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Barcellini A, Fodor A, Charalampopoulou A, Cassani C, Locati LD, Cioffi R, Bergamini A, Pignata S, Orlandi E, Mangili G. Radiation Therapy for Gestational Trophoblastic Neoplasia: Forward-Looking Lessons Learnt. Cancers (Basel) 2023; 15:4817. [PMID: 37835511 PMCID: PMC10571950 DOI: 10.3390/cancers15194817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) includes several rare malignant diseases occurring after pregnancy: invasive moles, choriocarcinoma, placental site trophoblastic tumours, and epithelioid trophoblastic tumours. Multidisciplinary protocols including multi-agent chemotherapy, surgery, and occasionally radiotherapy achieve good outcomes for some high-risk metastatic patients. In this narrative review of the published studies on the topic, we have tried to identify the role of radiotherapy. The available studies are mainly small, old, and retrospective, with incomplete data regarding radiotherapy protocols delivering low doses (which can make this disease appear radioresistant in some cases despite high response rates with palliative doses) to wide fields (whole-brain, whole-liver, etc.), which can increase toxicity. Studies considering modern techniques are needed to overcome these limitations and determine the full potential of radiotherapy beyond its antihemorrhagic and palliative roles.
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Affiliation(s)
- Amelia Barcellini
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy;
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy;
| | - Andrei Fodor
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
| | - Alexandra Charalampopoulou
- Radiobiology Unit, Research and Development Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy;
- Hadron Academy PhD Course, Istituto Universitario di STUDI Superiori (IUSS), 27100 Pavia, Italy
| | - Chiara Cassani
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Unit of Obstetrics and Gynecology, IRCCS, Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Laura Deborah Locati
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy;
- Translational Oncology Unit, Maugeri Clinical Research Institutes IRCCS, 27100 Pavia, Italy
| | - Raffaella Cioffi
- Unit of Gynaecology and Obstetrics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (R.C.); (A.B.); (G.M.)
| | - Alice Bergamini
- Unit of Gynaecology and Obstetrics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (R.C.); (A.B.); (G.M.)
| | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori, IRCCS-Fondazione G. Pascale Napoli, 80131 Naples, Italy;
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy;
| | - Giorgia Mangili
- Unit of Gynaecology and Obstetrics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (R.C.); (A.B.); (G.M.)
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Borella F, Cosma S, Ferraioli D, Preti M, Gallio N, Valabrega G, Scotto G, Rolfo A, Castellano I, Cassoni P, Bertero L, Benedetto C. From Uterus to Brain: An Update on Epidemiology, Clinical Features, and Treatment of Brain Metastases From Gestational Trophoblastic Neoplasia. Front Oncol 2022; 12:859071. [PMID: 35493999 PMCID: PMC9045690 DOI: 10.3389/fonc.2022.859071] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/17/2022] [Indexed: 11/13/2022] Open
Abstract
In this review, we provide the state of the art about brain metastases (BMs) from gestational trophoblastic neoplasia (GTN), a rare condition. Data concerning the epidemiology, clinical presentation, innovations in therapeutic modalities, and outcomes of GTN BMs are comprehensively presented with particular attention to the role of radiotherapy, neurosurgery, and the most recent chemotherapy regimens. Good response rates have been achieved thanks to multi-agent chemotherapy, but brain involvement by GTNs entails significant risks for patients’ health since sudden and extensive intracranial hemorrhages are possible. Moreover, despite the evolution of treatment protocols, a small proportion of these patients ultimately develops a resistant disease. To tackle this unmet clinical need, immunotherapy has been recently proposed. The role of this novel option for this subset of patients as well as the achieved results so far are also discussed.
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Affiliation(s)
- Fulvio Borella
- Division of Gynecology and Obstetrics 1, "City of Health and Science University Hospital", University of Turin, Turin, Italy.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Stefano Cosma
- Division of Gynecology and Obstetrics 1, "City of Health and Science University Hospital", University of Turin, Turin, Italy.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | | | - Mario Preti
- Division of Gynecology and Obstetrics 1, "City of Health and Science University Hospital", University of Turin, Turin, Italy.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Niccolò Gallio
- Division of Gynecology and Obstetrics 1, "City of Health and Science University Hospital", University of Turin, Turin, Italy.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | | | - Giulia Scotto
- Department of Oncology, University of Torino, Torino, Italy
| | - Alessandro Rolfo
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Isabella Castellano
- Pathology Unit, Department of Medical Sciences, "City of Health and Science University Hospital", University of Turin, Turin, Italy
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, "City of Health and Science University Hospital", University of Turin, Turin, Italy
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, "City of Health and Science University Hospital", University of Turin, Turin, Italy
| | - Chiara Benedetto
- Division of Gynecology and Obstetrics 1, "City of Health and Science University Hospital", University of Turin, Turin, Italy.,Department of Surgical Sciences, University of Turin, Turin, Italy
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Tsai J, Vellayappan B, Venur V, McGranahan T, Gray H, Urban RR, Tseng YD, Palmer J, Foote M, Mayr NA, Combs SE, Sahgal A, Chang EL, Lo SS. The optimal management of brain metastases from gestational trophoblastic neoplasia. Expert Rev Anticancer Ther 2022; 22:307-315. [PMID: 35114862 DOI: 10.1080/14737140.2022.2038566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Gestational trophoblastic diseases and neoplasias (GTDs and GTNs) comprise a spectrum of diseases arising from abnormally proliferating placental/trophoblastic tissue following an antecedent molar or non-molar pregnancy. These can spread to the brain hematogenously in about 10% of patients, mostly in high-risk disease. The optimal management of patients with brain metastases from GTN is unclear, with multiple systemic regimens under use and an uncertain role for radiotherapy. AREAS COVERED Here, we review the epidemiology, workup, and treatment of GTN with central nervous system (CNS) involvement. Literature searches in PubMed and Google Scholar were conducted using combinations of keywords such as "gestational trophoblastic disease," "gestational trophoblastic neoplasia," "choriocarcinoma," and "brain metastases." EXPERT OPINION Systemic therapy is the frontline treatment for GTN with brain metastases, and radiotherapy should only be considered in the context of a clinical trial or for resistant/recurrent disease. Surgery has a limited role in palliating symptoms or relieving intracranial pressure/bleeding. Given the highly specialized care these patients require, treatment at a high-volume referral center with multidisciplinary collaboration likely leads to better outcomes. Randomized trials should be conducted to determine the best systemic therapy option for GTN.
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Affiliation(s)
- Joseph Tsai
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
| | | | - Vyshak Venur
- Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Tresa McGranahan
- Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Heidi Gray
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | - Renata R Urban
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
| | - Joshua Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital, The Ohio State University, Columbus, OH, USA
| | - Matthew Foote
- Princess Alexandra Hospital, University of Queensland, ICON Cancer Care, Brisbane 4072, Australia
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
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Clinical characteristics and prognosis of ultra high-risk gestational trophoblastic neoplasia patients: A retrospective cohort study. Gynecol Oncol 2017; 146:81-86. [PMID: 28461032 DOI: 10.1016/j.ygyno.2017.04.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 04/09/2017] [Accepted: 04/15/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The gestational trophoblastic neoplasia (GTN) patients with the International Federation of Gynecology and Obstetrics (FIGO) score≥12 are defined as ultra high-risk GTN. This study aims to investigate the clinical characteristics, the treatment efficiency, and the prognosis of ultra high-risk GTN patients. METHODS Between January 2002 and December 2015, medical record data of 143 GTN patients with FIGO score≥12 at Peking Union Medical College Hospital (PUMCH) were reviewed. Ratios were compared using chi-square test, and prognostic risk factors were analyzed by univariate analysis and multivariate analysis. RESULTS Among the 143 ultra high-risk GTN patients, 94 (65.7%) patients had achieved complete remission and 15.9% (15/94) patients relapsed after complete remission. The 5-year overall survival (OS) rate of the entire cohort approached 67.9%. The results of the multivariate analysis revealed that non-molar antecedent pregnancy [Relative risk (RR) 4.689, 95% CI 1.448-15.189, P=0.010], brain metastases (RR 2.280, 95% CI 1.248-4.163, P=0.007), previous failed multiagent chemotherapy (RR 5.345, 95% CI 2.222-12.857, P=0.000) and surgery (RR 0.336, 95% CI 0.177-0.641, P=0.001) all had influence on the prognosis of ultra high-risk GTN patients. CONCLUSIONS GTN patients with FIGO score≥12 have a poor prognosis. More emphasis should be placed on non-molar antecedent pregnancy, brain metastases, and previous multiagent chemotherapy failure. Moreover, salvage surgery may improve the prognosis. Floxuridine-based multiagent chemotherapy is effective with manageable toxicity for ultra high-risk GTN patients.
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Xiao C, Yang J, Zhao J, Ren T, Feng F, Wan X, Xiang Y. Management and prognosis of patients with brain metastasis from gestational trophoblastic neoplasia: a 24-year experience in Peking union medical college hospital. BMC Cancer 2015; 15:318. [PMID: 25927660 PMCID: PMC4416412 DOI: 10.1186/s12885-015-1325-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 04/21/2015] [Indexed: 11/16/2022] Open
Abstract
Background The optimal treatment for patients with brain metastasis from gestational trophoblastic neoplasia (GTN) has not been established. This study aims to investigate the clinical characteristics and the management of brain metastasis from GTN in relation to patients’ outcomes. Methods We retrospectively investigated 109 GTN patients with brain metastasis treated at Peking Union Medical College Hospital from January 1990 to December 2013. Patients mainly received multiagent chemotherapy with florouracil or floxuridine, dactinomycin, etoposide, and vincristine (FAEV) combined with intrathecal methotrexate with or without surgery. Results In the 109 patients, sixty-two (56.1%) patients presented for primary therapy and 47 patients had failed chemotherapy elsewhere. Eight early demise patients who died before or during first cycle of chemotherapy were excluded from analysis. The median follow-up time was 47 months (range 9–180 months). The overall 5-year survival rate (OS) was 71.1%, while the OS rate for patients receiving primary chemotherapy in our hospital was 85.5%, and this fell to 51.9% in patients with failure multidrug chemotherapy elsewhere. Multivariate analysis demonstrated that International Federation of Gynecology and Obstetrics (FIGO) scores over 12 (Hazard ratio-HR 1.279, 95% CI 1.061-1.541, P = 0.010), failure of previous multidrug chemotherapy (HR 3.177, 95% CI 1.277-7.908, P = 0.013), and concurrent renal metastasis (HR 2.654, 95% CI 1.125-6.261, P = 0.026) were the risk factors of overall survival in patients with brain metastases from GTN. Conclusions Patients with brain metastasis from GTN have favorable outcome by multidrug chemotherapy and adjuvant therapies. Nevertheless, the prognosis is poor if the patients had previous multidrug failure chemotherapy history, concomitant with renal metastasis, or FIGO score over 12. Initial treatment with FAEV combined with intrathecal methotrexate chemotherapy can bring bright prospect to patients with brain metastases from GTN.
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Affiliation(s)
- Changji Xiao
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing Dongcheng District, 100730, Beijing, P. R. China.
| | - Junjun Yang
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing Dongcheng District, 100730, Beijing, P. R. China.
| | - Jing Zhao
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing Dongcheng District, 100730, Beijing, P. R. China.
| | - Tong Ren
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing Dongcheng District, 100730, Beijing, P. R. China.
| | - Fengzhi Feng
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing Dongcheng District, 100730, Beijing, P. R. China.
| | - Xirun Wan
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing Dongcheng District, 100730, Beijing, P. R. China.
| | - Yang Xiang
- Departments of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing Dongcheng District, 100730, Beijing, P. R. China.
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Sarwar N, Newlands ES, Seckl MJ. Gestational trophoblastic neoplasia: the management of relapsing patients and other recent advances. Curr Oncol Rep 2007; 6:476-82. [PMID: 15485618 DOI: 10.1007/s11912-004-0079-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The treatment of gestational trophoblastic neoplasia (GTN) represents one of the modern success stories in cancer medicine. Early diagnosis, effective treatments, monitoring of response with a series of serum human chorionic gonadotropin levels, and centralized care have all contributed to this success. Nevertheless, some patients relapse after initial chemotherapy. This review discusses the routine management of GTN and how to treat relapsed disease.
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Affiliation(s)
- Naveed Sarwar
- Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
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Soper JT, Spillman M, Sampson JH, Kirkpatrick JP, Wolf JK, Clarke-Pearson DL. High-risk gestational trophoblastic neoplasia with brain metastases: individualized multidisciplinary therapy in the management of four patients. Gynecol Oncol 2006; 104:691-4. [PMID: 17137617 DOI: 10.1016/j.ygyno.2006.10.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Revised: 10/23/2006] [Accepted: 10/24/2006] [Indexed: 12/26/2022]
Abstract
PURPOSE To report our recent experience managing four patients with brain metastases of gestational trophoblastic neoplasia (GTN), coordinating systemic chemotherapy with early neurosurgical intervention or stereotactic radiosurgery and intensive supportive care during initial therapy to prevent early mortality. MATERIALS AND METHODS A series of four consecutive patients with brain metastases from high-risk Stage IV GTN managed at our institution in 2003 and 2005. Patients were assigned FIGO stage and risk score prospectively. Because of concern for chronic toxicity resulting from concurrent moderate dose methotrexate and whole brain radiation, an individualized multidisciplinary approach was used to manage patients. RESULTS All four women presented with brain and pulmonary metastases; one had multiple liver metastases. Neurological symptoms at presentation included grand mal seizures in 2 patients, left upper extremity hemiparesis and headache each in 1 patient, while 1 patient was asymptomatic. Index pregnancies were term pregnancies in all patients with interval from prior delivery ranging from 2 weeks to 4 years. Two had received prior chemotherapy for postmolar GTN prior to the index pregnancy with incomplete follow-up. Initial hCG values ranged from 26,400 to 137,751 mIU/ml; FIGO risk scores were > or =16 for all patients. Systemic combination chemotherapy was initiated with etoposide and cisplatin followed by moderate/high-dose (500-1000 mg/m(2)) methotrexate combinations. Craniotomy was used before or during the first chemotherapy cycle to extirpate solitary lesions in 3 patients, while stereotactic radiosurgery was administered after the first cycle to treat two brain lesions in the remaining patient. None received whole brain radiation or intrathecal methotrexate. In one patient, selective angiographic embolization was used to control hemorrhage from multiple liver metastases. Two patients required ventilator support early in treatment to allow stabilization from intrathoracic hemorrhage and neutropenic sepsis with respiratory distress syndrome, respectively. Hysterectomy was performed in one patient after completion of salvage chemotherapy. All have completed maintenance chemotherapy and are in prolonged remission (12-24 months). Neurologic sequelae include persistent left upper extremity dyskinesia and weakness in one patient, and episodic grand mal seizures and pseudoseizures in a second patient with a pre-existing seizure disorder. CONCLUSION This case series documents the utility for a multidisciplinary approach to the treatment of brain metastases from GTN. Using early craniotomy or stereotactic radiosurgery combined with etoposide-cisplatin and moderate/high-dose methotrexate combination chemotherapy, we were able to stabilize patients early in their treatment and avoid whole brain radiation therapy or intrathecal chemotherapy.
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Affiliation(s)
- J T Soper
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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El-Lamie IKI, El Sayed HM, Badawie AG, Bayomi WA, El-Ghazaly HA, Khalaf-Allah AE, El-Mahallawy MN, El-Lamie KI. Evolution of treatment of high-risk metastatic gestational trophoblastic tumors: Ain Shams University experience. Int J Gynecol Cancer 2006; 16:866-74. [PMID: 16681775 DOI: 10.1111/j.1525-1438.2006.00592.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The aim of the current study is to evaluate the different treatment modalities used in the management of high-risk metastatic gestational trophoblastic tumors (GTT) between June 1992 and December 2004 at the Gynecologic Oncology Unit, Ain Shams University. Out of 261 patients diagnosed and treated for GTT, 70 (26.8%) were high risk metastatic patients based on the National Institutes of Health clinical classification. The mean age was 29.39 +/- 9.38 years (16-55 years), with six patients (8.6%) being older than 39 years, and the mean duration of follow-up was 79.74 +/- 40.44 months (6-157 months). Forty patients (57.14%) were diagnosed after molar pregnancy, 22 (31.43%) after abortion, and 8 (11.43%) after term pregnancy. Forty-two patients (60%) were diagnosed within 4 months of the occurrence of the disease, and 28 (40%) were diagnosed after more than 4 months. Sixty-seven patients were treated using different regimens according to the protocol of treatment at that time. The MAC regimen was used initially but has been subsequently abandoned in favor of EMA-CO (etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine [Oncovin]) regimen, which was later modified by omitting the CO arm to decrease its toxicity. If resistance developed, platinum-based therapy was given in the form of EMA-EP. Recently, our unit incorporated paclitaxel in the third-line treatment. Surgical intervention was used selectively. Fifty-seven (81.4%) patients could be cured; 43 by initial chemotherapy, with a mean of 7 +/- 0.46 courses (6-15), and 14 were salvaged by second- or third-line chemotherapy. Fourteen patients (20%) died during the study period; one was unrelated to GTT, while three died of acute respiratory distress syndrome before instituting proper therapy and two died of treatment complications. Using univariate and multivariate Cox regression analyses, the presence of brain and/or liver metastases was found to be the worst prognostic variable affecting the survival, followed by resistance to combination chemotherapy and then the type of antecedent pregnancy. The projected 5-year survival as estimated by Kaplan-Meier method was 78%.
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Affiliation(s)
- I K I El-Lamie
- Department of Obstetrics and Gynecology (Gynecologic Oncology Unit), Ain Shams University, Cairo, Egypt.
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Ghaemmaghami F, Behtash N, Ayatollahi H, Hanjani P. Successful treatment of two patients with gestational trophoblastic neoplasm presenting with emergent neurologic symptoms. Int J Gynecol Cancer 2006; 16:937-40. [PMID: 16681792 DOI: 10.1111/j.1525-1438.2006.00213.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The objective of this study is to present the successful treatment of two young patients with gestational trophoblastic neoplasms (GTN) presenting with emergent neurologic symptoms without any gynecological problems. Case 1, a 22-year-old patient, was admitted to an infectious disease ward, with admitting diagnosis of encephalitis due to neurologic symptoms. Case 2, a 33-year-old patient, underwent craniotomy due to hemorrhagic brain tumor in the neurosurgery department. The diagnosis of GTN should be considered in any woman of reproductive age who has neurologic symptoms. It seems that multiagent chemotherapy in conjunction with whole-brain irradiation results in acceptable survival rate in brain metastatic GTN patients. Craniotomy is often necessary in fulminant cases.
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Affiliation(s)
- F Ghaemmaghami
- Gynecology Oncology Department, Tehran University of Medical Sciences, Tehran, Iran
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Chang TC, Yen TC, Li YT, Wu YC, Chang YC, Ng KK, Jung SM, Wu TI, Lai CH. The role of 18F-fluorodeoxyglucose positron emission tomography in gestational trophoblastic tumours: a pilot study. Eur J Nucl Med Mol Imaging 2005; 33:156-63. [PMID: 16220307 DOI: 10.1007/s00259-005-1873-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Accepted: 05/22/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE We conducted a pilot trial to evaluate the value of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) in gestational trophoblastic tumours (GTTs). METHODS Patients with placental site trophoblastic tumour (PSTT), high-risk GTT (World Health Organisation score > or =8, disease onset at postpartum or greater than 6 months after antecedent pregnancy), metastatic GTT, recurrent/resistant GTT after chemotherapy, or post-molar GTT with unexplained abnormal beta-hCG regression and patients undergoing re-evaluation after salvage treatment were enrolled. PET was undertaken within 1 week after computed tomography (CT). Clinical impacts of additional PET were determined on a scan basis. RESULTS A total of 14 patients were recruited. Sixteen PET scans were performed, with one patient having three serial studies. Benefits of additional PET were seen in 7 of 16 (43.8%) scans; these benefits included disclosure of chemotherapy-resistant lesions (n = 2), exclusion of false-positive CT lesions (n = 1), detection of an additional lesion not found by conventional imaging (n = 1) in high-risk GTT at the start of primary chemotherapy, and confirmation of complete response to treatment for PSTT or to salvage therapy for recurrent/resistant GTT (n = 3). On the other hand, in two instances there were false-negative PET findings, six scans yielded no benefit, and one showed an indeterminate lesion. CONCLUSION Our preliminary results suggest that 18F-FDG PET is potentially useful in selected patients with GTT by providing precise mapping of metastases and tumour extent upfront, by monitoring treatment response and by localising viable tumours after chemotherapy. A larger study is necessary to further define the role of 18F-FDG PET in GTT.
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Affiliation(s)
- Ting Chang Chang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
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Response to the letter of Dr. Kohorn. Int J Gynecol Cancer 2005. [DOI: 10.1111/j.1525-1438.2005.00124.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Affiliation(s)
- Charles B Stevenson
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2380, USA
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Ghaemmaghami F, Behtash N, Memarpour N, Soleimani K, Hanjani P, Hashemi FA. Evaluation and management of brain metastatic patients with high-risk gestational trophoblastic tumors. Int J Gynecol Cancer 2004; 14:966-71. [PMID: 15361210 DOI: 10.1111/j.1048-891x.2004.14536.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A retrospective study to evaluate the characteristics of brain metastatic patients with gestational trophoblastic tumors (GTT) and to analyze the results of treatment has been performed. During 1996-2001, 40 patients with metastatic GTT were diagnosed at Vali-e-Asr Hospital, Tehran, Iran. Of them, nine with brain metastases, which were documented with the help of computed tomography scan, were evaluated retrospectively. Eight patients received EMA-EP regimen (etoposide, methotrexate, actinomycin, etoposide, and cisplatinum) and one received EMA-CO (etoposide, methotrexate, actinomycin, cyclophosphamide, and vincristin). All cases received whole brain irradiation therapy concurrently. The median age of the patients at diagnosis was 30 years (range: 17-53). Six of them were of early group (five with symptoms of central nervous system and one was detected during workup) and three were of late group (relapsed group). Five (56%) patients responded to treatment and four (44%) were deceased (three of them belonged to late group). It seems that multi-agent chemotherapy (EMA-EP) concurrently with whole brain irradiation results in acceptable survival rates in GTT patients with brain metastases.
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Affiliation(s)
- F Ghaemmaghami
- Department of Gynecology and Oncology, Tehran University of Medical Sciences, Tehran, Iran.
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Soper JT. Role of surgery and radiation therapy in the management of gestational trophoblastic disease. Best Pract Res Clin Obstet Gynaecol 2004; 17:943-57. [PMID: 14614891 DOI: 10.1016/s1521-6934(03)00091-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although sensitive human chorionic gonadotrophin (hCG) assays and advances in chemotherapy have assumed primary importance in the management of gestational trophoblastic disease (GTD), surgery and radiation therapy remain important in the overall management of patients. Management of molar pregnancies consists of surgical evacuation and subsequent monitoring. Hysterectomy may decrease the risk of post-molar trophoblastic disease. When incorporated into the primary management of malignant GTD, hysterectomy decreases chemotherapy requirements for patients with low-risk disease. Surgical intervention is frequently required to control complications of disease or as therapy to stabilize patients during chemotherapy. Salvage hysterectomy or other extirpative procedures may be integrated into the management of patients with chemorefractory disease. Interventional radiographical techniques are useful adjuncts to control haemorrhage from vaginal or pelvic metastases. Radiation therapy may also be combined with chemotherapy for the management of patients with brain metastases or, rarely, isolated metastases at other sites.
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Affiliation(s)
- John T Soper
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Box 3079, Duke University Medical Center, Durham, NC 27710, USA.
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16
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Affiliation(s)
- Ron Swensen
- Department of Gynecology and Obstetrics, Loma Linda University School of Medicine, California 92354, USA.
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17
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Mamelak AN, Withers GJ, Wang X. Choriocarcinoma brain metastasis in a patient with viable intrauterine pregnancy. Case report. J Neurosurg 2002; 97:477-81. [PMID: 12186481 DOI: 10.3171/jns.2002.97.2.0477] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report the case of a woman who presented during her 30th week of pregnancy with a large brain metastasis from a previously undetected metastatic choriocarcinoma. The metastasis caused significant neurological deficit due to mass effect, necessitating rapid intervention. Medical management included a regimen of high-dose corticosteroid medications for 36 hours, followed by cesarean delivery of the fetus and craniotomy to remove the metastatic tumor, chemotherapy and radiation therapy were begun within 1 week postsurgery. Both the baby and mother survived, and as of the 1-year follow-up examination, there was no evidence of disease in the mother. This is only the second report of a metastatic choriocarcinoma associated with a simultaneous viable intrauterine pregnancy, and the only case in which surgical removal of a brain metastasis was required. Coordinated multidisciplinary treatment of mother and fetus by members of the neurosurgery, medical oncology, neonatology, and obstetrics services facilitated a good outcome in this case.
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Affiliation(s)
- Adam N Mamelak
- Department of Neurosurgery, Huntington Memorial Hospital, Pasadena, California, USA.
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19
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Schechter NR. Reply. Gynecol Oncol 1999; 72:265-7. [PMID: 10021313 DOI: 10.1006/gyno.1998.5276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- NR Schechter
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
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Mena AM, Alastuey I. Whole brain radiotherapy for metastatic gestational trophoblastic disease. Gynecol Oncol 1999; 72:265-6. [PMID: 10021314 DOI: 10.1006/gyno.1998.5277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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