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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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Jiang F, Lin JK, Xiang Y, Xu ZF, Wan XR, Feng FZ, Ren T, Yang JJ, Zhao J. The impact of pulmonary metastases on therapeutic response and prognosis in malignant gestational trophoblastic neoplasia patients: a retrospective cohort study. Eur J Cancer 2021; 161:119-127. [PMID: 34911640 DOI: 10.1016/j.ejca.2021.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/31/2021] [Accepted: 11/07/2021] [Indexed: 11/03/2022]
Abstract
AIM The lung is the most common site of metastasis for gestational trophoblastic neoplasia (GTN). However, the level of influence of lung metastases on the prognosis of GTN and the degree to which lung metastases are considered in assessments of disease treatment options are unclear. Moreover, it is unclear which characteristics of lung metastases impact the disease. In this study, we evaluated the influence of lung metastases on the clinical course of GTN and identified lung imaging characteristics that impact treatment outcomes. METHODS A retrospective cohort study was conducted on GTN patients treated at Peking Union Medical College Hospital between 2002 and 2018. The baseline characteristics, first-line treatment outcomes and final outcomes of patients with lung metastases (Group 1) and those without lung metastases (Group 2) were compared. RESULTS The emergence of resistance occurred significantly more frequently in Group 1 (n = 994) than in Group 2 (n = 570) (19.52% versus 14.56%, p = 0.019), and the death rate was higher in Group 1 (0.91% versus 0%, p = 0.031). Among the patients treated with multi-agent chemotherapy, the rate of resistance and the number of treatment courses were significantly higher in Group 1 than in Group 2 (p = 0.002 and < 0.001, respectively). The lung imaging characteristics that impacted prognosis included the number of nodules, whether there were multiple nodules or a single nodule, and the number of nodules sized >1 cm. Multivariate analysis showed that a nodule measuring ≥1.8 cm was an independent risk factor for first-line treatment resistance and recurrence. CONCLUSION Although pulmonary metastases do not affect overall survival in GTN patients, the presence of lung metastases before treatment is associated with increased risk of disease recurrence and resistance to first-line multidrug chemotherapy, especially when pulmonary nodules are larger than 1.8 cm. CLINICAL TRIAL REGISTRATION N.A.
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Affiliation(s)
- Fang Jiang
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Jin-Kai Lin
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Yang Xiang
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China.
| | - Zhuo-Fan Xu
- School of Medicine, Tsinghua University, 30 Shuangqing Road, Haidian District, Beijing, China
| | - Xi-Run Wan
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Feng-Zhi Feng
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Tong Ren
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Jun-Jun Yang
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Jun Zhao
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
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Eiriksson L, Dean E, Sebastianelli A, Salvador S, Comeau R, Jang JH, Bouchard-Fortier G, Osborne R, Sauthier P. Guideline No. 408: Management of Gestational Trophoblastic Diseases. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:91-105.e1. [PMID: 33384141 DOI: 10.1016/j.jogc.2020.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/02/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This guideline reviews the clinical evaluation and management of gestational trophoblastic diseases, including surgical and medical management of benign, premalignant, and malignant entities. The objective of this guideline is to assist health care providers in promptly diagnosing gestational trophoblastic diseases, to standardize treatment and follow-up, and to ensure early specialized care of patients with malignant or metastatic disease. INTENDED USERS General gynaecologists, obstetricians, family physicians, midwives, emergency department physicians, anaesthesiologists, radiologists, pathologists, registered nurses, nurse practitioners, residents, gynaecologic oncologists, medical oncologists, radiation oncologists, surgeons, general practitioners in oncology, oncology nurses, pharmacists, physician assistants, and other health care providers who treat patients with gestational trophoblastic diseases. This guideline is also intended to provide information for interested parties who provide follow-up care for these patients following treatment. TARGET POPULATION Women of reproductive age with gestational trophoblastic diseases. OPTIONS Women diagnosed with a gestational trophoblastic disease should be referred to a gynaecologist for initial evaluation and consideration for primary surgery (uterine evacuation or hysterectomy) and follow-up. Women diagnosed with gestational trophoblastic neoplasia should be referred to a gynaecologic oncologist for staging, risk scoring, and consideration for primary surgery or systemic therapy (single- or multi-agent chemotherapy) with the potential need for additional therapies. All cases of gestational trophoblastic neoplasia should be discussed at a multidisciplinary cancer case conference and registered in a centralized (regional and/or national) database. EVIDENCE Relevant studies from 2002 onwards were searched in Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and Cochrane Systematic Reviews using the following terms, either alone or in combination: trophoblastic neoplasms, choriocarcinoma, trophoblastic tumor, placental site, gestational trophoblastic disease, hydatidiform mole, drug therapy, surgical therapy, radiotherapy, cure, complications, recurrence, survival, prognosis, pregnancy outcome, disease outcome, treatment outcome, and remission. The initial search was performed in April 2017 and updated in May 2019. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional significant articles were identified through cross-referencing the identified reviews. The total number of studies identified was 673, with 79 studies cited in this review. VALIDATION METHODS The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of Directors of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of Directors for the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework. See the online appendix tables for key to grading and interpretation of recommendations. BENEFITS These guidelines will assist physicians in promptly diagnosing gestational trophoblastic diseases and urgently referring patients diagnosed with gestational trophoblastic neoplasia to gynaecologic oncology for specialized management. Treating gestational trophoblastic neoplasia in specialized centres with the use of centralized databases allows for capturing and comparing data on treatment outcomes of patients with these rare tumours and for optimizing patient care. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES) RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
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Parker VL, Winter MC, Whitby E, Parker WAE, Palmer JE, Tidy JA, Pacey AA, Hancock BW, Harrison RF. Computed tomography chest imaging offers no advantage over chest X-ray in the initial assessment of gestational trophoblastic neoplasia. Br J Cancer 2021; 124:1066-1071. [PMID: 33328608 PMCID: PMC7961138 DOI: 10.1038/s41416-020-01206-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 10/23/2020] [Accepted: 11/26/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The International Federation of Gynaecology and Obstetrics (FIGO) score identifies gestational trophoblastic neoplasia (GTN) patients as low- or high-risk of single-agent chemotherapy resistance (SACR). Computed tomography (CT) has greater sensitivity than chest X-ray (CXR) in detecting pulmonary metastases, but effects upon outcomes remain unclear. METHODS Five hundred and eighty-nine patients underwent both CXR and CT during GTN assessment. Treatment decisions were CXR based. The number of metastases, risk scores, and risk category using CXR versus CT were compared. CT-derived chest assessment was evaluated as impact upon treatment decision compared to patient outcome, incidence of SACR, time-to-normal human chorionic gonadotrophin hormone (TNhCG), and primary chemotherapy resistance (PCR). RESULTS Metastasis detection (p < 0.0001) and FIGO score (p = 0.001) were higher using CT versus CXR. CT would have increased FIGO score in 188 (31.9%), with 43 re-classified from low- to high-risk, of whom 23 (53.5%) received curative single-agent chemotherapy. SACR was higher when score (p = 0.044) or risk group (p < 0.0001) changed. Metastases on CXR (p = 0.019) but not CT (p = 0.088) lengthened TNhCG. Logistic regression analysis found no difference between CXR (area under the curve (AUC) = 0.63) versus CT (AUC = 0.64) in predicting PCR. CONCLUSIONS CT chest would improve the prediction of SACR, but does not influence overall treatment outcome, TNhCG, or prediction of PCR. Lower radiation doses and cost mean ongoing CXR-based assessment is recommended.
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Affiliation(s)
- Victoria L. Parker
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK
| | - Matthew C. Winter
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.31410.370000 0000 9422 8284Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield, S10 2SJ UK
| | - Elspeth Whitby
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK
| | - William A. E. Parker
- grid.11835.3e0000 0004 1936 9262School of Medicine, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK
| | - Julia E. Palmer
- grid.31410.370000 0000 9422 8284Department of Gynaecological Oncology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Room H18, Glossop Road, Sheffield, S10 2JF UK
| | - John A. Tidy
- grid.31410.370000 0000 9422 8284Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield, S10 2SJ UK ,grid.31410.370000 0000 9422 8284Department of Gynaecological Oncology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Room H18, Glossop Road, Sheffield, S10 2JF UK
| | - Allan A. Pacey
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK
| | - Barry W. Hancock
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK
| | - Robert F. Harrison
- grid.11835.3e0000 0004 1936 9262Department of Automatic Control and Systems Engineering, The University of Sheffield, Mappin Street, Sheffield, S1 3JD UK
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Eiriksson L, Dean E, Sebastianelli A, Salvador S, Comeau R, Jang JH, Bouchard-Fortier G, Osborne R, Sauthier P. Directive clinique n o 408 : Prise en charge des maladies gestationnelles trophoblastiques. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:106-123.e1. [PMID: 33384137 DOI: 10.1016/j.jogc.2020.10.008] [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
OBJECTIF Cette directive passe en revue l'évaluation clinique et la prise en charge des maladies gestationnelles trophoblastiques, notamment les traitements chirurgicaux et médicamenteux des tumeurs bénignes, prémalignes et malignes. L'objectif de la présente directive clinique est d'aider les fournisseurs de soins de santé à rapidement diagnostiquer les maladies gestationnelles trophoblastiques, à normaliser les traitements et le suivi et à assurer des soins spécialisés précoces aux patientes dont l'atteinte est maligne ou métastatique. PROFESSIONNELS CONCERNéS: Gynécologues généralistes, obstétriciens, médecins de famille, sages-femmes, urgentologues, anesthésistes, radiologistes, anatomopathologistes, infirmières autorisées, infirmières praticiennes, résidents, gynécologues-oncologues, oncologues médicaux, radio-oncologues, chirurgiens, omnipraticiens en oncologie, infirmières en oncologie, pharmaciens, auxiliaires médicaux et autres professionnels de la santé qui traitent des patientes atteintes d'une maladie gestationnelle trophoblastique. La présente directive vise également à fournir des renseignements aux parties intéressées qui prodiguent des soins de suivi à ces patientes après le traitement. POPULATION CIBLE Femmes en âge de procréer atteintes d'une maladie gestationnelle trophoblastique. OPTIONS Les femmes ayant reçu un diagnostic de maladie gestationnelle trophoblastique doivent être orientées vers un gynécologue afin qu'il réalise une évaluation initiale, envisage une intervention chirurgicale primaire (évacuation ou hystérectomie) et effectue un suivi. Il y a lieu d'orienter les femmes ayant reçu un diagnostic de tumeur trophoblastique gestationnelle vers un gynécologue-oncologue afin qu'il effectue la stadification tumorale, établisse le score de risque et envisage l'intervention chirurgicale primaire ou un traitement systémique (mono- ou polychimiothérapie) et la nécessité d'éventuels traitements supplémentaires. Il est recommandé de discuter de chaque cas de néoplasie gestationnelle trophoblastique lors d'une réunion multidisciplinaire de cas oncologiques et de l'inscrire dans une base de données centralisée (régionale et/ou nationale). DONNéES PROBANTES: Des recherches ont été effectuées au moyen des bases de données Embase et MEDLINE, du Cochrane Central Register of Controlled Trials et de la Cochrane Database of Systematic Reviews afin de trouver les études publiées depuis 2002 utilisant un ou plusieurs des mots clés suivants : trophoblastic neoplasms, choriocarcinoma, trophoblastic tumor, placental site, gestational trophoblastic disease, hydatidiform mole, drug therapy, surgical therapy, radiotherapy, cure, complications, recurrence, survival, prognosis, pregnancy outcome, disease outcome, treatment outcome et remission. La recherche initiale a été effectuée en avril 2017; une mise à jour a été faite en mai 2019. Les données probantes pertinentes ont été sélectionnées aux fins d'inclusion selon l'ordre suivant : méta-analyses, revues systématiques, directives cliniques, essais cliniques randomisés, études de cohortes prospectives, études observationnelles, revues non systématiques, études de séries de cas et rapports. D'autres articles pertinents ont été trouvés en recoupant les revues répertoriées. Le nombre total d'études relevées était de 673, dont 79 études sont citées dans la présente revue. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs. La direction et le conseil d'administration de la Société de gynéco-oncologie du Canada ont passé en revue le contenu de la version préliminaire et ont soumis des commentaires à prendre en considération. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication. La qualité des données probantes a été évaluée au moyen des critères de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). Consulter les tableaux dans l'annexe en ligne pour connaître les critères de notation et d'interprétation des recommandations. BéNéFICES, RISQUES, COûTS: Les présentes recommandations aideront les médecins à diagnostiquer rapidement les maladies gestationnelles trophoblastiques et à orienter de façon urgente les patientes ayant reçu un diagnostic de maladie gestationnelle trophoblastique en gynécologie oncologique pour une prise en charge spécialisée. Le traitement des néoplasies gestationnelles trophoblastiques en centre spécialisé combiné à l'utilisation de bases de données centralisées permet de recueillir et de comparer des données sur les résultats thérapeutiques des patientes atteintes de ces tumeurs rares et d'optimiser les soins aux patientes. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).
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Frijstein MM, Lok CAR, Trommel NE, ten Kate‐Booij MJ, Massuger LFAG, Werkhoven E, Short D, Aguiar X, Fisher RA, Kaur B, Sarwar N, Sebire NJ, Seckl MJ. Lung metastases in low‐risk gestational trophoblastic neoplasia: a retrospective cohort study. BJOG 2019; 127:389-395. [DOI: 10.1111/1471-0528.16036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2019] [Indexed: 12/01/2022]
Affiliation(s)
- MM Frijstein
- Department of Gynaecological Oncology Centre of Gynaecological Oncology Amsterdam Amsterdam the Netherlands
- Department of Obstetrics and Gynaecology Erasmus University Medical Centre Rotterdam the Netherlands
- Department of Obstetrics and Gynaecology Radboud University Medical Centre Nijmegen the Netherlands
| | - CAR Lok
- Department of Gynaecological Oncology Centre of Gynaecological Oncology Amsterdam Amsterdam the Netherlands
| | - NE Trommel
- Department of Gynaecological Oncology Centre of Gynaecological Oncology Amsterdam Amsterdam the Netherlands
| | - MJ ten Kate‐Booij
- Department of Obstetrics and Gynaecology Erasmus University Medical Centre Rotterdam the Netherlands
| | - LFAG Massuger
- Department of Obstetrics and Gynaecology Radboud University Medical Centre Nijmegen the Netherlands
| | - E Werkhoven
- Department of Biometrics Netherlands Cancer Institute – Antoni van Leeuwenhoek Amsterdam the Netherlands
| | - D Short
- Department of Medical Oncology Charing Cross Hospital London UK
| | - X Aguiar
- Department of Medical Oncology Charing Cross Hospital London UK
| | - RA Fisher
- Department of Medical Oncology Charing Cross Hospital London UK
| | - B Kaur
- Department of Medical Oncology Charing Cross Hospital London UK
| | - N Sarwar
- Department of Medical Oncology Charing Cross Hospital London UK
| | - NJ Sebire
- Department of Medical Oncology Charing Cross Hospital London UK
| | - MJ Seckl
- Department of Medical Oncology Charing Cross Hospital London UK
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Outcome of First-Line Hysterectomy for Gestational Trophoblastic Neoplasia in Patients No Longer Wishing to Conceive and Considered With Isolated Lung Metastases: A Series of 30 Patients. Int J Gynecol Cancer 2018; 28:1766-1771. [DOI: 10.1097/igc.0000000000001367] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ObjectiveThis study aimed to assess the outcome of first-line hysterectomy in patients diagnosed as having gestational trophoblastic neoplasia (GTN) whose postoperative imaging showed lung images considered as metastases.MethodsFrom 1999 to 2016, patients no longer wishing to conceive, treated by their initial physician by hysterectomy, and whose postoperative imaging workup showed lung images considered as metastasis were identified in the French Trophoblastic Disease Reference Center database. We sought to identify significant predictive factors of requiring salvage chemotherapy.ResultsThirty patients were identified with a maximum number of 2 visible lung nodules and a median largest size of 14 mm on chest x-ray. Nine of these patients had an International Federation of Gynecology and Obstetrics score of higher than 6, and there were no postterm GTN. Twenty-two patients (73.33%; 95% confidence interval, 54.11–87.72; P = 0.0053) normalized their human chorionic gonadotropin (hCG) without salvage chemotherapy, whereas 7 received 1 line of salvage monochemotherapy (8-day methotrexate) and 1 required 2 lines of monochemotherapy (5-day actinomycin D after failure of methotrexate). After a 12.45-month median follow-up (range, 3–48.4 months) since the first normalized hCG, none of these patients died. The median interval between successful hysterectomy and hCG normalization was 3.15 months (range, 1.6–8.7 months). Patients who required salvage chemotherapy had a median size of the largest lung metastasis on chest computed tomography of 4 mm larger than those cured by hysterectomy (P = 0.0455).ConclusionsFor GTN patients no longer wishing to conceive with lung metastases discovered postoperatively, treated by hysterectomy, and whose hCG is decreasing, it is reasonable to expect and to inform patients that approximately 27% will require salvage chemotherapy. However, in patients with lung metastases discovered preoperatively, evidence to recommend first-line hysterectomy is insufficient and these patients should receive first-line chemotherapy.
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Durable remission for a woman with refractory choriocarcinoma treated with anti-endoglin monoclonal antibody and bevacizumab: A case from the New England Trophoblastic Disease Center, Brigham and Women's Hospital and Dana-Farber Cancer Institute. Gynecol Oncol 2018; 148:5-11. [DOI: 10.1016/j.ygyno.2017.11.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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The Role of Computed Tomography Scanning of the Thorax in the Initial Assessment of Gestational Trophoblastic Neoplasia. Int J Gynecol Cancer 2015; 25:1731-6. [DOI: 10.1097/igc.0000000000000534] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectiveThe aim of this study was to determine whether lesions found on computed tomography (CT) imaging of the thorax would affect FIGO (International Federation of Gynecology and Obstetrics) 2000 risk score and/or alter clinical management.MethodsThe Sheffield Trophoblastic Disease database was searched for all new patients registered for staging/scoring investigations between January 1, 2006, and June 30, 2010. The FIGO 2000 score was noted and then recalculated using information from CT scan reports. Where a change of risk score would have affected a patient’s management, the case notes were further reviewed.Results191 patients had undergone both modalities of imaging. Using standard FIGO scoring, 169 and 22 patients were noted to be at low and high risk, respectively. Using information from CT imaging, only a further 20 patients would have been reclassified as high risk. Fifteen of these “new” high-risk patients required salvage treatment with intravenous chemotherapy; all were cured.ConclusionsWith no potential advantage in terms of patient outcome and significantly increased radiation dose, there is little justification for routine CT imaging of the thorax in the initial assessment of new patients with gestational trophoblastic neoplasia.
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Vree M, van Trommel N, Kenter G, Sweep F, ten Kate-Booij M, Massuger L, Lok C. The influence of lung metastases on the clinical course of gestational trophoblastic neoplasia: a historical cohort study. BJOG 2015; 123:1839-45. [DOI: 10.1111/1471-0528.13622] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2015] [Indexed: 11/30/2022]
Affiliation(s)
- M Vree
- Department of Gynaecologic Oncology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - N van Trommel
- Department of Gynaecologic Oncology; Centre of Gynaecologic Oncology Amsterdam; Amsterdam The Netherlands
| | - G Kenter
- Department of Gynaecologic Oncology; Centre of Gynaecologic Oncology Amsterdam; Amsterdam The Netherlands
| | - F Sweep
- Department of Laboratory Medicine; Radboud University Medical Centre; Nijmegen The Netherlands
| | - M ten Kate-Booij
- Department of Gynaecologic Oncology; Erasmus Medical Centre; Rotterdam The Netherlands
| | - L Massuger
- Department of Obstetrics and Gynaecology; Radboud University Medical Centre; Nijmegen The Netherlands
| | - C Lok
- Department of Gynaecologic Oncology; Centre of Gynaecologic Oncology Amsterdam; Amsterdam The Netherlands
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Trophoblastic disease review for diagnosis and management: a joint report from the International Society for the Study of Trophoblastic Disease, European Organisation for the Treatment of Trophoblastic Disease, and the Gynecologic Cancer InterGroup. Int J Gynecol Cancer 2014; 24:S109-16. [PMID: 25341573 DOI: 10.1097/igc.0000000000000294] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE The objective of this study was to provide a consensus review on gestational trophoblastic disease diagnosis and management from the combined International Society for the Study of Trophoblastic Disease, European Organisation for the Treatment of Trophoblastic Disease, and the Gynecologic Cancer InterGroup. METHODS A joint committee representing various groups reviewed the literature obtained from PubMed searches. RESULTS AND CONCLUSIONS Guidelines were constructed on the basis of literature review. After initial diagnosis in local centers, centralization of pathology review and ongoing care is recommended to achieve the best outcomes.
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Thomakos N, Rodolakis A, Belitsos P, Zagouri F, Chatzinikolaou I, Dimopoulos AM, Papadimitriou CA, Antsaklis A. Gestational trophoblastic neoplasia with retroperitoneal metastases: a fatal complication. World J Surg Oncol 2010; 8:114. [PMID: 21192785 PMCID: PMC3023729 DOI: 10.1186/1477-7819-8-114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 12/30/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gestational Trophoblastic Neoplasia (GTN) is a pathologic entity that can affect any pregnancy and develop long after the termination of the pregnancy. Its course can be complicated by metastases to distant sites such as the lung, brain, liver, kidney and vagina. The therapeutic approach of this condition includes both surgical intervention and chemotherapy. The prognosis depends on many prognostic factors that determine the stage of the disease. CASE REPORT We present a woman with GTN and retroperitoneal metastatic disease who came to our department and was diagnosed as having high risk metastatic GTN. Accordingly she received chemotherapy as primary treatment but unfortunately developed massive bleeding after the first course of chemotherapy, was operated in an attempt to control bleeding but finally succumbed. CONCLUSION This case demonstrates that GTN, while usually curable, can be a deadly disease requiring improved diagnostic, treatment modalities and chemotherapeutic agents. The gynaecologist should be aware of all possible metastatic sites of GTN and the patient immediately referred to a specialist center for further assessment and treatment.
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Affiliation(s)
- Nikolaos Thomakos
- Department of Clinical and Therapeutics, Alexandra Hospital, School of Medicine, University of Athens, Greece
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Abstract
Gestational trophoblastic disease encompasses a range of pregnancy-related disorders, consisting of the premalignant disorders of complete and partial hydatidiform mole, and the malignant disorders of invasive mole, choriocarcinoma, and the rare placental-site trophoblastic tumour. These malignant forms are termed gestational trophoblastic tumours or neoplasia. Improvements in management and follow-up protocols mean that overall cure rates can exceed 98% with fertility retention, whereas most women would have died from malignant disease 60 years ago. This success can be explained by the development of effective treatments, the use of human chorionic gonadotropin as a biomarker, and centralisation of care. We summarise strategies for management of gestational trophoblastic disease and address some of the controversies and future research directions.
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Affiliation(s)
- Michael J Seckl
- Department of Cancer Medicine, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, UK.
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Darby S, Jolley I, Pennington S, Hancock BW. Does chest CT matter in the staging of GTN? Gynecol Oncol 2009; 112:155-60. [DOI: 10.1016/j.ygyno.2008.10.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 10/02/2008] [Accepted: 10/07/2008] [Indexed: 01/28/2023]
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Fleta Asín B, Esquillor Rodrigo MJ, Del Corral Beamonte E, Gonzalvo Liarte MC, Cía Gómez P. [An unusual cause of multiple pulmonary nodules]. Rev Clin Esp 2007; 207:475-6. [PMID: 17915174 DOI: 10.1157/13109844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- B Fleta Asín
- Servicio de Medicina Interna. Hospital Clínico Universitario. Zaragoza. España
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Allen SD, Lim AK, Seckl MJ, Blunt DM, Mitchell AW. Radiology of gestational trophoblastic neoplasia. Clin Radiol 2006; 61:301-13. [PMID: 16546459 DOI: 10.1016/j.crad.2005.12.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2005] [Revised: 10/26/2005] [Accepted: 12/05/2005] [Indexed: 12/20/2022]
Abstract
Gestational trophoblastic neoplasia (GTN) encompasses a broad spectrum of placental lesions from the pre-malignant hydatidiform mole (complete and partial) through to the malignant invasive mole, choriocarcinoma and rare placental site trophoblastic tumour (PSTT). Ultrasound remains the radiological investigation of choice for initial diagnosis, and it can also predict invasive and recurrent disease. Magnetic resonance imaging is of invaluable use in assessing extra-uterine tumour spread, tumour vascularity, and overall staging. Positron emission tomography and computed tomography undoubtedly have a role in recurrent and metastatic disease, while angiography has a place in disease and complication management. This review will describe the relevant pathophysiology and natural history of GTN, and the use of imaging techniques in the diagnosis and management of these conditions.
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Affiliation(s)
- S D Allen
- Department of Radiology, Charing Cross Hospital, Hammersmith Hospitals NHS Trust, London, UK
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Smith HO, Kohorn E, Cole LA. Choriocarcinoma and gestational trophoblastic disease. Obstet Gynecol Clin North Am 2006; 32:661-84. [PMID: 16310678 DOI: 10.1016/j.ogc.2005.08.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Gestational trophoblastic disease (GTD) encompasses a unique group of uncommon but interrelated conditions derived from placental trophoblasts. For the purposes of discussion GTD is the appropriate collective name for hydatidiform mole, whereas the term gestational trophoblastic neoplasia (GTN) is reserved for cases with persistent human chorionic gonadotropin (hCG) titer elevation after evacuation of hydatidiform mole, metastatic disease, or choriocarcinoma. Although the pathology and clinical behavior of CM and PM are different, the initial management of both conditions is surgical evacuation by suction curettage, determination of the baseline, and follow-up with (hCG) titers. There are guidelines for risk-factor scoring and a staging system that classifies untreated patients into distinct prognostic categories so that treatment outcomes can be objectively compared. The rates of GTN and choriocarcinoma are decreasing and survival has dramatically improved.
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Affiliation(s)
- Harriet O Smith
- University of New Mexico Health Sciences Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, 2211 Lomas Boulevard NE, Albuquerque, NM 87131-5286, USA.
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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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Ng TY, Wong LC. Diagnosis and management of gestational trophoblastic neoplasia. Best Pract Res Clin Obstet Gynaecol 2003; 17:893-903. [PMID: 14614888 DOI: 10.1016/s1521-6934(03)00098-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The FIGO Committee Report on the FIGO 2000 staging for gestational trophoblastic disease included criteria for the diagnosis of gestational trophoblastic neoplasia (GTN). It recommended investigative tools for diagnosing metastases. Anatomical and prognostic indicators were combined into a stage : risk score to stratify patients into low and high-risk groups. This is the first staging system to incorporate inclusive criteria that are likely to be adopted universally. The diagnostic evaluation of GTN is presented. The rationale of using the various investigative tools is discussed. The problem of measuring human chorionic gonadotrophin (hCG) levels using commercial kits and the phenomenon of 'phantom hCG' is explored. The use of single agent chemotherapy for low-risk disease versus multi-agent chemotherapy for high-risk disease is discussed. Controversies regarding when to stop chemotherapy are explored with a view to minimizing the short and long-term toxicity, in particular the small risk of developing a second malignancy. Recommendations for the follow up of patients after chemotherapy with particular reference to contraceptive advice and future pregnancies are discussed in the light of current evidence.
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Affiliation(s)
- T Y Ng
- Department of Obstetrics and Gynaecology, The University of Hong Kong, 6th Floor, Professorial Block, Queen Mary Hospital, Pokfulam Road, SAR Hong Kong, China.
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Affiliation(s)
- John T Soper
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27710, USA.
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