1
|
Wang X, Cheng Y, Li W, Mao R, Zhu T, Lu J, Yue X, Lu X. Management of relapsed gestational trophoblastic neoplasia: What can help to reduce the re-recurrence rate? J Obstet Gynaecol Res 2022; 48:1451-1457. [PMID: 35289459 DOI: 10.1111/jog.15228] [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: 09/02/2021] [Revised: 12/29/2021] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
AIM To explore the risk factors for re-recurrence in relapsed gestational trophoblastic neoplasia (GTN) and therapeutic approaches to reduce the re-recurrence rate. METHODS Data of relapsed GTN treated in the Obstetrics and Gynecology Hospital of Fudan University from January 1, 2015, to December 31, 2020, were reviewed retrospectively. Risk factors associated with re-recurrence were analyzed using Logistic regression analysis. RESULTS A total of 39 relapsed GTN patients were included in our study. At the time of the first relapse, 14 patients received single-agent chemotherapy and 25 patients received multi-agent chemotherapy. Surgery was performed in 19 patients. Complete remission was achieved in all of the patients. Re-recurrence occurred in 21 patients. Univariate analysis suggested that unifocal recurrence was the only factor significantly associated with re-recurrence (OR = 0.25, p = 0.04). Recurrence pattern-based subgroup analysis showed that the proportion of re-recurrence was lower in patients who received both surgery and chemotherapy compared to those who received only chemotherapy in the unifocal recurrence group (3/11 vs. 2/4), but not in the non-unifocal recurrence group (7/8 vs. 9/16). The results of the multivariate analysis showed that there was no significant difference in re-recurrence rates between the surgical approaches and that the non-unifocal recurrence pattern was an independent risk factor for re-recurrence. CONCLUSIONS For relapsed GTN with unifocal recurrence pattern, surgical removal of the lesion can effectively reduce the re-recurrence rate.
Collapse
Affiliation(s)
- Xingran Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yu Cheng
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Wenzhi Li
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Runye Mao
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Tingting Zhu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Jiaqi Lu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xiaoni Yue
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xin Lu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| |
Collapse
|
2
|
Branco-Silva M, Maesta I, Elias K, Berkowitz RS, Abbade JF, Horowitz NS. Consolidation chemotherapy in postmolar low-risk gestational trophoblastic neoplasia: a systematic review protocol. BMJ Open 2022; 12:e059484. [PMID: 35210351 PMCID: PMC8883264 DOI: 10.1136/bmjopen-2021-059484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Current evidence remains insufficient to strongly demonstrate the benefits of consolidation chemotherapy to all women with low-risk gestational trophoblastic neoplasia (GTN). This protocol outlines a systematic review to investigate whether consolidation chemotherapy is necessary for all patients with postmolar low-risk GTN after human chorionic gonadotropin normalisation with first-line single-agent chemotherapy. METHODS AND ANALYSIS A search string will be used to search the PubMed (MEDLINE), EMBASE, Web of Sciences, Scopus, LILACS and Cochrane Central Register of Controlled Trials databases. Articles will be screened at the title and abstract level, and then at the full article level by two independent reviewers using inclusion/exclusion criteria. Randomised and non-randomised study designs will be included, while case studies, commentaries, editorials, review articles, animal studies, basic science studies and cross-sectional studies, as well as studies not reporting relapse/recurrence rates and/or whether consolidation chemotherapy was delivered will be excluded. There will be no restrictions on date of publication, geographical location, study setting, or language of publication. The primary outcome is rate of recurrence/relapse. The assessments of randomised controlled trials will be performed using the risk of bias tool from the Cochrane Collaboration. Non-randomised studies will be assessed using the Newcastle-Ottawa scale. The quality of evidence will be assessed using the Grading quality of evidence and strength of recommendations (Grades of Recommendations, Assessment, Development and Evaluation) guidelines. ETHICS AND DISSEMINATION No formal ethical approval is required as all data collected will be secondary data and analysed anonymously. Results will be disseminated through a peer-reviewed publication and at scientific events. PROSPERO REGISTRATION NUMBER CRD42020164822.
Collapse
Affiliation(s)
- Mariza Branco-Silva
- Botucatu Medical School, Postgraduation Program in Tocogynecology, Sao Paulo State University Julio de Mesquita Filho, Sao Paulo, Brazil
| | - Izildinha Maesta
- Department of Gynecology and Obstetrics, Botucatu Medical School, Sao Paulo State University Julio de Mesquita Filho, Sao Paulo, Brazil
- Botucatu Trophoblastic Disease Center, Botucatu Medical School Hospital, São Paulo State University Julio de Mesquita Filho - UNESP, Botucatu, Brazil
| | - Kevin Elias
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ross Stuart Berkowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Joelcio Francisco Abbade
- Department of Gynecology and Obstetrics, Botucatu Medical School, Sao Paulo State University Julio de Mesquita Filho, Sao Paulo, Brazil
| | - Neil S Horowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Chau DB, Beavis AL, Ronnett BM, Jenson E, Gocke CD, Anderson J, Nickles Fader A, Stone R. Genetically Related Choriocarcinoma Developing 5 Yr After a Complete Hydatidiform Mole and Simulating a Cornual Ectopic Pregnancy. Int J Gynecol Pathol 2021; 39:367-372. [PMID: 31033803 DOI: 10.1097/pgp.0000000000000607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Persistent gestational trophoblastic disease can arise from any type of antecedent pregnancy, including molar and tubal pregnancies. While most cases of persistent gestational trophoblastic disease present within the first year following initial diagnosis, recurrence has rarely been reported many years after initial diagnosis. Distinguishing recurrence from a new independent lesion is clinically important. A 25-yr-old woman presented with a mass in the right uterine cornu that was discontiguous with the endometrial cavity and was associated with an elevated serum human chorionic gonadotropin level. She had a history of an invasive complete hydatidiform mole with lung involvement treated with chemotherapy 5 yr prior. Wedge resection of the right cornu was performed due to concern for a cornual ectopic pregnancy. Pathologic evaluation demonstrated a choriocarcinoma. Molecular genotyping confirmed the tumor as recurrent disease genetically related to the prior complete hydatidiform mole. She completed 4 cycles of EMA-CO therapy, and has been disease-free with undetectable serum human chorionic gonadotropin level for 2 yr.
Collapse
Affiliation(s)
- Danielle B Chau
- Department of Gynecology and Obstetrics, The Kelly Gynecologic Oncology Service (D.B.C., A.L.B., A.N.F., R.S.) Department of Pathology (B.M.R., E.J., C.D.G.) Department of Gynecology and Obstetrics (B.M.R., J.A.) Department of Oncology (C.D.G.), Johns Hopkins Hospital, Baltimore, Maryland
| | | | | | | | | | | | | | | |
Collapse
|
4
|
You B, Bolze PA, Lotz JP, Massardier J, Gladieff L, Joly F, Hajri T, Maucort-Boulch D, Bin S, Rousset P, Devouassoux-Shisheboran M, Roux A, Alves-Ferreira M, Grazziotin-Soares D, Langlois-Jacques C, Mercier C, Villeneuve L, Freyer G, Golfier F. Avelumab in Patients With Gestational Trophoblastic Tumors With Resistance to Single-Agent Chemotherapy: Cohort A of the TROPHIMMUN Phase II Trial. J Clin Oncol 2020; 38:3129-3137. [PMID: 32716740 PMCID: PMC7499607 DOI: 10.1200/jco.20.00803] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Women with gestational trophoblastic tumors (GTT) resistant to single-agent chemotherapy receive alternative chemotherapy regimens, which, although effective, cause considerable toxicity. All GTT subtypes express programmed death-ligand 1 (PD-L1), and natural killer (NK) cells are involved in trophoblast immunosurveillance. Avelumab (anti-PD-L1) induces NK cell-mediated cytotoxicity. The TROPHIMMUN trial assessed avelumab in women with chemotherapy-resistant GTT. METHODS In this phase II multicenter trial (ClinicalTrials.gov identifier: NCT03135769), women with GTT who experienced disease progression after single-agent chemotherapy received avelumab 10 mg/kg intravenously every 2 weeks until human chorionic gonadotropin (hCG) normalization, followed by 3 consolidation cycles. Rate of hCG normalization was the primary endpoint (2-step Simon design). RESULTS Between December 2016 and September 2018, 15 patients were treated. Median age was 34 years; disease stage was I or III in 53.3% and 46.7% of women, respectively; and International Federation of Gynecology and Obstetrics (FIGO) score was 0-4 in 33.3%, 5-6 in 46.7%, and ≥ 7 in 20% of patients. Prior treatment included methotrexate (100%) and actinomycin D (7%). Median follow-up was 25 months, and median number of avelumab cycles was 8 (range, 2-11). Grade 1-2 treatment-related adverse events occurred in 93% of patients, most commonly (≥ 25%) fatigue (33.3%), nausea/vomiting (33.3%), and infusion-related reaction (26.7%). One patient had grade 3 uterine bleeding (treatment unrelated). Eight patients (53.3%) had hCG normalization after a median of 9 avelumab cycles; none subsequently relapsed. Probability of normalization was not associated with disease stage, FIGO score, or baseline hCG. One patient subsequently had a healthy pregnancy. In avelumab-resistant patients (46.7%), hCG was normalized with actinomycin D (42.3%) or combination chemotherapy/surgery (57.1%). CONCLUSION In patients with single-agent chemotherapy-resistant GTT, avelumab had a favorable safety profile and cured approximately 50% of patients. Avelumab could be a new therapeutic option, particularly in patients who would otherwise receive combination chemotherapy.
Collapse
Affiliation(s)
- Benoit You
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Medical Oncology, Institut de Cancérologie des Hospices Civils de Lyon, Centre d'Investigation de Thérapeutiques en Oncologie et Hématologie de Lyon, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France
| | - Pierre-Adrien Bolze
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Jean-Pierre Lotz
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Hôpital Tenon, Pôle Onco-Hématologie Hôpitaux Universitaires de l'Est Parisien, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Jérome Massardier
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Service de Gynécologie Obstétrique, Unité de Diagnostic Anténatal, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Laurence Gladieff
- Département d'Oncologie Médicale, Institut Claudius Regaud, IUCT-ONCOPOLE, Toulouse, France
| | - Florence Joly
- Clinical Research Department, Centre François Baclesse, Caen Cedex, France
| | - Touria Hajri
- Centre de Référence des Maladies Trophoblastiques, Lyon, France
| | - Delphine Maucort-Boulch
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Service de Biostatistique, Hospices Civils de Lyon, Lyon; and CNRS UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Sylvie Bin
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Pascal Rousset
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Radiologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | | | - Adeline Roux
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Marine Alves-Ferreira
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Daniele Grazziotin-Soares
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Hôpital Tenon, Pôle Onco-Hématologie Hôpitaux Universitaires de l'Est Parisien, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Carole Langlois-Jacques
- Service de Biostatistique, Hospices Civils de Lyon, Lyon; and CNRS UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Catherine Mercier
- Service de Biostatistique, Hospices Civils de Lyon, Lyon; and CNRS UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Laurent Villeneuve
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Gilles Freyer
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Medical Oncology, Institut de Cancérologie des Hospices Civils de Lyon, Centre d'Investigation de Thérapeutiques en Oncologie et Hématologie de Lyon, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France
| | - Francois Golfier
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| |
Collapse
|
5
|
Yu H, Li J, Zhu T, Xue X, Lu X. Evaluation and influence of lung metastasis on patient outcome in gestational trophoblastic neoplasia: A 10-year study at a single institution. Eur J Obstet Gynecol Reprod Biol 2020; 251:162-166. [PMID: 32505789 DOI: 10.1016/j.ejogrb.2020.05.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the outcomes and related factors of gestational trophoblastic neoplasia (GTN) with lung metastasis in comparison with GTN without metastasis. STUDY DESIGN GTN is a spectrum of diseases arising from trophoblastic cells, and treatment outcome is promising because of its high sensitivity to chemotherapy. Lung metastasis is not usually considered to be an adverse prognostic factor in the evaluation and treatment of GTN. The clinical records of 48 GTN patients with lung metastasis and 162 GTN patients without metastasis were reviewed and analysed retrospectively from 2003 to 2013. Data were compared between patients with and without metastasis. RESULTS Twenty-five percent of GTN patients with lung metastasis presented with pre-treatment serum human chorionic gonadotropin ≥105 mIU/mL, which was significantly higher compared with GTN patients without metastasis (9.3 %, p < 0.01). Regarding the International Federation of Gynecology and Obstetrics (FIGO) score, 39.6 % of patients with lung metastasis were in the high-risk group (FIGO score ≥ 7), compared with 13.6 % of patients without metastasis (p < 0.01). However, on multi-variate analysis, only a FIGO score ≥7 was associated with lung metastasis. The relapse rate of GTN patients with lung metastasis was significantly higher than that of those without metastasis (8.3 % vs 0.6 %, p < 0.05). In the patients who relapsed, non-postmolar GTN, high-risk GTN and first-line chemoresistance were observed more frequently compared with the patients who did not relapse (p < 0.05). CONCLUSION GTN patients with lung metastasis appear to have increased risk of relapse compared with GTN patients without metastasis. To overcome this, there is a need to consider adjustment of the FIGO scoring system to enable GTN patients with lung metastasis to receive more intensive chemotherapy.
Collapse
Affiliation(s)
- Hailin Yu
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Jun Li
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Tingting Zhu
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Xiaohong Xue
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Xin Lu
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China.
| |
Collapse
|
7
|
Mu X, Yin R, Wang D, Song L, Ma Y, Zhao X, Li Q. Hepatic toxicity following actinomycin D chemotherapy in treatment of familial gestational trophoblastic neoplasia: A case report. Medicine (Baltimore) 2018; 97:e12424. [PMID: 30235719 PMCID: PMC6160083 DOI: 10.1097/md.0000000000012424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
RATIONALE Familial hydatidiform mole is extremely rare while familial gestational trophoblastic neoplasia (GTN) has never been reported. Inspired by 2 biological sisters with postmolar GTN and liver toxicity, we reviewed susceptible maternal-effect genes and explored the role of possible drug transporter genes in the development of GTN. PATIENT CONCERNS We reported one Chinese family where the two sisters developed postmolar GTN while experiencing fast remission and significant hepatic toxicity from actinomycin D chemotherapy. DIAGNOSES The index pregnancy was diagnosed with curettage. The following GTN was confirmed when there was a rise in beta-hCG for three consecutive weekly measurements over at least a period of 2 weeks. Computed tomography was used to identify lung metastasis. The elder sister was diagnosed with gestational trophoblastic neoplasia (III: 2) while the younger sister was diagnosed as III: 3 according to WHO scoring system. INTERVENTIONS Patients were treated with actinomycin D of 10 μg/kg intravenously for 5 days every 2 weeks. When hepatic toxicity was indicated, polyene phosphatidyl choline and magnesium isoglycyrrhizinate were prescribed. OUTCOMES Both patients responded extremely well to the 5-day actinomycin D regimen. Beta-hCG remained less than 2 mIU/ml after 5 cycles while computed tomography scan showed downsized pulmonary nodules. Both experienced significant rise in ALT and AST levels that could be ameliorated with corresponding medication. Monthly followed-up showed negative beta-hCG levels and normal liver enzyme levels. LESSONS We speculated that the known or unknown NLRP7 and KHDC3L mutations might be correlated with drug disposition in liver while liver drug transporters such as P-glycoprotein family that are also expressed in trophoblasts might be correlated to GTN susceptibility. Future genomic profiles of large samples alike using next generation sequencing are needed to confirm our hypothesis and discover yet unknown genes.
Collapse
Affiliation(s)
- Xiyan Mu
- Department of Obstetrics and Gynecology, West China Second Hospital of Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, PR China
| | - Rutie Yin
- Department of Obstetrics and Gynecology, West China Second Hospital of Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, PR China
| | - Danqing Wang
- Department of Obstetrics and Gynecology, West China Second Hospital of Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, PR China
| | - Liang Song
- Department of Obstetrics and Gynecology, West China Second Hospital of Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, PR China
| | - Yu Ma
- Department of Obstetrics and Gynecology, West China Second Hospital of Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, PR China
| | - Xia Zhao
- Department of Obstetrics and Gynecology, West China Second Hospital of Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, PR China
| | - Qingli Li
- Department of Obstetrics and Gynecology, West China Second Hospital of Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, PR China
| |
Collapse
|