Gestational trophoblastic tumors

Chemotherapy and targeted molecular therapies for brain metastases

As therapy for systemic cancers improves, an increasing number of patients are developing brain metastases. Although conventional therapy with surgery, radiation therapy and radiosurgery has improved the outcome of a significant number of patients, many develop multiple lesions that are not amenable to standard treatments. In this review, the current role of chemotherapy and targeted molecular agents for brain metastases is summarized and future directions are discussed.

Effects of Taxol on choriocarcinoma cells

OBJECTIVE

Taxol (Bristol-Myers Squibb) (paclitaxel) has been shown to be a potent inhibitor of cell growth for a variety of tumors. We were interested in the antiproliferative efficacy and biologic properties of this novel antineoplastic agent in choriocarcinoma cells.

STUDY DESIGN

Human choriocarcinoma cell lines JAR and BeWo were cultured as monolayers and treated with Taxol.

RESULTS

Proliferation of JAR and BeWo cells was inhibited by Taxol in a dose-related manner and 1 to 3 nmol/L was sufficient to achieve 50% growth reduction. This effect was accompanied by a marked induction of human chorionic gonadotropin secretion. The effect on human chorionic gonadotropin secretion was dependent on intact protein biosynthesis but not mediated by augmented messenger ribonucleic acid expression. In these choriocarcinoma cells Taxol promoted differentiation as shown by an increase in syncytiotrophoblastic-like cells. Combination of Taxol with either etoposide or methotrexate resulted in antagonistic growth inhibition.

CONCLUSION

Taxol is a highly effective antineoplastic agent in choriocarcinoma cells, and clinical trials in refractory disease would therefore be warranted. However, substances other than etoposide or methotrexate should be evaluated for combined treatment. In addition to growth inhibition, differentiation is also induced by Taxol, as shown by increased human chorionic gonadotropin secretion and changed morphologic features.

Decreased expression of epidermal growth factor and its receptor in the malignant transformation of trophoblasts

BACKGROUND

Gestational trophoblastic neoplasms comprise the neoplastic spectrum of nonmalignant hydatidiform mole, invasive hydatidiform mole, and truly malignant choriocarcinoma. Increasing evidence indicates that epidermal growth factor (EGF) acts as an enhancer of trophoblast function to produce human chorionic gonadotropin and that EGF and its receptor may provide a growth advantage to certain carcinoma cells. The current study was undertaken to evaluate a possible link between malignant transformation of trophoblast and expression of EGF and EGF receptor.

METHODS

Cytologic localization and cellular levels of expression of EGF and EGF receptor in hydatidiform mole, invasive hydatidiform mole, and choriocarcinoma tissue specimens were examined by the avidin-biotin immunoperoxidase techniques with monoclonal antibodies against EGF and EGF receptor.

RESULTS

EGF in hydatidiform mole and invasive mole was localized in syncytiotrophoblasts, whereas cytologic localization of EGF receptor in hydatidiform mole and invasive mole was observed in both cytotrophoblasts and syncytiotrophoblasts. By contrast, EGF and EGF receptor in choriocarcinoma were exhibited in cytotrophoblastic and syncytiotrophoblastic elements. Most (72%) hydatidiform moles immunostained intensely for EGF and EGF receptor, whereas most (78%) choriocarcinomas immunostained slightly for EGF and EGF receptor. Invasive mole occupied the middle position in the staining intensity for EGF and EGF receptor, between hydatidiform mole and choriocarcinoma, with 50% of the cases exhibiting moderate staining.

CONCLUSIONS

The simultaneous expression of EGF and EGF receptor in the neoplastic trophoblasts implies that EGF may act in an autocrine-paracrine manner in trophoblastic neoplasms. Furthermore, the results obtained suggest that cytologic expression of EGF and EGF receptor in trophoblastic neoplasms decreases in the malignant transformation of trophoblast.

Metastatic choriocarcinoma with neoplastic aneurysms cured by aneurysm resection and chemotherapy. Case report

A case of choriocarcinoma with brain and lung metastasis is reported. The patient was admitted for treatment of a cerebral hemorrhage from neoplastic aneurysms and, following removal of the hematoma and resection of the aneurysms, her carcinoma was successfully managed with chemotherapy. She has survived for 6 years after onset without neuroimaging evidence of recurrence. Surgical treatment of metastatic lesions followed by prolonged intensive chemotherapy are indicated for the improved prognosis of choriocarcinoma.

Respiratory failure due to choriocarcinoma: a study of 103 dyspneic patients

Treatment of choriocarcinoma is mostly successful but there is still appreciable mortality from early respiratory failure. A series of 135 patients with choriocarcinoma presenting with dyspnea between 1960 and 1988 was studied to find prognostic factors for early respiratory death and to identify how mortality may be further reduced. Mortality with respect to early respiratory death (ERD) was 11% and was significantly associated with WHO prognostic score, chest X-ray appearance, central cyanosis, tachycardia, anemia, and clinical evidence of pulmonary hypertension. Indicators on chest X ray of high risk of ERD were the presence of more than 10 opacities, extensive opacification of lung fields, size of metastases, and hazy background obscuring the vascular pattern. Intensity of initial treatment was not correlated with this outcome. A set of criteria has been derived which will predict ERD with 100% sensitivity and 38% positive predictive value. These are opacification of lung fields on chest X ray of more than 50%, OR initial plasma hCG level greater than 10(5) when there is anemia and a history of chest pain. Patients presenting with choriocarcinoma and dyspnea who fulfill these criteria should be considered for extracorporeal perfusion techniques. As respiratory failure in this condition is characterized by hypoxemia and right-to-left shunting, extracorporeal perfusion should be effective. Ventilation should be avoided as no patient survived mechanical ventilation.

Malignant and normally developing trophoblastic cells of human placenta display different characteristics defined by histochemical and biochemical mapping of endogenous lectins

Trophoblastic cells with their strictly controlled propensity for invasive growth hereby bear limited resemblance to malignant cells. Therefore, detailed description of molecular characteristics of this cell type in comparison to histologically related tumor cells may aid in defining physiologically relevant differences. In view of the potential importance of selective protein-carbohydrate interactions in recognitive processes, labelled neoglycoproteins were employed to evaluate systematically the presence and distribution of sugar receptors in tumor cells of chorionepithelioma and in trophoblastic cells of an early stage of gestation. Control reactions in glycohistochemistry, involving prolonged incubation, pH variation and use of nucleotides excluded the possibility that glycosidases or glycosyltransferases govern the sugar-specific binding to the tissue sections. Pronounced differences were detected in the expression of receptors (lectins) for alpha- and beta-glucosides as well as for N-acetylgalactosamine and N-acetylglucosamine. Further differences were revealed by probing both types of tissue with lactosylated, fucosylated, xylosylated and sialylated carrier protein. Upon developmental maturation of the normal cells in placenta the extent of binding of the neoglycoproteins decreased. The glycohistochemical differences between malignant and normally developing trophoblastic cells were found to be reflected in the alteration of expression of certain endogenous lectins, as ascertained by affinity chromatography and gel electrophoretic analysis. Consequently, we assume that the transient presence of certain endogenous lectins during early stages of gestation and their differential expression in relation to tumor cells of chorionepithelioma may be relevant for the special invasive and adhesive behavior of human trophoblastic cells.

ERV3 human endogenous provirus mRNAs are expressed in normal and malignant tissues and cells, but not in choriocarcinoma tumor cells

Messenger RNA expression of a human endogenous provirus, ERV3, has been characterized in 170 specimens of normal and malignant human tissues and cells. In contrast to the high expression in first-trimester and full-term placental chorionic villi, most other human tissues expressed ERV3 mRNAs at a level of 2-30% of placenta. However, ERV3 mRNAs were not detected in choriocarcinoma tumor cell lines. These studies suggest that the ERV3 provirus may have been preempted for a biological function and disruption of its mRNA expression results in choriocarcinoma.

Fertility in patients with gestational trophoblastic tumors treated with etoposide

The effect of etoposide containing drug combinations on reproductive performance was studied in women successfully treated for gestational trophoblastic disease between 1977 and 1984. Of the 74 women who wished to get pregnant 57 (77.0%) succeeded in having at least one live birth while five (6.8%) have ongoing pregnancies. Of eight (19.8%) women who have not become pregnant two (2.7%) had previous infertility problems antedating the development of gestational trophoblastic disease. The miscarriage rate was 124/1000. There was only one case of foetal death and one congenital abnormality (microcephaly possibly associated with cytomegalovirus infection) among 79 live births and stillbirths. This study indicates that etoposide (VP16-213) as is currently used in this unit for the treatment of gestational trophoblastic tumour is unlikely to have any long-term effect on fertility in most women.

Successful management of metastatic and primary germ cell tumors in the brain

Nine men and one woman with brain metastases from nonseminomatous germ cell tumors have been treated between 1977 and 1984. All the men had lung metastases. Nine patients had elevated serum values of human chorionic gonadotrophin (HCG), the level was greater than 40,000 IU/l in seven. They were treated with sequential combination chemotherapy either POMB/ACE or EP/OMB in which the methotrexate was given at a dose of 1 g/m2 and intrathecal methotrexate was given during courses not containing intravenous methotrexate. Eight of ten patients are alive, off treatment with no evidence of active disease, of whom five have been in remission and off treatment for more than 18 months. Two patients with primary intracranial nonseminomatous germ cell tumors were treated in a similar fashion. One patient died from enlargement of differentiated teratoma; the other is alive 9+ months off treatment with no evidence of disease. These results, which are better than any previously reported, indicate that chemotherapy is the preferred treatment of primary or metastatic nonseminomatous germ cell tumors of the brain and that only rarely will these patients benefit from surgery or radiotherapy.