Integration of Surgery and Other Techniques in the Management of Trophoblastic Malignancy

The added value of hysterectomy in the management of gestational trophoblastic neoplasia

BACKGROUND

Despite the undoubted effectiveness of chemotherapeutic treatment in gestational trophoblastic neoplasia (GTN), problems related to toxicity of chemotherapy and chemo-resistant disease have led to reconsideration of the use of hysterectomy. Aim of the present study was to evaluate indications for and outcome of hysterectomy in patients with GTN in a nation-wide cohort.

METHODS

Between 1977 and 2012, we identified all patients diagnosed with GTN and treated with hysterectomy from the Dutch national databases. Demographics, clinical characteristics and follow-up were recorded retrospectively.

RESULTS

One hundred and nine patients (16.5% of all registered patients with GTN) underwent hysterectomy as part of their management for GTN. The majority of patients was classified as low-risk disease (74.3%), post-molar GTN (73.5%) and disease confined to the uterus (65.1%). After hysterectomy, complete remission was achieved in 66.2% of patients with localized disease and in 15.8% of patients with metastatic disease. For patients with localized disease, treated with primary hysterectomy, treatment duration was significantly shorter (mean 3.2weeks and 8.0weeks respectively, p=0.01) with lower number of administered chemotherapy cycles (mean 1.5 and 5.8 respectively, p<0.01) than patients in a matched control group.

CONCLUSION

In selected cases, a hysterectomy may be an effective means to either reduce or eliminate tumor bulk. Primary hysterectomy should mainly be considered in older patients with localized disease and no desire to preserve fertility, whereas patients with chemotherapy-resistant disease may benefit from additional hysterectomy, especially when disease is localized. For patients with widespread metastatic disease, the benefit of hysterectomy lies in the removal of chemotherapy-resistant tumor bulk with subsequent effect on survival.

Role of Adjuvant Hysterectomy in Management of High-Risk Gestational Trophoblastic Neoplasia

Objectives

The objectives of the study were to investigate the role of and indications for adjuvant hysterectomy in patients with high-risk gestational trophoblastic neoplasia.

Methods

We retrospectively analyzed records of patients identified as having undergone adjuvant hysterectomy for high-risk gestational trophoblastic neoplasia at First Hospital of Xi’an Jiaotong University, Xi’an, China, between 1985 and 2005. Therapeutic response was defined as complete with normalization of human chorionic gonadotropin (hCG) concentration, partial response with a decrease of more than 50%, and no response with a decrease of 50% or less. Complete remission was defined as normal hCG at 3 consecutive weekly assays without clinical evidence of disease.

Results

A total of 21 patients (72.4%) showed an initial therapeutic response after surgery and 8 (27.6%) had no response. The initial therapeutic response was complete in 8 patients (27.6%) and partial in 13 (44.8%). During follow-up of 6 to 168 months, all 21 patients with an initial response and 2 of 8 patients without an initial response ultimately achieved complete remission (23 of 29 patients, 79.3%). Three patients (10.3%) had recurrence after primary remission; 2 patients (6.90%) died. Metastases outside of lungs or pelvic organs, number of metastases, presurgery chemoresistance to multidrug regimens, especially with 2 or more failed protocols, were considered possible reasons for decreased effectiveness of hysterectomy.

Conclusions

Our study suggests that timely adjuvant hysterectomy is likely to benefit cautiously selected patients with high-risk gestational trophoblastic neoplasia. Although preoperative metastases limited to pelvic organs or lungs should not be considered an absolute contraindication, adjuvant hysterectomy should generally not be performed in the presence of distant metastases beyond the pelvic organs and lungs.

Choriocarcinoma brain metastasis in a patient with viable intrauterine pregnancy. Case report

The authors report the case of a woman who presented during her 30th week of pregnancy with a large brain metastasis from a previously undetected metastatic choriocarcinoma. The metastasis caused significant neurological deficit due to mass effect, necessitating rapid intervention. Medical management included a regimen of high-dose corticosteroid medications for 36 hours, followed by cesarean delivery of the fetus and craniotomy to remove the metastatic tumor, chemotherapy and radiation therapy were begun within 1 week postsurgery. Both the baby and mother survived, and as of the 1-year follow-up examination, there was no evidence of disease in the mother. This is only the second report of a metastatic choriocarcinoma associated with a simultaneous viable intrauterine pregnancy, and the only case in which surgical removal of a brain metastasis was required. Coordinated multidisciplinary treatment of mother and fetus by members of the neurosurgery, medical oncology, neonatology, and obstetrics services facilitated a good outcome in this case.

Thoracotomy in the management of gestational choriocarcinoma. A clinicopathologic study

BACKGROUND

Pulmonary metastases occur frequently in patients with gestational choriocarcinoma and most of these patients achieve remission with chemotherapy alone. Thus, the indications for surgical intervention are limited, but in appropriately selected patients, resection of a chemotherapy-resistant lung lesion can be curative.

METHODS

Nine patients with choriocarcinoma metastatic to the lung underwent 11 thoracotomies. The procedure was done in two patients for diagnosis and in seven to remove a resistant focus of tumor in the lung. The excised resistant tumors in six patients were studied histopathologically, immunohistochemically, and by electron microscopic examination (one patient).

RESULTS

Six (66.6%) patients achieved complete remission for periods ranging from 3 months to 18 years, and three patients died of their disease. The residual lung nodules in these patients with chemotherapy-resistant tumors were characterized by the presence of large mononucleated tumor cells that showed features intermediate between those of cytotrophoblasts and syncytiotrophoblasts but lacking ultrastructural and immunohistochemical features of the intermediate trophoblasts seen in placental site tumors.

CONCLUSION

A major role for operative treatment of chemotherapy-resistant choriocarcinoma in the lung is suggested by the observation that some of the resistant tumors contain a unique variant of trophoblastic cells that show a decreased sensitivity to chemotherapy but are amenable to surgical resection.