51
|
Almohammadi NH. A histopathological profile of gestational trophoblastic disease in the Madinah Region of Saudi Arabia: A single institute experience. Niger J Clin Pract 2022; 25:1256-1261. [DOI: 10.4103/njcp.njcp_2049_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
52
|
Jiao L, Wang Y, Jiang J, Wang X, Zhang W, Zhu C, Xiang Y. Centralized surveillance of hydatidiform mole: 7-year experience from a regional hospital in China. Int J Gynecol Cancer 2021; 32:147-152. [PMID: 34799419 PMCID: PMC8862018 DOI: 10.1136/ijgc-2021-002797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/27/2021] [Indexed: 11/23/2022] Open
Abstract
Objective To assess the strategy and value of centralized surveillance of hydatidiform mole at a regional hospital in China and to investigate the necessity of prophylactic chemotherapy for high-risk complete hydatidiform mole. Methods Between February 2013 and February 2020, all women with hydatidiform mole in Dalian Women’s and Children’s Medical Center (Group) were registered for surveillance and treatment when indicated. Women with complete hydatidiform mole were categorized into low-risk and high-risk groups according to the criteria from Song Hongzhao’s trophoblastic neoplasia. Outcomes and treatments were analyzed retrospectively. Results In total, 703 women with hydatidiform mole were registered for surveillance with a follow-up rate of 97.9% (688/703). 680 women were enrolled and 52 (7.6%) developed post-molar gestational trophoblastic neoplasia, all with low-risk International Federation of Gynecology and Obstetrics (FIGO) scores 0–5. Post-molar gestational trophoblastic neoplasia was diagnosed in 12.3% (51/413) of patients with complete hydatidiform moles and 0.4% (1/263) of patients were diagnosed with partial hydatidiform moles (χ2=32.415, p<0.001). Post-molar gestational trophoblastic neoplasia was diagnosed in 27.7% (28/101) of the high-risk complete hydatidiform mole group and in 7.4% (23/312) of the low-risk complete hydatidiform mole group (χ2=29.196, p<0.001). No difference in the pre-treatment assessments of patients with post-molar gestational trophoblastic neoplasia was found between the low-risk and high-risk complete hydatidiform mole groups (all p>0.05). All 52 patients with post-molar gestational trophoblastic neoplasia were cured, with a complete response rate of 61.2% (30/49) with first-line single-agent chemotherapy. Conclusions A centralized hydatidiform mole surveillance program is feasible and effective and may improve the prognosis of patients with post-molar gestational trophoblastic neoplasia. Prophylactic chemotherapy is not recommended for women with high-risk complete hydatidiform mole with adequate surveillance.
Collapse
Affiliation(s)
- Lanzhou Jiao
- Department of Gynecology Oncology, Dalian Women's and Children's Medical Center (Group), Dalian, Liaoning, China
| | - Yaping Wang
- Department of Pathology, Dalian Women's and Children's Medical Center (Group), Dalian, Liaoning, China
| | - Jiyong Jiang
- Department of Gynecology Oncology, Dalian Women's and Children's Medical Center (Group), Dalian, Liaoning, China
| | - Xiuying Wang
- Department of Gynecology Oncology, Dalian Women's and Children's Medical Center (Group), Dalian, Liaoning, China
| | - Wenqing Zhang
- Department of Gynecology Oncology, Dalian Women's and Children's Medical Center (Group), Dalian, Liaoning, China
| | - Chenggong Zhu
- Department of Gynecology Oncology, Dalian Women's and Children's Medical Center (Group), Dalian, Liaoning, China
| | - Yang Xiang
- Department of Obstetrics & Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
53
|
She C, Li S, Wang X, Lu X, Liang H, Liu X. High-intensity focused ultrasound ablation as an adjuvant surgical salvage procedure in gestational trophoblastic neoplasia chemotherapy with chemoresistance or recurrence: two case reports. Int J Hyperthermia 2021; 38:1584-1589. [PMID: 34732086 DOI: 10.1080/02656736.2021.1998659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Chemotherapy is the main treatment strategy for gestational trophoblastic neoplasia (GTN). Surgical resection is crucial to deal with chemoresistance and recurrence following chemotherapy. The aim of this study was to explore if high-intensity focused ultrasound (HIFU) can be used as a complementary technique to surgical procedures in the management of GTN. CASE REPORT This case report described two females who previously developed chemoresistance or recurrence during chemotherapy and then underwent HIFU as an adjuvant surgical salvage procedure. For high-risk GTN patients with chemoresistance, HIFU treatment decreased the risk of chemoresistance and shortened the course of chemotherapy. It also reduced the dosage of chemotherapeutic agents used for the patient who suffered a recurrence. CONCLUSION For patients with GTN who desire to preserve their uterus, HIFU may be used as a complementary technique to surgical resection in the management of GTN.
Collapse
Affiliation(s)
- Chaokun She
- Department of Laboratory Medicine, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Zunyi City, China
| | - Sha Li
- Department of Gynecology and Obstetrics, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Zunyi City, China
| | - Xiaojun Wang
- Department of Clinical Medicine, Zunyi Medical and Pharmaceutical College, Zunyi City, China
| | - Xianghui Lu
- Department of Gynecology and Obstetrics, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Zunyi City, China
| | - Hao Liang
- Department of Gynecology, Chongqing Haifu Hospital, Chongqing, China
| | - Xiaoyun Liu
- Department of Gynecology and Obstetrics, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Zunyi City, China
| |
Collapse
|
54
|
Cheng H, Zong L, Kong Y, Wang X, Gu Y, Cang W, Zhao J, Wan X, Yang J, Xiang Y. Camrelizumab plus apatinib in patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia (CAP 01): a single-arm, open-label, phase 2 trial. Lancet Oncol 2021; 22:1609-1617. [PMID: 34624252 DOI: 10.1016/s1470-2045(21)00460-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment options for patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia are scarce. The synergistic antitumour effect of immunotherapy and antiangiogenic drugs has been shown in many solid tumours. This phase 2 trial evaluated the activity and safety of camrelizumab (PD-1 inhibitor) plus apatinib (VEGF receptor inhibitor) in patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia. METHODS This was a single-arm, open-label, phase 2 trial, done at a single tertiary health-care centre in Beijing, China. Women (18-70 years) with high-risk (International Federation of Gynecology and Obstetrics score ≥7) chemorefractory or relapsed gestational trophoblastic neoplasia who had received at least two lines of previously unsuccessful multidrug chemotherapy regimens and had an Eastern Cooperative Oncology Group performance status of 0-2 were eligible for inclusion. Patients received 4-week cycles of intravenous camrelizumab 200 mg every 2 weeks plus oral apatinib 250 mg once per day until disease progression or unacceptable toxicity. The primary endpoint was objective response rate assessed according to serum human chorionic gonadotrophin concentration. Activity and safety were analysed in all patients who received at least one dose of study drug. The study is ongoing, but recruitment is complete. The study is registered with ClinicalTrials.gov, NCT04047017. FINDINGS Between Aug 7, 2019, and March 18, 2020, 20 patients enrolled; 19 (95%) were diagnosed with choriocarcinoma and one (5%) had placental site trophoblastic tumour. The median follow-up duration was 18·5 months (IQR 14·6-20·9). The objective response rate was 55% (95% CI 32-77); ten (50%; 95% CI 27-73) patients had complete response. The most common grade 3 treatment-related adverse events were hypertension (five [25%] patients), rash (four [20%] patients), neutropenia (two [10%]), leukocytopenia (two [10%]), and aspartate aminotransferase increase (two [10%]). One patient had a treatment-related serious adverse event (aspartate aminotransferase 19-times higher than the upper limit of normal). No grade 4 or 5 treatment-related adverse events were reported. INTERPRETATION Camrelizumab plus apatinib showed promising antitumour activity and acceptable toxicity and could be a salvage therapy option for the treatment of high-risk chemorefractory or relapsed gestational trophoblastic neoplasia. Immune checkpoint inhibitors combined with chemotherapy for heavily-treated patients and upfront use of camrelizumab plus apatinib for patients with high-risk gestational trophoblastic neoplasia are under investigation in phase 2 trials. FUNDING National Natural Science Foundation of China, Jiangsu Hengrui Pharmaceuticals.
Collapse
Affiliation(s)
- Hongyan Cheng
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liju Zong
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yujia Kong
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyu Wang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Gu
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Cang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhao
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|
55
|
Luo F, Li L, Gao Q, Li YX. Evaluation of efficacy and safety of chemotherapy in the treatment of recurrent or resistant gestational trophoblastic neoplasia: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27320. [PMID: 34622830 PMCID: PMC8500640 DOI: 10.1097/md.0000000000027320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Gestational Trophoblastic Neoplasia (GTN) is a spectrum of pregnancy-associated tumours emerging from placental tissue. Generally, GTN patients are considered to have a high rate of recovery. However, almost 25 per cent of GTN tumours resist, or have a high probability of relapsing following the first line of chemo treatment. Thus, tumours that resist or relapse requires salvage chemotherapy, sometimes accompanied by surgery. Globally, clinicians utilize a range of salvage regimens. Currently, ongoing debates are centred around choosing the best regimens in terms of safety and efficacy. Therefore, the current research aims to appraise the success and level of safeness using chemotherapy to treat patients with resistant or recurrent GTN. METHODS The authors will conduct a methodological exploration in online-based databases to find Randomized Controlled Trials related to the adoption of chemotherapy agents as treatment for resistant or recurrent GTN patients. The databases are as follows: EMBASE, PubMed, Cochrane Database Central, UpToDate, Chinese National Knowledge Infrastructure, Web of Science, and WanFang Database. The search will be limited to articles published in either English or Chinese. Moreover, the authors will also perform a search for ongoing trials on online-based clinical trial registries. Two independent authors will screen and select articles for review. A similar process will be followed by two independent authors to complete the extraction of data and evaluate the bias risk. In relevant cases, the authors will contract trial investigators to obtain related, unpublished data. The authors will use the random-effects model for pooling data in RevMan software (v5.3). RESULTS The present systematic review aims to evaluate the efficacy and level of safeness associated with using chemotherapy for resistant or recurrent GTN patients. CONCLUSION The results of the proposed systematic analysis could summarize the most recent evidence for the use of chemotherapy agents on GTN patients. ETHICS AND DISSEMINATION Since the proposed study uses pre-published data, an ethical approval is not required. REVIEW REGISTRATION NUMBER Aug 25, 2021.osf.io/rgzbn. (https://osf.io/rgzbn/).
Collapse
Affiliation(s)
- Fang Luo
- Department of Gynecology, Wuhan Puren hospital, Wuhan, Hubei, China
| | - Li Li
- Department of pathology, wuhan puren hospital, Wuhan, Hubei, China
| | - Qing Gao
- Department of Gynecology, Wuhan Puren hospital, Wuhan, Hubei, China
| | - Yu-Xia Li
- Department of Gynaecology and Obstetrics, Wuhan Children's Hospita (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
| |
Collapse
|
56
|
Liu X, Pan X, Liu H, Ma X. Gut Microbial Diversity in Female Patients With Invasive Mole and Choriocarcinoma and Its Differences Versus Healthy Controls. Front Cell Infect Microbiol 2021; 11:704100. [PMID: 34513727 PMCID: PMC8428518 DOI: 10.3389/fcimb.2021.704100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/09/2021] [Indexed: 12/12/2022] Open
Abstract
Objective To investigate variation in gut microbiome in female patients with invasive mole (IM) and choriocarcinoma (CC) and compare it with healthy controls. Methods Fecal microbiome of 12 female patients with IM, 9 female patients with CC, and 24 healthy females were analyzed based on 16s rDNA sequencing. Alpha (α) diversity was evaluated using Shannon diversity index and Pielou evenness index, while beta (β) diversity was assessed using principle coordinate analysis (PCoA) of unweighted Unifrac distances. The potential functional changes of microbiomes were predicted using Tax4Fun. The relative abundance of microbial taxa was compared using Welch’s t test. The role of varied gut microbiota was analyzed via receiver operating characteristic (ROC) curve. Results The α diversity and β diversity were significantly different between IM patients and controls, but not between CC patients and controls. In addition, the abundance of cancer-related genes was significantly increased in IM and CC patients. Notably, a total of 19 families and 39 genera were found to have significant differences in bacterial abundance. ROC analysis indicated that Prevotella_7 may be a potential biomarker among IM, CC, and controls. Conclusion Our study demonstrated that the diversity and composition of gut microbiota among IM patients, CC patients, and healthy females were significantly different, which provides rationale for using gut microbiota as diagnostic markers and treatment targets, as well as for further study of gut microbiota in gestational trophoblastic neoplasia (GTN).
Collapse
Affiliation(s)
- Xiaomei Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xue Pan
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hao Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiaoxin Ma
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| |
Collapse
|
57
|
Yamaguchi N, Hamada Y, Inagaki R, Nemoto K, Yoshitomi H, Takakura S. Successful salvage treatment with paclitaxel, ifosfamide, and cisplatin in a patient with methotrexate-resistant gestational trophoblastic neoplasia who developed hypersensitivity reaction to etoposide. J Obstet Gynaecol Res 2021; 47:3737-3741. [PMID: 34278664 DOI: 10.1111/jog.14945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/01/2021] [Accepted: 07/07/2021] [Indexed: 12/01/2022]
Abstract
We report a 34-year-old woman with recurrent gestational trophoblastic neoplasia (GTN) who showed hypersensitivity to etoposide. Computed tomography (CT) revealed a 32-mm solid mass in the right lung and a 101-mm cystic mass with solid components in the left side of the liver. The patient's serum human chorionic gonadotropin (HCG) level was 689 439 mIU/mL. After eight cycles of combined paclitaxel 175 mg/m2 on day 1, ifosfamide 1 g/m2 on days 2-5, and cisplatin 20 mg/m2 on days 2-5 (TIP) every 3 weeks, the serum HCG level decreased to 2.4 mIU/mL. CT scan revealed disappearance of the lung tumor and significant reduction in the solid components of the liver tumor. Then, left hemihepatectomy was performed. After 3 months, there was no evidence of the disease, and the serum HCG level normalized. Thus, TIP chemotherapy, followed by residual mass resection, might be effective for methotrexate-resistant GTN.
Collapse
Affiliation(s)
- Noriko Yamaguchi
- Department of Obstetrics and Gynecology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Yoshinobu Hamada
- Department of Obstetrics and Gynecology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Risa Inagaki
- Department of Obstetrics and Gynecology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Kohei Nemoto
- Department of Obstetrics and Gynecology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Hideyuki Yoshitomi
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Satoshi Takakura
- Department of Obstetrics and Gynecology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| |
Collapse
|
58
|
Poli JG, Paiva G, Freitas F, Mora P, Velarde LGC, Junior JA, Filho JR, Elias KM, Horowitz NS, Braga A, Berkowitz RS. Folinic acid rescue during methotrexate treatment for low-risk gestational trophoblastic neoplasia - How much is just right? Gynecol Oncol 2021; 162:638-644. [PMID: 34266689 DOI: 10.1016/j.ygyno.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/27/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the outcomes of patients with low-risk gestational trophoblastic neoplasia (GTN) treated with 8-day methotrexate (MTX) with two different regimens of folinic acid (FA). METHODS Retrospective cohort study of low-risk GTN followed at Rio de Janeiro Federal University, from January/2000-December/2019 with 8-day MTX with FA at 0.1 mg/kg versus 15 mg fixed dose. RESULTS Among 667 patients with low-risk GTN, 323 were treated with FA at 0.1 mg/kg and 142 with FA at 15 mg fixed dose. The weight-based and fixed dose groups were comparable in terms of clinical profile but did differ in the hCG pretreatment level (8883 versus 5127 IU/L, p < 0.01) and FIGO risk score 5/6 (3.4% versus 18.3%, p < 0.01), respectively. Despite this, there was no difference in the remission rate in first-line treatment (76.8 versus 81%, p = 0.33), although FA at 0.1 mg/kg had a significantly higher number of chemotherapy cycles to remission (5 versus 4, p < 0.01), need to delay chemotherapy due to toxicity (6.8 versus 2.8%, p < 0.01) and time to remission, (12 versus 8 weeks, p < 0.01), respectively. A logistic regression analysis showed that the different FA rescue regimens appeared comparable in terms of achieving remission in first-line chemotherapy for low-risk GTN (OR:5.16, CI95%:0.84-31.64, p = 0.08). CONCLUSION FA with 15 mg fixed dose as compared to 0.1 mg/kg of FA was associated with similar primary remission rate, relapse or death among low-risk GTN treated with 8-day MTX. This regimen is highly practical, reduces visits to health facilities, appears equally safe and may be preferable with the 8-day MTX regimen in the treatment of low-risk GTN.
Collapse
Affiliation(s)
- Juliana Gomes Poli
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil
| | - Gabriela Paiva
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Fernanda Freitas
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Paulo Mora
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil; Brazilian National Cancer Institute. Hospital do Câncer 2, Rio de Janeiro, RJ, Brazil
| | | | - Joffre Amim Junior
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Jorge Rezende Filho
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil; National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, RJ, Brazil.
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
59
|
Singhal S, Kumar L, Kumar S, Khurana S, Bhatla N. Predictors of chemotherapy resistance & relapse in gestational trophoblastic neoplasia. Indian J Med Res 2021; 152:595-606. [PMID: 34145099 PMCID: PMC8224147 DOI: 10.4103/ijmr.ijmr_2585_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background & objectives: Gestational trophoblastic neoplasia (GTN) is a chemosensitive malignancy with an excellent cure rate. The primary objective of the present study was to determine the predictors of chemoresistance and disease relapse, and the secondary objective was to appraise the WHO/FIGO risk scoring and course of disease in women with GTN. Methods: In this retrospective study, case records of women treated for GTN from January 2011 to June 2019 were reviewed. For the purpose of comparison, sub-stratification of FIGO/WHO low risk group (≤6) into low (0-4) and intermediate (5-6) risk was done. Similarly, WHO high risk (≥7) group was sub-stratified into high (7-12) and ultra-high risk (≥13) groups. Results: Case records of 116 patients were included: 51.7 per cent (60/116) were of low risk disease and 48.2 per cent (56/116) were of high risk disease. Chemoresistance developed in 28.4 per cent (33/116) and relapse in 10.3 per cent (12/116) cases. Risk of chemoresistance was higher in low risk (0-6) while risk of relapse was more in high risk (≥7) group. On sub-stratification, chemoresistance was more with intermediate [0-4: 28.5% (10/35), 5-6: 44% (11/25), 7-12: 22.5% (9/40), ≥13: 18.7% (3/16)] and relapse with ultra-high risk score [0-4: 5.7% (2/35), 5-6: 4% (1/25), 7-12:10% (4/40), ≥13: 31.2% (5/16)]. Age, myometrial invasion, serum beta-human chorionic gonadotropin and tumour size were not related to chemoresistance or relapse. Interpretation & conclusions: WHO risk score and presence of metastatic disease predict the probability of developing chemotherapy resistance and disease relapse. Risk of chemotherapy resistance was higher in women with intermediate-risk score (5-6), and risk of relapse was more in those with ultra-high risk score (≥13).
Collapse
Affiliation(s)
- Seema Singhal
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology, Dr BR Ambedkar IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Sunesh Kumar
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Khurana
- Department of Medical Oncology, Dr BR Ambedkar IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Neerja Bhatla
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
60
|
Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin 2021; 39:649-670. [PMID: 33896537 DOI: 10.1016/j.ncl.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article serves as a comprehensive review of neurologic emergencies in pregnancy. Common initial presentations of neuroemergencies are reviewed with a clinical algorithm. Neurovascular disorders in pregnancy are reviewed, including acute ischemic strokes with data on tPA and thrombectomy; cerebral venous sinus thrombosis diagnosis and management; posterior reversible encephalopathy syndrome management; reversible cerebral vasoconstriction syndrome; and intracerebral hemorrhage. Attention is paid to management of cerebral edema and safety of osmotic therapies. A review of seizures in pregnancy is provided, including new-onset causes and decreased seizure thresholds. For status epilepticus, a low teratogenicity risk medication protocol in pregnancy is provided.
Collapse
Affiliation(s)
- Elizabeth Macri
- Department of Neurology, University of New Mexico, MSC10 5620, 1 University of New Mexico, Albuquerque, NM 87131, USA. https://twitter.com/SportsDoc2009
| | - Diana Greene-Chandos
- Neurosciences Critical Care Fellowship, Department of Neurology, University of New Mexico; MSC10 5620, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| |
Collapse
|
61
|
Kopelman ZA, Hope ER. High-Risk Gestational Trophoblastic Neoplasia from a Homozygous NLRP7 Mutation. Gynecol Oncol Rep 2021; 37:100803. [PMID: 34189227 PMCID: PMC8215180 DOI: 10.1016/j.gore.2021.100803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/18/2021] [Accepted: 05/31/2021] [Indexed: 11/15/2022] Open
Abstract
NLRP7 germline mutation can result in high risk gestational trophoblastic neoplasia. No successful reproductive outcomes have been reported with homozygous NLRP7 mutation. Germline testing should be considered for patients presenting with recurrent gestational trophoblastic disease. Once an NLRP7 mutation is diagnosed, consultation with reproductive endocrinology is necessary to discuss future fertility. Further research is needed in rare cases regarding gestational trophoblastic neoplasia recurrence and reproductive outcomes.
Collapse
Affiliation(s)
- Zachary A Kopelman
- Department of Obstetrics and Gynecology, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA
| | - Erica R Hope
- Department of Obstetrics and Gynecology, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA
| |
Collapse
|
62
|
Seckl MJ, Ghorani E. Progress to international harmonisation of care and future developments. Best Pract Res Clin Obstet Gynaecol 2021; 74:159-167. [PMID: 34119435 DOI: 10.1016/j.bpobgyn.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/18/2021] [Indexed: 01/01/2023]
Abstract
Considerable differences exist in the management of gestational trophoblastic disease (GTD) both nationally and internationally despite numerous efforts to harmonise patient care. This partly reflects differences in healthcare systems and availability of resources. However, even in first world equivalent economies with similar healthcare systems differences remain, which appear to impact survival. Recently, new international guidelines have been established in Europe through a series of consensus meetings. Improvement of outcomes will depend on the establishment of dedicated centres with appropriate patient pathways according to these guidelines. This review will highlight some of the differences and efforts to unify the management of GTD across the globe and discuss areas for future development.
Collapse
Affiliation(s)
- Michael J Seckl
- Dept Medical Oncology, Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W68RF, UK.
| | - Ehsan Ghorani
- Dept Medical Oncology, Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W68RF, UK
| |
Collapse
|
63
|
Soper JT. Gestational Trophoblastic Disease: Current Evaluation and Management. Obstet Gynecol 2021; 137:355-370. [PMID: 33416290 PMCID: PMC7813445 DOI: 10.1097/aog.0000000000004240] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
This review summarizes the current evaluation and management of gestational trophoblastic disease, including evacuation of hydatidiform moles, surveillance after evacuation of hydatidiform mole and the diagnosis and management of gestational trophoblastic neoplasia. Most women with gestational trophoblastic disease can be successfully managed with preservation of reproductive function. It is important to manage molar pregnancies properly to minimize acute complications and to identify gestational trophoblastic neoplasia promptly. Current International Federation of Gynecology and Obstetrics guidelines for making the diagnosis and staging of gestational trophoblastic neoplasia allow uniformity for reporting results of treatment. It is important to individualize treatment based on their risk factors, using less toxic therapy for patients with low-risk disease and aggressive multiagent therapy for patients with high-risk disease. Patients with gestational trophoblastic neoplasia should be managed in consultation with an individual experienced in the complex, multimodality treatment of these patients.
Collapse
Affiliation(s)
- John T Soper
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| |
Collapse
|
64
|
Peixinho C, Almeida A, Bartosch C, Cruz Pires M. Placental site trophoblastic tumour: five challenges of patient clinical management. BMJ Case Rep 2021; 14:14/1/e238994. [PMID: 33509882 PMCID: PMC7845717 DOI: 10.1136/bcr-2020-238994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Placental site trophoblastic tumour is a rare form of gestational trophoblastic disease accounting for about 1%-2% of all trophoblastic tumours. Diagnosis and management of placental site trophoblastic tumour can be difficult.We report a case of a 30-year-old woman diagnosed with a placental site trophoblastic tumour and identify the challenges in diagnosis and treatment of this rare situation. The presenting sign was abnormal vaginal bleeding that started 3 months after delivery. Image exams revealed an enlarged uterus with a heterogeneous mass, with vesicular pattern, and the increased vascularisation serum human chorionic gonadotropin level was above normal range. The histological diagnosis was achieved through hysteroscopic biopsy. Staging exams revealed pulmonary micronodules. The patient was successfully treated with hysterectomy and chemotherapy. The latest follow-up (37 months after diagnosis) was uneventful, and the patient exhibited no signs of recurrence or metastasis.
Collapse
Affiliation(s)
- Catarina Peixinho
- Department of Gynecology and Obstetrics, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Amélia Almeida
- Department of Gynecology and Obstetrics, Centro Hospitalar do Médio Ave, Famalicão, Portugal
| | - Carla Bartosch
- Department of Pathology, Instituto Portugues de Oncologia do Porto Francisco Gentil EPE, Porto, Portugal
| | - Mónica Cruz Pires
- Department of Gynecology, Instituto Portugues de Oncologia do Porto Francisco Gentil EPE, Porto, Portugal
| |
Collapse
|
65
|
Zhou B, Anglin HP, Quaas AM. Molar pregnancy after in vitro fertilization with euploid single embryo transfer. F S Rep 2021; 2:146-149. [PMID: 34278345 PMCID: PMC8267387 DOI: 10.1016/j.xfre.2021.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 11/27/2022] Open
Abstract
Objective To describe a case of molar pregnancy after in vitro fertilization (IVF) resulting from the transfer of a euploid embryo derived from a monopronuclear zygote. Design Case report and review of the literature. Setting Private practice IVF center. Patients A 42-year-old woman, gravida 3 para 0, with advanced maternal age and infertility who underwent IVF. Interventions Preimplantation genetic testing for aneuploidy using next-generation sequencing, single frozen euploid blastocyst transfer, and medical management of suspected missed abortion. Main Outcome Measures Genetic examination of products of conception and correlation with embryonic preimplantation genetic testing for aneuploidy results. Results Transfer of the euploid embryo derived from an abnormally fertilized oocyte (monopronuclear zygote) resulted in a clinical pregnancy suspected to be a missed abortion. Products of conception collected after medical management of the suspected missed abortion were analyzed using next-generation sequencing with the report "46,XX complete molar pregnancy". Conclusions To our knowledge, this is the first account of a complete molar pregnancy resulting from the transfer of a reported euploid embryo, highlighting the importance of understanding the limitations of genetic testing platforms in the setting of abnormally fertilized oocyte-derived embryos.
Collapse
Affiliation(s)
- Beth Zhou
- Division of Reproductive Endocrinology and Infertility, University of California, San Diego, California
| | - Helen Paige Anglin
- Division of Reproductive Endocrinology and Infertility, University of California, San Diego, California
| | - Alexander M Quaas
- Division of Reproductive Endocrinology and Infertility, University of California, San Diego, California.,Reproductive Partners San Diego, San Diego, California
| |
Collapse
|
66
|
Sugrue R, Foley O, Elias KM, Growdon WB, Sisodia RMC, Berkowitz RS, Horowitz NS. Outcomes of minimally invasive versus open abdominal hysterectomy in patients with gestational trophoblastic disease. Gynecol Oncol 2020; 160:445-449. [PMID: 33272644 DOI: 10.1016/j.ygyno.2020.11.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/21/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study is to compare surgical and oncologic outcomes for women undergoing MIH or open abdominal hysterectomy (OAH) for management of gestational trophoblastic disease (GTD). METHODS Patients who underwent hysterectomy for GTD between January 1, 2009 and December 31, 2018 were identified using an institutional database and tumor registry. Patients were stratified based on indication for and mode of hysterectomy. RESULTS 39 patients underwent hysterectomy for GTD - 22 MIH and 17 OAH. 26 hysterectomies (66.7%) were performed for primary treatment of GTD, 7 (17.9%) for chemoresistance, 2 (5.1%) for uterine hemorrhage, and 4 (10.3%) for other indications. Mean tumor size (4.2 vs 4.6 cm; p = .81) and operative time (136 vs 163 mins; p = .42) were similar in both groups. MIH was associated with significantly less blood loss (71.5 vs 427.3 ml; p = .03) and shorter hospital stay (1.5 vs 3.9 days, p = .02) than OAH. Postoperative histology comprised 12 complete moles (6 invasive), 8 choriocarcinomas, 9 placental site trophoblastic tumors and 9 epithelioid trophoblastic tumors. Median follow-up was 67.2 months (50.2 MIH, 79.3 OAH; range 11.1-131.2) and there was no difference in remission (81.8% MIH vs 76.5% OAH; p = .68). There were 7 recurrences (4 MIH, 3 OAH) and 3 deaths (2 MIH, 1 OAH). Overall survival was 97.3% at 2 years and 88.5% at 5 years. There was no significant difference in 5-year survival by mode of surgery (MIH 90.9%, OAH 83.3%; p = .40). CONCLUSIONS Patients undergoing MIH at our centers have similar oncologic outcomes, lower surgical blood loss and shorter hospital stay compared to those undergoing OAH. Overall survival is similar regardless of mode of surgery.
Collapse
Affiliation(s)
- R Sugrue
- The New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - O Foley
- The New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - K M Elias
- The New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - W B Growdon
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - R M C Sisodia
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - R S Berkowitz
- The New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - N S Horowitz
- The New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| |
Collapse
|
67
|
Wang K, Chen Y. Management and prognostic analysis of patients with gestational trophoblastic neoplasia (GTN) in FIGO stage IV and its special type. Clin Exp Metastasis 2020; 38:47-59. [PMID: 33219408 PMCID: PMC7882548 DOI: 10.1007/s10585-020-10064-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/08/2020] [Indexed: 11/17/2022]
Abstract
GTN is a group malignant diseases from placental trophoblastic cells. There are very few cases of GTN with FIGO (International Federation of Gynecology and Obstetrics) stage IV all over the world, and the special types (patients with metastatic lesions and with no evidence of GTN neither in genitalia nor in lungs) have rarely been reported. It is necessary to conduct large retrospective studies aimed at exploring the diagnosis, treatment and outcomes of this disease. In this retrospective study, 716 patients with GTN were treated at Zhejiang University School of Medicine Women’s Hospital between January 1999 and September 2019; 26 patients were diagnosed as stage IV GTN; Among the 26 stage IV GTN patients, 5 were defined as the special types. The 5-year OS rate of the total 26 FIGO stage IV GTN patients was 69.0%. There was no significant difference of survival rate between stage IV GTN and its special type. And no significant differences in blood type, antecedent pregnancy type, the interval from last known pregnancy, pretreatment serum HCG (human chorionic gonadotropin) level, maximum diameter of tumors, FIGO score, underwent surgery or not and pathological pattern by the outcomes. Age, number of tumor lesions, primary chemotherapy regimen was EMA-CO or EP-EMA protocol and chemoresponse affected the prognosis significantly. Only number of tumor lesions > 8 was independent prognostic factors associated with poorer OS.
Collapse
Affiliation(s)
- Kai Wang
- Department of Oncology, Zhejiang University School of Medicine Women's Hospital, No. 1 Xueshi Road, Hangzhou, China
| | - Yaxia Chen
- Department of Oncology, Zhejiang University School of Medicine Women's Hospital, No. 1 Xueshi Road, Hangzhou, China.
| |
Collapse
|
68
|
Boyce J, Tawagi K, Cole JT. Primary colon adenocarcinoma with choriocarcinoma differentiation: a case report and review of the literature. J Med Case Rep 2020; 14:220. [PMID: 33190644 PMCID: PMC7667771 DOI: 10.1186/s13256-020-02544-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/30/2020] [Indexed: 11/15/2022] Open
Abstract
Background Choriocarcinoma is an aggressive malignancy of trophoblastic tissue, typically of gestational etiology. Sporadic, nongestational cases are rarely found outside of the gonads. There are only 31 cases of primary choriocarcinoma of the colon reported in the literature. As a consequence of their rarity and aggressive nature, timely diagnosis and effective treatment have proved challenging, and prognosis is very poor. For that reason, we present a rare case with prolonged survival in the youngest reported patient . Case presentation A 26-year-old Caucasian woman presented with abdominal cramping and rectal and vaginal bleeding. Elevated serum human chorionic gonadotropin and an 8-cm right-sided mass seen on ultrasound suggested ectopic pregnancy. The patient was treated with methotrexate; however, her symptoms persisted, and her human chorionic gonadotropin levels continued to rise. Further workup showed a large mass of the sigmoid colon with multiple hepatic lesions suggestive of metastases. Preliminary pathology showed adenocarcinoma. Despite surgical resection and initiation of FOLFOX chemotherapy (folinic acid, fluorouracil, oxaliplatin), the patient had significant clinical deterioration, and her human chorionic gonadotropin increased exponentially. Further pathological review showed two distinct phenotypes: adenocarcinoma merging with choriocarcinoma. The result of evaluation of the metastatic lesions was also positive for choriocarcinoma. Treatment was promptly changed to a choriocarcinoma-targeting chemotherapy regimen of EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine), resulting in rapid and dramatic response. The patient had mild progression after 1 year and was switched back to FOLFOX with bevacizumab. After five cycles, scans showed further progression, and the patient was started on third-line therapy with FOLFIRI (folinic acid, fluorouracil, irinotecan) and bevacizumab. Eighteen months after her diagnosis, the patient was alive and maintaining an overall response. Conclusions Our patient achieved a marked response and prolonged survival. Although a comprehensive review of the literature showed that survival with these tumors has improved over the past 10 years, prognosis remains poor. Currently, there is no established algorithm for the management of these rare tumors, but both the literature and our patient’s case indicate that a choriocarcinoma-targeted regimen is critical for survival. Further evaluation of these rare tumors is warranted in order to identify pathological patterns that may help in the diagnosis, management, and survival of these malignancies.
Collapse
Affiliation(s)
- Jessica Boyce
- Legacy Emanuel Medical Center, 2801 North Gantenbein Avenue, Portland, OR, 97227, USA. .,Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA, 70121, USA.
| | - Karine Tawagi
- Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA, 70121, USA
| | - John T Cole
- Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA, 70121, USA
| |
Collapse
|
69
|
Ngu SF, Ngan HYS. Surgery including fertility-sparing treatment of GTD. Best Pract Res Clin Obstet Gynaecol 2020; 74:97-108. [PMID: 33127305 PMCID: PMC7547826 DOI: 10.1016/j.bpobgyn.2020.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 01/01/2023]
Abstract
Gestational trophoblastic disease (GTD) consists of a spectrum of diseases, including hydatidiform moles, invasive mole, metastatic mole, choriocarcinoma, placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). GTD is a relatively uncommon disease occurring in women of reproductive age, with high cure rates. Primary treatment of hydatidiform moles includes uterine evacuation, followed by close monitoring of serial hCG levels to detect for post-molar gestational trophoblastic neoplasia (GTN). In patients with GTN, the main therapy consists of chemotherapy, although some surgical procedures are important in selected patients to achieve curing. Hysterectomy is the mainstay treatment for PSTT or ETT and may be considered in selected patients for management of hydatidiform mole and malignant GTN especially in chemoresistant disease. Resection of metastatic lesions such as in the lung or brain can be considered in selected patients with isolated chemoresistant tumour. Surgical treatment of GTD will be discussed in this chapter.
Collapse
Affiliation(s)
- Siew-Fei Ngu
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Queen Mary Hospital, 6/F Professorial Block, 102 Pokfulam Road, Hong Kong.
| | - Hextan Y S Ngan
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Queen Mary Hospital, 6/F Professorial Block, 102 Pokfulam Road, Hong Kong.
| |
Collapse
|
70
|
Bouchard-Fortier G, Ghorani E, Short D, Aguiar X, Harvey R, Unsworth N, Kaur B, Sarwar N, Seckl MJ. Following chemotherapy for gestational trophoblastic neoplasia, do residual lung lesions increase the risk of relapse? Gynecol Oncol 2020; 158:698-701. [PMID: 32654764 DOI: 10.1016/j.ygyno.2020.06.483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There remains uncertainty about the prognostic significance of residual lung lesion on imaging after completion of treatment of low- or high-risk gestational trophoblastic neoplasia (GTN). Here, we determine if such residual lung lesions are associated with an increased risk of relapse. METHODS We retrospectively screened our electronic database to identify patients with low- or high-risk GTN and lung metastases between 2004 and 18. Recurrences among patients with or without residual lung lesions on imaging were compared. Chi square analysis and Kaplan-Meier survival curves were constructed. As the numbers of cases were low, we combined this data with our previously published and non-overlapping patient cohort (1995-2004). RESULTS Of 1304 GTN patients treated at our centre between 2004 and 18, 99 had lung metastases without other distant sites. There were 40 patients (40.4%) with residual lung lesions. Whilst an increased rate of relapse was observed among patients with residual lung lesions (4/40; 10.0%) compared to without such lesions (3/59; 5.1%), this difference was not statistically significant (p = .35). By combining the data with our previous cohort, there was an increase in relapse rate of patients with residual lung lesions (5/63; 7.9%) compared to those without such lesions (4/112; 3.6%). However, this difference was also not statistically significant (p = .21). CONCLUSION Residual lung lesions on imaging after completion of GTN treatment are common. However, this finding did not statistically increase relapse rate. Due to low number of recurrent events, a multi-centre, larger dataset would be needed to provide more definitive evidence.
Collapse
Affiliation(s)
- Genevieve Bouchard-Fortier
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada; Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK.
| | - Ehsan Ghorani
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Dee Short
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Xianne Aguiar
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Richard Harvey
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Nick Unsworth
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Baljeet Kaur
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Naveed Sarwar
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| |
Collapse
|
71
|
Tu X, Chen R, Huang G, Lu N, Chen Q, Bai X, Li B. Factors Predicting Severe Myelosuppression and Its Influence on Fertility in Patients with Low-Risk Gestational Trophoblastic Neoplasia Receiving Single-Agent Methotrexate Chemotherapy. Cancer Manag Res 2020; 12:4107-4116. [PMID: 32581584 PMCID: PMC7276201 DOI: 10.2147/cmar.s252664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/06/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the potential factors to predict severe myelosuppression among low-risk gestational trophoblastic neoplasia (GTN) patients with single-agent methotrexate (MTX) chemotherapy. To analyze reproductive outcomes of patients with or without severe myelosuppression after achieving complete remission (CR). Patients and Methods The retrospective study included 319 low-risk GTN patients registered from January 2008 to December 2018 in our hospital. Patients were divided into two groups according to myelosuppression grading. Their clinical data and reproductive outcomes were compared and analyzed. Results A higher proportion of patients in group A received second-line chemotherapy than group B (P<0.001). The number of total chemotherapy courses was more in group A than group B (P=0.001), while the number of MTX chemotherapy courses was more in group B than group A (P=0.001). When the joint predictor of pretreatment albumin (ALB) was not more than 44.5 g/L, pretreatment serum creatinine (Scr) was not less than 75.6 μmol/L, and the number of MTX chemotherapy courses was not less than four, there was a moderate predictive value. There was no significant difference of reproductive outcomes between the two groups after achieving CR. Conclusion Although some patients developed severe myelosuppression, MTX was still the effective first-line treatment for low-risk GTN patients. Patient’s pretreatment ALB was not more than 44.5 g/L, pretreatment Scr was not less than 75.6 μmol/L, and the number of MTX chemotherapy courses not less than four could be used as combined predictors to recognize the risk of severe myelosuppression. Severe myelosuppression had no significant adverse influence on fertility after achieving CR.
Collapse
Affiliation(s)
- Xiaoyu Tu
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Ruizhe Chen
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Genping Huang
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Nanjia Lu
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Qin Chen
- Department of Pathology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Xiaoxia Bai
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Baohua Li
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| |
Collapse
|
72
|
Brown NA, Elenitoba-Johnson KSJ. Enabling Precision Oncology Through Precision Diagnostics. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2020; 15:97-121. [PMID: 31977297 DOI: 10.1146/annurev-pathmechdis-012418-012735] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Genomic testing enables clinical management to be tailored to individual cancer patients based on the molecular alterations present within cancer cells. Genomic sequencing results can be applied to detect and classify cancer, predict prognosis, and target therapies. Next-generation sequencing has revolutionized the field of cancer genomics by enabling rapid and cost-effective sequencing of large portions of the genome. With this technology, precision oncology is quickly becoming a realized paradigm for managing the treatment of cancer patients. However, many challenges must be overcome to efficiently implement the transition of next-generation sequencing from research applications to routine clinical practice, including using specimens commonly available in the clinical setting; determining how to process, store, and manage large amounts of sequencing data; determining how to interpret and prioritize molecular findings; and coordinating health professionals from multiple disciplines.
Collapse
Affiliation(s)
- Noah A Brown
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan 48109, USA;
| | - Kojo S J Elenitoba-Johnson
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA;
| |
Collapse
|
73
|
Outcomes in the management of high-risk gestational trophoblastic neoplasia in trophoblastic disease centers in South America. Int J Gynecol Cancer 2020; 30:1366-1371. [DOI: 10.1136/ijgc-2020-001237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/03/2020] [Accepted: 04/17/2020] [Indexed: 12/29/2022] Open
Abstract
BackgroundSouth America has a higher incidence of gestational trophoblastic disease than North America or Europe, but whether this impacts chemotherapy outcomes is unclear. The purpose of this study was to evaluate outcomes among women with high-risk gestational trophoblastic neoplasia (GTN) treated at trophoblastic disease centers in developing South American countries.MethodsThis retrospective cohort study included patients with high-risk GTN treated in three trophoblastic disease centers in South America (Botucatu and Rio de Janeiro, Brazil, and Buenos Aires, Argentina) from January 1990 to December 2014. Data evaluated included demographics, clinical presentation, FIGO stage, WHO prognostic risk score, and treatment-related information. The primary treatment outcome was complete sustained remission by 18 months following completion of therapy or death.ResultsAmong 1264 patients with GTN, 191 (15.1%) patients had high-risk GTN and 147 were eligible for the study. Complete sustained remission was ultimately achieved in 87.1% of cases overall, including 68.4% of ultra high-risk GTN (score ≥12). Early death (within 4 weeks of initiating therapy) was significantly associated with ultra high-risk GTN, occurring in 13.8% of these patients (p=0.003). By Cox’s proportional hazards regression, factors most strongly related to death were non-molar antecedent pregnancy (RR 4.35, 95% CI 1.71 to 11.05), presence of liver, brain, or kidney metastases (RR 4.99, 95% CI 1.96 to 12.71), FIGO stage (RR 3.14, 95% CI 1.52 to 6.53), and an ultra-high-risk prognostic risk score (RR 7.86, 95% CI 2.99 to 20.71). Median follow-up after completion of chemotherapy was 4 years. Among patients followed to that timepoint, the probability of survival was 90% for patients with high-risk GTN (score 7–11) and 60% for patients with ultra-high-risk GTN (score ≥12).ConclusionTrophoblastic disease centers in developing South American countries have achieved high remission rates in high-risk GTN, but early deaths remain an important problem, particularly in ultra-high-risk GTN.
Collapse
|
74
|
Xue Y, Sun R, Zheng W, Yang L, An R. Forskolin promotes vasculogenic mimicry and invasion via Notch‑1‑activated epithelial‑to‑mesenchymal transition in syncytiolization of trophoblast cells in choriocarcinoma. Int J Oncol 2020; 56:1129-1139. [PMID: 32319581 PMCID: PMC7115352 DOI: 10.3892/ijo.2020.4997] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 01/23/2020] [Indexed: 02/06/2023] Open
Abstract
Choriocarcinoma (CC) is characterized by earlier blood metastasis compared with other female genital tumors and a high incidence of massive hemorrhage. Vasculogenic mimicry (VM) is highly associated with metastasis, and syncytiotrophoblast is involved in the formation of VM in CC. Forskolin is a typical activator of the cAMP pathway, which is involved in the syncytiolization of trophoblastic cells. In the present study, to determine the effects and mechanism of forskolin on cell invasion and VM during syncytiolization in vitro and in vivo, JEG-3 and JAR cell lines were treated with 100 µM forskolin for 48 h, and wound healing and invasion assays were used to verify cell migratory and invasive capacities. A 3D culture and tube formation assays were established to detect VM. Variation of morphology and markers of the epithelial-to-mesenchymal transition (EMT) were assessed, and the role of the Notch signaling pathway was investigated in CC cells treated with forskolin. The results of the present study demonstrated that 100 µM forskolin induced syncytiolization of trophoblastic cells and enhanced the migratory and invasive abilities of JEG-3 and JAR cell lines. In addition, the capacity of VM was significantly increased, whereas tube formation ability was decreased by forskolin in vitro and in vivo compared with the respective control groups. The cellular morphology exhibited EMT during the syncytiolization process, which was further supported by the changes in EMT marker expression, including downregulation of E-cadherin and cytokeratin and upregulation of N-cadherin, vimentin and zinc finger E-box-binding homeobox 1. The Notch-1 signaling pathway was activated to induce EMT in forskolin-induced VM process in CC cells, and VM and EMT could be reversed by using the γ-secretase inhibitor DAPT to block the Notch-1 pathway. Overall, the results of the present study demonstrated that forskolin enhanced the capacity of VM formation and metastasis through Notch-1-activated EMT in the syncytiolization of trophoblastic cells.
Collapse
Affiliation(s)
- Yan Xue
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Rong Sun
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Wei Zheng
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Lei Yang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Ruifang An
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| |
Collapse
|
75
|
Effectiveness and toxicity of second-line actinomycin D in patients with methotrexate-resistant postmolar low-risk gestational trophoblastic neoplasia. Gynecol Oncol 2020; 157:372-378. [PMID: 32037196 DOI: 10.1016/j.ygyno.2020.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 01/30/2020] [Accepted: 02/01/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate both the outcomes and toxicity of second-line actinomycin D (ActD) chemotherapy in methotrexate (MTX) - resistant low-risk postmolar gestational trophoblastic neoplasia (GTN) with 5-day ActD versus pulsed ActD. METHODS This retrospective cohort study included patients with MTX-resistant low-risk postmolar GTN from 1974 to 2016. Second-line chemotherapy consisted of 5-day ActD (10-12 μg/kg per day for 5 days every 14 days) or biweekly ActD (1.25 mg/m2 every 2 weeks). Data on patient characteristics, disease presentation, treatment outcome, and toxicity were collected. RESULTS Sixty-eight MTX-resistant patients receiving ActD as second-line chemotherapy were identified (5-day ActD, 53 patients; pulsed ActD, 15 patients). No significant differences were observed in patient/disease characteristics and sustained remission (overall rate 72%) between second-line ActD regimens. Time to hCG remission was significantly faster (median 21 vs 47 days, p = .04) and required fewer treatment cycles (median 1 vs 2, p < .001) with 5-day ActD. Thrombocytopenia was only observed with 5-day ActD (64.6 vs 0%, p < .001). The frequency (60.4 vs 16.7%, p = .009) and severity (grade 3: 37.9 vs 0%, p = .045) of oral mucositis was significantly higher with 5-day ActD. Grade 2 alopecia was significantly more frequent (70.6 vs 16.7%, p = .02) with 5-day ActD. CONCLUSIONS While 5-day ActD and pulsed ActD achieve comparable remission rates, due to its reduced toxicity, ease of administration, and patient convenience, pulsed ActD should be the treatment of choice for MTX-resistant postmolar low-risk GTN.
Collapse
|