Cellular reaction in trophoblastic tumours

Future Directions for Gestational Trophoblastic Disease

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.

Mixed Gestational Trophoblastic Tumors-Challenging Clinicopathological Presentations

Mixed gestational trophoblastic tumors are exceptionally rare and have variable clinicopathological presentations. We report 3 such tumors with different combinations of choriocarcinoma (CC), placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT). The patients' age ranged from 38 to 44 years. Mixed trophoblastic tumor was not considered at the initial diagnosis and all 3 tumors were proven of gestational origin by DNA genotyping. Patient #1 presented with serum human chorionic gonadotropin (hCG) of 97 mIU/mL and a 5.6-cm cervical mass that was initially interpreted as PSTT on biopsy. Hysterectomy revealed a mixed PSTT (60%) and ETT (40%) with extrauterine metastases of only the ETT component. The tumor recurred 15 months after a multiagent chemotherapy and was tested positive for programmed death-ligand 1. The patient received immune checkpoint inhibitor therapy and remained disease-free after 24 months. Patient #2 presented with vaginal bleeding and serum hCG of 46,458 mIU/mL. An endometrial biopsy was interpreted as CC. Recurrence developed in the uterus and lung after methotrexate-based chemotherapy. A mixed CC and ETT were eventually diagnosed upon consultation review. Patient #3 presented with a complete hydatidiform mole and serum hCG of 744,828 mIU/mL. Three months after methotrexate, followed by actinomycin D therapy, a uterine mass was found. Hysterectomy revealed a mixed CC and PSTT. In conclusion, the rarity, elusive presentation, and wide range of histology make the diagnosis of mixed trophoblastic tumors highly challenging. The clinical management and prognosis are dictated by each component of the tumor. CC component must be considered when the patient presents with a high serum hCG level.

Immunotherapy for Gestational Trophoblastic Neoplasia: A New Paradigm

BACKGROUND

Immune checkpoint immunotherapy (CPI) targeting programmed cell death 1 (PD-1)/ligand (PD-L1) has been shown to be an effective treatment for gestational trophoblastic neoplasia (GTN). This includes those with multidrug resistance, ultra-high-risk disease, and epithelioid trophoblastic tumour/placental site trophoblastic tumour subtypes that are inherently chemotherapy resistant, but there is also emerging evidence in low-risk disease.

OBJECTIVES

We set out to generate an overview of the current data supporting the use of CPI for GTN in both high-risk and low-risk disease and to consider future research goals and directions in order to implement CPI in current treatment guidelines.

METHODS

We identified and reviewed the published data on the use of CPI agents in GTN.

OUTCOME

133 patients were identified who had been treated with CPI for GTN with pembrolizumab (23), avelumab (22), camrelizumab (57), toripalimab (15), or other anti-PD-1 agents (16), of whom 118 had high-risk diseases, relapse or multi-drug resistant disease, and 15 low-risk diseases. Overall 85 patients achieved complete remission, 77 (of 118) with high-risk disease, and 8 (of 15) with low-risk disease. 1 patient with complete remission in the high-risk group developed a relapse 22 months after anti-PD-1 treatment had been stopped. Treatment was generally well tolerated across studies.

CONCLUSIONS AND OUTLOOK

The majority of high-risk patients (77/118) treated with CPI are cured and this is particularly relevant amongst those with chemotherapy resistant disease who otherwise have very limited treatment options. Priorities for future research include determining whether these agents have a role earlier in the disease course, the utility of combination with chemotherapy, and effects on future fertility. Treatment availability remains a concern due to the high price of these agents.

ACT Up TIL Now: The Evolution of Tumor-Infiltrating Lymphocytes in Adoptive Cell Therapy for the Treatment of Solid Tumors

The past decades of cancer immunotherapy research have provided profound evidence that the immune system is capable of inducing durable tumor regression. Although many commercialized anti-cancer immunotherapies are available to patients, these treatment options only scrape the surface of the potential immune-related treatment possibilities for cancer. Additionally, many individuals are ineligible for established immunotherapies due to their cancer type. The adoptive cell transfer of autologous tumor-infiltrating lymphocytes has been used in humans for over 30 years to treat metastatic melanoma, and continued modifications are making it increasingly more effective against other types of cancer. This comprehensive review outlines this therapy from its infancy through to the present day, bringing to light modifications and optimizations to the traditional workflow, as well as highlighting the influence of new methods and technologies.

Cytokines of the placenta and extra-placental membranes: biosynthesis, secretion and roles in establishment of pregnancy in women

Virtually all known cytokines have been demonstrated to be expressed in the placenta and associated fetal and maternal membranes during normal gestation. In addition to playing their traditional roles as modulators of immunological function, cytokines derived from the placenta and extraplacental membranes, together with other locally-derived growth factors, appear to be implicated in various aspects of implantation and placental development. Imbalances in the intrauterine cytokine milieu around the time of implantation and invasion may play a causative role in disorders associated with early pregnancy failure, and are also associated with the abnormal trophoblast development seen in gestational trophoblastic disease. Cytokines thus appear to be an important component of a paracrine/autocrine communication network operating within the feto-maternal interface to ensure the successful establishment of pregnancy.

Recent advances in gestational trophoblastic disease

Important advances continue to occur in both our understanding and management of gestational trophoblastic disease. Complete molar pregnancy is being diagnosed earlier in pregnancy which affects its clinical and pathological presentation. The use of chemotherapy in persistent gestational trophoblastic tumors continues to be refined and our understanding of the immunobiology of these tumors has substantially advanced.

Role of tumor-infiltrating lymphocytes in the host defense mechanism against lung cancer

Tumor-infiltrating lymphocytes (TIL) and tumor-associated macrophages (TAM) were recovered from 22 patients with primary lung cancer. The TIL did not exhibit any cytolytic activity against various target cells. The average percentage of TIL recovered was 6.7 +/- 1.3% in patients without recurrence, as compared to 3.6 +/- 0.6% in those with recurrence within 2 years after complete resection of lung cancer (P less than 0.05). The average cytostatic activity of TAM was 38.5 +/- 6.8% in patients without recurrence, although it was 25.2 +/- 4.6% in those with recurrence within 2 years after complete resection (P less than 0.1). The activity of macrophage activating factor (MAF) induced by TIL was also higher in patients showing no recurrence. A significant positive correlation was observed between MAF activity induced by TIL and the cytostatic activity of individual TAM. These results suggest that antitumor activity of TAM may be controlled by specifically sensitized TIL through lymphokines.

Histopathologic classification of uterine choriocarcinoma

Histopathologic features of uterine choriocarcinoma were studied to establish new criteria for grading malignancy of the disease. Thirteen items of histopathologic findings concerning the degree of differentiation and the forms of masses of trophoblasts (Trs), the manner of Tr invasion, and host response of surrounding tissues were studied with relationship to prognosis in 70 patients with uterine lesions (alive, 49; dead, 21). Chi-square test results were examined for each item in relation to prognosis of the patients. Four items were thought to have significance and were selected as criteria: (1) island formation; (2) massive proliferation of intermediate-type Trs; (3) rectangular infiltration of Trs to surrounding muscle fibers; and (4) atypia of Trs at the end-point of tumor invasion. A discriminant analysis was carried out (under the standardization of tumor extension and the historical staging of treatment). From the results obtained in discriminant analysis, scores were given to the four items that existed in the specimen. New criteria for grading malignancy are proposed based on scoring these four items. The algebraic sum of the scores had a possible range of +4 to -16. Patients with scores of -9 and above had a low-grade malignancy with a mortality rate of 7%. Patients with scores of -10 and lower had a mortality of 69% and were classified as having tumors of high-grade malignancy.

Gestational trophoblastic tumors

Although virtually 100% of women who develop gestational trophoblastic tumors enter a long-term complete remission, there are many aspects of trophoblastic disease that arouse interest. Epidemiological studies have shown a large geographical variation in the percentage of conceptions that result in a hydatidiform mole and have stimulated studies on the immunological differences of the low and high risk populations. Chromosomal analysis is now complementing the pathological differentiation between complete and partial moles. There is still debate as to which factors are positively associated with the progression of a hydatidiform mole through invasive mole to choriocarcinoma. There are also considerable differences in the proportion of molar patients receiving chemotherapy in different centers. In addition to these topics, this article will review several recently introduced treatment regimens which show improved results with reduced toxicity.

A method for improved yield and purity in extracting lymphocytes from lung tumors

Tumor-infiltrating lymphocytes (TIL) from human pulmonary tumors have been studied as a model for local depression of cell-mediated immunity at the tumor site. To better characterize these lymphoid infiltrates, a new method of lymphocyte extraction of high yield and purity was developed. The TIL from 11 human lung tumors of varying histologic types were prepared. After mechanical disaggregation to a single cell suspension, the TIL, contaminated with tumor cells and macrophages, were incubated with carbonyl iron to deplete macrophages. Further purification was performed in a unit gravity sedimentation apparatus utilizing a continuous 2-4% Ficoll gradient. Usable TIL recovery was 41.2 +/- 7.7% of input cells and was minimally contaminated by tumor cells and macrophage/monocytes. The high yield and purity of TIL preparations have resulted in a higher proportion of tumors suitable for immunological analysis. An example of the type of experiments possible with such preparations is shown.

Quantitation of proliferative and cytotoxic precursor cells directed against human tumours: limiting dilution analysis in peripheral blood and at the tumour site

Blood and tumour-infiltrating lymphocytes (TIL) from 16 cancer patients have been examined under limiting dilution conditions to determine the frequency of cells responding in mixed tumour-lymphocyte cultures (MLTC) to autologous tumour and Interleukin-2 (IL-2). Tumour-derived lymphocytes showed a high spontaneous response to IL-2 alone 1/1,900 in TIL; 1/6,000 in PBL suggesting the presence of "activated" T cells in situ. Proliferative frequencies were increased in MLTC in both blood (1/3,779) and TIL (1/1,084). Phenotypic analyses showed that total T-cell contents of the responder populations were comparable but TIL were enriched for the OKT8+ subset with a corresponding reduction in OKT4+. TIL showed increased numbers of OKMI+ and Tac+ lymphocytes. The major cytotoxic precursor expanding under these conditions was reactive against autologous tumour. K562 (NK) were present at a lesser frequency--particularly in TIL. The data show a concentration and activation of reactive lymphocytes at the tumour site and establish conditions for the clonal expansion of specifically cytotoxic T cells.

Histologic stromal reaction of the host with gestational choriocarcinoma and its relation to clinical stage classification and prognosis

One of the factors determining the prognosis of choriocarcinoma is the stromal reaction of the host. We have been interested in the histologic findings of this reaction, and we studied the relationship between the CPV classification, which had been used in our department, and our clinical stage. There was no relation of stage distribution to CPV classification. For instance, Type C, which has a strong stromal reaction, did not display any parallel relation with stage. When mortality rates and stages are compared, however, it is noteworthy that the mortality rate for Type C cases is small in Stage I and is less than 50% even in Stage III, in which metastasis is considered to be inevitable; thus, more than half of the cases are cured. On the contrary, Types P and C tend to be associated with high mortality rates even in Stages I and II, in which metastasis is not certain.

Walker Prize Lecture, 1977. Choriocarcinoma: can we afford to cure cancer

The way the management of patients with trophoblastic tumours has depended on the acquisition of new knowledge and new drugs is demonstrated. Emphasis is put on the ability to detect early disease by biochemical markers and on the ability to define on a multifactorial basis the resistance potential of the tumours. This provides a basis for stratification of treatment and the use of prophylactic chemotherapy to prevent cerebral metastases in certain patients. Although chemotherapy is often intensive and prolonged, there has so far been little evidence of long-term effects and many women have had normal pregnancies subsequently, but the limitations of present data are discussed. The difficulties of matching available resources to society's needs in the cancer field make it necessary to consider whether such treatment is unjustifiably expensive. It is shown that for these tumours early diagnosis not only proves effective in therapeutic terms but provides substantial financial savings. It is suggested that screening programmes for cancer cannot be accepted or rejected on principle. In judging them on their individual merits it is appropriate to anticipate interaction between earlier diagnosis and more effective drug treatment.

Human tumour--lymphocyte interaction in vitro. V. Comparison of the reactivity of tumour-infiltrating, blood and lymph-node lymphocytes with autologous tumour cells

Lymphocytes prepared from the blood, tumour-draining lymph node and tumour were tested for immune reactivity with freshly isolated autologous tumour cells from biopsies. Reactivity was assessed by the autologous tumour stimulation assay and by lymphocytotoxicity. Activity was found in 6/11 blood preparations, 7/10 lymph nodes and 1/7 tumour-infiltrating lymphocytes in tumour stimulation assays and in 6/19 blood, 8/18 lymph-node and 5/20 tumour-infiltrating lymphocytes in cytotoxicity assays. Tests with material from patients with nasopharyngeal carcinoma showed a higher frequency of cytotoxicity in the tumour-infiltrating lymphocytes than in other solid tumours. There was a correlation between results of the two assays when performed on the same preparations and between the levels of reactivity in lymph node and blood from the same patient. Cytotoxicity in the lymph nodes showed specificity in that cells from a long-term culture (K562) known to be sensitive to natural killer activity and from allogeneic tumour biopsies were only rarely damaged. Cytotoxicity against K562 was more frequently determined in blood lymphocytes. Tumour-infiltrating lymphocytes were non-reactive in patients when the blood and lymph-node lymphocytes were active.

Risk and prognostic factors in trophoblastic neoplasia

Three hundred and seventeen patients with gestational trophoblastic tumors were investigated and treated between 1957-1973. The risk of trophoblastic tumor was influenced by the outcome of the antecedent pregnancy (hydatidiform mole, non-mole abortion, term delivery) and the ABO blood groups of the mating couple; it was also influenced by the patient's age. The response to treatment with chemotherapy and , where appropriate, with surgery and radiotherapy, was influenced prfoundly by several factors. These included 1) the outcome of the antecedent pregnancy, 2) the total body burden of tumor at the time treatment stated as reflected by the urinary output of human chorionic gonadotrophin (CG), 3) the interval between the antecedent pregnancy and the start of chemotherapy, 4) the ABO groups of the mating couple, 5) the extent of mononuclear cell infiltration in the tumor, 6) the immunological status of the patient at the start of treatment, 7) the size of tumor masses, 8) the site of metastases and particularly the presence of intracranial metastases, and possibly by 9) the age and 10) the parity of the patient. A detailed study of the HLA antigens of the patient, her husband, and antecedent child has shown no positive effect on risk or prognosis. These data provide a basis for a scoring system that allows the prognosis to be defined at the time of diagnosis and facilitates tisk of drug resistance. Applied retrospectively to the cases from which the scoring system was generated, prognostic groups with survival rates ranging from 0-100% can be defined. Unfavorable prognostic factors combine so as to increase the probability of drug resistance.

Choriocarcinoma in Ibadan: clinicopathologic studies

The host tissue reaction to choriocarcinoma was studied in 81 Nigerian patients. A mononuclear cellular reaction, observed in about 42 per cent of the patients, was composed mainly of lymphocytes, plasma cells, histiocytes, and eosinophils in varying quantities around tumor deposits. No correlation was found between the survival of the patients and the intensity of the cellular reaction. Late presentation by our patients for medical advice and treatment may partly account for the relatively poor response to chemotherapy. The syncytiotrophoblast appears to play a primary role in vascular invasion by the neoplastic trophoblast.

The histopathology of trophoblastic tumours

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Mononuclear cell content of human solid tumors

The mononuclear cell content and mononuclear cell function of human solid tumors were determined. Twenty-eight primary, and 17 metastatic solid tumors, including 6 lymph node metastases, were obtained from 45 patients. Cells were released from the tumors by mincing, scraping, and sieving. Analysis of the cellular content was determined by light microscopy, and tumor lymphocyte function was determined by stimulation of blastogenesis with PHA, PWM, Con-A, MLC, and SLO. A median of 3.3 X 10(7) tumor cells with 12.5% viability was obtained per gram of tumor, and a median of 7.8 X 10(6) lymphocytes with a viability of 96% and 0.35 X 10(6) macrophages with a viability of 85% was also obtained per gram of tumor. Significant lymphocyte responses to various mitogens and antigens were obtained in 31-40% of the tumor lymphocyte preparations. From 9.4% to 23% had vigorous responses with a stimulation index greater than 10. Primary tumors contained significantly more lymphocytes than metastatic tumors; thus, the percent lymphocytes in primary tumors was 13.5% compared to 5% for metastatic tumors. In contrast, some of the lymphocyte responses were significantly greater for metastatic tumors than primary tumors. These data suggest that the direct study of lymphocytes infiltrating primary and metastatic tumors may be a useful approach to understanding tumor immunity in man.

Immunological aspects of trophoblastic neoplasia

Immune mechanisms appear to contribute to the good response of choriocarcinoma to chemotherapy. Immunosuppression induced by an advanced state of the disease or by therapy is disadvantageous to the chemotherapeutic response. The antigens concerned in the immune responses have not been identified but present evidence points away from known allospecific antigens as a major contributor to the responsiveness of this tumour.