1
|
Branco-Silva M, Maestá I, Horowitz N, Elias K, Seckl M, Berkowitz R. Recurrence and resistance risk factors in low-risk gestational trophoblastic neoplasia. Int J Gynecol Cancer 2024:ijgc-2024-005770. [PMID: 39375166 DOI: 10.1136/ijgc-2024-005770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2024] Open
Abstract
Gestational trophoblastic neoplasia (GTN) is a group of rare but highly curable pregnancy-related tumors, especially in low-risk cases. However, around 25% of patients with GTN develop either resistant or recurrent disease after initial chemotherapy. To enhance the understanding of the mechanisms driving treatment failures and to develop more personalized and effective therapeutic strategies, this review explored diverse factors influencing low-risk GTN prognosis. These factors include FIGO (International Federation of Gynecology and Obstetrics) risk score, histology, patient age, pregnancy type, human chorionic gonadotropin (hCG) levels, disease duration, tumor characteristics, metastasis, Doppler ultrasonography, and consolidation chemotherapy. Additionally, the review examined independent risk determinants for disease recurrence and resistance to single-agent chemotherapy in patients with low-risk GTN. In most previous studies on the risk factors related to low-risk GTN, resistance and recurrence have typically been examined independently, despite their overlapping and interrelated nature. Furthermore, they often involve small sample sizes, suffer from methodological shortcomings, and exhibit limited statistical power.Studies utilizing multivariate analysis have shown that independent risk determinants for resistance to first-line treatment include FIGO score, metastatic disease, pre-treatment hCG level, interval between antecedent pregnancy and GTN diagnosis, tumor size, uterine artery pulsatility index (UAPI), choriocarcinoma, lung metastases, lung nodule size, and clearance hCG quartile. The independent predictive factors associated with recurrence include lung metastases, lung nodule size, interval between antecedent pregnancy and chemotherapy, interval from first chemotherapy to hCG normalization, post-delivery low-risk GTN, number of chemotherapy courses to achieve hCG normalization, and number of consolidation chemotherapy cycles. However, while these identified predictive factors offer valuable guidance, the variability in definitions and populations across studies may have implications for the generalizability of their findings. A comprehensive approach using clear definitions and taking into account multiple predictive factors may be necessary for accurately assessing the risk of resistance and recurrence in patients with low-risk GTN.
Collapse
Affiliation(s)
- Mariza Branco-Silva
- Postgraduate Program in Tocogynecology, Botucatu Medical School, Universidade Estadual Paulista Júlio de Mesquita Filho Faculdade de Medicina - Câmpus de Botucatu, Botucatu, Brazil
| | - Izildinha Maestá
- Botucatu Trophoblastic Disease Center, Botucatu Medical School Hospital, Department of Gynecology and Obstetrics, Sao Paulo State University Julio de Mesquita Filho, Botucatu, Brazil
| | - Neil 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, Massachusetts, USA
- Division of Gynecologic Oncology,Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kevin 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, Massachusetts, USA
- Division of Gynecologic Oncology,Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Seckl
- Trophoblastic Tumour Screening and Treatment Centre, Imperial College London - Charing Cross Campus, London, UK
| | - Ross 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, Massachusetts, USA
- Division of Gynecologic Oncology,Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Wang R, Ge Y, Dong X, Wang H, Wang L, Gao M. Analysis of Fertility Prognosis and Risk Factors in Patients Post-Gestational Trophoblastic Disease. Reprod Sci 2024; 31:3095-3101. [PMID: 39026051 DOI: 10.1007/s43032-024-01594-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/09/2024] [Indexed: 07/20/2024]
Abstract
To retrospectively analyze the fertility outcomes and prognosis of gestational trophoblastic disease (GTD) patients, providing a basis for targeted fertility guidance and counseling. 82 GTD patients of childbearing age who received treatment at the Obstetrics and Gynecology Department of Lanzhou University First Hospital from January 2016 to January 2023 were stratified into re-pregnancy (n = 20) and non-re-pregnancy (n = 33) cohorts based on their pregnancy outcomes. The impacts of various factors on pregnancy outcomes were subsequently evaluated, encompassing the rates of subsequent pregnancies, live births, miscarriages, ectopic pregnancies, and ongoing pregnancies. Finally, logistics regression model was employed to analyze the risk factors affecting re-pregnancy in GTD patients. The study delineated those patients with different GTD pathologies had varying re-pregnancy rates (mole, erosive mole and choriocarcinoma accounted for 66.04%, 30.19% and 3.77%, respectively). Treatment predominantly involved uterine curettage, with fewer cases receiving chemotherapy alone or in conjunction with curettage accounted for 67.92%, 5.66%, and 26.42%, respectively. The average chemotherapy frequency was 4.59 ± 2.43 sessions, and a majority sought reproductive counseling. Re-pregnancy occurred in 37.74% of patients. The live birth rate was 65.00%, with miscarriage and ectopic pregnancy rates at 25.00% and 5.00% respectively. Logistic regression analysis pinpointed the absence of pre-pregnancy counseling as a significant independent risk factor for re-pregnancy in GTD patients (p < 0.05). While chemotherapy may influence ovarian function, with the majority of patients desiring children post-recovery, pregnancy rates remain high. Fertility counseling significantly enhances re-pregnancy success rates in GTD survivors, emphasizing its recommendation for those aiming to conceive post-recovery.
Collapse
Affiliation(s)
- Rong Wang
- Reproductive Medicine Center, The First Hospital of Lanzhou University, No. 1 Dong Gang Xi Road, Chengguan District, Lanzhou, 730000, Gansu, China
- First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Yan Ge
- First Clinical Medical College, Lanzhou University, Lanzhou, China
- Obstetrics and Gynecology Department, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Xianghua Dong
- Reproductive Medicine Center, The First Hospital of Lanzhou University, No. 1 Dong Gang Xi Road, Chengguan District, Lanzhou, 730000, Gansu, China
- First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Haiping Wang
- Reproductive Medicine Center, The First Hospital of Lanzhou University, No. 1 Dong Gang Xi Road, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Liyan Wang
- Reproductive Medicine Center, The First Hospital of Lanzhou University, No. 1 Dong Gang Xi Road, Chengguan District, Lanzhou, 730000, Gansu, China
| | - Mingxia Gao
- Reproductive Medicine Center, The First Hospital of Lanzhou University, No. 1 Dong Gang Xi Road, Chengguan District, Lanzhou, 730000, Gansu, China.
- First Clinical Medical College, Lanzhou University, Lanzhou, China.
| |
Collapse
|
3
|
Ghorani E, Seckl MJ. Future Directions for Gestational Trophoblastic Disease. Hematol Oncol Clin North Am 2024:S0889-8588(24)00115-1. [PMID: 39322464 DOI: 10.1016/j.hoc.2024.08.019] [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: 09/27/2024]
Abstract
Gestational trophoblastic disease encompasses a spectrum of premalignant and malignant conditions. While centralized care models significantly improve survival rates, many countries still lack such specialized centers, leading to preventable deaths. Current research focuses on refining diagnostic and treatment methods, aiming to better predict the risk of malignancy and reduce the need for aggressive therapies. Immunotherapy has emerged as a promising treatment modality, offering high cure rates with fewer side effects compared to traditional chemotherapy. Global efforts must continue to expand access to specialized care and integrate new therapies to improve outcomes and reduce treatment-related harm.
Collapse
Affiliation(s)
- Ehsan Ghorani
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK
| | - Michael J Seckl
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK.
| |
Collapse
|
4
|
Joyce CM, Maher GJ, Dineen S, Suraweera N, McCarthy TV, Coulter J, O'Donoghue K, Seckl MJ, Fitzgerald B. Morphology combined with HER2 D-DISH ploidy analysis to diagnose partial hydatidiform mole: an evaluation audit using molecular genotyping. J Clin Pathol 2024:jcp-2023-209269. [PMID: 38555105 DOI: 10.1136/jcp-2023-209269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/17/2024] [Indexed: 04/02/2024]
Abstract
AIMS A hydatidiform mole (HM) is classified as complete (CHM) or partial (PHM) based on its morphology and genomic composition. Ancillary techniques are often required to confirm a morphologically suspected PHM diagnosis. This study sought to evaluate the clinical accuracy of PHM diagnosis using morphological assessment supported by HER2 dual-colour dual-hapten in situ hybridisation (D-DISH) ploidy determination. METHODS Over a 2-year period, our unit examined 1265 products of conception (POCs) from which 103 atypical POCs were diagnosed as PHM or non-molar conceptuses with the assistance of HER2 D-DISH ploidy analysis. We retrospectively audited a sample of 40 of these atypical POCs using short tandem repeat genotyping. DNA extracted from formalin-fixed paraffin-embedded tissue was genotyped using 24 polymorphic loci. Parental alleles in placental villi were identified by comparison to those in maternal decidua. To identify triploid PHM cases, we sought three alleles of equal peak height or two alleles with one allele peak twice the height of the other at each locus. RESULTS Thirty-six of the 40 cases (19 PHM and 17 non-molar) were successfully genotyped and demonstrated complete concordance with the original diagnosis. All PHMs were diandric triploid of dispermic origin. In two non-molar diploid cases, we identified suspected trisomies (13 and 18), which potentially explains the pregnancy loss in these cases. CONCLUSIONS This study validates the use of HER2 D-DISH ploidy analysis to support the diagnosis of a morphologically suspected PHM in our practice.
Collapse
Affiliation(s)
- Caroline M Joyce
- Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology, University College Cork, Cork, Ireland
- Department of Biochemistry & Cell Biology, University College Cork, Cork, Ireland
- INFANT Research Centre, University College Cork, Cork, Ireland
| | - Geoffrey J Maher
- Trophoblastic Tumour Screening & Treatment Centre, Imperial College NHS Trust, Charing Cross Hospital, London, UK
| | - Susan Dineen
- Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology, University College Cork, Cork, Ireland
- Department of Pathology, Cork University Hospital, Cork, Ireland
| | - Nirosha Suraweera
- Trophoblastic Tumour Screening & Treatment Centre, Imperial College NHS Trust, Charing Cross Hospital, London, UK
| | - Tommie V McCarthy
- Department of Biochemistry & Cell Biology, University College Cork, Cork, Ireland
| | - John Coulter
- Department of Obstetrics & Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Keelin O'Donoghue
- Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology, University College Cork, Cork, Ireland
- INFANT Research Centre, University College Cork, Cork, Ireland
| | - Michael J Seckl
- Trophoblastic Tumour Screening & Treatment Centre, Imperial College NHS Trust, Charing Cross Hospital, London, UK
| | - Brendan Fitzgerald
- Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology, University College Cork, Cork, Ireland
- Department of Pathology, Cork University Hospital, Cork, Ireland
| |
Collapse
|
5
|
Bartusevicius A, Bartuseviciene E, Maseviciene M, Sukovas A, Birbalaite I, Karpaviciute M. Heterotopic Tubal Choriocarcinoma Coexistent with a Viable Intrauterine Pregnancy: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1226. [PMID: 39202507 PMCID: PMC11356048 DOI: 10.3390/medicina60081226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 07/10/2024] [Accepted: 07/26/2024] [Indexed: 09/03/2024]
Abstract
Background and Objectives: Choriocarcinoma is an aggressive oncological disease that manifests as trophoblast tissue proliferation. The vast majority of primary lesions affect the uterus, with primarily extrauterine lesions being a rarity. Choriocarcinoma with an ongoing pregnancy is extremely rare because fetuses usually do not survive the third trimester. Case Report: We present a case of heterotopic tubal choriocarcinoma coexisting with a viable intrauterine pregnancy. A 30-year-old, 39-week pregnant woman (gravida 2, para 2) came to our hospital complaining of acute upper abdominal pain. During routine prenatal screening in the first trimester, no pathological ultrasound findings were detected. Similar abdominal pain episodes had been recorded at 18, 27, and 32 weeks of gestation, when patient was hospitalized for examination and observation, but the cause of symptoms at that time of gestation remained unclear. The patient underwent an emergency caesarean section due to severe abdominal pain and fetal compromise. She delivered a live male infant. During the surgery, around 1000 mL of blood clots were evacuated, and the excision of the right fallopian tube and masses, as well as the control of significant blood loss was performed. Postoperative serum beta-hCG was elevated to 139 482 IU/L, while imaging studies showed no metastasis. The histological examination of the excised tissue samples confirmed a diagnosis of tubal choriocarcinoma. With a FIGO score of 8, the patient received three courses of the EP/EMA regimen. After more than a year, the patient showed no radiographic signs of distant metastasis and is now in complete remission. Conclusions: This case highlights the diagnostic complexity of such extremely rare scenarios. Even though such cases are rare, it demonstrates the necessity for improved diagnostic measures to enhance patient outcomes in similar clinical situations.
Collapse
Affiliation(s)
- Arnoldas Bartusevicius
- Department of Obstetrics and Gynaecology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (E.B.); (A.S.)
| | - Egle Bartuseviciene
- Department of Obstetrics and Gynaecology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (E.B.); (A.S.)
| | - Minginte Maseviciene
- Department of Pathological Anatomy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Arturas Sukovas
- Department of Obstetrics and Gynaecology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (E.B.); (A.S.)
| | - Ieva Birbalaite
- Faculty of Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (I.B.); (M.K.)
| | - Migle Karpaviciute
- Faculty of Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (I.B.); (M.K.)
| |
Collapse
|
6
|
Bonomo I, Fopa S, Van Vinckenroy G, Maillard C. Giant complete hydatidiform mole: a case report and review of the literature. J Med Case Rep 2024; 18:277. [PMID: 38867300 PMCID: PMC11170884 DOI: 10.1186/s13256-024-04474-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/26/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND This case describes the youngest patient documented in the literature who presented with a giant hydatidiform mole, effectively addressed through conservative treatment. CASE PRESENTATION Our department received a 20-year-old Caucasian patient who was admitted due to significant metrorrhagia in an undisclosed pregnancy. During examination, we identified a massive, highly vascularized hydatidiform mole measuring 22 cm (cm). We performed a surgical dilatation and curettage. The anatomopathological findings confirmed the presence of a complete hydatidiform mole (CHM). Following the established guidelines, we conducted weekly monitoring of human chorionic gonadotropin (hCG). Unfortunately, the patient discontinued the follow-up and became pregnant again before achieving hCG negativation. CONCLUSION This case suggests that conservative treatment is a viable option regardless of the size of gestational trophoblastic disease (GTD), especially when the preservation of fertility is a crucial consideration, as effectively demonstrated in our case.
Collapse
Affiliation(s)
- Iris Bonomo
- Department of Breast and Reconstructive Surgery, Institut Bergonié, Centre de Lutte Contre le Cancer de Bordeaux, 229 Cours de l'Argonne, 33076, Bordeaux, France.
| | - Suzy Fopa
- Department of Obstetrics, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgique
| | - Grégory Van Vinckenroy
- Deparment of Gynecology and Obstetrics, Grand Hôpital de Charleroi, 6000, Charleroi, Belgique
| | - Charlotte Maillard
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgique
| |
Collapse
|
7
|
Mangla M, Palo S, Kanikaram P, Kaur H. Non-gestational choriocarcinoma: unraveling the similarities and distinctions from its gestational counterpart. Int J Gynecol Cancer 2024; 34:926-934. [PMID: 38123189 DOI: 10.1136/ijgc-2023-004906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Choriocarcinoma is a highly vascular and invasive tumor of anaplastic trophoblast, predominantly made up of cytotrophoblasts and syncytiotrophoblasts without villi. Based on its origin, choriocarcinoma can be either gestational or non-gestational. Non-gestational choriocarcinoma can be of germ cell origin, or can be seen in association with a somatic high-grade malignancy. It is difficult to differentiate gestational from non-gestational choriocarcinoma, especially in the reproductive age group. It is important to distinguish between the two, for accurate staging and prognostication, deciding the primary treatment modality, (ie, surgery or chemotherapy), and tailoring follow-up timeframes after diagnosis. An extensive literature search was performed regarding all cases of non-gestational choriocarcinoma, published before March 2023. A note was made of whether the origin of choriocarcinoma was ascertained and how gestational choriocarcinoma was differentiated from non-gestational choriocarcinoma. The keywords used for literature search were "non-gestational choriocarcinoma", "primary choriocarcinoma", "ovarian choriocarcinoma", "ovarian germ cell tumors", or "choriocarcinomatous differentiation". This review aims to summarize the similarities and differences in the epidemiology, pathogenesis, clinical presentation, and management guidelines between gestational and non-gestational choriocarcinoma, which can form an important educational resource for clinicians and laboratory physicians dealing with such cases.
Collapse
Affiliation(s)
- Mishu Mangla
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences - Bibinagar, Hyderabad, Telangana, India
| | - Seetu Palo
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences - Bibinagar, Hyderabad, Telangana, India
| | - Poojitha Kanikaram
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences - Bibinagar, Hyderabad, Telangana, India
| | - Harpreet Kaur
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences - Bilaspur, Bilaspur, Himachal Pradesh, India
| |
Collapse
|
8
|
Usui H, Sato A, Katayama E, Nakamura N, Koga K. A phantom human chorionic gonadotropin in the case of molar pregnancy. Oxf Med Case Reports 2024; 2024:omae038. [PMID: 38784771 PMCID: PMC11110852 DOI: 10.1093/omcr/omae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/25/2024] [Accepted: 03/19/2024] [Indexed: 05/25/2024] Open
Abstract
Accurately interpreting persistent, low human chorionic gonadotropin (hCG) levels is essential for managing gestational trophoblastic disease. Erroneous interpretation can lead to inappropriate interventions, including unnecessary chemotherapy or hysterectomy, or unjustified changes in chemotherapeutic regimens due to misidentification of a false-positive hCG as a true positive. The predominant etiology of phantom hCG is the presence of heterophilic antibodies. Consequently, screening for urine hCG is indispensable for its diagnosis because immunoglobulin is not generally present in urine. Here, we report about phantom hCG after a complete hydatidiform mole. Initial urine hCG evaluations were negative, although the serum hCG levels remained positive, leading to the diagnosis of phantom hCG. After subsequent delivery, urine hCG levels persisted at diminished levels. However, a different assay yielded negative hCG results for both serum and urine samples. The patient subsequently gave birth. The absence of hCG was consistently confirmed over five years.
Collapse
Affiliation(s)
- Hirokazu Usui
- Department of Obstetrics and Gynecology, Reproductive Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Asuka Sato
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Eri Katayama
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Natsuko Nakamura
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, Reproductive Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| |
Collapse
|
9
|
Lok C, Seckl M. Guidelines and Multidisciplinary Care Are Essential to Improve Survival Rates and Quality of Life Globally for Women with Gestational Trophoblastic Disease. Gynecol Obstet Invest 2024; 89:163-165. [PMID: 38679007 DOI: 10.1159/000539107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 04/07/2024] [Indexed: 05/01/2024]
Affiliation(s)
- Christianne Lok
- Center Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Michael Seckl
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, UK
| |
Collapse
|
10
|
Blay JY, Casali P, Ray-Coquard I, Seckl MJ, Gietema J, de Herder WW, Caplin M, Klümpen HJ, Glehen O, Wyrwicz L, Peeters R, Licitra L, Girard N, Piperno-Neumann S, Kapiteijn E, Idbaih A, Franceschi E, Trama A, Frezza AM, Hohenberger P, Hindi N, Martin-Broto J, Schell J, Rogasik M, Lejeune S, Oliver K, de Lorenzo F, Weinman A. Management of patients with rare adult solid cancers: objectives and evaluation of European reference networks (ERN) EURACAN. THE LANCET REGIONAL HEALTH. EUROPE 2024; 39:100861. [PMID: 38384730 PMCID: PMC10879812 DOI: 10.1016/j.lanepe.2024.100861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 02/23/2024]
Abstract
About 500,000 patients with rare adult solid cancers (RASC) are diagnosed yearly in Europe. Delays and unequal quality of management impact negatively their survival. Since 2017, European reference networks (ERN) aim to improve the quality of care of patients with rare disease. The steering committee of EURACAN, including physicians, researchers and patients review here the previous actions, present objectives of the ERN EURACAN dedicated to RASC. EURACAN promoted management in reference centres, and equal implementation of excellence and innovation in Europe and developed 22 clinical practice guidelines (CPGs). Additionally, fourteen information brochures translated in 24 EU languages were developed in collaboration with patient advocacy groups (ePAGs) and seventeen training session were organized. Nevertheless, connections to national networks in the 26 participating countries (106 centres), simplification of cross-border healthcare, international multidisciplinary tumour boards, registries and monitoring of the quality of care are still required. In this Health Policy, evaluation criteria of the performances of the network and of health care providers are proposed.
Collapse
Affiliation(s)
- Jean-Yves Blay
- Department of Medical Oncology, Centre Leon Berard & Centre de Recherche en Cancérologie de Lyon (CRCL) & Université Claude Bernard Lyon 1, Lyon, France
| | - Paolo Casali
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori and University of Milan, Milan, Italy
| | - Isabelle Ray-Coquard
- Department of Medical Oncology, Centre Leon Berard & Centre de Recherche en Cancérologie de Lyon (CRCL) & Université Claude Bernard Lyon 1, Lyon, France
| | - Michael J. Seckl
- Department of Medical Oncology, Imperial College Hospitals National Health Service (NHS) Trust (ICHNT), London, United Kingdom
| | - Jourik Gietema
- Department of Medical Oncology, University Medical Centre Groningen, Groningen, the Netherlands
- University of Groningen Groningen, the Netherlands
| | - Wouter W. de Herder
- Department of Internal Medicine, Sector of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Martyn Caplin
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Heinz-Josef Klümpen
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Olivier Glehen
- Department of Surgical Oncology, Centre Hospitalier Lyon Sud, Equipe CICLY & Université Claude Bernard Lyon 1, Lyon, France
| | - Lucjan Wyrwicz
- M Sklodowska Curie Memorial Cancer Centre, Warsaw, Poland
| | - Robin Peeters
- Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Lisa Licitra
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori and University of Milan, Milan, Italy
| | - Nicolas Girard
- Department of Medical Oncology, Institut Curie, Paris, France
| | | | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Ahmed Idbaih
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau, ICM, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurologie 2-Mazarin, Paris, France
| | - Enrico Franceschi
- Azienda USL / IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Annalisa Trama
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori and University of Milan, Milan, Italy
| | - Anna-Maria Frezza
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori and University of Milan, Milan, Italy
| | - Peter Hohenberger
- Div. of Surgical Oncology and Thoracic Surgery, Mannheim University Medical Centre, University of Heidelberg, Mannheim, Germany
| | - Nadia Hindi
- Fundación Jiménez Díaz University Hospital, Madrid, Spain
- Spanish Group for Research on Sarcoma (GEIS), Spain
| | - Javier Martin-Broto
- Fundación Jiménez Díaz University Hospital, Madrid, Spain
- Spanish Group for Research on Sarcoma (GEIS), Spain
| | | | | | - Stephane Lejeune
- European Organisation for Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - Kathy Oliver
- The International Brain Tumour Alliance (IBTA), Tadworth, United Kingdom
| | | | - Ariane Weinman
- European Patient Organisation for Rare Diseases (EURORDIS-Rare Diseases Europe), Brussels, Belgium
| |
Collapse
|
11
|
Bartosch C, Nadal A, Braga AC, Salerno A, Rougemont AL, Van Rompuy AS, Fitzgerald B, Joyce C, Allias F, Maher GJ, Turowski G, Tille JC, Alsibai KD, Van de Vijver K, McMahon L, Sunde L, Pyzlak M, Downey P, Wessman S, Patrier S, Kaur B, Fisher R. Practical guidelines of the EOTTD for pathological and genetic diagnosis of hydatidiform moles. Virchows Arch 2024; 484:401-422. [PMID: 37857997 DOI: 10.1007/s00428-023-03658-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/30/2023] [Accepted: 09/15/2023] [Indexed: 10/21/2023]
Abstract
Hydatidiform moles are rare and thus most pathologists and geneticists have little experience with their diagnosis. It is important to promptly and correctly identify hydatidiform moles given that they are premalignant disorders associated with a risk of persistent gestational trophoblastic disease and gestational trophoblastic neoplasia. Improvement in diagnosis can be achieved with uniformization of diagnostic criteria and establishment of algorithms. To this aim, the Pathology and Genetics Working Party of the European Organisation for Treatment of Trophoblastic Diseases has developed guidelines that describe the pathological criteria and ancillary techniques that can be used in the differential diagnosis of hydatidiform moles. These guidelines are based on the best available evidence in the literature, professional experience and consensus of the experts' group involved in its development.
Collapse
Affiliation(s)
- Carla Bartosch
- Department of Pathology, Cancer Biology & Epigenetics Group, Research Center of IPO Porto (CI-IPOP) / RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Center Raquel Seruca (Porto.CCC) and Centro Hospitalar Universitário S. João, Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal.
| | - Alfons Nadal
- Department of Pathology, Clínic Barcelona, Department of Basic Clinical Practice, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Ana C Braga
- Department of Pathology, University Hospital Centre of São João (CHUSJ) / Faculty of Medicine - University of Porto (FMUP) / School of Health (ESS) - Polytechnic Institute of Porto (P. PORTO), Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Angela Salerno
- Anatomia Patologica, Ospedale Maggiore AUSL Bologna, Bologna, Italy
| | | | | | | | - Caroline Joyce
- Department of Clinical Biochemistry, Cork University Hospital, Ireland/ Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology, University College Cork, Cork, Ireland
| | - Fabienne Allias
- Department of Pathology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Geoffrey J Maher
- Trophoblastic Tumour Screening & Treatment Centre, Imperial College NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - Gitta Turowski
- Department of Pathology, Oslo University Hospital, INNPATH Tirolkliniken, Innsbruck, Austria
| | | | - Kinan Drak Alsibai
- Department of Pathology and Center of Biological Resources (CRB Amazonie), Cayenne Hospital Center Andrée Rosemon, 97306, Cayenne, France
| | | | - Lesley McMahon
- Scottish Hydatidiform Mole Follow-Up Service, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Lone Sunde
- Department of Clinical Genetics, Aalborg University Hospital, Denmark/Department of Biomedicine, Aarhus University, Aalborg, Aarhus, Denmark
| | - Michal Pyzlak
- Department of Pathology, Institute of Mother and Child, Warsaw, Poland
| | - Paul Downey
- Department of Pathology, National Maternity Hospital, Dublin, D02YH21, Ireland
| | - Sandra Wessman
- Department of Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden
| | - Sophie Patrier
- Department of Pathology, Rouen University Hospital, Rouen, France
| | - Baljeet Kaur
- Department of Pathology, North West London Pathology, Imperial College NHS Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Rosemary Fisher
- Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital. Fulham Palace Road, London, W6 8RF, UK
| |
Collapse
|
12
|
Bolze P, Schoenen S, Margaillan M, Braga A, Sauthier P, Elias K, Seckl M, Winter M, Coulter J, Lok C, Joneborg U, Undurraga Malinverno M, Hajri T, Massardier J, You B, Golfier F, Goffin F. Chemotherapy is not needed when complete evacuation of gestational choriocarcinoma leads to hCG normalization. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108012. [PMID: 38350264 DOI: 10.1016/j.ejso.2024.108012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/23/2024] [Accepted: 02/07/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND The standard treatment for gestational choriocarcinoma is chemotherapy. OBJECTIVE To describe the risk of recurrence with expectant management of gestational choriocarcinoma that has reached a normal human chorionic gonadotropin level after tumor removal without adjuvant chemotherapy. METHODS A retrospective multicenter international cohort study was conducted from 1981 to 2017 involving 11 gestational trophoblastic disease reference centers with patient's follow-up extended until 2023. Clinical and biological data of included patients were extracted from each center's database. The inclusion criteria were i) histological diagnosis of gestational choriocarcinoma in any kind of placental tissue retrieved, ii) spontaneous normalization of human chorionic gonadotropin level following choriocarcinoma retrieval, iii) patient did not receive any oncological treatment for the choriocarcinoma, iv) and at least 6 months of follow-up after the first human chorionic gonadotropin level normalization. RESULTS Among 80 patients with retrieved gestational choriocarcinoma and whose human chorionic gonadotropin level normalized without any other oncological therapy, none had a recurrence of choriocarcinoma after a median follow-up of 50 months. The median interval between choriocarcinoma excision and human chorionic gonadotropin level normalization was 48 days. The International Federation of Gynecology and Obstetrics/World Health Organization risk score was ≤6 in 93.7% of the cases. CONCLUSIONS This multicenter international study reports that selected patients with gestational choriocarcinoma managed in gestational trophoblastic disease reference centers did not experience any relapse when the initial tumor evacuation is followed by human chorionic gonadotropin level normalization without any additional treatment. Expectant management may be a safe approach for highly selected patients.
Collapse
Affiliation(s)
- Pa Bolze
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France.
| | - S Schoenen
- Centre Belge de Référence des Maladies Trophoblastiques, Liège, Belgium.
| | - M Margaillan
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France
| | - A Braga
- Rio de Janeiro Trophoblastic Disease Reference Center, Rio de Janeiro, Brazil
| | - P Sauthier
- Réseau des Maladies Trophoblastiques Du Québec, Montréal, Canada
| | - K Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, USA
| | - M Seckl
- Charing Cross Gestational Trophoblastic Disease Center, London, UK
| | - M Winter
- Sheffield Center for Trophoblastic Diseases, Sheffield, UK
| | - J Coulter
- Department of Gynaecology Obstetrics, Cork University Maternity Hospital, Cork, Ireland
| | - C Lok
- Center of Gynaecologic Oncology, Amsterdam, Netherlands
| | - U Joneborg
- Department of Women's and Children's Health and Department of Pelvic Cancer, Karolinska Institutet/University Hospital, Stockholm, Sweden
| | - M Undurraga Malinverno
- Unité D'oncogynécologie, Département de Gynécologie et Obstétrique, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - T Hajri
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France
| | - J Massardier
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France
| | - B You
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France
| | - F Golfier
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France
| | - F Goffin
- Centre Belge de Référence des Maladies Trophoblastiques, Liège, Belgium
| |
Collapse
|
13
|
Willy D, Schmitz R, Möllers M, Heitplatz B, Kuntze A, Stratis Y, Bahlke K, Röpke A, Meyer-Wittkopf M, Oelmeier K. Severe, very early onset preeclampsia in a Covid 19-positive woman with a twin pregnancy presenting with a hydatidiform mole and coexisting normal fetus: a case report. Front Med (Lausanne) 2024; 11:1340905. [PMID: 38414622 PMCID: PMC10896921 DOI: 10.3389/fmed.2024.1340905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/17/2024] [Indexed: 02/29/2024] Open
Abstract
Cases of hydatidiform moles with a coexisting fetus are sparse and patients are at high risk for severe complications. Patients and physicians often face the dilemma of the wish to continue pregnancy until viability of the fetus while the risk for maternal complications increases. We present an educational case of a twin pregnancy presenting with a hydatidiform mole and coexisting normal fetus with a placenta praevia. The patient developed severe, early onset preeclampsia with beginning HELLP-syndrome and was tested Covid-19 positive in the further course. Termination of pregnancy was conducted via caesarean section at 18 + 6 weeks of pregnancy. Histopathology and genetic analysis confirmed a complete hydatidiform mole next to a normal placenta. Close follow-up examinations were conducted and showed normal findings including ß HCG levels normalizing within 5 months. This case combines several rare, difficult and severe medical conditions and demonstrates how an individualized therapy by an interdisciplinary team covering a highly sensitive topic was developed in a situation where no guidelines exist.
Collapse
Affiliation(s)
- Daniela Willy
- Department of Gynecology and Obstetrics, University Hospital Münster, Münster, Germany
| | - Ralf Schmitz
- Department of Gynecology and Obstetrics, University Hospital Münster, Münster, Germany
| | - Mareike Möllers
- Department of Gynecology and Obstetrics, University Hospital Münster, Münster, Germany
| | - Barbara Heitplatz
- Gerhard-Domagk-Institute of Pathology, University Hospital Münster, Münster, Germany
| | - Anna Kuntze
- Gerhard-Domagk-Institute of Pathology, University Hospital Münster, Münster, Germany
| | - Yvonne Stratis
- Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Katrin Bahlke
- Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Albrecht Röpke
- Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | | | - Kathrin Oelmeier
- Department of Gynecology and Obstetrics, University Hospital Münster, Münster, Germany
| |
Collapse
|
14
|
Kaur B, Nadal A, Bartosch C, Rougemont AL. Expert Pathology for Gestational Trophoblastic Disease: Towards an International Multidisciplinary Team Meeting. Gynecol Obstet Invest 2024; 89:166-177. [PMID: 38190817 PMCID: PMC11151979 DOI: 10.1159/000536028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/24/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Gestational trophoblastic disease (GTD), comprising hydatidiform moles and gestational trophoblastic tumours, is extremely rare. Exact diagnosis is crucial to indicate the appropriate treatment and to prevent complications. The scarcity and variability in the number of cases available for reporting, lack of specialised training in GTD, and non-existence of refresher courses implies that the pathologist dealing with these rare and, at times, extremely challenging cases is not completely confident in their diagnosis. OBJECTIVES The objective of this study was to explore the benefits of implementation of an international multidisciplinary conference (virtual) to aid diagnosis of difficult cases and support clinical management of GTD. METHODS A short survey was circulated to all 46 members of the EOTTD pathology and genetics working party and further spread to other colleagues who practice GTD. This showed that the pathologists and geneticists working with GTD patients do not feel adequately supported and equipped with dealing with these rare diseases. OUTCOME Virtual cross-border multidisciplinary team meetings (MDTs) were initiated in April 2022, bringing together participants from 11 European countries on a bi-yearly basis. Mean numbers of 3 patients are discussed during the MDTs followed by 3-4 quality assessment cases. A participant survey was conducted at the end of virtual meeting with an average satisfaction rate of 9.5. The pathologists felt supported and benefited from networking and clinical collaboration. CONCLUSIONS AND OUTLOOK This international MDT continues to provide support in managing the uncertainty with difficult and rare cases and enhances the pathologists training and experience. The frequency of meetings and the number of cases discussed per meeting will be increased in 2023 given the positive response. This will empower individuals and organisations to work together and improve diagnosis and the prognosis for these young patients.
Collapse
Affiliation(s)
- Baljeet Kaur
- Department of Pathology, North West London Pathology (NWLP), Imperial College NHS Trust, London, UK
| | - Alfons Nadal
- Department of Pathology, Clínic Barcelona, Department of Basic Clinical Practice, University of Barcelona, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Carla Bartosch
- Department of Pathology, Cancer Biology and Epigenetics Group, Research Center of IPO Porto (CI-IPOP)/RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto)/Porto Comprehensive Cancer Center Raquel Seruca (Porto.CCC), Porto, Portugal
| | - Anne-Laure Rougemont
- Division of Clinical Pathology, Diagnostic Department, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| |
Collapse
|
15
|
Parker VL, Winter MC, Tidy JA, Palmer JE, Sarwar N, Singh K, Aguiar X, Hancock BW, Pacey AA, Seckl MJ, Harrison RF. PREDICT-GTN 2: Two-factor streamlined models match FIGO performance in gestational trophoblastic neoplasia. Gynecol Oncol 2024; 180:152-159. [PMID: 38091775 DOI: 10.1016/j.ygyno.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/07/2023] [Accepted: 11/15/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE The International Federation of Gynecology and Obstetrics (FIGO) scoring system uses the sum of eight risk-factors to predict single-agent chemotherapy resistance in Gestational Trophoblastic Neoplasia (GTN). To improve ease of use, this study aimed to generate: (i) streamlined models that match FIGO performance and; (ii) visual-decision aids (nomograms) for guiding management. METHODS Using training (n = 4191) and validation datasets (n = 144) of GTN patients from two UK specialist centres, logistic regression analysis generated two-factor models for cross-validation and exploration. Performance was assessed using true and false positive rate, positive and negative predictive values, Bland-Altman calibration plots, receiver operating characteristic (ROC) curves, decision-curve analysis (DCA) and contingency tables. Nomograms were developed from estimated model parameters and performance cross-checked upon the training and validation dataset. RESULTS Three streamlined, two-factor models were selected for analysis: (i) M1, pre-treatment hCG + history of failed chemotherapy; (ii) M2, pre-treatment hCG + site of metastases and; (iii) M3, pre-treatment hCG + number of metastases. Using both training and validation datasets, these models showed no evidence of significant discordance from FIGO (McNemar's test p > 0.78) or across a range of performance parameters. This behaviour was maintained when applying algorithms simulating the logic of the nomograms. CONCLUSIONS Our streamlined models could be used to assess GTN patients and replace FIGO, statistically matching performance. Given the importance of imaging parameters in guiding treatment, M2 and M3 are favoured for ongoing validation. In resource-poor countries, where access to specialist centres is problematic, M1 could be pragmatically implemented. Further prospective validation on a larger cohort is recommended.
Collapse
Affiliation(s)
- Victoria L Parker
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Level 4 The Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK.
| | - Matthew C Winter
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Level 4 The Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK; Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - John A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Julia E Palmer
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Naveed Sarwar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Kamaljit Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Xianne Aguiar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Barry W Hancock
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Level 4 The Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK
| | - Allan A Pacey
- Faculty of Biology, Medicine and Health, Core Technology Facility, 46 Grafton Street, University of Manchester, Manchester, M13 9NT, UK
| | - Michael J Seckl
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Robert F Harrison
- Department of Automatic Control and Systems Engineering, The University of Sheffield, Mappin Street, Sheffield S1 3JD, UK
| |
Collapse
|
16
|
Mitric C, Yang K, Bhat G, Lheureux S, Laframboise S, Li X, Bouchard-Fortier G. Gestational trophoblastic neoplasia: does centralization of care impact clinical management? Int J Gynecol Cancer 2023; 33:1724-1732. [PMID: 37723102 DOI: 10.1136/ijgc-2023-004526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
OBJECTIVE International societies advocate for gestational trophoblastic neoplasia referral to designated expert centers. This study assessed the impact of centralization of trophoblastic care on clinical outcomes. METHODS A centralized program was implemented in 2018 at two affiliated academic hospitals, Princess Margaret Cancer Center and Mount Sinai Hospital. A retrospective analysis of patients treated between 2000 and 2022 was performed and the clinical outcomes were compared before (2000-2017) and after (2018-2022) centralization. Statistical analyses were performed with significance set as p<0.05. RESULTS A total of 94 patients with trophoblastic neoplasia were included: 60 pre-centralization and 34 post-centralization, 79.8% low-risk and 18.1% high-risk. Centralization led to significant improvement for: (1) accurate score documentation (from 37.9% to 89.3%,); (2) contraception counseling (from 67.2% to 96.7%); (3) median time from diagnosis to chemotherapy (from 9 days to 1 day); and (4) incomplete follow-up (from 20.7% to 3.3%) (all p<0.05). First-line chemotherapy for low-risk neoplasia was dactinomycin in 47.9% and 87.0% pre- and post-centralization, respectively (p=0.005). The median number of chemotherapy cycles decreased from seven to four (p=0.01), and the median number of consolidation cycles increased from two to three (p<0.001). Serum human chorionic gonadotropin (hCG) levels of 10 000-100 000 IU/L were significantly associated with longer time to hCG normalization and higher risk of resistance to first-line chemotherapy compared with hCG levels <1000 IU/L. CONCLUSION Centralization of trophoblastic neoplasia care leads to greater guideline compliance, faster chemotherapy initiation, fewer chemotherapy cycles with optimized consolidation, and enhanced surveillance completion. This supports the establishment of trophoblastic neoplasia expert centers.
Collapse
Affiliation(s)
- Cristina Mitric
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Kelsey Yang
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Gita Bhat
- Medical Oncology, Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Stephanie Lheureux
- Medical Oncology, Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Stephane Laframboise
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Xuan Li
- Department of Biostatistics, Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Geneviève Bouchard-Fortier
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
17
|
Usui H, Mikiya A, Katayama E, Nakamura N, Sato A, Matsui H, Shozu M, Koga K. Total human chorionic gonadotropin is a more suitable diagnostic marker of gestational trophoblastic diseases than the free β-subunit of human chorionic gonadotropin. Pract Lab Med 2023; 37:e00343. [PMID: 38025990 PMCID: PMC10661586 DOI: 10.1016/j.plabm.2023.e00343] [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: 09/22/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives Human chorionic gonadotropin (hCG) levels are essential for the management of trophoblastic diseases. This study aimed to compare the sensitivities and relationships of two hCG measurement methods (total hCG and the free β-subunit of hCG) in managing gestational trophoblastic disease (GTD). Design and Methods We analyzed data from patients treated for GTD at Chiba University Hospital between 2008 and 2019. We focused on cases where both total hCG (mIU/mL) and the free β-subunit of hCG (ng/mL) were measured on the same day. Results Out of 80 patients (mean age 38.9 ± 11.7 years) and 158 measurements, 26 had values below the sensitivity threshold for both tests. Fifty-nine measurements were positive for total hCG but below the sensitivity threshold for the free β-subunit of hCG, whereas only two showed the opposite. Seventy-one measurements were positive for both total hCG and the free β-subunit of hCG. There was a significant correlation between total hCG and the free β-subunit of hCG with both positive values, (r = 0.94, p < 0.001; Spearman's correlation test). Of the 85 measurements with undetectable free β-subunit levels, 26 also had undetectable total hCG levels. However, total hCG was detectable in 59 patients from these cases, with a median value (interquartile range) of 2.9 (1.75-4.9) mIU/mL. Conclusions In the management of GTD, the use of the free β-subunit system alone cannot be recommended.
Collapse
Affiliation(s)
- Hirokazu Usui
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Atsuko Mikiya
- Department of Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Eri Katayama
- Department of Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Natsuko Nakamura
- Department of Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Asuka Sato
- Department of Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Hideo Matsui
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makio Shozu
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Kaori Koga
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| |
Collapse
|
18
|
Coopmans L, Larsson A, Joneborg U, Lok C, van Trommel N. Surgical Management of Gestational Trophoblastic Disease. Gynecol Obstet Invest 2023; 89:214-229. [PMID: 37788661 DOI: 10.1159/000534065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 09/04/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Gestational trophoblastic disease (GTD) is a rare pregnancy-related condition consisting of premalignant and malignant forms arising from proliferation of trophoblastic cells. The malignant forms are collectively referred to as gestational trophoblastic neoplasia (GTN) and are highly sensitive to chemotherapy. However, surgical procedures remain indispensable in the diagnosis and treatment of GTD. OBJECTIVES The aim of this review was to summarize surgical interventions in the treatment of GTD and GTN. We reviewed indications, efficacy, possible complications, and oncological outcomes of surgery. METHODS Three searches were performed in the databases of PubMed, Embase, and the Cochrane Library to create an up-to-date overview of existing literature on the following subjects: (1) the role of primary hysterectomy in GTD and GTN; (2) the role of second curettage in GTD and GTN; (3) fertility sparing surgery in GTN; (4) surgical management of metastases. Included articles originated from the time period 1952-2022. Articles written in English, Spanish, and French were included. OUTCOMES Thirty-eight articles were found and selected. Surgical evacuation through suction curettage is most used and advised in the treatment of GTD. A second curettage could be beneficial in patients with low hCG levels and low FIGO scores. In women who have completed their families, primary hysterectomy might be considered as the risk of subsequent GTN is lower than after suction curettage. In case of the rare forms of GTN (epithelioid trophoblastic tumor or placental site trophoblastic tumor) surgical tumor resection remains the most important step in treatment. Data on fertility sparing surgery in GTN are scarce and this treatment should be considered experimental. CONCLUSION AND OUTLOOK Surgery remains an important part of treatment of GTD and is sometimes indispensable to achieve curation. Further collection of evidence is needed to determine treatment steps.
Collapse
Affiliation(s)
- Leonoor Coopmans
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands,
| | - Agnes Larsson
- Department of Gynecologic Cancer Surgery, Karolinska University Hospital and Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Ulrika Joneborg
- Department of Gynecologic Cancer Surgery, Karolinska University Hospital and Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Christianne Lok
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nienke van Trommel
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands
| |
Collapse
|
19
|
Bogani G, Ray-Coquard I, Mutch D, Vergote I, Ramirez PT, Prat J, Concin N, Ngoi NYL, Coleman RL, Enomoto T, Takehara K, Denys H, Lorusso D, Takano M, Sagae S, Wimberger P, Segev Y, Kim SI, Kim JW, Herrera F, Mariani A, Brooks RA, Tan D, Paolini B, Chiappa V, Longo M, Raspagliesi F, Benedetti Panici P, Di Donato V, Caruso G, Colombo N, Pignata S, Zannoni G, Scambia G, Monk BJ. Gestational choriocarcinoma. Int J Gynecol Cancer 2023; 33:1504-1514. [PMID: 37758451 DOI: 10.1136/ijgc-2023-004704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Gestational choriocarcinoma accounts for 5% of gestational trophoblastic neoplasms. Approximately 50%, 25%, and 25% of gestational choriocarcinoma occur after molar pregnancies, term pregnancies, and other gestational events, respectively. The FIGO scoring system categorizes patients into low (score 0 to 6) and high risk (score 7 or more) choriocarcinoma. Single-agent and multi-agent chemotherapy are used in low- and high-risk patients, respectively. Chemotherapy for localized disease has a goal of eradication of disease without surgery and is associated with favorable prognosis and fertility preservation. Most patients with gestational choriocarcinoma are cured with chemotherapy; however, some (<5.0%) will die as a result of multi-drug resistance, underscoring the need for novel approaches in this group of patients. Although there are limited data due to its rarity, the treatment response with immunotherapy is high, ranging between 50-70%. Novel combinations of immune checkpoint inhibitors with targeted therapies (including VEGFR-2 inhibitors) are under evaluation. PD-L1 inhibitors are considered a potential important opportunity for chemo-resistant patients, and to replace or de-escalate chemotherapy to avoid or minimize chemotherapy toxicity. In this review, the Rare Tumor Working Group and the European Organization for Research and Treatment of Cancer evaluated the current landscape and further perspective in the management of patients diagnosed with gestational choriocarcinoma.
Collapse
Affiliation(s)
- Giorgio Bogani
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Isabelle Ray-Coquard
- Centre Leon Berard, LYON CEDEX 08, France
- Hesper lab, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - David Mutch
- Washington University in Saint Louis, St Louis, Missouri, USA
| | - Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium
| | - Pedro T Ramirez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas, USA
| | - Jaime Prat
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Nicole Concin
- Department of Gynecology and Obstetrics; Innsbruck Medical Univeristy, Innsbruck, Austria
| | | | | | - Takayuki Enomoto
- Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Belgium
| | - Kazuhiro Takehara
- Department of Gynecologic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | | | | | - Masashi Takano
- Department of Obstetrics and Gynecology, National Defense Medical College, Tokorozawa, Japan
| | - Satoru Sagae
- Gynecologic Oncology, Tokeidai Kinen Byoin, Sapporo, Japan
| | - Pauline Wimberger
- Gyncology and Obstetrics, Technische Universitat Dresden Medizinische Fakultat Carl Gustav Carus, Dresden, Germany
| | - Yakir Segev
- Obstetrics and Gynecology, Carmel Hospital, Haifa, Israel
| | - Se Ik Kim
- Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Jae-Weon Kim
- Obstetrics and gynecology, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Fernanda Herrera
- Centre Hospitalier Universitaire Vaudois Departement doncologie CHUV-UNIL, Lausanne, Switzerland
| | - Andrea Mariani
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Rebecca A Brooks
- Section of Gynecologic Oncology, University of Chicago Medicine, Chicago, Illinois, USA
| | - David Tan
- National University Cancer Institute, Singapore
| | - Biagio Paolini
- Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italy
| | - Valentina Chiappa
- Department of Gynecologic Oncology, IRCCS National Cancer Institute, Milan, Italy
| | | | | | | | | | | | - Nicoletta Colombo
- Medical Gynecologic Oncology Unit; University of Milan Bicocca; Milan; Italy, European Institute of Oncology, Milano, Italy
| | - Sandro Pignata
- Gynaecological Oncology, National Cancer Institute Napels, Naples, Italy
| | - Gianfranco Zannoni
- Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Bradley J Monk
- Virginia G Piper Cancer Center - Biltmore Cancer Center, Phoenix, Arizona, USA
| |
Collapse
|
20
|
Helbig M, Steinmann M, Jaschinski S, Seckl M, Meier W, Fehm T, Volkmer A. Primary hepatic metastatic epitheloid trophoblastic tumor of the uterus treated with multimodal therapy including pembrolizumab and thermoablation. Case report of an extremely rare disease and review of the literature. Gynecol Oncol Rep 2023; 49:101281. [PMID: 37822711 PMCID: PMC10562736 DOI: 10.1016/j.gore.2023.101281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023] Open
Abstract
Epithelioid trophoblastic tumor (ETT) is a rare gestational trophoblastic tumor, first described by Shih and Kurman in 1998. ETT often present as abnormal vaginal bleeding in women of reproductive age, but unlike more common forms of GTN tend to produce much less human chorionic gonadotropin (hCG) for the volume of disease present. ETT can occur after any gestational event and can occur in both intrauterine and extrauterine sites. We present a case of a 46-year-old female patient incidentally diagnosed with ETT and hepatic metastasis. Therapy was multimodal and involved chemotherapy, operation, thermoablation of liver metastases and immunocheckpoint inhibitor. The patient remains disease free for almost four years now. ETT presents a diagnostic challenge due to their rarity and histologic resemblance to other pathologies. ETT can be relatively chemo resistant and are therefore often treated surgically. Misdiagnosis might delay effective treatment and affects survival.
Collapse
Affiliation(s)
- M. Helbig
- University Hospital of Düsseldorf, Department of Gynecology and Obstetrics, Germany
| | - M. Steinmann
- Medical Practice for Gynecology and Obstetrics, Düsseldorf, Germany
| | - S. Jaschinski
- University Hospital of Düsseldorf, Institute of Pathology, Germany
| | - M.J. Seckl
- Gestational Trophoblastic Disease and Malignant Ovarian Germ Cell Tumor Services, Charing Cross Hospital Campus of Imperial College London, London, UK
| | - W. Meier
- University Hospital of Düsseldorf, Department of Gynecology and Obstetrics, Germany
| | - T. Fehm
- University Hospital of Düsseldorf, Department of Gynecology and Obstetrics, Germany
| | - A.K. Volkmer
- University Hospital of Düsseldorf, Department of Gynecology and Obstetrics, Germany
| |
Collapse
|
21
|
Barcellini A, Fodor A, Charalampopoulou A, Cassani C, Locati LD, Cioffi R, Bergamini A, Pignata S, Orlandi E, Mangili G. Radiation Therapy for Gestational Trophoblastic Neoplasia: Forward-Looking Lessons Learnt. Cancers (Basel) 2023; 15:4817. [PMID: 37835511 PMCID: PMC10571950 DOI: 10.3390/cancers15194817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) includes several rare malignant diseases occurring after pregnancy: invasive moles, choriocarcinoma, placental site trophoblastic tumours, and epithelioid trophoblastic tumours. Multidisciplinary protocols including multi-agent chemotherapy, surgery, and occasionally radiotherapy achieve good outcomes for some high-risk metastatic patients. In this narrative review of the published studies on the topic, we have tried to identify the role of radiotherapy. The available studies are mainly small, old, and retrospective, with incomplete data regarding radiotherapy protocols delivering low doses (which can make this disease appear radioresistant in some cases despite high response rates with palliative doses) to wide fields (whole-brain, whole-liver, etc.), which can increase toxicity. Studies considering modern techniques are needed to overcome these limitations and determine the full potential of radiotherapy beyond its antihemorrhagic and palliative roles.
Collapse
Affiliation(s)
- Amelia Barcellini
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy;
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy;
| | - Andrei Fodor
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
| | - Alexandra Charalampopoulou
- Radiobiology Unit, Research and Development Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy;
- Hadron Academy PhD Course, Istituto Universitario di STUDI Superiori (IUSS), 27100 Pavia, Italy
| | - Chiara Cassani
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Unit of Obstetrics and Gynecology, IRCCS, Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Laura Deborah Locati
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy;
- Translational Oncology Unit, Maugeri Clinical Research Institutes IRCCS, 27100 Pavia, Italy
| | - Raffaella Cioffi
- Unit of Gynaecology and Obstetrics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (R.C.); (A.B.); (G.M.)
| | - Alice Bergamini
- Unit of Gynaecology and Obstetrics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (R.C.); (A.B.); (G.M.)
| | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori, IRCCS-Fondazione G. Pascale Napoli, 80131 Naples, Italy;
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy;
| | - Giorgia Mangili
- Unit of Gynaecology and Obstetrics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (R.C.); (A.B.); (G.M.)
| |
Collapse
|
22
|
Wang W, Kong Y, Li Y, Wan X, Feng F, Ren T, Zhao J, Xiang Y, Yang J. Pulmonary resection of residual lesions of pulmonary metastasis from gestational trophoblastic neoplasia. Int J Gynecol Cancer 2023; 33:1376-1382. [PMID: 37524495 PMCID: PMC10511965 DOI: 10.1136/ijgc-2023-004375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/12/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE To evaluate the prognosis and recurrence in patients with residual lesions of pulmonary metastasis from gestational trophoblastic neoplasia after initial treatment, and to explore the clinical significance of pulmonary resection. METHODS A retrospective analysis was performed on 606 patients with residual lesions from pulmonary metastasis after receiving standardized chemotherapy as initial treatment in Peking Union Medical College Hospital from January 2002 to December 2018. Patients were divided into surgery (51 patients) and non-surgery (555 patients) groups. The prognosis of these patients was compared. Risk factors affecting recurrence were analyzed to explore the effect of pulmonary resection. RESULTS Among low risk patients, complete remission rate was 100% and recurrence rate was <1% in both groups. Among high risk patients, complete remission and recurrence rates were 93.5% and 10.3% in the surgery group and 94.7% and 14.3% in the non-surgery group, respectively. There was no significant difference in prognostic features between the two groups (all p>0.05). No significant difference was found in recurrence rates based on recurrence risk factors (≥3.2 cm residual lung lesions, prognosis score ≥9.0, and drug resistance) between the two groups (all p>0.05). CONCLUSION After standardized chemotherapy, pulmonary resection was not necessary for initially treated stage III gestational trophoblastic neoplasia patients whose blood β human chorionic gonadotropin levels normalized and residual lung lesions remained stable. These patients should be closely monitored during follow-up, regardless of the size of the residual lung lesions or high/low risk score, especially within a year after complete remission.
Collapse
Affiliation(s)
- Weidi Wang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Disease, Beijing, China
| | - Yujia Kong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Yuan Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Tong Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Jun Zhao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China
| |
Collapse
|
23
|
Deleuze A, Massard C, Le Du F, You B, Lefeuvre-Plesse C, Bolze PA, de la Motte Rouge T. Management of trophoblastic tumors : review of evidence, current practice, and future directions. Expert Rev Anticancer Ther 2023; 23:699-708. [PMID: 37198729 DOI: 10.1080/14737140.2023.2215438] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/15/2023] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Gestational trophoblastic neoplasia (GTN) is a group of rare tumors characterized by abnormal trophoblastic proliferation following pregnancy including invasive moles, choriocarcinomas, and intermediate trophoblastic tumors (ITT). Although the treatment and follow-up of GTN has been heterogeneous, globally the emergence of expert networks has helped to harmonize its management. AREAS COVERED We provide an overview of the current knowledge, diagnosis, and management strategies in GTN and discuss innovative therapeutic options under investigation. While chemotherapy has been the historical backbone of GTN treatment, promising drugs such as immune checkpoint inhibitors targeting the PD-1/PD-L1 pathway and anti-angiogenic tyrosine kinase inhibitors are currently being investigated remodeling the therapeutical landscape of trophoblastic tumors. EXPERT OPINION Chemotherapy regimens for GTN have potential long-term effects on fertility and quality of life, making innovative and less toxic therapeutic approaches necessary. Immune checkpoint inhibitors have shown promise in reversing immune tolerance in GTN and have been evaluated in several trials. However, immunotherapy is associated with rare but life-threatening adverse events and evidence of immune-related infertility in mice, highlighting the need for further research and careful consideration of its use. Innovative biomarkers could help personalize GTN treatments and reduce chemotherapy burden in some patients.
Collapse
Affiliation(s)
- Antoine Deleuze
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | | | - Fanny Le Du
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Benoit You
- Department of Gynecological Oncological, and Obstetrics Department, Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
- French Reference Center for Trophoblastic Diseases, University Hospital Lyon Sud, Lyon, France
- Institute of Cancerology, Hospices Civils de Lyon, CITOHL, Lyon, UR, France
| | | | - Pierre-Adrien Bolze
- Department of Gynecological Oncological, and Obstetrics Department, Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
- Institute of Cancerology, Hospices Civils de Lyon, CITOHL, Lyon, UR, France
| | | |
Collapse
|
24
|
McMahon LM, Joyce CM, Cuthill L, Mitchell H, Jabbar I, Sweep F. Measurement of Human Chorionic Gonadotrophin in Women with Gestational Trophoblastic Disease. Gynecol Obstet Invest 2023; 89:178-197. [PMID: 37307803 PMCID: PMC11151977 DOI: 10.1159/000531499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The objective of this study was to collect information on human chorionic gonadotrophin (hCG) laboratory testing and reporting in women with gestational trophoblastic disease (GTD), to assess the associated challenges, and to offer perspectives on hCG testing harmonisation. DESIGN Information was collected from laboratories by electronic survey (SurveyMonkey) using a questionnaire designed by members of the European Organisation for the Treatment of Trophoblastic Disease (EOTTD) hCG working party. PARTICIPANTS The questionnaire was distributed by the EOTTD board to member laboratories and their associated scientists who work within the GTD field. SETTING The questionnaire was distributed and accessed via an online platform. METHODS The questionnaire consisted of 5 main sections. These included methods used for hCG testing, quality procedures, reporting of results, laboratory operational aspects, and non-GTD testing capability. In addition to reporting these survey results, examples of case scenarios which illustrate the difficulties faced by laboratories providing hCG measurement for GTD patient management were described. The benefits and challenges of using centralised versus non-centralised hCG testing were discussed alongside the utilisation of regression curves for management of GTD patients. RESULTS Information from the survey was collated and presented for each section and showed huge variability in responses across laboratories even for those using the same hCG testing platforms. An educational example was presented, highlighting the consequence of using inappropriate hCG assays on clinical patient management (Educational Example A), along with an example of biotin interference (Educational Example B) and an example of high-dose hook effect (Educational Example C), demonstrating the importance of knowing the limitations of hCG tests. The merits of centralised versus non-centralised hCG testing and use of hCG regression curves to aid patient management were discussed. LIMITATIONS To ensure the survey was completed by laboratories providing hCG testing for GTD management, the questionnaire was distributed by the EOTTD board. It was assumed the EOTTD board held the correct laboratory contact, and that the questionnaire was completed by a scientist with in-depth knowledge of laboratory procedures. CONCLUSIONS The hCG survey highlighted a lack of harmonisation of hCG testing across laboratories. Healthcare professionals involved in the management of women with GTD should be aware of this limitation. Further work is needed to ensure an appropriate, quality-assured laboratory service is available for hCG monitoring in women with GTD.
Collapse
Affiliation(s)
- Lesley M. McMahon
- Hydatidiform Mole Follow-up Service Scotland, Ninewells Hospital, and Medical School, Dundee, UK
| | - Caroline M. Joyce
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork and Department of Biochemistry & Cell Biology, University College Cork, Cork, Ireland
- Department of Clinical Biochemistry, Cork University Hospital, Wilton, Cork, Ireland
| | - Lyndsey Cuthill
- Hydatidiform Mole Follow-up Service Scotland, Ninewells Hospital, and Medical School, Dundee, UK
| | | | - Imran Jabbar
- Department of Laboratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Fred Sweep
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - on behalf of the hCG working party of the EOTTD
- Hydatidiform Mole Follow-up Service Scotland, Ninewells Hospital, and Medical School, Dundee, UK
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork and Department of Biochemistry & Cell Biology, University College Cork, Cork, Ireland
- Department of Clinical Biochemistry, Cork University Hospital, Wilton, Cork, Ireland
- Wellington Parade, Deal, UK
- Department of Laboratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
25
|
McMahon L, Maher GJ, Joyce C, Niemann I, Fisher R, Sunde L. When to Consult a Geneticist Specialising in Gestational Trophoblastic Disease. Gynecol Obstet Invest 2023; 89:198-213. [PMID: 37245506 DOI: 10.1159/000531218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/22/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Gestational trophoblastic disease comprises hydatidiform moles and a rare group of malignancies that derive from trophoblasts. Although there are typical morphological features that may distinguish hydatidiform moles from non-molar products of conception, such features are not always present, especially at early stages of pregnancy. Furthermore, mosaic/chimeric pregnancies and twin pregnancies make pathological diagnosis challenging while trophoblastic tumours can also pose diagnostic problems in terms of their gestational or non-gestational origin. OBJECTIVES The aim of this study was to show that ancillary genetic testing can be used to aid diagnosis and clinical management of GTD. METHODS Each author identified cases where genetic testing, including short tandem repeat (STR) genotyping, ploidy analysis, next-generation sequencing, and immunostaining for p57, the product of the imprinted gene CDKN1C, facilitated accurate diagnosis and improved patient management. Representative cases were chosen to illustrate the value of ancillary genetic testing in different scenarios. OUTCOME Genetic analysis of placental tissue can aid in determining the risk of developing gestational trophoblastic neoplasia, facilitating discrimination between low risk triploid (partial) and high risk androgenetic (complete) moles, discriminating between a hydatidiform mole twinned with a normal conceptus and a triploid conception and identification of androgenetic/biparental diploid mosaicism/chimerism. STR genotyping of placental tissue and targeted gene sequencing of patients can identify women with an inherited predisposition to recurrent molar pregnancies. Genotyping can distinguish gestational from non-gestational trophoblastic tumours using tissue or circulating tumour DNA and can also identify the causative pregnancy which is the key prognostic factor for placental site and epithelioid trophoblastic tumours. CONCLUSIONS AND OUTLOOK STR genotyping and p57 immunostaining have been invaluable to the management of gestational trophoblastic disease in many situations. The use of next-generation sequencing and of liquid biopsies is opening up new pathways for GTD diagnostics. Development of these techniques has the potential to identify novel biomarkers of GTD and further refine diagnosis.
Collapse
Affiliation(s)
- Lesley McMahon
- Hydatidiform Mole Follow-Up Service (HMFUS) Scotland, Ninewells Hospital and Medical School, Dundee, UK
| | - Geoffrey J Maher
- Trophoblastic Tumour Screening and Treatment Centre, Imperial College NHS Trust, Charing Cross Hospital, London, UK,
| | - Caroline Joyce
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Ireland
| | - Isa Niemann
- Department of Gynaecology and Obstetrics, Randers Regional Hospital, Randers, Denmark
| | - Rosemary Fisher
- Trophoblastic Tumour Screening and Treatment Centre, Imperial College NHS Trust, Charing Cross Hospital, London, UK
| | - Lone Sunde
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Clinical Genetics, Aalborg University Hospital, Aalborg, Denmark
| |
Collapse
|
26
|
Hamid M, Joyce CM, Carroll HK, Kenneally C, Mulcahy S, O'Neill MK, Coulter J, O'Reilly S. Challenging gestational trophoblastic disease cases and mimics: An exemplar for the management of rare tumours. Eur J Obstet Gynecol Reprod Biol 2023; 286:76-84. [PMID: 37224702 DOI: 10.1016/j.ejogrb.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Rare tumour management is challenging for clinicians as evidence bases are limited and clinical trials are difficult to conduct. It is even more difficult for patients where self-reliance alone is insufficient to overcome the challenges of navigating care which is often poorly evidence based. In Ireland, a national Gestational Trophoblastic Disease (GTD) service was established as one of 3 initiatives for rare tumours by the National Cancer Control Programme. The service has a national clinical lead, a dedicated supportive nursing service and a clinical biochemistry liaison team. This study sought to assess the impact of a GTD centre using national clinical guidelines and integrating and networking with European and International GTD groups on the clinical management of challenging GTD cases and to consider the application of this model of care to other rare tumour management. STUDY DESIGN In this article, we analyse the impact of a national GTD service on five challenging cases, and review how the service affects patient management in this rare tumour type. These cases were selected from a cohort of patients who were voluntarily registered in the service based on the diagnostic management dilemma they posed. RESULTS Case management was impacted by the identification of GTD mimics, the provision of lifesaving treatment of metastatic choriocarcinoma with brain metastasis, networking with international colleagues, the identification of early relapse, the use of genetics to differentiate treatment pathways and prognosis, and supportive supervision of treatment courses of up to 2 years of therapy in a cohort of patients starting or completing families. CONCLUSION The National GTD service could be an exemplar for the management of rare tumours (such as cholangiocarcinoma) in our jurisdiction which could benefit from a similar constellation of supports. Our study demonstrates the importance of a nominated national clinical lead, dedicated nurse navigator support, registration of cases and networking. The impact of our service would be greater if registration was mandatory rather than voluntary. Such a measure would also ensure equity of access for patients to the service, assist in quantifying the need for resourcing and facilitate research to improve outcomes.
Collapse
Affiliation(s)
- M Hamid
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland
| | - C M Joyce
- Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology, University College Cork, Cork, Ireland; Department of Biochemistry and Cell Biology, University College Cork, Cork, Ireland; Department of Clinical Biochemistry, Cork University Hospital, Cork, Ireland.
| | - H K Carroll
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland
| | - C Kenneally
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - S Mulcahy
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Mary-Kate O'Neill
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - J Coulter
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - S O'Reilly
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland; Cancer Research @UCC, University College Cork, Cork, Ireland
| |
Collapse
|
27
|
Singh K, Rollins S, Ireson J. Gestational Trophoblastic Disease: Best Practice Nursing Guidelines. Gynecol Obstet Invest 2023; 89:247-253. [PMID: 37040714 DOI: 10.1159/000530570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/29/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Clinical outcomes in gestational trophoblastic disease (GTD) are generally excellent, but GTD is a rare and complex condition that requires specialist information and support to offer a gold standard of care. Across Europe, specialist nurses and/or midwives are increasingly common in the GTD multidisciplinary team to work alongside medical professionals in a holistic model of care; however, the role is sometimes non-existent or can vary significantly between GTD centres. OBJECTIVES The aim of the European Organisation for Treatment of Trophoblastic Diseases' (EOTTD) is to harmonise best practice in Europe. To provide a basis for the European standardisation of best practice nursing care in GTD, a group of European GTD nurses/midwives composed guidelines for minimal requirements and optimal nursing care of GTD patients. METHODS Members of the EOTTD member countries with nursing representation attended multiple workshops, both virtual and in person, and guidelines were created by consensus and evidence where available. OUTCOME 16 nurses and 1 midwife from 4 countries (England, Ireland, Sweden, and the Netherlands) contributed. The group created flow diagrams for treatment and screening patients, showing minimum and best practice nursing care for patients with GTD. CONCLUSION Despite the many different models of care and resources available to GTD services, this consensus working group has provided a set of guidelines to drive forward a patient focused holistic model of care for GTD patients. This is an original paper, whereby no such guidelines in GTD nursing have been developed before. The implementation of guidelines will encourage other health care professionals to improve the provision of patient care.
Collapse
Affiliation(s)
- Kam Singh
- Sheffield Trophoblastic Disease Centre, Weston Park Hospital, Sheffield, UK
| | - Sarah Rollins
- Sheffield Trophoblastic Disease Centre, Weston Park Hospital, Sheffield, UK
| | - Jane Ireson
- Sheffield Trophoblastic Disease Centre, Weston Park Hospital, Sheffield, UK
| |
Collapse
|
28
|
Khoiwal K, Gill P, Chawla L, Agrawal S, Chaturvedi J. What is your diagnosis? J Turk Ger Gynecol Assoc 2023; 24:76-78. [PMID: 36919689 PMCID: PMC10019005 DOI: 10.4274/jtgga.galenos.2022.2022-2-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Kavita Khoiwal
- Department Obstetrics and Gynaecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Poonam Gill
- Department Obstetrics and Gynaecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Latika Chawla
- Department Obstetrics and Gynaecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Shruti Agrawal
- Department Obstetrics and Gynaecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Jaya Chaturvedi
- Department Obstetrics and Gynaecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| |
Collapse
|
29
|
Black L, Bowes A, Seckl M, Maher G, Kaur B, Arumainayagam J, Acharya S. Epithelioid trophoblastic tumor with antecedent molar pregnancy in an HIV-positive patient. Clin Case Rep 2023; 11:e7114. [PMID: 36998325 PMCID: PMC10043136 DOI: 10.1002/ccr3.7114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 02/15/2023] [Accepted: 03/02/2023] [Indexed: 03/30/2023] Open
Abstract
Epithelioid trophoblastic tumor (ETT) is a rare malignancy arising from neoplastic proliferation of chorionic-type intermediate trophoblasts. ETT poses significant challenges to clinicians in the diagnosis and treatment and can hence lead to a poor prognosis. We report a unique case of metastatic ETT in a HIV-positive patient.
Collapse
|
30
|
Braga A, Andrade T, do Carmo Borges de Souza M, Campos V, Freitas F, Maestá I, Sun SY, Pedrotti LG, Bessel M, Junior JA, Filho JR, Elias KM, Horowitz NS, Berkowitz RS. Presentation, medical complications and development of gestational trophoblastic neoplasia of hydatidiform mole after intracytoplasmic sperm injection as compared to hydatidiform mole after spontaneous conception - a retrospective cohort study and literature review. Gynecol Oncol 2023; 170:179-185. [PMID: 36706644 DOI: 10.1016/j.ygyno.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/11/2023] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To describe the natural history of hydatidiform mole (HM) after intracytoplasmic sperm injection (ICSI), emphasizing the clinical and oncological outcomes, as compared to patients who had HM after spontaneous conception (SC). STUDY DESIGN Retrospective historical cohort study of patients with HM followed at the Rio de Janeiro Federal University, from January 1st 2000-December 31st 2020. RESULTS Comparing singleton HM after SC to those following ICSI there were differences in terms of maternal age (24 vs 34 years, p < 0.01), gestational age at diagnosis (10 vs 7 weeks, p < 0.01), preevacuation human chorionic gonadotropin levels (200,000 vs 99,000 IU/L, p < 0.01), occurrence of genital bleeding (60.5 vs 26.9%, p < 0.01) and hyperemesis (23 vs 3.9%, p = 0.02) at presentation, and time to remission (12 vs 5 weeks, p < 0.01), respectively. There were no differences observed in the cases of twin mole, regardless of the form of fertilization that gave rise to HM, except molar histology with greater occurrence of partial hydatidiform mole (10.7 vs 40.0%, p = 0.01) following ICSI. Univariate logistic regression for occurrence of postmolar GTN after ICSI identified no predictor variable for this outcome. However, after adjusting for maternal age and complete hydatidiform mole histology, multivariable logistic regression showed the risk of GTN with HM after ICSI had an adjusted odds ratio of 0.22 (95%CI:0.05-0.93, p = 0.04), suggesting a possible protective effect when compared to HM after SC. CONCLUSIONS Singleton HM after ICSI are diagnosed earlier in gestation, present with fewer medical complications, and may be less likely to develop GTN when compared with HM after SC.
Collapse
Affiliation(s)
- Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil; Postgraduate Program in Applied Health Sciences, Vassouras University, Rio de Janeiro, RJ, Brazil; National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, RJ, Brazil.
| | - Taiane Andrade
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - Maria do Carmo Borges de Souza
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - Vanessa Campos
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil
| | - Fernanda Freitas
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil
| | - Izildinha Maestá
- Botucatu Trophoblastic Disease Center of the Clinical Hospital of Botucatu Medical School, Department of Gynecology and Obstetrics, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Sue Yazaki Sun
- Departament of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | | | - Joffre Amim Junior
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - Jorge Rezende Filho
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - 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, USA
| |
Collapse
|
31
|
de Codt M, Jadoul P, Luyckx M, Squifflet JL, Dolmans MM, Maillard C, Baurain JF, Marbaix E, Gerday A. Hysteroscopic management of molar pregnancy: A series of 36 cases. Rare Tumors 2023; 15:20363613231168767. [PMID: 37035475 PMCID: PMC10074611 DOI: 10.1177/20363613231168767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/22/2023] [Indexed: 04/05/2023] Open
Abstract
Background: Hydatidiform Mole (HM) is the most common form of gestational trophoblastic disease. Dilatation and curettage is the classical treatment of this affection. Hysteroscopic resection (HsR) is an alternative for the treatment of intra-uterine pathology. Objective: To describe the feasibility of HsR for the management of HM. Result: Case series of patients who had a complete or partial HM confirmed by histological examination of the trophoblastic tissue resected by operative hysteroscopy between 2007 and 2019. After approval of our ethics committee, we evaluated 36 patients who underwent hysteroscopic resection for molar pregnancy. Histological analysis showed partial HM in 28 patients (77.8%) and complete HM in 8 (22.2%). Main surgical complications were uterine perforation in one patient and glycine resorption in 10 patients with two cases of hyponatremia corrected by standard treatment. We performed an ultrasound control 1 month after the intervention in 19 patients (52.8%) as they had slow decrease of HCG or bleeding complaints and found retained product of conception (RPOC) in six patients (16.7%). Conclusion: This first report on a small number of patients demonstrate that hysteroscopic resection is a feasible procedure for the management of molar pregnancy. Direct visualization of the procedure helps the surgeon to control the resection. Further studies are mandatory to compare this technique with D&C in term of RPOC and fertility outcomes as it remains the standard treatment.
Collapse
Affiliation(s)
- Matthieu de Codt
- Department of Gynecology, Centre Hospitalier Universitaire Namur-Godinne, Namur, Belgium
| | - Pascale Jadoul
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Mathieu Luyckx
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institut Roi Albert 2- IRA2, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jean-Luc Squifflet
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institut Roi Albert 2- IRA2, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Charlotte Maillard
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jean-François Baurain
- Institut Roi Albert 2- IRA2, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Department of Oncology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Etienne Marbaix
- Department of Anatomic Pathology, Cliniques Universitaires Saint-Luc, and de Duve Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Amandine Gerday
- Department of Gynecology and Andrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institut Roi Albert 2- IRA2, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
32
|
Braga A, Canelas AC, Torres B, Maesta I, Giongo Pedrotti L, Bessel M, Vieira dos Santos Esteves AP, Amim Junior J, Rezende Filho J, Elias KM, Horowitz NS, Berkowitz RS. Neutrophil/lymphocyte ratio and other blood cell component counts are not associated with the development of postmolar gestational trophoblastic neoplasia. PLoS One 2022; 17:e0277892. [PMID: 36454778 PMCID: PMC9714693 DOI: 10.1371/journal.pone.0277892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/06/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To relate preevacuation platelet count and leukogram findings, especially neutrophil/lymphocyte ratios (NLR) and platelet/lymphocyte ratios with the occurrence of gestational trophoblastic neoplasia (GTN) after complete hydatidiform mole (CHM) among Brazilian women. METHODS Retrospective cohort study of patients with CHM followed at Rio de Janeiro Federal University, from January/2015-December/2020. Before molar evacuation, all patients underwent a medical evaluation, complete blood count and hCG measurement, in addition to other routine preoperative tests. The primary outcome was the occurrence of postmolar GTN. RESULTS From 827 cases of CHM treated initially at the Reference Center, 696 (84.15%) had spontaneous remission and 131 (15.85%) developed postmolar GTN. Using optimal cut-offs from receiver operating characteristic curves and multivariable logistic regression adjusted for the possible confounding variables of age and preevacuation hCG level (already known to be associated with the development of GTN) we found that ≥2 medical complications at presentation (aOR: 1.96, CI 95%: 1.29-2.98, p<0.001) and preevacuation hCG ≥100,000 IU/L (aOR: 2.16, CI 95%: 1.32-3.52, p<0.001) were significantly associated with postmolar GTN after CHM. However, no blood count profile findings were able to predict progression from CHM to GTN. CONCLUSION Although blood count is a widely available test, being a low-cost test and mandatory before molar evacuation, and prognostic for outcome in other neoplasms, its findings were not able to predict the occurrence of GTN after CHM. In contrast, the occurrence of medical complications at presentation and higher preevacuation hCG levels were significantly associated with postmolar GTN and may be useful to guide individualized clinical decisions in post-molar follow-up and treatment of these patients.
Collapse
Affiliation(s)
- Antonio Braga
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Maternal Child Health, Postgraduate Program in Medical Sciences, Faculty of Medicine of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
- National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, Rio de Janeiro, Brazil
- Postgraduate Program in Applied Health Sciences, Vassouras University, Rio de Janeiro, Rio de Janeiro, Brazil
- * E-mail:
| | - Ana Clara Canelas
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Berenice Torres
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Izildinha Maesta
- Department of Gynecology and Obstetrics, Botucatu Trophoblastic Disease Center of the Clinical Hospital of Botucatu Medical School, São Paulo State University - UNESP, Botucatu, São Paulo, Brazil
| | | | - Marina Bessel
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ana Paula Vieira dos Santos Esteves
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Joffre Amim Junior
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jorge Rezende Filho
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Kevin M. Elias
- Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Neil S. Horowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ross S. Berkowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| |
Collapse
|
33
|
Advances in diagnostics and management of gestational trophoblastic disease. Radiol Oncol 2022; 56:430-439. [PMID: 36286620 PMCID: PMC9784364 DOI: 10.2478/raon-2022-0038] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/30/2022] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Gestational trophoblastic disease (GTD) is a heterogeneous group of rare tumours characterised by abnormal proliferation of trophoblastic tissue. It consists of benign or premalignant conditions, such as complete and partial molar pregnancy and variants of malignant diseases. The malignant tumours specifically are commonly referred to as gestational trophoblastic neoplasia (GTN). They consist of invasive mole, choriocarcinoma, placental-site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). CONCLUSIONS Patients with GTD are often asymptomatic, although vaginal bleeding is a common presenting symptom. With the advances in ultrasound imaging in early pregnancy, the diagnosis of molar pregnancy is most commonly made in the first trimester of pregnancy. Sometimes, additional imaging such as chest X-ray, CT or MRI can help detect metastatic disease. Most women can be cured, and their reproductive function can be preserved. In this review, we focus on the advances in management strategies for gestational trophoblastic disease as well as possible future research directions.
Collapse
|
34
|
Dataset for the Reporting of Gestational Trophoblastic Neoplasia: Recommendations From the International Collaboration on Cancer Reporting (ICCR). Int J Gynecol Pathol 2022; 41:S34-S43. [DOI: 10.1097/pgp.0000000000000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
35
|
Ramírez LAC, Maestá I, Bianconi MI, Jankilevich G, Otero S, Mejía CRV, Cortés-Charry R, Elias KM, Horowitz NS, Seckl M, Berkowitz RS. Clinical Presentation, Treatment Outcomes, and Resistance-related Factors in South American Women with Low-risk Postmolar Gestational Trophoblastic Neoplasia. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:746-754. [PMID: 35760362 PMCID: PMC9948113 DOI: 10.1055/s-0042-1748974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE There are few multinational studies on gestational trophoblastic neoplasia (GTN) treatment outcomes in South America. The purpose of this study was to assess the clinical presentation, treatment outcomes, and factors associated with chemoresistance in low-risk postmolar GTN treated with first-line single-agent chemotherapy in three South American centers. METHODS Multicentric, historical cohort study including women with International Federation of Gynecology and Obstetrics (FIGO)-staged low-risk postmolar GTN attending centers in Argentina, Brazil, and Colombia between 1990 and 2014. Data were obtained on patient characteristics, disease presentation, and treatment response. Logistic regression was used to assess the relationship between clinical factors and resistance to first-line single-agent treatment. A multivariate analysis of the clinical factors significant in univariate analysis was performed. RESULTS A total of 163 women with low-risk GTN were included in the analysis. The overall rate of complete response to first-line chemotherapy was 80% (130/163). The rates of complete response to methotrexate or actinomycin-D as first-line treatment, and actinomycin-D as second-line treatment postmethotrexate failure were 79% (125/157), 83% (⅚), and 70% (23/33), respectively. Switching to second-line treatment due to chemoresistance occurred in 20.2% of cases (33/163). The multivariate analysis demonstrated that patients with a 5 to 6 FIGO risk score were 4.2-fold more likely to develop resistance to first-line single-agent treatment (p = 0.019). CONCLUSION 1) At presentation, most women showed clinical characteristics favorable to a good outcome, 2) the overall rate of sustained complete remission after first-line single-agent treatment was comparable to that observed in developed countries, 3) a FIGO risk score of 5 or 6 is associated with development of resistance to first-line single-agent chemotherapy.
Collapse
Affiliation(s)
- Luz Angela Correa Ramírez
- Postgraduation Program in Tocogynecology of Botucatu Medical School, São Paulo State University Julio de Mesquita Filho - UNESP, Support Program for Foreign Doctoral Students (PAEDEx/UNESP) Botucatu, SP, Brazil.,Clinical Department, Universidad de Caldas, Manizales, Caldas, Colombia
| | - Izildinha Maestá
- Botucatu Trophoblastic Disease Center of the Clinical Hospital of Botucatu Medical School, Department of Gynecology and Obstetrics, São Paulo State University Julio de Mesquita Filho - UNESP, Botucatu, SP, Brazil
| | - María Inés Bianconi
- Carlos G Durand Hospital Trophoblastic Disease Center, Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Gustavo Jankilevich
- Carlos G Durand Hospital Trophoblastic Disease Center, Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Silvina Otero
- Carlos G Durand Hospital Trophoblastic Disease Center, Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | - Rafael Cortés-Charry
- Department of Obstetrics and Gynecology, Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela
| | - Kevin M Elias
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Centre, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Centre, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Michael Seckl
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ross S Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Centre, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| |
Collapse
|
36
|
Current Evidence on Immunotherapy for Gestational Trophoblastic Neoplasia (GTN). Cancers (Basel) 2022; 14:cancers14112782. [PMID: 35681761 PMCID: PMC9179472 DOI: 10.3390/cancers14112782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 05/26/2022] [Accepted: 06/01/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Gestational trophoblastic neoplasia (GTN) is a rare tumor group that arises from the malignant transformation of placental tissue. Based on the evaluation of International Federation of Gynecology and Obstetrics (FIGO) anatomic staging and FIGO prognostic score, GTN is divided into low-, high-, and ultra-high-risk groups if the score obtained is less than or equal to 6, greater than 6 or greater than 12, respectively. The standard treatment is chemotherapy, using a single agent in low-risk disease and multiagent chemotherapy in high- and ultra-high-risk GTN. In chemoresistant forms of GTN, the use of immune checkpoint inhibitors, such as anti-PD-1 or anti-PD-L1/2, could represent a new therapeutic strategy. In this study, we evaluate the available evidence on immune checkpoint inhibitors for GTN treatment. Abstract Background: Gestational trophoblastic disease includes a rare group of benign and malignant tumors derived from abnormal trophoblastic proliferation. Malignant forms are called gestational trophoblastic neoplasia (GTN) and include invasive mole, choriocarcinoma, placental site trophoblastic tumor and epithelioid trophoblastic tumor. Standard treatment of GTN is chemotherapy. The regimen of choice mainly depends on the FIGO prognostic score. Low-risk and high-risk GTN is treated with single-agent or multiagent chemotherapy, respectively. In the case of chemoresistance, immunotherapy may represent a new therapeutic strategy. Methods: Literature obtained from searches on PubMed concerning GTN and immunotherapy was reviewed. Results: Programmed cell death 1 (PD-1) and its ligands (PD-L1/2) are expressed in GTN. Published data on PD-1/PD-L1 inhibitors alone in GTN were available for 51 patients. Pembrolizumab is an anti-PD-1 inhibitor used in chemoresistant forms of GTN. In the TROPHIMMUN trial, Avelumab, a monoclonal antibody inhibiting PD-L1, showed promising results only in patients with GTN resistant to monochemotherapy. Conversely, in patients with resistance to multiagent chemotherapy, treatment with Avelumab was discontinued due to severe toxicity and disease progression. The association of Camrelizumab and Apatinib could represent a different treatment for forms of GTN refractory to polychemotherapy or for relapses. Conclusions: Anti-PD-1 or anti-PD-L1 might represent an important new treatment strategy for the management of chemoresistant/refractory GTN.
Collapse
|
37
|
Schoenen S, Delbecque K, Van Rompuy AS, Marbaix E, Noel JC, Delvenne P, Moerman P, Vergote I, Kridelka F, Vandewal A, Han S, Goffin F. Importance of pathological review of gestational trophoblastic diseases: results of the Belgian Gestational Trophoblastic Diseases Registry. Int J Gynecol Cancer 2022; 32:ijgc-2021-003312. [PMID: 35487585 DOI: 10.1136/ijgc-2021-003312] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the added value of a centralized pathology review of the diagnoses of gestational trophoblastic diseases by expert pathologists and its potential impact on clinical management in a prospective multicenter study based on the Belgian Gestational Trophoblastic Diseases Registry. METHODS From July 2012 to December 2020, the two referral centers of the registry were solicited to advise on 1119 cases. Referral pathologists systematically reviewed all of the initial histological diagnoses. Cases initially assessed by expert pathologists were excluded. A total of 867 files were eligible for the study. Concordance between diagnoses of gestational trophoblastic diseases made by general 'non-expert' and expert pathologists was analyzed together with the potential impact of the alterations on clinical management. Expert pathologists were working in an academic setting with high exposure to placental pathology and national recognition. RESULTS The rate of discordance between expert and non-expert pathologists for the initial diagnoses was 35%. Almost 95% of complete moles were confirmed by the expert pathologists, but only 61% for partial moles. Compared with previous studies, ancillary techniques (p57 immunohistochemistry, karyotype) were used twice as often by both groups of pathologists in this survey. The diagnosis of gestational trophoblastic neoplasia was altered in 42% of cases. When the initial diagnosis was altered, the clinical relevance of this correction was estimated as down staging, up staging, or not relevant in 65%, 33% and 2% of cases respectively. CONCLUSION Systematic centralized pathological review of gestational trophoblastic diseases modified the diagnosis in a third of cases. The results also show that a change in diagnosis would impact clinical management in 98% of patients.
Collapse
Affiliation(s)
- Sophie Schoenen
- Gynecology and Obstetrics, University of Liege Central University Hospital, Liège, Belgium
| | - Katty Delbecque
- Pathology Anatomy, University of Liege Central University Hospital, Liège, Belgium
| | | | - Etienne Marbaix
- Pathology, University Hospital Saint-Luc, Bruxelles, Belgium
| | | | - Philippe Delvenne
- Pathology, University of Liege Central University Hospital, Liège, Belgium
| | - Philippe Moerman
- Pathology, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Ignace Vergote
- Gynecology and Obstetrics, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium
| | - Frédéric Kridelka
- Gynecology and Obstetrics, University of Liege Central University Hospital, Liège, Belgium
| | - Aleide Vandewal
- Gynecology and Obstetrics, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Sileny Han
- Gynecological Oncology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Frederic Goffin
- Gynecology and Obstetrics, University of Liege Central University Hospital, Liège, Belgium
| |
Collapse
|
38
|
Wang X, Cheng Y, Li W, Mao R, Zhu T, Lu J, Yue X, Lu X. Management of relapsed gestational trophoblastic neoplasia: What can help to reduce the re-recurrence rate? J Obstet Gynaecol Res 2022; 48:1451-1457. [PMID: 35289459 DOI: 10.1111/jog.15228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/29/2021] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
AIM To explore the risk factors for re-recurrence in relapsed gestational trophoblastic neoplasia (GTN) and therapeutic approaches to reduce the re-recurrence rate. METHODS Data of relapsed GTN treated in the Obstetrics and Gynecology Hospital of Fudan University from January 1, 2015, to December 31, 2020, were reviewed retrospectively. Risk factors associated with re-recurrence were analyzed using Logistic regression analysis. RESULTS A total of 39 relapsed GTN patients were included in our study. At the time of the first relapse, 14 patients received single-agent chemotherapy and 25 patients received multi-agent chemotherapy. Surgery was performed in 19 patients. Complete remission was achieved in all of the patients. Re-recurrence occurred in 21 patients. Univariate analysis suggested that unifocal recurrence was the only factor significantly associated with re-recurrence (OR = 0.25, p = 0.04). Recurrence pattern-based subgroup analysis showed that the proportion of re-recurrence was lower in patients who received both surgery and chemotherapy compared to those who received only chemotherapy in the unifocal recurrence group (3/11 vs. 2/4), but not in the non-unifocal recurrence group (7/8 vs. 9/16). The results of the multivariate analysis showed that there was no significant difference in re-recurrence rates between the surgical approaches and that the non-unifocal recurrence pattern was an independent risk factor for re-recurrence. CONCLUSIONS For relapsed GTN with unifocal recurrence pattern, surgical removal of the lesion can effectively reduce the re-recurrence rate.
Collapse
Affiliation(s)
- Xingran Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yu Cheng
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Wenzhi Li
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Runye Mao
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Tingting Zhu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Jiaqi Lu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xiaoni Yue
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xin Lu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| |
Collapse
|
39
|
Phianpiset R, Ruengkhachorn I, Kuljarusnont S, Jareemit N, Udompunturak S. Predictive factors associated with resistance to initial methotrexate treatment in women with low-risk gestational trophoblastic neoplasia. Asia Pac J Clin Oncol 2022; 18:e495-e506. [PMID: 35253996 DOI: 10.1111/ajco.13774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 01/31/2022] [Indexed: 11/30/2022]
Abstract
AIM To compare clinical characteristics and identify factors predictive of resistance to initial treatment with methotrexate-folinic acid (MTX-FA) in women with low-risk gestational trophoblastic neoplasia (GTN). METHODS Retrospective chart reviews were conducted in patients diagnosed with low-risk GTN who were treated with MTX-FA at Siriraj Hospital between 2002 and 2018. Demographic data, disease characteristics, treatment response, toxicity, and data of the subsequent pregnancy were collected and analyzed. Groups of patients who were responsive or resistant to treatment were compared. Stepwise logistic regression analysis was used to identify factors predictive of resistance to methotrexate chemotherapy. RESULTS Totally, 113 patients were eligible for analysis. The primary remission rate was 55.8% with first-line MTX-FA. All other patients achieved remission by subsequent treatment with actinomycin D or multiple-agent chemotherapy. Relapse of disease occurred in 4.4% and the overall survival rate was 99.1%. Univariate analysis showed that pretreatment serum hCG, neutrophil-to-lymphocyte ratio at baseline, and serum hCG ratio of the first three consecutive cycles (C) were significantly associated with resistance to MTX-FA. Independent factors that predict failure to respond to first-line MTX-FA were pretreatment serum hCG ≥15,000 IU/L, a less than 4.8-fold reduction of serum hCG between cycle 1 and cycle 2 (C1/C2), and a less than seven-fold reduction of serum hCG from cycle 2 to cycle 3 (C2/C3). CONCLUSIONS First-line MTX-FA treatment is effective in 55.8% of patients. Pretreatment serum hCG, and serum hCG ratio between consecutive treatment cycles can predict initial treatment failure.
Collapse
Affiliation(s)
- Rattiya Phianpiset
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Irene Ruengkhachorn
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sompop Kuljarusnont
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nida Jareemit
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suthipol Udompunturak
- Clinical Epidemiology Clinic, Office for Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
40
|
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.
Collapse
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:
| |
Collapse
|
41
|
Two cases of uneventful pregnancies following the treatment of choriocarcinoma. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh211220028c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction. Gestational trophoblastic disease represents a distinguished
group of disorders that are derived from placental trophoblastic tissue
aroused from abnormal fertilization. Choriocarcinoma is a malignant human
chorionic gonadotropin-producing epithelial tumor arising from villous
trophoblast. The choice of the chemotherapy regime is based on the
International Federation of Gynecology and Obstetrics stage and World Health
Organisation score of the disease. The aim of this article is to show that
successful pregnancy is possible even after treatment of high-risk
gestational trophoblastic neoplasia. Outlines of cases. We present two
successfully treated patients who achieved pregnancy and delivered healthy
babies in term. Conclusion. Gestational trophoblastic neoplasia has become
the most curable malignant disease since the introduction of chemotherapy,
which is effective and well-tolerated, and allows fertility preservation in
high-proportion of women.
Collapse
|
42
|
Ghorani E, Seckl MJ. Emergency craniotomy: a life-saving procedure as part of multi-modal therapy of GTN. J Gynecol Oncol 2022; 33:e52. [PMID: 35443295 PMCID: PMC9024186 DOI: 10.3802/jgo.2022.33.e52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/13/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Ehsan Ghorani
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Hospitals NHS Trust, London, UK
| | - Michael J Seckl
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Hospitals NHS Trust, London, UK
| |
Collapse
|
43
|
Joyce CM, Fitzgerald B, McCarthy TV, Coulter J, O'Donoghue K. Advances in the diagnosis and early management of gestational trophoblastic disease. BMJ MEDICINE 2022; 1:e000321. [PMID: 36936581 PMCID: PMC9978730 DOI: 10.1136/bmjmed-2022-000321] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/21/2022] [Indexed: 12/23/2022]
Abstract
Gestational trophoblastic disease describes a group of rare pregnancy related disorders that span a spectrum of premalignant and malignant conditions. Hydatidiform mole (also termed molar pregnancy) is the most common form of this disease. Hydatidiform mole describes an abnormal conceptus containing two copies of the paternal genome, which is classified as partial when the maternal genome is present or complete when the maternal genome is absent. Hydatidiform mole typically presents in the first trimester with irregular vaginal bleeding and can be suspected on ultrasound but confirmation requires histopathological evaluation of the products of conception. Most molar pregnancies resolve without treatment after uterine evacuation, but occasionally the disease persists and develops into gestational trophoblastic neoplasia. Close monitoring of women after molar pregnancy, with regular measurement of human chorionic gonadotrophin concentrations, allows for early detection of malignancy. Given the rarity of the disease, clinical management and treatment is best provided in specialist centres where very high cure rates are achievable. This review looks at advances in the diagnosis and early management of gestational trophoblastic disease and highlights updates to disease classification and clinical guidelines. Use of molecular genotyping for improved diagnostic accuracy and risk stratification is reviewed and future biomarkers for the earlier detection of malignancy are considered.
Collapse
Affiliation(s)
- Caroline M Joyce
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Biochemistry and Cell Biology, University College Cork, Cork, Ireland
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Ireland
| | - Brendan Fitzgerald
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- Department of Pathology, Cork University Hospital, Cork, Ireland
| | - Tommie V McCarthy
- Department of Biochemistry and Cell Biology, University College Cork, Cork, Ireland
| | - John Coulter
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Keelin O'Donoghue
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| |
Collapse
|
44
|
Horowitz NS, Eskander RN, Adelman MR, Burke W. Epidemiology, diagnosis, and treatment of gestational trophoblastic disease: A Society of Gynecologic Oncology evidenced-based review and recommendation. Gynecol Oncol 2021; 163:605-613. [PMID: 34686354 DOI: 10.1016/j.ygyno.2021.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/28/2021] [Accepted: 10/04/2021] [Indexed: 12/22/2022]
Affiliation(s)
- N S Horowitz
- Brigham & Women's Hospital/Dana Farber Cancer Institute, Boston, MA, USA.
| | - R N Eskander
- University of California, San Diego, Moores Cancer Center, La Jolla, CA, USA
| | | | - W Burke
- Stony Brook Medicine, Long Island, NY, USA
| |
Collapse
|
45
|
Hoeijmakers YM, Eysbouts YK, Massuger LFAG, Dandis R, Inthout J, van Trommel NE, Ottevanger PB, Thomas CMG, Sweep FCGJ. Early prediction of post-molar gestational trophoblastic neoplasia and resistance to methotrexate, based on a single serum human chorionic gonadotropin measurement. Gynecol Oncol 2021; 163:531-537. [PMID: 34602288 DOI: 10.1016/j.ygyno.2021.09.016] [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: 05/03/2021] [Revised: 09/11/2021] [Accepted: 09/21/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Clinicians are unable to provide individualized counseling regarding risk of progression for patients with a complete hydatidiform mole (CHM). We developed nomograms enabling early prediction of post-molar gestational trophoblastic neoplasia (GTN) and resistance to methotrexate (MTX) based on a single serum human chorion gonadotropin (hCG) measurement. METHODS We generated two nomograms with logistic regression: to predict post-molar GTN, and MTX resistance. For patients with high probability to progress to post-molar GTN or MTX resistance, we determined hCG cut-offs at 97.5% specificity to select patients for additional- or adjustments in current treatment. RESULTS The nomograms had a good to excellent ability to distinguish either between patients with uneventful hCG regression versus progression to post molar GTN, or between patients cured by MTX versus patients in whom resistance would occur. At 97.5% specificity, we identified 66% (95%CI 56-75) of the 149 patients who would progress to post-molar GTN, four weeks after initial curettage. For patients treated with MTX, we identified 55% (95%CI 23-83) of the 43 patients who would become resistant, preceding their third course at 97.5% specificity. CONCLUSION The nomograms and cut-off levels can be used to assist in counseling for patients diagnosed with CHM.
Collapse
Affiliation(s)
- Yvonne M Hoeijmakers
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Yalck K Eysbouts
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Rana Dandis
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joanna Inthout
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - N E van Trommel
- Center for Gynecologic Oncology Amsterdam, location Antoni van Leeuwenhoek- the Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Chris M G Thomas
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| |
Collapse
|
46
|
Descargues P, Hajri T, Massardier J, Lotz JP, Devouassoux-Shisheboran M, Allias Montmayeur F, You B, Golfier F, Bolze PA. Gestational trophoblastic neoplasia after human chorionic gonadotropin normalization in a retrospective cohort of 7761 patients in France. Am J Obstet Gynecol 2021; 225:401.e1-401.e9. [PMID: 34019886 DOI: 10.1016/j.ajog.2021.05.006] [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: 03/22/2021] [Revised: 05/11/2021] [Accepted: 05/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The risk of malignant transformation of molar pregnancies after human chorionic gonadotropin levels return to normal is low, roughly 0.4%, but may justify an adaptation of monitoring strategies for certain patients. OBJECTIVE This study aimed to determine the risk of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization in women with molar pregnancy and identify risk factors for this type of malignant transformation to optimize follow-up protocols after human chorionic gonadotropin normalization. STUDY DESIGN This was a retrospective observational national cohort study based at the French National Center for Trophoblastic Diseases of 7761 patients, treated between 1999 and 2020 for gestational trophoblastic disease, whose human chorionic gonadotropin levels returned spontaneously to normal. RESULTS Among 7761 patients whose human chorionic gonadotropin levels returned to normal, 20 (0.26%) developed gestational trophoblastic neoplasia. The risk of malignant transformation varied with the type of mole, from 0% (0 of 2592 cases) for histologically proven partial mole to 0.36% for complete mole (18 of 5045) and 2.1% (2 of 95) for twin molar pregnancy. The median time to diagnosis of malignant transformation after human chorionic gonadotropin normalization was 11.4 months (range, 1-34 months). At diagnosis, 16 of 20 patients (80%) had the International Federation of Gynecology and Obstetrics stage I tumor, and 10 of 20 patients (50%) had a tumor classified as low risk in terms of the International Federation of Gynecology and Obstetrics score. In 9 of 20 patients (45%), the most common first-line treatment was combination chemotherapy. A quarter of these tumors (5 of 20) were histologically proven placental site or epithelioid trophoblastic tumors. In univariate analysis, the factors significantly associated with a higher risk of developing gestational trophoblastic neoplasia after the end of the normal human chorionic gonadotropin monitoring period were age of ≥45 years (odds ratio, 8.3; 95% confidence interval, 2.0-32.7; P=.004) and time to human chorionic gonadotropin normalization of ≥8 weeks (odds ratio, 7.7; 95% confidence interval, 1.1-335; P=.03). The risk was even higher for human chorionic gonadotropin normalization times of ≥17 weeks (odds ratio, 19.5; 95% confidence interval, 3.3-206; P<.001). CONCLUSION In this group of patients with gestational trophoblastic disease, none of the those with pathologically verified partial mole had malignant transformation, supporting the current recommendation of stopping human chorionic gonadotropin monitoring after 3 successive negative tests. In cases of complete mole or twin molar pregnancy, we proposed to extend the monitoring period with quarterly human chorionic gonadotropin measurements for an additional 30 months in patients with the identified risk factors for late malignant transformation (age, ≥45 years; time to human chorionic gonadotropin normalization, ≥8 weeks).
Collapse
Affiliation(s)
- Pierre Descargues
- Department of Gynecological Surgery and Oncology, Obstetrics, University of Lyon 1, University Hospital Lyon Sud, Pierre-Bénite, France; French Center for Trophoblastic Diseases, University Hospital Lyon Sud, Pierre-Bénite, France.
| | - Touria Hajri
- Department of Gynecological Surgery and Oncology, Obstetrics, University of Lyon 1, University Hospital Lyon Sud, Pierre-Bénite, France; French Center for Trophoblastic Diseases, University Hospital Lyon Sud, Pierre-Bénite, France
| | - Jérôme Massardier
- Department of Gynecological Surgery and Oncology, Obstetrics, University of Lyon 1, University Hospital Lyon Sud, Pierre-Bénite, France; French Center for Trophoblastic Diseases, University Hospital Lyon Sud, Pierre-Bénite, France
| | - Jean-Pierre Lotz
- Medical Oncology and Cellular Therapy Department, Hospital Tenon, Public Assistance Hospitals of Paris, Alliance for Cancer Research (APREC), Paris, France
| | | | | | - Benoit You
- Medical Oncology, Investigational Center for Treatments in Oncology and Hematology of Lyon, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - François Golfier
- Department of Gynecological Surgery and Oncology, Obstetrics, University of Lyon 1, University Hospital Lyon Sud, Pierre-Bénite, France; French Center for Trophoblastic Diseases, University Hospital Lyon Sud, Pierre-Bénite, France
| | - Pierre-Adrien Bolze
- Department of Gynecological Surgery and Oncology, Obstetrics, University of Lyon 1, University Hospital Lyon Sud, Pierre-Bénite, France; French Center for Trophoblastic Diseases, University Hospital Lyon Sud, Pierre-Bénite, France
| |
Collapse
|
47
|
Coulter J, van Trommel N, Lok C. Ten steps to establish a national centre for gestational trophoblastic disease. Curr Opin Oncol 2021; 33:435-441. [PMID: 34172592 DOI: 10.1097/cco.0000000000000756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Gestational trophoblastic disease (GTD) is a group of heterogeneous disorders characterized by abnormal proliferation of trophoblastic tissue. GTD is a rare disease that is curable in the vast majority of patients when managed appropriately. The aim of the review is to discuss the important steps necessary to establish a center of excellence for GTD. RECENT FINDINGS Care of patients with a rare disease is complicated by lack of strong evidence, scattering of patients across the country and limited expertise of medical professionals. The establishment of a center of excellence requires awareness of its benefit, funding, a solid business case and most of all dedicated clinicians. A multidisciplinary team and formulation of national guidelines are important steps before clinical pathways can be developed and treatment can be evaluated for improvement of care and research purposes. International embedding can facilitate the process and lead to the development of a (inter) national acknowledged sustainable center of excellence. SUMMARY Centers of excellence could optimize the care of patients with GTD and promote research.
Collapse
Affiliation(s)
- John Coulter
- Department of Obstetrics and Gynecology, Cork University Maternity Hospital, Cork, Ireland
| | - Nienke van Trommel
- Department of Gynecologic Oncology, Centre of Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Christianne Lok
- Department of Gynecologic Oncology, Centre of Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
48
|
Poli JG, Paiva G, Freitas F, Mora P, Velarde LGC, Junior JA, Filho JR, Elias KM, Horowitz NS, Braga A, Berkowitz RS. Folinic acid rescue during methotrexate treatment for low-risk gestational trophoblastic neoplasia - How much is just right? Gynecol Oncol 2021; 162:638-644. [PMID: 34266689 DOI: 10.1016/j.ygyno.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/27/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the outcomes of patients with low-risk gestational trophoblastic neoplasia (GTN) treated with 8-day methotrexate (MTX) with two different regimens of folinic acid (FA). METHODS Retrospective cohort study of low-risk GTN followed at Rio de Janeiro Federal University, from January/2000-December/2019 with 8-day MTX with FA at 0.1 mg/kg versus 15 mg fixed dose. RESULTS Among 667 patients with low-risk GTN, 323 were treated with FA at 0.1 mg/kg and 142 with FA at 15 mg fixed dose. The weight-based and fixed dose groups were comparable in terms of clinical profile but did differ in the hCG pretreatment level (8883 versus 5127 IU/L, p < 0.01) and FIGO risk score 5/6 (3.4% versus 18.3%, p < 0.01), respectively. Despite this, there was no difference in the remission rate in first-line treatment (76.8 versus 81%, p = 0.33), although FA at 0.1 mg/kg had a significantly higher number of chemotherapy cycles to remission (5 versus 4, p < 0.01), need to delay chemotherapy due to toxicity (6.8 versus 2.8%, p < 0.01) and time to remission, (12 versus 8 weeks, p < 0.01), respectively. A logistic regression analysis showed that the different FA rescue regimens appeared comparable in terms of achieving remission in first-line chemotherapy for low-risk GTN (OR:5.16, CI95%:0.84-31.64, p = 0.08). CONCLUSION FA with 15 mg fixed dose as compared to 0.1 mg/kg of FA was associated with similar primary remission rate, relapse or death among low-risk GTN treated with 8-day MTX. This regimen is highly practical, reduces visits to health facilities, appears equally safe and may be preferable with the 8-day MTX regimen in the treatment of low-risk GTN.
Collapse
Affiliation(s)
- Juliana Gomes Poli
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil
| | - Gabriela Paiva
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Fernanda Freitas
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Paulo Mora
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil; Brazilian National Cancer Institute. Hospital do Câncer 2, Rio de Janeiro, RJ, Brazil
| | | | - Joffre Amim Junior
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Jorge Rezende Filho
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University), Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University. Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil; National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, RJ, Brazil.
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
49
|
Ferrandina G, Scambia G. Improving single-agent chemoresistance risk identification in gestational trophoblastic neoplasia. Lancet Oncol 2021; 22:1054-1056. [PMID: 34181885 DOI: 10.1016/s1470-2045(21)00327-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Gabriella Ferrandina
- Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome 00168, Italy; Università Cattolica del Sacro Cuore, Istituto di Ginecologia e Ostetricia, Rome, Italy.
| | - Giovanni Scambia
- Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome 00168, Italy; Università Cattolica del Sacro Cuore, Istituto di Ginecologia e Ostetricia, Rome, Italy
| |
Collapse
|
50
|
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.
Collapse
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.
| |
Collapse
|