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Parker VL, Winter MC, Tidy JA, Hancock BW, Palmer JE, Sarwar N, Kaur B, McDonald K, Aguiar X, Singh K, Unsworth N, Jabbar I, Pacey AA, Harrison RF, Seckl MJ. PREDICT-GTN 1: Can we improve the FIGO scoring system in gestational trophoblastic neoplasia? Int J Cancer 2023; 152:986-997. [PMID: 36346113 PMCID: PMC10108153 DOI: 10.1002/ijc.34352] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022]
Abstract
Gestational trophoblastic neoplasia (GTN) patients are treated according to the eight-variable International Federation of Gynaecology and Obstetrics (FIGO) scoring system, that aims to predict first-line single-agent chemotherapy resistance. FIGO is imperfect with one-third of low-risk patients developing disease resistance to first-line single-agent chemotherapy. We aimed to generate simplified models that improve upon FIGO. Logistic regression (LR) and multilayer perceptron (MLP) modelling (n = 4191) generated six models (M1-6). M1, all eight FIGO variables (scored data); M2, all eight FIGO variables (scored and raw data); M3, nonimaging variables (scored data); M4, nonimaging variables (scored and raw data); M5, imaging variables (scored data); and M6, pretreatment hCG (raw data) + imaging variables (scored data). Performance was compared to FIGO using true and false positive rates, positive and negative predictive values, diagnostic odds ratio, receiver operating characteristic (ROC) curves, Bland-Altman calibration plots, decision curve analysis and contingency tables. M1-6 were calibrated and outperformed FIGO on true positive rate and positive predictive value. Using LR and MLP, M1, M2 and M4 generated small improvements to the ROC curve and decision curve analysis. M3, M5 and M6 matched FIGO or performed less well. Compared to FIGO, most (excluding LR M4 and MLP M5) had significant discordance in patient classification (McNemar's test P < .05); 55-112 undertreated, 46-206 overtreated. Statistical modelling yielded only small gains over FIGO performance, arising through recategorisation of treatment-resistant patients, with a significant proportion of under/overtreatment as the available data have been used a priori to allocate primary chemotherapy. Streamlining FIGO should now be the focus.
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Affiliation(s)
- Victoria L Parker
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Matthew C Winter
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK.,Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Barry W Hancock
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Julia E Palmer
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Naveed Sarwar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Baljeet Kaur
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Katie McDonald
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Xianne Aguiar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kamaljit Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nick Unsworth
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Imran Jabbar
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Allan A Pacey
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Robert F Harrison
- Department of Automatic Control and Systems Engineering, The University of Sheffield, Sheffield, UK
| | - Michael J Seckl
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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2
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Weng Y, Liu Y, Benjoed C, Wu X, Tang S, Li X, Xie X, Lu W. Evaluation and simplification of risk factors in FIGO 2000 scoring system for gestational trophoblastic neoplasia: a 19-year retrospective analysis. J Zhejiang Univ Sci B 2022; 23:218-229. [PMID: 35261217 DOI: 10.1631/jzus.b2100895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The International Federation of Gynecology and Obstetrics (FIGO) 2000 scoring system classifies gestational trophoblastic neoplasia (GTN) patients into low- and high-risk groups, so that single- or multi-agent chemotherapy can be administered accordingly. However, a number of FIGO-defined low-risk patients still exhibit resistance to single-agent regimens, and the risk factors currently adopted in the FIGO scoring system possess inequable values for predicting single-agent chemoresistance. The purpose of this study is therefore to evaluate the efficacy of risk factors in predicting single-agent chemoresistance and explore the feasibility of simplifying the FIGO 2000 scoring system for GTN. METHODS The clinical data of 578 GTN patients who received chemotherapy between January 2000 and December 2018 were retrospectively reviewed. Univariate and multivariate logistic regression analyses were carried out to identify risk factors associated with single-agent chemoresistance in low-risk GTN patients. Then, simplified models were built and compared with the original FIGO 2000 scoring system. RESULTS Among the eight FIGO risk factors, the univariate and multivariate analyses identified that pretreatment serum human chorionic gonadotropin (hCG) level and interval from antecedent pregnancy were consistently independent predictors for both first-line and subsequent single-agent chemoresistance. The simplified model with two independent factors showed a better performance in predicting single-agent chemoresistance than the model with the other four non-independent factors. However, the addition of other co-factors did improve the efficiency. Overall, simplified models can achieve favorable performance, but the original FIGO 2000 prognostic system still features the highest discrimination. CONCLUSIONS Pretreatment serum hCG level and interval from antecedent pregnancy were independent predictors for both first-line and subsequent single-agent chemoresistance, and they had greater weight than other non-independent factors in predicting single-agent chemoresistance. The simplified model composed of certain selected factors is a promising alternative to the original FIGO 2000 prognostic system, and it shows comparable performance.
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Affiliation(s)
- Yang Weng
- Women's Reproductive Health Key Research Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Yuanyuan Liu
- Women's Reproductive Health Key Research Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Chitapa Benjoed
- Women's Reproductive Health Key Research Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Xiaodong Wu
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Sangsang Tang
- Women's Reproductive Health Key Research Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Xiao Li
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China.,Center for Uterine Cancer Diagnosis and Therapy Research of Zhejiang Province, Hangzhou 310006, China
| | - Xing Xie
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China.,Center for Uterine Cancer Diagnosis and Therapy Research of Zhejiang Province, Hangzhou 310006, China
| | - Weiguo Lu
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China. .,Center for Uterine Cancer Diagnosis and Therapy Research of Zhejiang Province, Hangzhou 310006, China. .,Cancer Center of Zhejiang University, Hangzhou 310058, China.
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3
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Wallin E, Niemann I, Faaborg L, Fokdal L, Joneborg U. Differences in Administration of Methotrexate and Impact on Outcome in Low-Risk Gestational Trophoblastic Neoplasia. Cancers (Basel) 2022; 14:cancers14030852. [PMID: 35159119 PMCID: PMC8834333 DOI: 10.3390/cancers14030852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary Low-risk gestational trophoblastic neoplasia is a rare but highly curable malignancy. The most common first line treatment is methotrexate, which can be administered in different forms. In order to investigate the impact of route of administration on methotrexate resistance, toxicity demanding treatment switch, complete remission and relapse, we performed an observational study including women with low-risk gestational trophoblastic neoplasia in a population-based setting in Sweden and Denmark. We found that oral compared to intra-muscular administration of methotrexate gives a higher rate of drug resistance, but does not affect rates of complete remission, recurrence or overall survival. Intra-muscular treatment was associated with more toxicity leading to switch of treatment. We conclude that, although a larger proportion of women develop drug resistance, oral methotrexate, which is easy to administer and highly tolerable, could be an option for well-informed and motivated women. Abstract Methotrexate (MTX) is frequently used as first-line treatment for low-risk gestational trophoblastic neoplasia (GTN). Intravenous and intramuscular (im) routes of administration are the most common methods, although oral administration is used by some Scandinavian centers. The primary aim of this study was to assess the impact of form of administration (im/oral) on resistance to methotrexate (MTX-R) treatment in low-risk GTN. Secondary aims were time to hCG normalization, rates of toxicity-induced treatment switch, and rates of complete remission and recurrence. In total, 170 women treated at Karolinska University Hospital in Sweden and Aarhus University Hospital in Denmark between 1994 and 2018 were included, of whom 107 were given im and 63 oral MTX. MTX-R developed in 35% and 54% in the im and oral groups, respectively (p = 0.01). There was no difference in days to hCG normalization (42 vs. 41 days, p = 0.50) for MTX-sensitive women. Toxicity-induced treatment switch was only seen in the im group. Complete remission was obtained in 99.1% and 100% (p = 0.44), and recurrence rate within one year was 2.8% and 1.6% (p = 0.29). The form of administration of MTX had a significant impact on development of MTX-R and treatment-associated toxicity, but does not affect rates of complete remission, recurrence or survival.
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Affiliation(s)
- Emelie Wallin
- Department of Women’s and Children’s Health, Karolinska Institutet, 171 21 Stockholm, Sweden;
- Department of Pelvic Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Isa Niemann
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark;
- Department of Obstetrics and Gynecology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Louise Faaborg
- Department of Oncology, Vejle Hospital, 7100 Vejle, Denmark;
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark;
| | - Ulrika Joneborg
- Department of Women’s and Children’s Health, Karolinska Institutet, 171 21 Stockholm, Sweden;
- Correspondence:
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4
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Braga A, Elias KM, Horowitz NS, Berkowitz RS. Challenges in the Treatment of Low-risk Gestational Trophoblastic Neoplasia. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:503-506. [PMID: 34461659 PMCID: PMC10302923 DOI: 10.1055/s-0041-1735177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Antonio Braga
- Department of Obstetrics and Gynecology, Centro de Doenças Trofoblásticas do Rio de Janeiro, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.,Department of Maternal Child, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Kevin M Elias
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Centre, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Centre, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Ross S Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Centre, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
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5
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Korkmaz V, Sunar V, Akar S, Alinca CM, Arik Z, Boran N, Ozdal B, Ustun YE. Comparison of weekly methotrexate regimen versus methotrexate folinic acid 8-day regimen for treatment of low-risk gestational trophoblastic neoplasia. Asia Pac J Clin Oncol 2021; 18:326-332. [PMID: 34185962 DOI: 10.1111/ajco.13623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 05/30/2021] [Indexed: 11/30/2022]
Abstract
AIM We aimed to compare weekly methotrexate (MTX) regimen and methotrexate-folinic acid (MTX-FA) 8-day regimen in the first line treatment of low-risk gestational trophoblastic neoplasia (GTN). METHODS The study included 73 patients with low-risk GTN according to FIGO risk score (FIGO risk score < 7). All patients received either weekly MTX (30-50 mg/m2 intramuscular weekly) or MTX-FA 8-day (MTX 1 mg/kg IV on day 1, 3, 5, and 7, FA 15 mg orally on day 2, 4, 6, and 8 given 24 h after each MTX dose, every 14 days) regimens in the first-line treatment of low-risk GTN. The baseline clinicopathological characteristics and treatment outcomes were analyzed retrospectively. RESULTS The median age of all patients was 29 (18-51) years, and the median FIGO risk score was 3 (1-6). Of the patients recruited, 53 received MTX-FA 8-day, and 20 had MTX weekly regimens. There was a significant difference between the two groups with respect to FIGO risk scores (3 [1-6] vs. 2 [1-5], p = 0.023, MTX-FA 8-day vs. MTX weekly, respectively). The complete response rate was significantly higher in MTX-FA 8-day group compared to MTX weekly group (83% [44/53] vs. 60% [12/20] p = 0.038). In univariate and multivariate regression analyses, only presence of lung metastasis was found to be an independent risk factor for treatment resistance (OR: 3.959, 95% CI 1.105-14.179, p = 0.035). CONCLUSION MTX-FA 8-day regimen is more effective than weekly MTX regimen in the first line treatment of low-risk GTN including patients even with higher FIGO risk scores. Treatment resistance may develop especially in patients with lung metastasis.
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Affiliation(s)
- Vakkas Korkmaz
- Department of Gynecologic Oncology, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Veli Sunar
- Department of Medical Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Serra Akar
- Department of Gynecologic Oncology, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Cihat Murat Alinca
- Department of Gynecologic Oncology, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Zafer Arik
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Nurettin Boran
- Department of Gynecologic Oncology, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Bülent Ozdal
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Yaprak Engin Ustun
- Department of Gynecology and Obstetrics, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
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6
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Chen L, Xi L, Jiang J, Yin R, Qu P, Li X, Wan X, Chen Y, Hu D, Mao Y, Pan Z, Cheng X, Wang X, Li Q, Weng D, Zhang X, Zhang H, Ping Q, Liu X, Xie X, Kong B, Ma D, Lu W. Chemotherapy initiation with single-course methotrexate alone or combined with dactinomycin versus multi-course methotrexate for low-risk gestational trophoblastic neoplasia: a multi-centric randomized clinical trial. Front Med 2021; 16:276-284. [PMID: 34181195 DOI: 10.1007/s11684-021-0855-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/15/2021] [Indexed: 11/29/2022]
Abstract
We aimed to evaluate the effectiveness and safety of single-course initial regimens in patients with low-risk gestational trophoblastic neoplasia (GTN). In this trial (NCT01823315), 276 patients were analyzed. Patients were allocated to three initiated regimens: single-course methotrexate (MTX), single-course MTX + dactinomycin (ACTD), and multi-course MTX (control arm). The primary endpoint was the complete remission (CR) rate by initial drug(s). The primary CR rate was 64.4% with multi-course MTX in the control arm. For the single-course MTX arm, the CR rate was 35.8% by one course; it increased to 59.3% after subsequent multi-course MTX, with non-inferiority to the control (difference -5.1%,95% confidence interval (CI) -19.4% to 9.2%, P = 0.014). After further treatment with multi-course ACTD, the CR rate (93.3%) was similar to that of the control (95.2%, P = 0.577). For the single-course MTX + ACTD arm, the CR rate was 46.7% by one course, which increased to 89.1% after subsequent multi-course, with non-inferiority (difference 24.7%, 95% CI 12.8%-36.6%, P < 0.001) to the control. It was similar to the CR rate by MTX and further ACTD in the control arm (89.1% vs. 95.2%, P =0.135). Four patients experienced recurrence, with no death, during the 2-year follow-up. We demonstrated that chemotherapy initiation with single-course MTX may be an alternative regimen for patients with low-risk GTN.
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Affiliation(s)
- Lili Chen
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Ling Xi
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jie Jiang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Rutie Yin
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, China
| | - Pengpeng Qu
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, 300052, China
| | - Xiuqin Li
- Shengjing Hospital of China Medical University, Shenyang, 110021, China
| | - Xiaoyun Wan
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Yaxia Chen
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Dongxiao Hu
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Yuyan Mao
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Zimin Pan
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Xiaodong Cheng
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Xinyu Wang
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Qingli Li
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, China
| | - Danhui Weng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xi Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Hong Zhang
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, 300052, China
| | - Quanhong Ping
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, 300052, China
| | - Xiaomei Liu
- Shengjing Hospital of China Medical University, Shenyang, 110021, China
| | - Xing Xie
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Beihua Kong
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, 250012, China.
| | - Ding Ma
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Weiguo Lu
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China.
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7
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Braga A, Paiva G, Ghorani E, Freitas F, Velarde LGC, Kaur B, Unsworth N, Lozano-Kuehne J, Dos Santos Esteves APV, Rezende Filho J, Amim J, Aguiar X, Sarwar N, Elias KM, Horowitz NS, Berkowitz RS, Seckl MJ. Predictors for single-agent resistance in FIGO score 5 or 6 gestational trophoblastic neoplasia: a multicentre, retrospective, cohort study. Lancet Oncol 2021; 22:1188-1198. [PMID: 34181884 DOI: 10.1016/s1470-2045(21)00262-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with gestational trophoblastic neoplasia who have an International Federation of Gynaecology and Obstetrics (FIGO) risk score of 5 or 6 usually receive non-toxic single-agent chemotherapy as a first-line treatment. Previous studies suggest that only a third of patients have complete remission, with the remaining patients requiring toxic multiagent chemotherapy to attain remission. As stratification factors are unknown, some centres offer multiagent therapy upfront, resulting in overtreatment of many patients. We aimed to identify predictive factors for resistance to single-agent therapy to inform clinicians on which patients presenting with a FIGO score of 5 or 6 are likely to benefit from upfront multiagent chemotherapy. METHODS We did a multicentre, retrospective, cohort study of patients with gestational trophoblastic neoplasia presenting with a FIGO score of 5 or 6, who received treatment at three gestational trophoblastic neoplasia reference centres in the UK, Brazil, and the USA between Jan 1, 1964, and Dec 31, 2018. All patients who had been followed up for at least 12 months after remission were included. Patients were excluded if they had received a non-standard single-agent treatment (eg, etoposide); had been given a previously established first-line multiagent chemotherapy regimen; or had incomplete data for our analyses. Patient data were retrieved from medical records. The primary outcome was the incidence of chemoresistance after first-line or second-line single-agent chemotherapy. Variables associated with chemoresistance to single-agent therapies were identified by logistic regression analysis. In patient subgroups defined by choriocarcinoma histology and metastatic disease status, we did bootstrap modelling to define thresholds of pretreatment human chorionic gonadotropin concentrations and identify groups of patients with a greater than 80% risk (ie, a positive predictive value [PPV] of 0·8) of resistance to single-agent chemotherapy. FINDINGS Of 5025 patients with low-risk gestational trophoblastic neoplasia, we identified 431 patients with gestational trophoblastic neoplasia presenting with a FIGO risk score of 5 or 6. All patients were followed up for a minimum of 2 years. 141 (40%) of 351 patients developed resistance to single-agent treatments and required multiagent chemotherapy to achieve remission. Univariable and multivariable logistic regression revealed metastatic disease status (multivariable logistic regression analysis, odds ratio [OR] 1·9 [95% CI 1·1-3·2], p=0·018), choriocarcinoma histology (3·7 [1·9-7·4], p=0·0002), and pretreatment human chorionic gonadotropin concentration (2·8 [1·9-4·1], p<0·0001) as significant predictors of resistance to single-agent therapies. In patients with no metastatic disease and without choriocarcinoma, a pretreatment human chorionic gonadotropin concentration of 411 000 IU/L or higher yielded a PPV of 0·8, whereas in patients with either metastases or choriocarcinoma, a pretreatment human chorionic gonadotropin concentration of 149 000 IU/L or higher yielded the same PPV for resistance to single-agent therapy. INTERPRETATION Approximately 60% of women with gestational trophoblastic neoplasia presenting with a FIGO risk score of 5 or 6 achieve remission with single-agent therapy; almost all remaining patients have complete remission with subsequent multiagent chemotherapy. Primary multiagent chemotherapy should only be given to patients with metastatic disease and choriocarcinoma, regardless of pretreatment human chorionic gonadotropin concentration, or to those defined by our new predictors. FUNDING None. TRANSLATION For the Portuguese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Antonio Braga
- Rio de Janeiro Trophoblastic Disease Centre, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil; Postgraduate Programme in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil; Postgraduate Programme in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil; Young Leadership Physicians Programme, National Academy of Medicine, Rio de Janeiro, Brazil
| | - Gabriela Paiva
- Rio de Janeiro Trophoblastic Disease Centre, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil; Postgraduate Programme in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Ehsan Ghorani
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Fernanda Freitas
- Rio de Janeiro Trophoblastic Disease Centre, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil; Postgraduate Programme in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | | | - Baljeet Kaur
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Nick Unsworth
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jingky Lozano-Kuehne
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Ana Paula Vieira Dos Santos Esteves
- Rio de Janeiro Trophoblastic Disease Centre, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Jorge Rezende Filho
- Rio de Janeiro Trophoblastic Disease Centre, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil; Postgraduate Programme in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Joffre Amim
- Rio de Janeiro Trophoblastic Disease Centre, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil; Postgraduate Programme in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Xianne Aguiar
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Naveed Sarwar
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kevin M Elias
- Department of Obstetrics, Gynecology and Reproductive Biology, Division of Gynecologic Oncology, New England Trophoblastic Disease Centre, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Division of Gynecologic Oncology, New England Trophoblastic Disease Centre, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ross S Berkowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Division of Gynecologic Oncology, New England Trophoblastic Disease Centre, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Michael J Seckl
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.
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Winter MC. Treatment of low-risk gestational trophoblastic neoplasia. Best Pract Res Clin Obstet Gynaecol 2021; 74:67-80. [PMID: 33741258 DOI: 10.1016/j.bpobgyn.2021.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/08/2021] [Indexed: 12/20/2022]
Abstract
Low-risk gestational trophoblastic neoplasia (GTN), defined as FIGO/WHO score 0-6, is highly curable with an overall survival rate, which is approximately 100%. For most low-risk GTN patients, first-line single-agent chemotherapy with either methotrexate or actinomycin-D is recommended with overall complete human chorionic gonadotrophin (hCG) response rates of 60%-90% in mostly retrospective, non-randomised studies. The few randomised trials that exist are not appropriately powered or designed to define the optimal first-line treatment. Approximately 25%-30% of low-risk patients will develop resistance to initial single-agent chemotherapy with an increase in the FIGO score, a diagnosis of choriocarcinoma, higher pre-treatment hCG and the presence of metastatic disease being associated with an increase in the risk of resistance. The optimal treatment of patients scoring WHO 5 and 6 remains poorly defined given that approximately 70%-80% of these patients develop resistance to first-line single-agent chemotherapy, and there is an urgent need to refine the FIGO/WHO scoring system so that these patients can be identified for more intensive therapy from the outset. Despite this, almost all low-risk patients who experience treatment failure with first-line monotherapy will be cured with either sequential single-agent chemotherapy or multiagent chemotherapy with or without surgery. Given the associated increased short and longer-term toxicities associated with multi-agent chemotherapy, promising strategies to reduce the exposure of women to combination chemotherapy in low-risk disease have been investigated, including the use of carboplatin and immune check-point inhibitors. Further evaluation is required to define optimal patient selection, particularly with the use of immunotherapeutic agents given their significant increased costs and lack of longer-term safety data. Although there is a clear need to revise the FIGO/WHO (2000) scoring system, consistent international use of this is recommended to facilitate the comparison of data along with future focus in the development of international collaborative translational and clinical research, including randomised controlled trials.
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Affiliation(s)
- Matthew C Winter
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, S10 2SJ, United Kingdom.
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Epstein E, Joneborg U. Sonographic characteristics of post-molar gestational trophoblastic neoplasia at diagnosis and during follow-up, and relationship with methotrexate resistance. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:759-765. [PMID: 31909527 DOI: 10.1002/uog.21971] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/06/2019] [Accepted: 12/20/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To describe the sonographic characteristics of post-molar gestational trophoblastic neoplasia (GTN) at diagnosis and during follow-up, and to assess their association with methotrexate (MTX) resistance (R) as first-line chemotherapy. METHODS This was a retrospective study of all women treated for post-molar GTN at Karolinska University Hospital, Stockholm, Sweden, between October 2010 and December 2017, who had undergone expert transvaginal ultrasound assessment ≤ 2 weeks prior to, or ≤ 1 week after, the start of first-line MTX treatment. Women with a detectable uterine lesion were followed up with repeat scans during treatment, as well as after treatment in cases of persistent lesions. The association between MTX-R and sonographic findings at inclusion was assessed. RESULTS Of 47 eligible women, 36 were included in the analysis after excluding those who had not undergone structured transvaginal ultrasound assessment and those who started treatment at another center. The median age at diagnosis was 33 (interquartile range (IQR), 27-43) years and 35/36 (97%) women were in the FIGO low-risk group (risk score, 0-6). At inclusion, no uterine lesions were found in eight (22%) women, focal lesions in 24 (67%) women and global lesions in four (11%) women. Median maximum lesion diameter was 40.4 (IQR, 31.3-49.4) mm and 26/28 (93%) lesions had a color score of 3 or 4. Arteriovenous fistulas were found in 9/28 (32%) women and theca lutein cysts in 4/36 (11%) women. Four women with GTN lesion at inclusion underwent hysterectomy prior to the first follow-up ultrasound scan and a fifth woman with a growing lesion underwent hysterectomy, which revealed persistent viable trophoblastic tissue. All remaining women reached complete remission and median time to human chorionic gonadotropin normalization was 2.7 (IQR, 1.4-3.7) months. During ultrasound follow-up, 88% (21/24) of lesions resolved completely. Two women with a persisting lesion remained in complete remission. Median time to disappearance of vascularity was 5.8 (IQR, 3.7-9.3) months and median time to resolution of the lesion was 6.8 (IQR, 3.7-9.3) months. MTX-R developed in 12/31 (39%) women. Uterine tumors ≥ 4 cm (73% vs 17%; P = 0.008) and global lesions (25% vs 0%; P = 0.03) were significantly more common in women with compared to those without MTX-R. CONCLUSION Uterine lesions were detected at the time of diagnosis in 78% of women with post-molar GTN. The vast majority of the lesions resolved completely during follow-up, after a median of 7 months. MTX-R was more common in uterine tumors of 4 cm, or larger, and in global lesions. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Epstein
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Sodersjukhuset, Stockholm, Sweden
| | - U Joneborg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
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Harvey RA, Elias KM, Lim A, Bercow A, Short D, Horowitz NS, Berkowitz RS, Agarwal R, Seckl MJ. Uterine artery pulsatility index and serum BMP-9 predict resistance to methotrexate therapy in gestational trophoblastic neoplasia: A cohort study. Curr Probl Cancer 2020; 45:100622. [PMID: 32800689 DOI: 10.1016/j.currproblcancer.2020.100622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 06/27/2020] [Accepted: 07/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Methotrexate is the most common first-line chemotherapy for low-risk gestational trophoblastic neoplasia (GTN). Uterine artery pulsatility index (UAPI) is an ultrasound marker for tumor vascularity that has been associated with an increased risk of methotrexate resistance. The combination of circulating angiogenic factor levels with UAPI data may improve the capacity of this model to predict chemoresistance. METHODS This was a single-center cohort study of women newly diagnosed between January 2008 and June 2012 with low-risk GTN during postmolar surveillance and treated with single-agent methotrexate at Charing Cross Hospital, a UK national center for treatment of gestational trophoblastic disease. Two hundred seventeen women underwent an ultrasound for UAPI measurement prior to initiation of chemotherapy. To examine serologic markers of methotrexate resistance among this cohort, we performed a case-control study using archived serum from 76 patients who could be matched based on prognostic risk score. Serum samples were examined by immunoassay to measure 8 different angiogenic factors (VEGF-A, FGF-basic, PLGF-1, PDGF-BB, EGF, ANGPT2, BMP-9, and ENG). Receiver-operator characteristic area under the curve (AUC) values were calculated for the ability of each analyte to correctly classify patients as methotrexate sensitive (MTX-S) or resistant (MTX-R). RESULTS Total human chorionic gonadotropin levels were similar between the MTX-S and MTX-R groups. UAPI values were significantly higher in MTX-S (median 1.30 [interquartile range {IQR} = 0.80-1.90]) compared to MTX-R patients (median 0.875 [IQR = 0.60-1.30]; P < 0.0001) with AUC 0.68 (95% confidence interval 0.61-0.76; P < 0.0001). In univariate analysis, only BMP-9 concentrations were significantly different between groups, lower among MTX-S (median of 225 ng/L, IQR = 170-287) compared to MTX-R patients (median 280 ng/L [IQR = 200-339]; P= 0.03). Combining UAPI with BMP-9 concentration improved prediction for chemoresistance with AUC 0.77 (95% confidence interval 0.66-0.88; P < 0.0001). CONCLUSION Circulating levels of BMP-9 are elevated in newly diagnosed women with low-risk GTN destined to fail primary methotrexate therapy. A combined test using serum BMP-9 plus UAPI might improve prediction of MTX-R in low-risk GTN.
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Affiliation(s)
- Richard A Harvey
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Campus of Imperial College Healthcare NHS Trust, London, UK
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA.
| | - Adrian Lim
- Imaging Department of Imperial College Healthcare NHS Trust, London, UK
| | - Alexandra Bercow
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Dee Short
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Campus of Imperial College Healthcare NHS Trust, London, UK
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Roshan Agarwal
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Campus of Imperial College Healthcare NHS Trust, London, UK
| | - Michael J Seckl
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Campus of Imperial College Healthcare NHS Trust, London, UK; Molecular Oncology, Department of Surgery and Cancer, Hammersmith Hospital Campus of Imperial College London, London, UK
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Dekeister K, Bolze PA, Tod M, Tod R, Massardier J, Lotz JP, Hajri T, Colomban O, Seckl MJ, Osborne R, Freyer G, Golfier F, You B. Validation of an online tool for early prediction of the failure-risk in gestational trophoblastic neoplasia patients treated with methotrexate. Cancer Chemother Pharmacol 2020; 86:15-24. [PMID: 32500221 DOI: 10.1007/s00280-020-04086-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 05/15/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE In a low-risk gestational trophoblastic neoplasia (GTN) treated with methotrexate (MTX), the modeled hCG (human chorionic gonadotropin) residual concentration (hCGres), calculated with NONMEM program® (NM) during the first 50 treatment days, is a predictor of MTX-resistance risk. This model was implemented with another algorithm on https://www.biomarker-kinetics.org/hCG . The objective was to confirm the validity of the website estimations with respect to NM. METHODS The consistencies of modeled hCGres estimated by NM and by the website were assessed in a dataset of 60 fictive patients with simulated hCG profiles, as well as in an independent database of 531 actual patients. Moreover, the hCGres predictive values regarding MTX failure-risk were assessed. RESULTS The values of hCGres obtained with both methods were highly consistent in the fictive patient and in the actual patient datasets: median relative prediction errors (RPE) were - 0.059 and 9.9 × 10-7, respectively. The ROC AUCs for predictions of MTX failure-risk were 0.90 (95% CI 0.87,0.93) with both NM and the website. The gradual association between increasing hCGres and the 2-year MTX failure-free survival was confirmed. CONCLUSION There is a high consistency of hCGres estimates obtained with the two methods. The website is meant to help clinicians in the interpretation of hCG decline curves of MTX-treated GTN patients. hCGres is now validated for more than 1690 patients in four independent datasets, and its recognition as an early predictor of MTX resistance for treatment adjustment and for the future studies should be considered.
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Affiliation(s)
- Kathleen Dekeister
- Oncology Medical Department, CITOHL, Université Claude Bernard Lyon-1, Hospices Civils de Lyon, Lyon, France.
- EMR 3738 Ciblage Thérapeutique en Oncologie, Faculté de Médecine Lyon-Sud, BP12, 69310, Pierre-Bénite Cedex, France.
| | - Pierre-Adrien Bolze
- French Trophoblastic Disease Reference, Hospices Civils de Lyon, Lyon, France
- Gynecology-Obstetrics Department, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Michel Tod
- EMR 3738 Ciblage Thérapeutique en Oncologie, Faculté de Médecine Lyon-Sud, BP12, 69310, Pierre-Bénite Cedex, France
| | - Rémi Tod
- EMR 3738 Ciblage Thérapeutique en Oncologie, Faculté de Médecine Lyon-Sud, BP12, 69310, Pierre-Bénite Cedex, France
| | - Jérôme Massardier
- French Trophoblastic Disease Reference, Hospices Civils de Lyon, Lyon, France
- Gynecology-Obstetrics Department, Centre Hospitalier Femme Mère Enfant, Bron, France
| | - Jean-Pierre Lotz
- Oncology Medical Department, Groupe Hospitalier APHP, Sorbonne Université, Hôpital Tenon, Paris, France
| | - Touria Hajri
- French Trophoblastic Disease Reference, Hospices Civils de Lyon, Lyon, France
| | - Olivier Colomban
- EMR 3738 Ciblage Thérapeutique en Oncologie, Faculté de Médecine Lyon-Sud, BP12, 69310, Pierre-Bénite Cedex, France
| | - Michael J Seckl
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, W68RF, UK
| | - Ray Osborne
- Gynecology-Obstetrics Department, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Gilles Freyer
- Oncology Medical Department, CITOHL, Université Claude Bernard Lyon-1, Hospices Civils de Lyon, Lyon, France
- EMR 3738 Ciblage Thérapeutique en Oncologie, Faculté de Médecine Lyon-Sud, BP12, 69310, Pierre-Bénite Cedex, France
| | - François Golfier
- EMR 3738 Ciblage Thérapeutique en Oncologie, Faculté de Médecine Lyon-Sud, BP12, 69310, Pierre-Bénite Cedex, France
- French Trophoblastic Disease Reference, Hospices Civils de Lyon, Lyon, France
- Gynecology-Obstetrics Department, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Benoit You
- Oncology Medical Department, CITOHL, Université Claude Bernard Lyon-1, Hospices Civils de Lyon, Lyon, France
- EMR 3738 Ciblage Thérapeutique en Oncologie, Faculté de Médecine Lyon-Sud, BP12, 69310, Pierre-Bénite Cedex, France
- French Trophoblastic Disease Reference, Hospices Civils de Lyon, Lyon, France
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Sharami SRY, Saffarieh E. A review on management of gestational trophoblastic neoplasia. J Family Med Prim Care 2020; 9:1287-1295. [PMID: 32509606 PMCID: PMC7266251 DOI: 10.4103/jfmpc.jfmpc_876_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The rare presence of malignant cancerous cells afar any type of pregnancy is known as gestational trophoblastic neoplasia (GTN). GTN are benign lesions which mostly happen due to the activity of extravillous trophoblast cells and the placental villous tree development. These kinds of diseases would be occurring mainly due to the following clinicopathologic conditions: (I) existence of epithelioid trophoblastic tumor (ETT), (II) rare type of choriocarcinoma cancer, (III) gestational trophoblastic tumor of mole, and (IV) the rare malignant tumor of placental site trophoblastic tumor. OBJECTIVE This comprehensive study is trying to review the most recent approaches in comprehension of pathogenesis, more precise diagnosis, and also the most effective therapeutic procedures for patients who suffer from GTN disorders. MATERIALS AND METHOD A comprehensive research was carried out on scientific databases of Science Citation Index (SCI), MEDLINE, EMBASE, HMIC, PubMed, CINAHL, Google Scholar, Cochrane Database of Systematic Reviews (CDSR), and PsycINFO over the time period of 2005 to 2019. The keywords which applied for discovering more related records were including: Gestational trophoblastic diseases (GTD), Gestational trophoblastic neoplasia (GTN), molar pregnancy, choriocarcinoma, human chorionic gonadotropin (hCG), diagnosis, management and treatment. CONCLUSION In spite of the fact that GTN patients are treated with conventional surgical therapies or/and chemotherapy, in some patients with resistant disease, these therapies may not be effective and patients may die. Some novel remedial agents are required for decreasing the level of toxicity caused through administering conventional chemotherapy and also treating the patients who suffer from refractory or resistant disease. The newest issues are related to GTN diagnosis, process of progression of hydatidiform mole (HM) to GTN, and the issue of GTN drug resistance. In this regard, we should have a comprehensive knowledge on GTN genetics for answering all the available questions about this disorder.
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Affiliation(s)
| | - Elham Saffarieh
- Abnormal Uterine Bleeding Research Center, Semnan University of Medical Science, Semnan, Iran
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Zhu CC, Liu HY, Wei Y, Shen Z, Qian LL, Song WG, Wang J, Wu DB, Zhang XF, Zhou Y. Low-risk gestational trophoblastic neoplasia outcome after treatment with VMP regimen from 2005 to 2017. Taiwan J Obstet Gynecol 2019; 58:332-337. [PMID: 31122520 DOI: 10.1016/j.tjog.2019.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2018] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and toxicity of VMP regimen applied to the patients with low-risk gestational trophoblastic neoplasia (LR-GTN) treated in Anhui provincial hospital. MATERIALS AND METHODS Between 2005 and 2017, 87 patients with low-risk gestational trophoblastic neoplasia received VMP regimen, consisted of vincristine (VCR), methotrexate (MTX) and platinum (cisplatin, carboplatin or nedaplatin), 68 of whom received VMP as their first-line chemotherapy, and 19 methotrexate-failed patients received VMP regimen as their second-line chemotherapy. The staging and scoring system was based on International Federation of Gynecology and Obstetrics (FIGO 2000) criteria. We describe and analyze their baseline characteristics, remission/resistance/recurrence rates, adverse reactions and prognosis. RESULTS The first-line VMP protocol can achieve an 83.8% remission rate and it tended to develop resistance when the pretreatment β-hCG reaches 7503.5 IU/L, and can achieve complete remission with FAV and EMA-CO as the salvage regimen. Among the 19 methotrexate-failed patients, 2 of whom were yet resistant to VMP regimen, followed by several courses of salvage chemotherapy such as FAV and EMP, and achieved 89.5% remission rate in second-line VMP group. Resistance to this regimen was obviously related with higher pre-treatment HCG whether used as primary or salvage treatment. Severe myelosuppression (grade 3 or 4) was shown in 4 (5.9%) of 68 cases, of which none was grade 4. CONCLUSION For patients diagnosed with LR-GTN VMP regimen was a safe and effective treatment with a high rate of remission.
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Affiliation(s)
- Chen-Chen Zhu
- Department of Obstetrics and Gynecology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Han-Yuan Liu
- Department of Obstetrics and Gynecology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Ying Wei
- Department of Obstetrics and Gynecology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Zhen Shen
- Department of Obstetrics and Gynecology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Li-Li Qian
- Department of Obstetrics and Gynecology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Wei-Guo Song
- Department of Obstetrics and Gynecology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Juan Wang
- Department of Obstetrics and Gynecology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Da-Bao Wu
- Department of Obstetrics and Gynecology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Xue-Fen Zhang
- Department of Obstetrics and Gynecology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, PR China
| | - Ying Zhou
- Department of Obstetrics and Gynecology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui 230001, PR China.
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Kang HL, Zhao Q, Yang SL, Duan W. Efficacy of Combination Therapy with Actinomycin D and Methotrexate in the Treatment of Low-Risk Gestational Trophoblastic Neoplasia. Chemotherapy 2019; 64:42-47. [PMID: 31163446 DOI: 10.1159/000500165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/27/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We aimed to identify an optimal regimen for low-risk gestational trophoblastic neoplasia (LR-GTN) providing reduction in dosage and toxicity/side effects, enhancement of therapeutic efficacy, and a shorter treatment duration. METHODS A total of 149 LR-GTN patients were enrolled in the affiliated Beijing Maternity Hospital of Capital Medical University from January 2014 to January 2017 and randomly divided into 3 groups with 50 cases in the methotrexate (MTX) group, 49 in actinomycin D (ACT-D) group, and 50 in ACT-D+MTX group. Follow-up recorded symptoms, physical and bimanual gynecological examinations, routine blood test, serum β-HCG level, liver and renal functions, electrolytes, electrocardiogram before each treatment course, and pelvic and abdominal B-mode ultrasound or pelvic/abdominal/chest computed tomography. RESULTS Serum complete remission (SCR) was 96.0, 87.8, and 83.7% for the ACT-D+MTX, ACT-D, and MTX groups, respectively, with SCR being highest in the ACT-D+MTX group, statistically higher than in the MTX group. Vomiting was the only side effect differing significantly by chemotherapy regimen, with a distinctly higher incidence in the ACT-D+MTX group compared with the MTX group (p = 0.028). The reduction rate of serum β-HCG in the ACT-D+MTX group was significantly greater than in the other 2 groups. CONCLUSION Combined ACT-D+MTX chemotherapy achieved overall better efficacy and showed less toxicity than ACT-D or MTX alone, and thus can be prioritized for the treatment of LR-GTN.
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Affiliation(s)
- Hai-Li Kang
- Gynecologic Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Qun Zhao
- Gynecologic Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Shu-Li Yang
- Gynecologic Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Wei Duan
- Gynecologic Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China,
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Mangili G, Cioffi R, Danese S, Frigerio L, Ferrandina G, Cormio G, Rabaiotti E, Scarfone G, Gadducci A, Bergamini A, Pisano C, Candiani M. Does methotrexate (MTX) dosing in a 8-day MTX/FA regimen for the treatment of low-risk gestational trophoblastic neoplasia affect outcomes? The MITO-9 study. Gynecol Oncol 2018; 151:449-452. [PMID: 30266260 DOI: 10.1016/j.ygyno.2018.09.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/15/2018] [Accepted: 09/21/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare clinical outcomes of patients diagnosed with low-risk gestational trophoblastic neoplasia (GTN) receiving intramuscular methotrexate 50 mg total dose/day versus 1 mg/kg/day in a 8-day methotrexate/folinic acid (MTX/FA) regimen. METHODS This retrospective, multicenter study included 176 patients: 99 (56%) receiving methotrexate 50 mg total dose/day on days 1, 3, 5, 7 alternated with FA 7,5 mg on days 2, 4, 6, 8, every 14 days (group A); and 77 patients (44%), receiving methotrexate 1 mg/kg/day on days 1, 3, 5, 7 alternated with FA 7,5 mg on days 2, 4, 6, 8, every 14 days (group B). Patients' characteristics and outcomes were compared by univariate analysis. RESULTS Forty-five patients (25.6%) developed resistance to MTX and received a second-line treatment, 7 (4%) received a third-line treatment and 8 (4.5%) relapsed after initial remission. There was no difference between group A and B patients in the average number of chemotherapy cycles required to achieve remission (5.7 ± 2.6 vs 6.3 ± 2.3, p = 0.106). The 2 treatment groups showed comparable rates of MTX resistance (28.3% vs 22.1%, p = 0.387) and relapse (3% vs 6.5%, p = 0.300). There was no difference in the incidence of treatment toxicity of any CTCAE grade between group A and B patients (16.2% vs 15.2%, p = 0.999). Subgroup analysis stratifying patients by weight (<50 kg, ≥60 kg, ≥70 kg, ≥80 kg) confirmed these results. CONCLUSION The 2 MTX schedules showed comparable efficacy in the treatment of low-risk GTN with an acceptable rate of toxicity.
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Affiliation(s)
- Giorgia Mangili
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Raffaella Cioffi
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Saverio Danese
- Obstetrics and Gynecology Unit, Ospedale S. Anna, Turin, Italy
| | - Luigi Frigerio
- Obstetrics and Gynecology Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Gabriella Ferrandina
- Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS -Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro Cormio
- Gynecologic Oncology Unit, Istituto Tumori "Giovanni Paolo II", University of Bari, Italy
| | - Emanuela Rabaiotti
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanna Scarfone
- Obstetrics and Gynecology Unit, IRCCS Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Angiolo Gadducci
- Division of Gynecology and Obstetrics, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Alice Bergamini
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carmela Pisano
- Department of Gynecologic and Urologic Oncology, Fondazione Pascale, National Cancer Institute of Naples, Italy
| | - Massimo Candiani
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Low-Risk Gestational Trophoblastic Neoplasia in Manitoba: Experience With Alternating Methotrexate and Dactinomycin. Int J Gynecol Cancer 2018; 28:1448-1452. [PMID: 30095710 DOI: 10.1097/igc.0000000000001347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVES The aim of this study was to review the treatment and outcomes of low-risk gestational trophoblastic neoplasia (GTN) in Manitoba over more than 3 decades, with a focus on those treated with alternating methotrexate and dactinomycin, a protocol that has only rarely been described. MATERIALS AND METHODS We retrospectively reviewed all patients with GTN referred to CancerCare Manitoba from January 1977 to December 2012. Cases were classified as low risk as per the modified WHO-FIGO prognostic scoring system (score, ≤6). Demographic, treatment, and outcomes data were abstracted, and descriptive statistics and time-to-event analysis were performed. The low-risk protocol used at CancerCare Manitoba consists of alternating single-agent use of methotrexate and dactinomycin, each for 5 days, on a 14-day cycle. RESULTS Sixty-seven cases of GTN were identified, of which 52 were low risk. Thirty-nine patients were initiated on alternating methotrexate and dactinomycin. Thirty-four (87.2%) achieved primary cure on this regimen, with a median of 4.4 cycles administered (range, 2-7). Median time to response was 56 days. One patient achieved cure after receiving a repeat course of methotrexate as their final cycle. Second-line multiagent chemotherapy was required by 4 patients. Two patients experienced grade 3 toxicities, and none greater than grade 3. There were no recurrences. CONCLUSIONS Alternating methotrexate and dactinomycin is an effective treatment protocol for low-risk GTN, with high rates of primary cure and acceptable toxicity.
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Li L, Wan X, Feng F, Ren T, Yang J, Zhao J, Jiang F, Xiang Y. Pulse actinomycin D as first-line treatment of low-risk post-molar non-choriocarcinoma gestational trophoblastic neoplasia. BMC Cancer 2018; 18:585. [PMID: 29792175 PMCID: PMC5966914 DOI: 10.1186/s12885-018-4512-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 05/16/2018] [Indexed: 11/25/2022] Open
Abstract
Background Little data exists predicting the resistance to actinomycin D (Act-D) single-agent for gestational trophoblastic neoplasia (GTN). The objective was to determine the overall success of pulse Act-D and the factors predictive of resistance to pulse Act-D in the treatment of low-risk, non-choriocarcinoma post-molar GTN. Methods From January 2013 to October 2016, according to the FIGO criteria for the diagnosis of post-molar disease and the FIGO risk-factor scoring system for GTN, a total of 135 patients with post-molar non-choriocarcinoma GTN who were chemotherapy-naive with a FIGO score < 7 were treated with single-agent pulse Act-D as a first-line regimen, in Peking Union Medical College Hospital. The pulse Act-D regimen is defined as 1.25 mg/m2 (max 2 mg) IV push every other week. All patients were followed until May 2017. Epidemiological and clinical data were compared between patients with remission and resistance to Act-D to determine predictive factors by univariate and multivariate analysis. Results Ninety-six of 135 patients (71.1%) achieved complete remission after first-line chemotherapy of pulse Act-D. In multivariate analysis, existing invasive uterine lesions observed by pre-chemotherapy transvaginal ultrasound (odds ratio [OR] 7.5, 95% confidence intervals [CI] 2.7–20.8), FIGO score ≥ 5 (OR 15.2, 95% CI 1.5–156.1) and pre-chemotherapy levels of β-hCG ≥ 4000 IU/L (OR 3.1, 95% CI 1.2–8.3) were independent high-risk factors predicting resistance to pulse Act-D as single-agent chemotherapy. During follow-up, no relapse, treatment-associated serious adverse events, or death occurred. Conclusions As first-line chemotherapy, pulse Act-D was effective and tolerable for patients with low-risk post-molar non-choriocarcinoma. Existing invasive uterine lesions observed by pre-chemotherapy transvaginal ultrasound, a FIGO score ≥ 5, and pre-chemotherapy levels of β-hCG ≥ 4000 IU/L were independent factors for resistance to pulse Act-D. Electronic supplementary material The online version of this article (10.1186/s12885-018-4512-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lei Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Tong Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Jun Zhao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Fang Jiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China.
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Maestá I, Nitecki R, Horowitz NS, Goldstein DP, de Freitas Segalla Moreira M, Elias KM, Berkowitz RS. Effectiveness and toxicity of first-line methotrexate chemotherapy in low-risk postmolar gestational trophoblastic neoplasia: The New England Trophoblastic Disease Center experience. Gynecol Oncol 2018; 148:161-167. [DOI: 10.1016/j.ygyno.2017.10.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 11/24/2022]
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Ayatollahi H, Yekta Z, Afsari E. A pilot randomized controlled clinical trial of second uterine curettage versus usual care to determine the effect of re-curettage on patients' need for chemotherapy among women with low risk, nonmetastatic gestational trophoblastic neoplasm in Urmia, Iran. Int J Womens Health 2017; 9:665-671. [PMID: 29033610 PMCID: PMC5614780 DOI: 10.2147/ijwh.s139226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The objective of this study was to determine if second curettage was associated with a decreased need for the number of chemotherapy treatments compared to usual care. Methods A pilot randomized controlled clinical trial was designed at Motahhari Referral Hospital in 2014. Fifty-two patients with low risk, nonmetastatic gestational trophoblastic neoplasm were assigned randomly to two arms. The interventional arm included a repeat uterine curettage, and the control group received standard care (chemotherapy). All participants were followed periodically over 6 months. Primary outcome was defined as the number of chemotherapy courses in each arm. Student’s t-test and receiver operator characteristics (ROC) curve were applied for statistical analysis as appropriate. Results Fifty percent of participants who underwent re-curettage did respond to intervention with no further chemotherapy after 6 months of follow-up. The intervention arm had higher number of remissions without chemotherapy compared to those who received usual care. In the subgroup analysis, the ROC curve could predict the re-curettage treatment response by beta human chorionic gonadotropin (BhCG) level significantly. No complications were reported in the intervention arm. Conclusion Second curettage is an alternative effective procedure to decrease the need for chemotherapy among patients with low risk, nonmetastatic gestational trophoblastic neoplasm. Further clinical trials with larger sample size may be needed to determine the effective role of second curettage among patients.
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Affiliation(s)
- Haleh Ayatollahi
- Department of Gynecology and Obstetrics, Reproductive Health Research Center
| | - Zahra Yekta
- Department of Community and Preventive Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Elnaz Afsari
- Department of Gynecology and Obstetrics, Reproductive Health Research Center
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Parker V, Pacey A, Palmer J, Tidy J, Winter M, Hancock B. Classification systems in Gestational trophoblastic neoplasia - Sentiment or evidenced based? Cancer Treat Rev 2017; 56:47-57. [DOI: 10.1016/j.ctrv.2017.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/07/2017] [Accepted: 04/08/2017] [Indexed: 11/29/2022]
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Elias KM, Harvey RA, Hasselblatt KT, Seckl MJ, Berkowitz RS. Type I interferons modulate methotrexate resistance in gestational trophoblastic neoplasia. Am J Reprod Immunol 2017; 77. [DOI: 10.1111/aji.12666] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/17/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- Kevin M. Elias
- New England Trophoblastic Disease Center; Division of Gynecologic Oncology; Department of Obstetrics, Gynecology and Reproductive Biology; Dana-Farber Cancer Institute; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
| | - Richard A. Harvey
- Charing Cross Gestational Trophoblastic Disease Centre; Charing Cross Campus of Imperial College Healthcare NHS Trust; London UK
| | - Kathleen T. Hasselblatt
- New England Trophoblastic Disease Center; Division of Gynecologic Oncology; Department of Obstetrics, Gynecology and Reproductive Biology; Dana-Farber Cancer Institute; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
| | - Michael J. Seckl
- Charing Cross Gestational Trophoblastic Disease Centre; Charing Cross Campus of Imperial College Healthcare NHS Trust; London UK
- Lung Cancer Biology Group; Division of Medicine; Hammersmith Campus of Imperial College School of Medicine; London UK
| | - Ross S. Berkowitz
- New England Trophoblastic Disease Center; Division of Gynecologic Oncology; Department of Obstetrics, Gynecology and Reproductive Biology; Dana-Farber Cancer Institute; Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
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Winter MC, Tidy JA, Hills A, Ireson J, Gillett S, Singh K, Hancock BW, Coleman RE. Risk adapted single-agent dactinomycin or carboplatin for second-line treatment of methotrexate resistant low-risk gestational trophoblastic neoplasia. Gynecol Oncol 2016; 143:565-570. [PMID: 27756557 DOI: 10.1016/j.ygyno.2016.10.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/21/2016] [Accepted: 10/01/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the outcome of patients treated with second-line chemotherapy for methotrexate-resistant low-risk GTN at the Sheffield Centre, UK between 2001 and 2015, including the novel use of single-agent carboplatin as a strategy to reduce exposure to combination chemotherapy. METHODS 392 low-risk GTN patients were treated with first-line methotrexate. The selection of chemotherapy regimen following methotrexate-resistance depended on the volume of residual disease as indicated by the serum hCG value at the time, with patients switching to either single-agent dactinomycin at an hCG level<150IU/L from 2001-2010 and <300IU/L since 2010, or to combination treatment with etoposide/dactinomycin (EA) above these thresholds. In order to reduce exposure to more toxic combination chemotherapy regimens, our treatment policy was revised in 2011, with the recommendation of single-agent carboplatin as an alternative to EA at hCG levels >300IU/L. RESULTS 136 (35%) of 392 received second-line chemotherapy following methotrexate-resistance. 59 patients received single-agent dactinomycin with 53 (90%) patients achieving complete hCG response, 3 patients requiring combination chemotherapy or surgery, and 3 patients subsequently spontaneously resolving. 56 patients received EA chemotherapy with hCG complete response in 50 (89%) patients, and the remaining 6 patients were cured with further multi-agent chemotherapy or surgery. With carboplatin, 17/21 (81%) achieved an overall complete hCG response rate, with 4 patients requiring third-line EA. Carboplatin was well tolerated with no significant alopecia; myelosuppression was the most significant toxicity. Overall survival for all patients was 100%. CONCLUSION These data show the continued excellent outcomes for methotrexate-resistant low-risk patients treated with single-agent dactinomycin or EA. Our experience with carboplatin is promising and provides an alternative regimen for methotrexate-resistant low-risk disease that avoids alopecia and in-patient treatment.
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Affiliation(s)
- M C Winter
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom.
| | - J A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - A Hills
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - J Ireson
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - S Gillett
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - K Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - B W Hancock
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - R E Coleman
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
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Lee YJ, Park JY, Kim DY, Suh DS, Kim JH, Kim YM, Kim YT, Nam JH. Comparing and evaluating the efficacy of methotrexate and actinomycin D as first-line single chemotherapy agents in low risk gestational trophoblastic disease. J Gynecol Oncol 2016; 28:e8. [PMID: 27819410 PMCID: PMC5323289 DOI: 10.3802/jgo.2017.28.e8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 09/19/2016] [Accepted: 09/28/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare responses to single-agent chemotherapies and evaluate the predictive factors of resistance in low risk (LR) gestational trophoblastic disease (GTD). The chemotherapy agents included methotrexate (MTX) and actinomycin D (ACT-D). METHODS We conducted a retrospective study of 126 patients with GTD who were treated between 2000 and 2013. A total of 71 patients with LR GTD were treated with MTX (8-day regimen or weekly regimen, n=53) or ACT-D (bi-weekly pulsed regimen or 5-day regimen, n=18). The successful treatment group and the failed treatment group were compared and analyzed to identify prognostic factors. RESULTS The complete response rates were 83.3% for ACT-D and 62.2% for MTX, with no statistically significant difference. There was no severe adverse effect reported for either group. Longer interval durations from the index pregnancy (>2 months, p=0.040) and larger tumor size (>3 cm, p=0.020) were more common in non-responders than in responders; these results were statistically significant. CONCLUSION Based on our results, ACT-D may be a better option than MTX as a first-line single chemotherapy agent for LR GTD. The bi-weekly pulsed ACT-D regimen had minimal, or at least the same, toxicities compared with MTX. However, due to the lack of strong supporting evidence, it cannot be conclusively stated that this is the best single agent for first-line chemotherapy in LR GTD patients. Further larger controlled trials will be necessary to establish the best guidelines for GTD treatment.
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Affiliation(s)
- Young Jae Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeong Yeol Park
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Dae Yeon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dae Shik Suh
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jong Hyeok Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yong Man Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young Tak Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Joo Hyun Nam
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Factors Related to Treatment Outcomes in Low-risk Gestational Neoplasia. TUMORI JOURNAL 2016; 103:177-181. [DOI: 10.5301/tj.5000550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2016] [Indexed: 11/20/2022]
Abstract
Objective To define the factors associated with methotrexate (MTX) resistance in patients with low-risk gestational trophoblastic neoplasia (GTN). Methods A total of 63 patients with low-risk GTN according to International Federation of Gynecology and Obstetrics (FIGO) criteria were included. A total of 37 (58.7%) patients were treated with successive doses of 1 mg/kg intramuscular (IM) MTX on days 1, 3, 5, and 7, and 0.1 mg/kg IM folinic acid (FA) on days 2, 4, 6, and 8, until β-human chorionic gonadotropin (hCG) levels were normalized. After the β-hCG value dropped to the normal level, an additional cycle of MTX/FA was administered. This protocol is defined as the standard protocol. In a watchful waiting protocol, the same 8-day IM MTX/FA regimen was given only once (n = 8) or twice (n = 18) to 26 (41.3%) patients and patients in whom β-hCG values declined were subjected to follow-up and no additional cycles were administered as long as there was a decrease in β-hCG value. Clinical response and factors affecting therapeutic outcomes were analyzed retrospectively. Results Of 63 patients, 47 (74.3%) were cured with primary MTX/FA treatment irrespective of any protocol. Of the 16 patients who were not able to be treated with primary MTX/FA, 3 were treated with single-agent actinomycin-D and 11 were treated with multi-agent chemotherapy. Univariate analysis showed that a pretreatment β-hCG level of ≥5000 IU/L was related to reduced therapeutic response (p = 0.001). The FIGO score, antecedent gestational pathology, and treatment with standard or watchful waiting protocol were not related to treatment response. Conclusions The level of β-hCG prior to therapy is an important factor for predicting therapeutic outcomes. It should be noted that the success of the therapy decreases notably in case of high β-hCG level.
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Taylor F, Short D, Harvey R, Winter MC, Tidy J, Hancock BW, Savage PM, Sarwar N, Seckl MJ, Coleman RE. Late spontaneous resolution of persistent molar pregnancy. BJOG 2016; 123:1175-81. [DOI: 10.1111/1471-0528.13867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2015] [Indexed: 11/30/2022]
Affiliation(s)
- F Taylor
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - D Short
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - R Harvey
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - MC Winter
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - J Tidy
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - BW Hancock
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - PM Savage
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - N Sarwar
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - MJ Seckl
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - RE Coleman
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
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Clinical Characteristics of Gestational Trophoblastic Neoplasia: A 15-Year Hospital-Based Study. Int J Gynecol Cancer 2016; 26:216-21. [DOI: 10.1097/igc.0000000000000570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
ObjectiveTo analyze the clinical profile of invasive mole (IM) and choriocarcinoma (CCA) in the past 15 years in Western China.Materials and MethodsA retrospective study was performed on 221 patients with IM and 70 patients with CCA treated in the First Affiliated Hospital of Xi’an Jiaotong University from 1994 to 2009. Patients were assigned into 3 groups by 5 years, and the clinical characteristics were compared among these groups.ResultsThe incidence was not significantly changed in the past 15 years, whereas the mean age of gestational trophoblastic neoplasia (GTN) was increased significantly, especially for the patients 40 years or older. The symptoms of the patients with GTN did not show significant variation, but the number of patients with CCA without clinical symptoms was increased significantly. The mean values of beta human chorionic gonadotropin in the patients with IM and those with CCA were 459.43 and 661.70 mIu/L, respectively, and the size of uterine lesion was concentrated at 4 cm or less in both the patients with IM and those with CCA, without significant differences.ConclusionsIn the past 15 years, the incidence of GTN was still higher than in other countries from 1994 to 2009, and the mean age of patients with GTN was increased significantly, especially for the patients older than 40 years. Furthermore, patients with no clinical manifestations increased significantly, which should be paid more attention in the future works. Serum level of beta human chorionic gonadotropin and pelvic ultrasonography are still 2 important indexes for diagnosing and monitoring condition of GTN.
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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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A retrospective study to evaluate single agent methotrexate treatment in low risk gestational choriocarcinoma in the United Kingdom. Gynecol Oncol 2014; 136:258-63. [PMID: 25542400 DOI: 10.1016/j.ygyno.2014.12.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/14/2014] [Accepted: 12/16/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine whether single agent chemotherapy with intramuscular methotrexate 50mg administered on days 1, 3, 5, and 7 and oral folinic acid 15mg administered on days 2, 4, 6, and 8 in 2 weekly cycles (IM MTX/FA) is an effective treatment regimen for patients with low risk gestational choriocarcinoma. METHOD Electronic databases were searched to identify patients with gestational choriocarcinoma at the Sheffield and Charing Cross supra-regional trophoblastic disease centres from January 2000 to December 2011. Clinical notes of low risk patients with FIGO score 0-6 were retrospectively reviewed to assess treatment outcomes and subsequent relapse. RESULTS 65 patients were identified with low risk choriocarcinoma. Serum hCG levels normalised in 24 patients without the requirement of chemotherapy (19 with histological confirmation, 4 highly suspicious histology and 1 clinical diagnosis). Of 23 patients with histologically confirmed choriocarcinoma, 8 (35%) had a sustained complete response to IM MTX/FA and did not relapse. Both patients with FIGO score 6, and 1 patient with FIGO stage III metastatic disease developed resistance to IM MTX/FA and required further treatment. Despite the development of drug resistance or relapse all patients were successfully salvaged by subsequent treatments. CONCLUSIONS Not all patients with low risk choriocarcinoma that have had primary intervention prior to staging, such as surgical resection or uterine evacuation will require chemotherapy, providing hCG levels continue to decline to normal. Low risk (FIGO 0-5) patients should initially receive IM MTX/FA due to its low toxicity, outpatient administration and reasonable efficacy. Patients with FIGO score 6 or FIGO stage III disease should make an informed choice between IM MTX/FA and combination chemotherapy.
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