mortality rate was 12.6%. There were no statistical differences in overall survival rate, SCR rate, SCR rate of initial treatment, drug resistance rate, recurrence rate and mortality in the 5-FU group and the EMA/CO group (P > 0.05). The median follow-up was 106 months. Kaplan-Meier analysis showed that the 1-year survival rate, 5-year survival rate and 10-year survival rate in the 5-FU group were 91.9%, 84.3% and 84.3% respectively. The 1-year survival rate, 5-year survival rate and 10-year survival rate of the EMA/CO group were all 91.7%, and there was no statistical difference in the overall survival time between the 2 groups (P > 0.05). COX proportional stepwise regression analysis showed that only clinical staging was an independent risk factor of the prognosis of high-risk GTN (P = 0.003). Conclusion Both 5-FU regimen and EMA / CO regimen can be used as the first-line treatment for high-risk GTN patients, and their effects are similar. For high-risk GTN patients with drug resistance, EMA / CO, FAEV and PEB can be used as second-line salvage chemotherapy.

Differences in Administration of Methotrexate and Impact on Outcome in Low-Risk Gestational Trophoblastic Neoplasia

Simple Summary

Low-risk gestational trophoblastic neoplasia is a rare but highly curable malignancy. The most common first line treatment is methotrexate, which can be administered in different forms. In order to investigate the impact of route of administration on methotrexate resistance, toxicity demanding treatment switch, complete remission and relapse, we performed an observational study including women with low-risk gestational trophoblastic neoplasia in a population-based setting in Sweden and Denmark. We found that oral compared to intra-muscular administration of methotrexate gives a higher rate of drug resistance, but does not affect rates of complete remission, recurrence or overall survival. Intra-muscular treatment was associated with more toxicity leading to switch of treatment. We conclude that, although a larger proportion of women develop drug resistance, oral methotrexate, which is easy to administer and highly tolerable, could be an option for well-informed and motivated women.

Abstract

Methotrexate (MTX) is frequently used as first-line treatment for low-risk gestational trophoblastic neoplasia (GTN). Intravenous and intramuscular (im) routes of administration are the most common methods, although oral administration is used by some Scandinavian centers. The primary aim of this study was to assess the impact of form of administration (im/oral) on resistance to methotrexate (MTX-R) treatment in low-risk GTN. Secondary aims were time to hCG normalization, rates of toxicity-induced treatment switch, and rates of complete remission and recurrence. In total, 170 women treated at Karolinska University Hospital in Sweden and Aarhus University Hospital in Denmark between 1994 and 2018 were included, of whom 107 were given im and 63 oral MTX. MTX-R developed in 35% and 54% in the im and oral groups, respectively (p = 0.01). There was no difference in days to hCG normalization (42 vs. 41 days, p = 0.50) for MTX-sensitive women. Toxicity-induced treatment switch was only seen in the im group. Complete remission was obtained in 99.1% and 100% (p = 0.44), and recurrence rate within one year was 2.8% and 1.6% (p = 0.29). The form of administration of MTX had a significant impact on development of MTX-R and treatment-associated toxicity, but does not affect rates of complete remission, recurrence or survival.

Lectin galactoside-binding soluble 3 binding protein mediates methotrexate resistance in choriocarcinoma cell lines

Choriocarcinoma is one of the most aggressive gestational trophoblastic neoplasias (GTN). Methotrexate (MTX) resistance is the main cause of treatment failure in choriocarcinoma. However, the mechanism of MTX resistance in choriocarcinoma is poorly known. This study aims to explore the function of Lectin galactoside-binding soluble 3 binding protein (LGALS3BP) in MTX-resistance in choriocarcinoma cells. Gradual dose escalation of MTX was used to establish MTX-resistant choriocarcinoma cells (JAR-MTX and JEG3-MTX cell lines). RNA-sequencing was used to explore the differentially expressed genes. Plasmids or SiRNA transfection was used to regulate the expression of LGALS3BP. ELISA was used to detect the concentrations of LGALS3BP in the serum of MTX-sensitive and MTX-resistant patients. qRT-PCR, Western blot, and CCK-8 assay were used to determine the effects of LGALS3BP on MTX-resistance in JAR and JEG3 cells. The results showed the relative resistance index (RI) of MTX is 791.50 and 1040.04 in JAR-MTX and JEG3-MTX, respectively. LGALS3BP was up-regulated in MTX-resistant cells compared to original cells in both RNA and protein level. The concentrations of LGALS3BP were higher in the sera of MTX-resistant patients than in MTX-sensitive patients. Knocking down LGALS3BP can reverse the MTX-resistance in JAR-MTX and JEG3-MTX cells. In summary, we preliminarily established two MTX-resistant cells, and performed RNA-sequencing, and found LGALS3BP may play important role in MTX-resistance. Our work not only provides a research tool (MTX-resistant cells) for other researchers, but gives some hint on how MTX resistance is regulated.

Advances in the diagnosis and early management of gestational trophoblastic disease

Gestational trophoblastic disease describes a group of rare pregnancy related disorders that span a spectrum of premalignant and malignant conditions. Hydatidiform mole (also termed molar pregnancy) is the most common form of this disease. Hydatidiform mole describes an abnormal conceptus containing two copies of the paternal genome, which is classified as partial when the maternal genome is present or complete when the maternal genome is absent. Hydatidiform mole typically presents in the first trimester with irregular vaginal bleeding and can be suspected on ultrasound but confirmation requires histopathological evaluation of the products of conception. Most molar pregnancies resolve without treatment after uterine evacuation, but occasionally the disease persists and develops into gestational trophoblastic neoplasia. Close monitoring of women after molar pregnancy, with regular measurement of human chorionic gonadotrophin concentrations, allows for early detection of malignancy. Given the rarity of the disease, clinical management and treatment is best provided in specialist centres where very high cure rates are achievable. This review looks at advances in the diagnosis and early management of gestational trophoblastic disease and highlights updates to disease classification and clinical guidelines. Use of molecular genotyping for improved diagnostic accuracy and risk stratification is reviewed and future biomarkers for the earlier detection of malignancy are considered.

Molar Pregnancy Complicated by Impending Thyroid Storm

Gestational trophoblastic diseases, which include molar pregnancy, have an increased risk of complications associated with the thyroid gland. This condition is mainly caused by elevated levels of beta-human chorionic gonadotropin produced during pregnancy, which is exaggerated in molar pregnancy and can lead to thyrotoxicosis. Hence, it is important to recognize the signs and symptoms of hyperthyroidism among women of childbearing age to prevent complications such as thyroid storm. Medical management of thyroid storm before surgery is critical to prevent adverse maternal outcomes. Here, we report a rare case of impending thyroid storm induced by molar pregnancy.

Recurrent Androgenetic Complete Hydatidiform Moles with p57KIP2-Positive in a Chinese Family

Androgenetic complete hydatidiform moles (CHMs) are associated with an increased risk of gestational trophoblastic neoplasia. P57^KIP2 expression in hydatidiform moles is thought to be a powerful marker for differentiating CHMs from partial hydatidiform moles (PHMs). However, since there are so few such families clinically, very few studies have addressed the importance of p57^KIP2-positive in the diagnosis and prognosis of CHM. This study aimed to emphasize the significance of the accurate diagnosis of rare CHM and careful follow-up. The classification of the hydatidiform mole was based on morphologic examination and p57^KIP2 expression was determined by p57^KIP2 immunohistochemical staining. Copy number variation sequencing was used to determine the genetic make-up of the mole tissues. In addition, the short tandem repeat polymorphism analysis was used to establish the parental origin of the moles. Finally, whole-exome sequencing was performed to identify the causal genetic variants associated with this case. In one Chinese family, the proband had numerous miscarriages throughout her two marriages. Morphologic evaluation and molecular genotyping accurately sub-classified two molar specimens as uniparental disomy CHM of androgenetic origin. Furthermore, p57^KIP2 expression was found in cytotrophoblasts and villous stromal cells. In the tissue, there were hyperplasia trophoblastic cells and heteromorphic nuclei. In this family, no deleterious variant genes associated with recurrent CHM were detected. It is important to evaluate the prognostic value of p57^KIP2 expression in androgenetic recurrent CHM. This knowledge may help to minimize erroneous diagnosis of CHMs as PHMs, as well as making us aware of the need to manage potential gestational trophoblastic neoplasia.