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Li J, Du Z, Xu T, Li C, Ba S, Zhu H. Epithelioid trophoblastic tumor with lung metastasis: A case report and literature review. Medicine (Baltimore) 2024; 103:e38108. [PMID: 38968534 PMCID: PMC11224836 DOI: 10.1097/md.0000000000038108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 04/12/2024] [Indexed: 07/07/2024] Open
Abstract
RATIONALE Epithelioid trophoblastic tumor (ETT) is an extremely rare variant of gestational trophoblastic neoplasms (GTNs). The biological behavior and therapeutic schedule of ETT remains to be defined which frequently poses diagnostic and therapeutic challenges. Although ETT is a relatively indolent malignancy tumor, the therapeutic efficacy and survival rate decrease significantly when presented with metastases. The lung is the most common site of ETT metastasis. PATIENT CONCERNS A 39-year-old female patient presented with irregular vaginal bleeding and slight distention pain in lower abdomen. DIAGNOSES The patient was diagnosed ETT with lung metastasis after surgery and immunohistochemical staining. INTERVENTIONS A total abdominal hysterectomy plus bilateral salpingectomy and histopathology were performed. The patient received 3 cycles of etoposide, methotrexate, actinomycin-D/etoposide, cisplatin (EMA/EP) regimen chemotherapy after surgery. Due to the presence of lung metastasis, she received pulmonary lesion resection and another cycle of postoperative chemotherapy. OUTCOMES The patients showed a good response to treatment initially. However, the patient did not complete the full initial treatment for family reasons and had signs of recurrence after 2.5 months. The serum β-hCG level gradually elevated and the lung imaging showed that the lesion area gradually expanded. After 15 months of follow-up, the patient declined further treatment due to a lack of presenting symptoms. LESSONS The diagnosis of ETT should be taken into consideration in patients with abnormal vaginal bleeding and low levels of β-hCG. Patients with metastatic disease should be treated with complete surgical resection and intensive combination chemotherapy to maximize the opportunity for cure. Targeted biological agents might be potential therapeutic strategies for chemotherapy-resistant or recurrent patients.
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Affiliation(s)
- Jing Li
- Department of Obstetrics and Gynecology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Zhenwu Du
- Department of Orthopaedics, The Second Hospital of Jilin University, Changchun, Jilin, China
- Research Center, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Tianmin Xu
- Department of Obstetrics and Gynecology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Chenhong Li
- Department of Obstetrics and Gynecology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Shumin Ba
- Department of Obstetrics and Gynecology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - He Zhu
- Department of Obstetrics and Gynecology, The Second Hospital of Jilin University, Changchun, Jilin, China
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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
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Ng JS, Ilancheran A. The role of surgery in gestational trophoblastic disease: an overview. Int J Gynecol Cancer 2024; 34:409-415. [PMID: 38438170 DOI: 10.1136/ijgc-2023-004584] [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: 03/06/2024] Open
Abstract
Gestational trophoblastic disease comprises a group of rare, and potentially malignant, conditions that arise from abnormal trophoblastic proliferation. When there is invasion and evidence of metastatic disease, gestational trophoblastic neoplasia is used. While chemotherapy is the mainstay of treatment for gestational trophoblastic neoplasia, the role of surgery has come full circle in recent years. Before the introduction of highly effective systemic treatment options, surgery was the default treatment. Surgery for gestational trophoblastic neoplasia often yielded unsatisfactory results and mortality remained high. In recent years, the role of adjuvant surgery in the management of gestational trophoblastic neoplasia has been examined with great interest. We aim to provide an overview of the various surgical approaches employed in managing gestational trophoblastic neoplasia, including their indications, techniques, and outcomes. Additionally, we discuss whether there is a role to do less in surgery for gestational trophoblastic neoplasia and describe our experience with a modified surgical technique for its treatment. By summarizing the current evidence, this article highlights the significant contributions of surgery to the holistic management of patients with gestational trophoblastic neoplasia and provides a framework on which to base management and treatment programs.
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Affiliation(s)
- Joseph S Ng
- Department of Obstetrics and Gynecology, National University of Singapore, Singapore
- Gynecologic Cancer Program, National University Cancer Institute, Singapore
| | - Arunachalam Ilancheran
- Department of Obstetrics and Gynecology, National University of Singapore, Singapore
- Gynecologic Cancer Program, National University Cancer Institute, Singapore
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Marquina G, Szewczyk G, Goffin F. The Rare of the Rarest: Placental Site Trophoblastic Tumor, Epithelioid Trophoblastic Tumor, Atypical Placental Site Nodule. Gynecol Obstet Invest 2024; 89:239-246. [PMID: 38281479 DOI: 10.1159/000536494] [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: 03/08/2023] [Accepted: 01/25/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Epithelioid Trophoblastic Tumor (ETT) and Placental Site Trophoblastic Tumor (PSTT) are two of the rarest GTNs that share certain features at diagnosis and management. Atypical Placental Site Nodule (APSN) is a relatively new entity considered as a premalignant lesion. OBJECTIVES AND METHODS The aim of this review was to summarize the main characteristics of each of these entities, their diagnostic features, and their treatment's standard of care including fertility-sparing treatments. OUTCOME This study provides a thorough review of ETT, PSTT, and APSN. CONCLUSIONS The reader will gain an insight view of these rare tumors arising from the intermediate trophoblast.
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Affiliation(s)
- Gloria Marquina
- Department of Medical Oncology, Hospital Clínico San Carlos, Department of Medicine, School of Medicine, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria (IdISSC), EURACAN Referral Centre, Madrid, Spain
| | - Grzegorz Szewczyk
- Department of Biophysics, Physiology and Pathophysiology, Medical University of Warsaw, Warsaw, Poland
- Department of Obstetrics, Perinatology and Gynaecology, Medical University of Warsaw, Warsaw, Poland
| | - Frederic Goffin
- Department of Obstetrics and Gynecology, CHU de Liège and Hospital de la Citadelle, University of Liege, Liege, Belgium
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Golfier F, Seckl MJ. From National to International Collaboration in Gestational Trophoblastic Disease: Hurdles and Possibilities. Gynecol Obstet Invest 2023; 89:254-258. [PMID: 37827125 PMCID: PMC11152002 DOI: 10.1159/000534321] [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: 05/15/2023] [Accepted: 09/24/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Today, most women with gestational trophoblastic disease (GTD) can expect to be cured, particularly if they live in middle- to high-income countries with access to GTD centres. In contrast, countries lacking organized GTD care achieve lower survival rates. OBJECTIVES The aim of the study was to review and consider some of the successes and areas for improvement in GTD care that have been achieved through national and international collaborations. METHODS The authors searched PubMed and used their own knowledge of working nationally and internationally in GTD to write this review. CONCLUSIONS The establishment of expert centres and national systems for managing GTD is associated with the best disease outcomes. National and in particular international collaboration is most likely to result in further optimisation of management protocols and outcomes. OUTLOOK It remains crucial for countries lacking GTD centres to try to establish such facilities with support from national agencies and international expert societies.
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Affiliation(s)
- Francois Golfier
- Department of Obstetrics and Gynecology, French Trophoblastic Disease Reference Center, Lyon Sud University Hospital, Lyon1 Claude Bernard University, Lyon, France
| | - Michael J. Seckl
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College London, London, UK
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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.
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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
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Baas IO, Westermann AM, You B, Bolze PA, Seckl M, Ghorani E. Immunotherapy for Gestational Trophoblastic Neoplasia: A New Paradigm. Gynecol Obstet Invest 2023; 89:230-238. [PMID: 37703867 PMCID: PMC11152029 DOI: 10.1159/000533972] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/27/2023] [Indexed: 09/15/2023]
Abstract
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.
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Affiliation(s)
- Inge O Baas
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands,
| | - Anneke M Westermann
- Department of Medical Oncology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Benoit You
- Université Lyon 1, Hospices Civils De Lyon, Centre Français De Référence Des Maladies Trophoblastiques, Hôpital Lyon Sud, CITOHL, EA 3738 CICLY, Univ Lyon 1, Lyon, France
| | - Pierre-Adrien Bolze
- Université Lyon 1, Hospices Civils De Lyon, Centre Français De Référence Des Maladies Trophoblastiques, Hôpital Lyon Sud, CITOHL, EA 3738 CICLY, Univ Lyon 1, Lyon, France
| | - Michael Seckl
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Ehsan Ghorani
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
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Mangla M, Rahiman EA, Kaur H, Kanikaram P. Gestational trophoblastic neoplasia with concurrent metastasis to the mother and child: a systematic literature review. J Turk Ger Gynecol Assoc 2023; 24:206-219. [PMID: 37675557 PMCID: PMC10493811 DOI: 10.4274/jtgga.galenos.2023.2023-5-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/03/2023] [Indexed: 09/08/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) arising in the placenta and presenting as a metastatic disease concurrently in the mother and the baby is extremely rare. GTN poses a diagnostic dilemma to the treating clinicians. In the current review, an electronic search of Scopus, PubMed, Embase and other databases was conducted for case reports and case series of GTN co-existing or metastatic to both the mother and the baby, published to date. Globally, a total of twenty-two cases of GTN with metastasis to both the mother and baby was found. The previous history of histopathology confirmed molar pregnancy was present in 4/22 cases. The median time to diagnose GTN in the mother was six weeks post-partum. In the majority of cases, diagnosis of maternal disease was made after the infant presented with clinical manifestation. Overall survival was reported in 17/22 mothers up to varying latest follow-up and in 6/22 infants. A knowledge of the varied clinical presentation, eliciting a history of previous pregnancy loss/term pregnancy and serum beta human chorionic gonadotrophin (β-hCG) estimations were helpful for early diagnosis. The concurrent presence of GTN in the mother and baby is a rare entity and poses a diagnostic dilemma. Diagnosis in the mother often follows diagnosis in the baby after an infant presents with clinical manifestations. GTN is a highly chemo-sensitive tumour, but the main prognostic factors determining survival are the time to diagnosis following previous pregnancy and serum β-hCG levels.
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Affiliation(s)
- Mishu Mangla
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Bibinagar, Hyderabad, India
| | - Emine A. Rahiman
- Division of Pediatric Hematology-Oncology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Harpreet Kaur
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India
| | - Poojitha Kanikaram
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Bibinagar, Hyderabad, India
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Liu Y, Zhang X, Ren X, Sun J, Wen Y, Guo Z, Ma Q. Tandem mass tag (TMT) quantitative protein analysis-based proteomics and parallel reaction monitoring (PRM) validation revealed that MST4 accelerates osteosarcoma proliferation by increasing MRC2 activity. Mol Carcinog 2023; 62:1338-1354. [PMID: 37378424 DOI: 10.1002/mc.23567] [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: 08/25/2022] [Revised: 02/14/2023] [Accepted: 03/14/2023] [Indexed: 06/29/2023]
Abstract
Osteosarcoma is one of the most common orthopedic malignancies and is characterized by rapid disease progression and a poor prognosis. Currently, research on methods to inhibit osteosarcoma proliferation is still limited. In this study, we found that MST4 levels were significantly increased in osteosarcoma cell lines and tumor tissues compared to normal controls and demonstrated that MST4 is an influential factor in promoting osteosarcoma proliferation both in vivo and in vitro. Proteomic analysis was performed on osteosarcoma cells in the MST4 overexpression and vector expression groups, and 545 significantly differentially expressed proteins were identified and quantified. The candidate differentially expressed protein MRC2 was then identified using parallel reaction monitoring validation. Subsequently, MRC2 expression was silenced with small interfering RNA (siRNA), and we were surprised to find that this alteration affected the cell cycle of MST4-overexpressing osteosarcoma cells, promoted apoptosis and impaired the positive regulation of osteosarcoma growth by MST4. In conclusion, this study identified a novel approach for suppressing osteosarcoma proliferation. Reduction of MRC2 activity inhibits osteosarcoma proliferation in patients with high MST4 expression by altering the cell cycle, which may be valuable for treating osteosarcoma and improving patient prognosis.
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Affiliation(s)
- Yunyan Liu
- Department of Orthopedic Surgery, Orthopedic Oncology Institute, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaoyu Zhang
- Department of Orthopedic Surgery, Orthopedic Oncology Institute, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Xingguang Ren
- Department of Orthopedic Surgery, Orthopedic Oncology Institute, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Jin Sun
- Department of Orthopedic Surgery, Orthopedic Oncology Institute, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Yanhua Wen
- Department of Orthopedic Surgery, Orthopedic Oncology Institute, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Zheng Guo
- Department of Orthopedic Surgery, Orthopedic Oncology Institute, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Qiong Ma
- Department of Orthopedic Surgery, Orthopedic Oncology Institute, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
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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.
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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
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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.
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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
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12
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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. This case has highlighted that gestational trophoblastic neoplasia (GTN) in HIV infection can behave differently with likelihood of recurrence and that lung mass lesions in women with raised hCG should alert the clinician to the possibility of GTN.
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13
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Braga A, Paiva G, Cattai CJ, Elias KM, Horowitz NS, Berkowitz RS. Current chemotherapeutic options for the treatment of gestational trophoblastic disease. Expert Opin Pharmacother 2023; 24:245-258. [PMID: 36399723 DOI: 10.1080/14656566.2022.2150075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Gestational trophoblastic neoplasia (GTN) is a rare tumor that arises from trophoblastic tissues with high remission rates after chemotherapy treatment. GTN can develop from any gestational events, such as miscarriage, ectopic pregnancy, and preterm/term pregnancy, but is more frequent after hydatidiform mole. The sensitivity of this tumor to chemotherapy and the presence of an exceptional tumor marker allow high remission rates, especially when patients are treated in referral centers. AREAS COVERED Observational, retrospective, prospective, systematic reviews, and meta-analysis studies focusing on GTN treatment. We searched PubMed, Medline, and the Library of Congress from January 1965 to May 2022. EXPERT OPINION Early GTN diagnosis allows low-toxic and highly effective treatment. Even multimetastatic disease has high rates of remission with multiagent regimen chemotherapy. Surgery is reserved for uterine disease in patients who have completed childbearing, in cases of chemoresistance to multiagent regimens or in the rare cases of placental site trophoblastic tumor or epithelioid trophoblastic tumor. While resistance is managed by salvage chemotherapy, cases with limited clinical response to sequential regimens have been successfully treated with immunotherapy.
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Affiliation(s)
- Antonio Braga
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil.,Department of Medicine, Vassouras Medical School, Postgraduate Program in Applied Health Sciences, Vassouras University, Vassouras, RJ, Brazil.,National Academy of Medicine, Young Leadership Physician Program, Rio de Janeiro, RJ, Brazil
| | - Gabriela Paiva
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil
| | - Cassia Juliana Cattai
- , Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, 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
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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]
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15
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Wang YN, Dong Y, Wang L, Chen YH, Hu HY, Guo J, Sun L. Special epithelioid trophoblastic tumor: A case report. World J Clin Cases 2022; 10:9354-9360. [PMID: 36159420 PMCID: PMC9477662 DOI: 10.12998/wjcc.v10.i26.9354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/29/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Epithelioid trophoblastic tumor (ETT) is a special type of gestational trophoblastic tumor. However, its pathogenesis has been incompletely elucidated. ETT rarely occurs in the ovaries and fallopian tubes, unlike placental site trophoblastic tumor, requiring a histopathological biopsy and immunohistochemistry for further diagnosis.
CASE SUMMARY A 29-year-old woman with irregular vaginal bleeding and elevated serum chorionic gonadotropin (β-hCG) levels presented similar symptoms to ectopic pregnancy. Transvaginal ultrasound revealed abnormal echoes of the left adnexa. Postoperatively, the pathology of the left ovary and fallopian tube was reported as ETT. The patient was followed up with regular hCG measurements and ultrasounds. The blood hCG values showed an upward trend 3 mo after the operation and then chemotherapy was prescribed. The current health status is normal.
CONCLUSION For women of childbearing age with elevated serum β-hCG levels, practitioners should consider ETT and be alert to the poor prognosis of the disease. After surgery, the patient's condition should be closely observed to prevent recurrence and metastasis. Postoperative chemotherapy is only helpful for treating the disease to a certain extent.
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Affiliation(s)
- Ya-Nan Wang
- Departments of Clinical, Jining Medical University, Jining 272000, Shandong Province, China
| | - Yan Dong
- Departments of Clinical, Jining Medical University, Jining 272000, Shandong Province, China
| | - Lin Wang
- Departments of Clinical, Jining Medical University, Jining 272000, Shandong Province, China
| | - Ya-Hui Chen
- Departments of Clinical, Jining Medical University, Jining 272000, Shandong Province, China
| | - Hai-Yang Hu
- Department of Gynecology, Affiliated Hospital of Jining Medical University, Jining 272000, Shandong Province, China
| | - Jing Guo
- Department of Pathology, Affiliated Hospital of Jining Medical University, Jining 272000, Shandong Province, China
| | - Lin Sun
- Department of Gynecology, Affiliated Hospital of Jining Medical University, Jining 272000, Shandong Province, China
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Yamamoto E, Nishino K, Niimi K, Ino K. Epidemiologic study on gestational trophoblastic diseases in Japan. J Gynecol Oncol 2022; 33:e72. [PMID: 36047375 PMCID: PMC9634103 DOI: 10.3802/jgo.2022.33.e72] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/30/2022] [Accepted: 07/10/2022] [Indexed: 11/30/2022] Open
Abstract
Objective This study aims to estimate the population-based incidence of gestational trophoblastic diseases (GTDs) and to identify the characteristics of gestational trophoblastic neoplasia (GTN) in Japan. Methods The annual number of GTD and live births from 1974 to 2018 were used to estimate the incidence of GTD. The data of 1,574 GTN cases from 1999 to 2018 were analyzed to identify the characteristics of low-risk GTN, high-risk GTN, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT). Results The incidence of hydatidiform mole was 2.02 per 1,000 live births on average which decreased from 1974 to 2008 and increased from 2009 to 2018. The incidence of low-risk GTN, high-risk GTN, PSTT, and ETT was 15.3, 3.5, 0.3, and 0.07 per 100,000 live births, respectively. The estimated incidence of post-molar GTN was 9.8% of molar patients. High-risk GTN was diagnosed more pathologically, had more various kinds of antecedent pregnancies, and had longer intervals after the antecedent pregnancy compared to low-risk GTN. Furthermore, 8.2% of high-risk GTN occurred after the subsequent non-molar pregnancy of hydatidiform mole. The cumulative percentage of developing high-risk GTN after hydatidiform mole reached 89.3% at the 60th month. Conclusion The incidence of hydatidiform mole, low-risk GTN, high-risk GTN was 2.02 per 1,000 live births, 15.3 per 100,000 live births, and 3.5 per 100,000 live births, respectively. High-risk GTN was diagnosed more pathologically and later after the antecedent pregnancy than low-risk GTN. Following molar patients for five years is needed to improve the mortality of malignant GTN. The incidence of hydatidiform mole and gestational trophoblastic neoplasia (GTN) in Japan was estimated. The incidence of post-molar GTN was stable at approximately 10%. Of high-risk GTN, 8.2% occurred after the subsequent non-molar pregnancy of hydatidiform mole. Following molar patients for 5 year is necessary for early diagnosis of high-risk GTN.
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Affiliation(s)
- Eiko Yamamoto
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Kimihiro Nishino
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiko Ino
- Department of Obstetrics and Gynecology, Wakayama Medical University, Wakayama, Japan
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17
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Gorun F, Tomescu L, Motoc A, Citu C, Sas I, Serban DM, Forga M, Citu IM, Gorun OM. Clinical features and management of trophoblastic epithelioid tumors: A systematic review. Medicine (Baltimore) 2022; 101:e29934. [PMID: 35905248 PMCID: PMC9333520 DOI: 10.1097/md.0000000000029934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND This study aimed to systematically review the existing literature on epithelioid trophoblastic tumors (ETTs), the rarest type of gestational trophoblastic neoplasia. METHODS A systematic review according to PRISMA guidelines was performed, using ScienceDirect, Web of Science, and Scopus databases. The only filter used was the English language. Eligibility/inclusion criteria: retrospective observational studies (case reports, case series) including full case description of epithelioid trophoblastic tumor lesions. RESULTS Seventy studies were assessed for synthesis, including 147 cases. 66.7% of patients with ETT presented with irregular vaginal bleeding. Pretreatment β-hCG levels ranged up to 1000 mIU/mL in 58.5% patients. Of most patients, 42.2% had stage I disease, 10.9% stage II, 25.2% stage III, and 21.8% of patients had stage IV. The most common sites of metastatic disease were the lungs, followed by the liver and brain. After treatment, complete remission was achieved in 75.5% of patients, partial remission in 10.2% of patients, and 14.3% of patients died. On univariate and multivariate analyses, stage IV disease was an independent prognostic factor for overall and disease-free survival. CONCLUSIONS Hysterectomy and metastatic lesion resection are essential for controlling ETT. Investigational studies on molecules like EGFR, VEGF, PD-1, CD105, and LPCAT1 are potential therapeutic targets for metastatic ETT.
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Affiliation(s)
- Florin Gorun
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Larisa Tomescu
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timisoara, Romania
- *Correspondence: Tomescu Larisa- Cristina, Department of Obstetrics and Gynecology, “Victor Babeș” University of Medicine and Pharmacy Timișoara, Romania, Eftimie Murgu Sq. no. 2, 300041 Timișoara, Romania (e-mail: )
| | - Andrei Motoc
- Department of Anatomy and Embryology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timisoara, Romani
| | - Cosmin Citu
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Ioan Sas
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Denis Mihai Serban
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Marius Forga
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Ioana Mihaela Citu
- Department of Internal Medicine I, “Victor Babes” University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Oana Maria Gorun
- Department of Obstetrics and Gynecology, Municipal Emergency Clinical Hospital Timisoara, Timisoara, Romani
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Sensitive screening of single nucleotide polymorphisms in cell free DNA for diagnosis of gestational tumours. NPJ Genom Med 2022; 7:26. [PMID: 35396509 PMCID: PMC8993869 DOI: 10.1038/s41525-022-00297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/04/2022] [Indexed: 11/24/2022] Open
Abstract
Tumours expressing human chorionic gonadotropin (hCG), the majority of which are difficult to biopsy due to their vascularity, have disparate prognoses depending on their origin. As optimal management relies on accurate diagnosis, we aimed to develop a sensitive cell free DNA (cfDNA) assay to non-invasively distinguish between cases of gestational and non-gestational origin. Deep error-corrected Illumina sequencing of 195 common single nucleotide polymorphisms (SNPs) in cfDNA and matched genomic DNA from 36 patients with hCG-secreting tumours (serum hCG 5 to 3,042,881 IU/L) and 7 controls with normal hCG levels (≤4 IU/L) was performed. cfDNA from confirmed gestational tumours with hCG levels ranging from 1497 to 700,855 IU/L had multiple (n ≥ 12) ‘non-host’ alleles (i.e. alleles of paternal origin). In such cases the non-host fraction of cfDNA ranged from 0.3 to 40.4% and correlated with serum hCG levels. At lower hCG levels the ability to detect non-host cfDNA was variable, with the detection limit dependent on the type of causative pregnancy. Patients with non-gestational tumours were identifiable by the absence of non-host cfDNA, with copy number alterations detectable in the majority of cases. Following validation in a larger cohort, our sensitive assay will enable clinicians to better inform patients, for whom biopsy is inappropriate, of their prognosis and provide optimum management.
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19
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Liu W, Zhao W, Huang X. Outcomes and prognostic factors of placental-site trophoblastic tumor: a retrospective study of 58 cases. Arch Gynecol Obstet 2022; 306:1633-1641. [DOI: 10.1007/s00404-022-06502-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/28/2022] [Indexed: 11/02/2022]
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20
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Clark M, Tchrakian N, Clarke B, Metser U, Bouchard-Fortier G. Placenta increta mimicking placental site trophoblastic tumor. Int J Gynecol Cancer 2021; 31:1481-1485. [PMID: 34725244 DOI: 10.1136/ijgc-2021-002988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 12/26/2022] Open
Affiliation(s)
- Mitchell Clark
- Gynecologic Oncology, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Blaise Clarke
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ur Metser
- Medical Imaging, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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21
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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
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22
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Ngan HYS, Seckl MJ, Berkowitz RS, Xiang Y, Golfier F, Sekharan PK, Lurain JR, Massuger L. Diagnosis and management of gestational trophoblastic disease: 2021 update. Int J Gynaecol Obstet 2021; 155 Suppl 1:86-93. [PMID: 34669197 PMCID: PMC9298230 DOI: 10.1002/ijgo.13877] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Gestational trophoblastic disease (GTD) arises from abnormal placenta and is composed of a spectrum of premalignant to malignant disorders. Changes in epidemiology of GTD have been noted in various countries. In addition to histology, molecular genetic studies can help in the diagnostic pathway. Earlier detection of molar pregnancy by ultrasound has resulted in changes in clinical presentation and decreased morbidity from uterine evacuation. Follow-up with human chorionic gonadotropin (hCG) is essential for early diagnosis of gestational trophoblastic neoplasia (GTN). The duration of hCG monitoring varies depending on histological type and regression rate. Low-risk GTN (FIGO Stages I-III: score <7) is treated with single-agent chemotherapy but may require additional agents; although scores 5-6 are associated with more drug resistance, overall survival approaches 100%. High-risk GTN (FIGO Stages II-III: score ≥7 and Stage IV) is treated with multiagent chemotherapy, with or without adjuvant surgery for excision of resistant foci of disease or radiotherapy for brain metastases, achieving a survival rate of approximately 90%. Gentle induction chemotherapy helps reduce early deaths in patients with extensive tumor burden, but late mortality still occurs from recurrent treatment-resistant tumors.
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Affiliation(s)
- Hextan Y. S. Ngan
- Department of Obstetrics and GynecologyUniversity of Hong KongQueen Mary HospitalHong KongChina
| | - Michael J. Seckl
- Department of Medical OncologyCharing Cross Trophoblastic Disease CenterCharing Cross Campus of Imperial College LondonLondonUK
| | - Ross S. Berkowitz
- Department of Obstetrics and GynecologyDivision of Gynecologic OncologyBrigham and Women's HospitalDana‐Farber Cancer InstituteHarvard Medical SchoolBostonMassachusettsUSA
| | - Yang Xiang
- Department of Obstetrics and GynecologyPeking Union Medical College HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - François Golfier
- Department of Obstetrics and GynecologyFrench Trophoblastic Disease Reference CentreLyon University HospitalClaude Bernard Lyon 1 UniversityLyonFrance
| | - Paradan K. Sekharan
- Department of Obstetrics and GynecologyInstitute of Maternal and Child HealthMedical CollegeCalicutIndia
| | - John R. Lurain
- John I. Brewer Trophoblastic Disease CenterNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Leon Massuger
- Department of Obstetrics and GynecologyDivision of Gynecologic OncologyRadboud University Medical Centre NijmegenNijmegenThe Netherlands
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23
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Uterine Epithelioid Trophoblastic Tumor in a 44-Year-Old Woman: A Diagnostic Dilemma. Clin Pract 2021; 11:631-639. [PMID: 34563007 PMCID: PMC8482181 DOI: 10.3390/clinpract11030078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/25/2021] [Accepted: 09/08/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Epithelioid trophoblastic tumor (ETT) is a rare and newly defined disease, which most commonly occurs in women of reproductive age and can be a sequela of any gestational event. ETT can be present in both intrauterine and extrauterine sites. CASE REPORT A woman of reproductive age, without specific comorbidities and with a single pregnancy and natural childbirth eight years ago, was diagnosed initially with poorly differentiated pleomorphic leiomyosarcoma on the hemostatic uterine curettage. CONCLUSION Our case highlights that ETT presents a diagnostic challenge due to its rarity and histologic resemblance to other pathologies. Misdiagnosis delays effective treatment and affects survival. To date, only 8 cases of ETT of the uterus without previous gestational event and normal human chorionic gonadotropin (β-HCG) levels in a 60-year literature survey have been reported.
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Nakamura B, Cowan M, Griffin BB, Victoria Fischer J, Lurain JR, Strohl AE. Successful management of stage IV epithelioid trophoblastic tumor using multimodality treatment: A case report. Gynecol Oncol Rep 2021; 37:100802. [PMID: 34195329 PMCID: PMC8239721 DOI: 10.1016/j.gore.2021.100802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/27/2021] [Indexed: 11/18/2022] Open
Abstract
ETT is a rare variant of GTN that is more chemoresistant than choriocarcinoma. Approximately 25–35% of patients with ETT present with metastatic disease. Chemotherapy for ETT should consist of an etoposide/platinum-based regimen. Multimodality treatment can result in successful management of stage IV ETT.
Epithelioid trophoblastic tumor (ETT) is a rare variant of gestational trophoblastic neoplasia (GTN) that develops from chorionic-type intermediate trophoblast, is more resistant to chemotherapy than choriocarcinoma, and presents with metastatic disease in 25–35% of cases. We report a case of a 32-year-old who presented one week postpartum with severe abdominal pain and was found to have profound anemia and an elevated hCG level. CT scans and MRI revealed bleeding from hepatic masses, multiple hemorrhagic pulmonary nodules, a 7 cm uterine mass, and brain metastases. She underwent emergent hepatic embolization, was started on induction chemotherapy with weekly low-dose etoposide and cisplatin followed by a transition to etoposide, high-dose methotrexate, actinomycin D, etoposide, and cisplatin (HD EMA-EP), received stereotactic brain radiotherapy, and subsequently underwent minimally-invasive hysterectomy. She remains disease free over one year after the completion of treatment. An aggressive multimodal treatment approach employing etoposide/cisplatin-based chemotherapy as well as surgical procedures to control hemorrhage or excise resistant disease, and radiotherapy for brain metastases can result in successful treatment of stage IV ETT.
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Affiliation(s)
- Brad Nakamura
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew Cowan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brannan B. Griffin
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jean Victoria Fischer
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John R. Lurain
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- John I. Brewer Trophoblastic Disease Center, USA
| | - Anna E. Strohl
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- John I. Brewer Trophoblastic Disease Center, USA
- Robert H. Lurie Comprehensive Cancer Center, USA
- Corresponding author at: 250 E. Superior St. Suite 05-2175, Chicago, IL 60611, USA.
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25
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Seckl MJ, Ghorani E. Progress to international harmonisation of care and future developments. Best Pract Res Clin Obstet Gynaecol 2021; 74:159-167. [PMID: 34119435 DOI: 10.1016/j.bpobgyn.2021.05.006] [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: 05/18/2021] [Accepted: 05/18/2021] [Indexed: 01/01/2023]
Abstract
Considerable differences exist in the management of gestational trophoblastic disease (GTD) both nationally and internationally despite numerous efforts to harmonise patient care. This partly reflects differences in healthcare systems and availability of resources. However, even in first world equivalent economies with similar healthcare systems differences remain, which appear to impact survival. Recently, new international guidelines have been established in Europe through a series of consensus meetings. Improvement of outcomes will depend on the establishment of dedicated centres with appropriate patient pathways according to these guidelines. This review will highlight some of the differences and efforts to unify the management of GTD across the globe and discuss areas for future development.
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Affiliation(s)
- Michael J Seckl
- Dept Medical Oncology, Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W68RF, UK.
| | - Ehsan Ghorani
- Dept Medical Oncology, Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W68RF, UK
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26
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Porter A, Barcelon JM, Budker RL, Marsh L, Moriarty JM, Aguiar X, Rao J, Ghorani E, Kaur B, Maher G, Seckl MJ, Konecny GE, Cohen JG. Treatment of metastatic placental site trophoblastic tumor with surgery, chemotherapy, immunotherapy and coil embolization of multiple pulmonary arteriovenous fistulate. Gynecol Oncol Rep 2021; 36:100782. [PMID: 34036138 PMCID: PMC8134973 DOI: 10.1016/j.gore.2021.100782] [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: 03/06/2021] [Revised: 04/25/2021] [Accepted: 04/30/2021] [Indexed: 11/28/2022] Open
Abstract
Placental site trophoblastic tumor can be resistant to chemotherapy. Multidisciplinary care is required for management of advanced disease. Increased PD-L1 expression can help guide use of immunotherapies. Complete responses are possible with aggressive multidisciplinary management.
Placental Site Trophoblastic Tumor (PSTT) is a rare malignancy that often presents with extensive disease and can be resistant to traditional treatments. We present the case of a woman with stage IV PSTT who was initially managed with neoadjuvant chemotherapy followed by tumor debulking. Adjuvant therapy was guided by further pathologic analysis that revealed high levels of staining for PD-L1 as well as the presence of tumor infiltrating lymphocytes (TILs). Subsequently, the patient was treated with traditional chemotherapy with the EP/EMA regimen with the addition of pembrolizumab. The patient’s treatment course was complicated by the development of pulmonary arteriovenous malformations, autoimmune thyroiditis thought to be secondary to immunotherapy, and significant tinnitus secondary to platinum agents. Currently the patient is in follow up and remains in a complete remission.
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Affiliation(s)
- A Porter
- University of California Los Angeles, Division of Hematology Oncology, Los Angeles, CA, USA
| | - J M Barcelon
- University of California Los Angeles, Division of Gynecologic Oncology, Los Angeles, CA, USA
| | - R L Budker
- University of California Los Angeles, Division of Gynecologic Oncology, Los Angeles, CA, USA
| | - L Marsh
- University of California Los Angeles, Division of Gynecologic Oncology, Los Angeles, CA, USA
| | - J M Moriarty
- University of California Los Angeles, Division of Interventional Radiology, Los Angeles, CA, USA
| | - X Aguiar
- California Los Angeles, Department of Pathology, Los Angeles, CA, USA
| | - J Rao
- California Los Angeles, Department of Pathology, Los Angeles, CA, USA
| | - E Ghorani
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, United Kingdom
| | - B Kaur
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, United Kingdom
| | - G Maher
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, United Kingdom
| | - M J Seckl
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, United Kingdom
| | - G E Konecny
- University of California Los Angeles, Division of Hematology Oncology, Los Angeles, CA, USA
| | - J G Cohen
- University of California Los Angeles, Division of Gynecologic Oncology, Los Angeles, CA, USA
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27
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Cortés-Charry R, Hennah L, Froeling FEM, Short D, Aguiar X, Tin T, Harvey R, Unsworth N, Kaur B, Savage P, Sarwar N, Seckl MJ. Increasing the human chorionic gonadotrophin cut-off to ≤1000 IU/l for starting actinomycin D in post-molar gestational trophoblastic neoplasia developing resistance to methotrexate spares more women multi-agent chemotherapy. ESMO Open 2021; 6:100110. [PMID: 33845362 PMCID: PMC8044379 DOI: 10.1016/j.esmoop.2021.100110] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 01/01/2023] Open
Abstract
Background A human chorionic gonadotropin (hCG) cut-off of ≤300 IU/l for starting actinomycin D (ActD) in post-molar gestational trophoblastic neoplasia (GTN) patients developing methotrexate resistance (MTX-R) reduced the number of women needing toxic multi-agent chemotherapy (etoposide, MTX and ActD alternating weekly with cyclophosphamide and vincristine; EMA/CO) without affecting survival. Here we assess whether an increased hCG cut-off of ≤1000 IU/l spares more women EMA/CO. Patients and methods All post-molar GTN patients treated with first-line methotrexate and folinic acid (MTX/FA) were identified in a national cohort between 2009 and 2016. Data collected included age, FIGO score, the hCG levels at MTX-R, and treatment outcomes. Results In total, 609 GTN patients commenced treatment with MTX/FA achieving a complete response in 57% (348/609). Resistance developed in 25.1% (153/609) at an hCG ≤ 1000 IU/l and switching to ActD achieved remission in 92.8% without any major toxicity with the remaining 7.2% remitting on EMA/CO. Comparative analysis of patients switching at an hCG <100 versus 100-300 versus 300-1000 IU/l revealed a significant fall in the cure rate with second-line ActD from 97% (93/96) to 87% (34/39) to 78% (14/18), respectively, P = 0.009. However, by increasing the hCG cut-off from ≤300 to ≤1000 IU/l, 14 patients were spared EMA/CO chemotherapy. Moreover, in the present series, all post-molar GTN remain in remission. Conclusion This study demonstrates that increasing the hCG cut-off from ≤300 to ≤1000 IU/l for choosing patients for ActD following MTX-R spares more women with GTN from the greater toxicity of EMA/CO without compromising 100% survival outcomes. An hCG cut-off of ≤1000 IU/l for ActD over EMA/CO treatment in MTX-R GTN spares women toxicity without affecting survival. On developing MTX-R, as the hCG cut-off for selecting ActD versus EMA/CO rises, the complete response rate for ActD falls. Half of FIGO-7 patients were cured on single-agent treatment (MTX/FA or sequential ActD), warranting further investigation.
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Affiliation(s)
- R Cortés-Charry
- Department of Obstetrics and Gynecology, Gestational Trophoblastic Disease Unit, Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela
| | - L Hennah
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - F E M Froeling
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - D Short
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - X Aguiar
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - T Tin
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - R Harvey
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - N Unsworth
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - B Kaur
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - P Savage
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - N Sarwar
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - M J Seckl
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK.
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Fisher RA, Maher GJ. Genetics of gestational trophoblastic disease. Best Pract Res Clin Obstet Gynaecol 2021; 74:29-41. [PMID: 33685819 DOI: 10.1016/j.bpobgyn.2021.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/06/2020] [Accepted: 01/08/2021] [Indexed: 01/26/2023]
Abstract
The abnormal pregnancies complete and partial hydatidiform mole are genetically unusual, being associated with two copies of the paternal genome. Typical complete hydatidiform moles (CHMs) are diploid and androgenetic, while partial hydatidiform moles (PHMs) are diandric triploids. While diagnosis can usually be made on the basis of morphology, ancillary techniques that exploit their unusual genetic origin can be used to facilitate diagnosis. Genotyping and p57 immunostaining are now routinely used in the differential diagnosis of complete and partial hydatidiform moles, for investigating unusual mosaic or chimeric products of conception with a molar component and identifying the rare diploid, biparental HMs associated with an inherited predisposition to molar pregnancies. Genotyping also plays an important role in the differential diagnosis of gestational and non-gestational trophoblastic tumours and identification of the causative pregnancy where tumours are gestational. Recent developments include the use of cell-free DNA for non-invasive diagnosis of these conditions.
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Affiliation(s)
- Rosemary A Fisher
- Trophoblastic Tumour Screening and Treatment Centre, Faculty of Medicine, Imperial College London, Charing Cross Campus, Fulham Palace Road, London, W6 8RF, UK.
| | - Geoffrey J Maher
- Trophoblastic Tumour Screening and Treatment Centre, Faculty of Medicine, Imperial College London, Charing Cross Campus, Fulham Palace Road, London, W6 8RF, UK
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Abstract
PURPOSE OF REVIEW This review demonstrates the evidence for new systemic anticancer treatments and how they integrate within conventional management for gestational trophoblastic neoplasia (GTN). We present the evidence on atypical placental site nodules, and how they incorporate within the GTN spectrum, as well as updates regarding GTN staging and follow-up. RECENT FINDINGS First-line treatment for GTN still lies in conventional chemotherapy, although the introduction of anti-PD1/PD-L1 immune checkpoint inhibitors has shown significant promise in management of relapsed disease, with responses reported in multiple relapsed choriocarcinomas as well as epithelioid trophoblastic tumours and placental site trophoblastic tumours (ETT/PSTT). Following completion of treatment, ETT/PSTT still require life-long surveillance but for other GTN, no recurrences have been detected after 7 years. SUMMARY Checkpoint inhibitors are likely to play an increasing role in the future management of GTN management. Further refinement of prognostic factors to identify those most at risk of GTN recurrence is warranted so that surveillance can be focussed on those most at risk, whilst minimizing unnecessary intervention for those at lower risk.
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Affiliation(s)
- James Clark
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Road, London W68RF UK
| | - Susanna Slater
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Road, London W68RF UK
| | - Michael J Seckl
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Road, London W68RF UK
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Yu H, Zhang W, Han P, Yang B, Feng X, Zhou P, Zhu X, Zhou B, Chen W, Qian J, Yu J. MST4 Regulates Epithelial-Mesenchymal Transition of Choriocarcinoma by Mediating TGF-β1 Expression. Onco Targets Ther 2020; 13:11935-11946. [PMID: 33244239 PMCID: PMC7683511 DOI: 10.2147/ott.s269168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/09/2020] [Indexed: 02/06/2023] Open
Abstract
Background Mammalian Ste20-like kinase 4 (MST4), also known as serine/threonine kinase 26 (STK26), promotes development of several cancers and is found to be highly expressed in the placenta. However, in choriocarcinoma that originated from the placenta, the expression of MST4 was undetermined and its mechanism was unknown. In this study, the expression of MST4 in choriocarcinoma as well as the underlying mechanism was explored. Purpose To detect the expression of MST4 in patient samples and mechanism of mediating EMT by MST4 in choriocarcinoma. Patients and Methods The metastatic lesions of choriocarcinoma (n=17) and volunteer villus (n=17) were collected to determine MST4 expression using immunohistochemistry and H&E staining. We use siRNA and lentiviral vector to knockdown MST4 and use plasmid to overexpress MST4 in choriocarcinoma. Then, we apply real-time polymerase chain reaction (RT-PCR), Western blot assay and immunofluorescence assay to detect target protein expressions. Cell invasion and migration and cell proliferation were detected by transwell assay and wound healing assay and CCK-8 and cell colony formation. Results MST4 is lowly expressed in the metastatic lesions of choriocarcinoma patients when compared with normal villus. Knockdown of MST4 activated epithelial–mesenchymal transition (EMT) process, significantly increasing the ability of invasion and migration in choriocarcinoma cell lines (JAR and JEG-3). In contrast, the EMT process was restrained in choriocarcinoma cell lines with overexpressed MST4. Meanwhile, genome-wide gene expression array, Western blot and ELISA revealed that tumor growth factor-beta 1 (TGF-β1) has significantly increased. The EMT process and metastatic prompting biofunction were reversed after using TGF-β1 inhibitor (LY364947) in the choriocarcinoma cell lines with MST4 knockdown. Conclusion Our studies demonstrated that MST4 was lowly expressed in patient samples. Additionally, JAR and JEG-3 increase cell invasion and migration ability while there is no influence on cell proliferation with MST4 knockdown. Conversely, the metastatic ability of JAR and JEG-3 was decreased with overexpressed MST4. Moreover, TGF-β1 was a key factor after MST4 knockdown. In conclusion, MST4 affects choriocarcinoma EMT by mediating TGF-β1 expression.
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Affiliation(s)
- Hanxi Yu
- Department of Gynecology, The First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310006, People's Republic of China
| | - Weichen Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, The First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310006, People's Republic of China
| | - Peilin Han
- Department of Gynecology, The First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310006, People's Republic of China
| | - Beng Yang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, The First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310006, People's Republic of China
| | - Xiaode Feng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, The First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310006, People's Republic of China
| | - Ping Zhou
- Department of Gynecology, The First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310006, People's Republic of China
| | - Xiaoxu Zhu
- Department of Gynecology, The First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310006, People's Republic of China
| | - Bingqian Zhou
- Department of Gynecology, The First Affiliated Hospital of Zhejiang University, School of Medicine, Pujiang 322200, People's Republic of China
| | - Wei Chen
- Department of Medical Oncology, Tongde Hospital of Zhejiang Province, Hangzhou 310012, People's Republic of China
| | - Jianhua Qian
- Department of Gynecology, The First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310006, People's Republic of China
| | - Jun Yu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery First Affiliated Hospital, The First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310006, People's Republic of China
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Chaves MM, Maia T, Cunha TM, Veiga VF. Placental site trophoblastic tumour: the rarest subtype of gestational trophoblastic disease. BMJ Case Rep 2020; 13:13/10/e235756. [PMID: 33040035 DOI: 10.1136/bcr-2020-235756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Placental site trophoblastic tumour (PSTT) is a very rare form of gestational trophoblastic disease that grows slowly, secretes low levels of beta-subunit of human chorionic gonadotropin (β-hCG), presents late-onset metastatic potential and is resistant to several chemotherapy regimens. Here, we report a case of PSTT in a 36-year-old woman who presented with amenorrhea and persistently elevated serum level of β-hCG after a miscarriage. Transvaginal ultrasound revealed a hypovascular ill-defined solid lesion of the uterine fundus and MRI showed a tumour infiltrating the external myometrium with discrete early enhancement and signal restriction on diffusion-weighted imaging. PSTT was suspected, and after endometrial biopsy by hysteroscopy and posterior hysterectomy, microscopic examination allowed the final diagnosis. The level of β-hCG dropped significantly in about a month after surgical treatment. Due to the rarity of PSTT, reporting new cases is crucial to improve the diagnosis and managing of these patients.
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Affiliation(s)
- Mariana M Chaves
- Radiology, Hospital do Divino Espirito Santo de Ponta Delgada EPE, Ponta Delgada, Portugal
| | - Tiago Maia
- Pathology, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisboa, Portugal
| | - Teresa Margarida Cunha
- Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisbon, Portugal
| | - Vera Furtado Veiga
- Gynecology, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisboa, Portugal
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Hancock BW, Tidy J. Placental site trophoblastic tumour and epithelioid trophoblastic tumour. Best Pract Res Clin Obstet Gynaecol 2020; 74:131-148. [PMID: 33139212 DOI: 10.1016/j.bpobgyn.2020.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 01/01/2023]
Abstract
Placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT) are the rarest subtypes of gestational trophoblastic disease (GTD). Their diagnosis is complicated and lacks specific and sensitive tumour markers. They are slow-growing tumours and can occur months to years after any type of antecedent pregnancy. The primary treatment for localised disease is hysterectomy. However, extra-uterine invasion and/or metastasis occur in about one-third of cases and still cause death in a small number. Most patients are young; hence, fertility preservation is a consideration. The major obstacle for prognosis is chemotherapy resistance. The current understanding of these tumours remains elusive and no randomized controlled trials have been done. Even those centres treating a large number of patients with GTD will infrequently manage PSTT/ETT. In this review, we assess progress in the understanding of the disease and discuss four main clinical challenges - establishing conformity of practice, devising a risk-adapted approach to clinical management, establishing long-term follow-up data and evaluating therapies for poor prognosis and multi drug-resistant patients.
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Affiliation(s)
| | - John Tidy
- Director, Sheffield Trophoblastic Disease Centre, UK
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Bouchard-Fortier G, Ghorani E, Short D, Aguiar X, Harvey R, Unsworth N, Kaur B, Sarwar N, Seckl MJ. Following chemotherapy for gestational trophoblastic neoplasia, do residual lung lesions increase the risk of relapse? Gynecol Oncol 2020; 158:698-701. [PMID: 32654764 DOI: 10.1016/j.ygyno.2020.06.483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There remains uncertainty about the prognostic significance of residual lung lesion on imaging after completion of treatment of low- or high-risk gestational trophoblastic neoplasia (GTN). Here, we determine if such residual lung lesions are associated with an increased risk of relapse. METHODS We retrospectively screened our electronic database to identify patients with low- or high-risk GTN and lung metastases between 2004 and 18. Recurrences among patients with or without residual lung lesions on imaging were compared. Chi square analysis and Kaplan-Meier survival curves were constructed. As the numbers of cases were low, we combined this data with our previously published and non-overlapping patient cohort (1995-2004). RESULTS Of 1304 GTN patients treated at our centre between 2004 and 18, 99 had lung metastases without other distant sites. There were 40 patients (40.4%) with residual lung lesions. Whilst an increased rate of relapse was observed among patients with residual lung lesions (4/40; 10.0%) compared to without such lesions (3/59; 5.1%), this difference was not statistically significant (p = .35). By combining the data with our previous cohort, there was an increase in relapse rate of patients with residual lung lesions (5/63; 7.9%) compared to those without such lesions (4/112; 3.6%). However, this difference was also not statistically significant (p = .21). CONCLUSION Residual lung lesions on imaging after completion of GTN treatment are common. However, this finding did not statistically increase relapse rate. Due to low number of recurrent events, a multi-centre, larger dataset would be needed to provide more definitive evidence.
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Affiliation(s)
- Genevieve Bouchard-Fortier
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada; Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK.
| | - Ehsan Ghorani
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Dee Short
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Xianne Aguiar
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Richard Harvey
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Nick Unsworth
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Baljeet Kaur
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Naveed Sarwar
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
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Lok C, van Trommel N, Massuger L, Golfier F, Seckl M. Practical clinical guidelines of the EOTTD for treatment and referral of gestational trophoblastic disease. Eur J Cancer 2020; 130:228-240. [PMID: 32247260 DOI: 10.1016/j.ejca.2020.02.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIM Gestational trophoblastic disease (GTD) is a heterogeneous group of disorders characterised by abnormal proliferation of trophoblastic tissue. Since GTD and its malignant sequel gestational trophoblastic neoplasia (GTN) are rare diseases, little evidence is available from randomised controlled trials on optimal treatment and follow-up. Treatment protocols vary within Europe, and even between different centres within countries. One of the goals of the 'European Organisation for Treatment of Trophoblastic Diseases' (EOTTD) is to harmonise treatment in Europe. To provide a basis for European standardisation of definitions, treatment and follow-up protocols in GTD, we composed a set of guidelines for minimal requirements and optimal management of GTD. METHODS Members from each EOTTD country attended multiple workshops during annual EOTTD meetings. Clinical guidelines were formulated by consensus and evidence where available. The following guidelines were discussed: diagnostics of GTD and GTN, treatment of low-risk GTN, high-risk GTN, ultra-high-risk GTN, placental site and epithelioid trophoblastic tumours and follow-up. RESULTS Between 40 and 65 EOTTD members from 17 European countries and 7 non-European countries attended the clinical workshops held on 6 occasions. Flow diagrams for patient management were composed to display minimum and best practice for most treatment situations. New agreed definitions of recurrence and chemotherapy resistance were formulated. CONCLUSIONS Despite the many differences between and within the participating countries, an important step in uniform treatment of GTD and GTN within Europe was made by the Clinical Working Party of the EOTTD. This is an example on how guidelines and harmonisation can be achieved within international networks.
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Affiliation(s)
- Christianne Lok
- Department of Gynecologic Oncology, Centre for Gynecologic Oncology Amsterdam, Location Antoni van Leeuwenhoek - The Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Nienke van Trommel
- Department of Gynecologic Oncology, Centre for Gynecologic Oncology Amsterdam, Location Antoni van Leeuwenhoek - The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Leon Massuger
- Department of Gynecologic Oncology, Radboud University Medical Hospital, Nijmegen, the Netherlands
| | - François Golfier
- Department of Gynecologic and Oncologic Surgery and Obstetrics, French Trophoblastic Disease Centre, Lyon University Hospitals, Lyon Sud Hospital, France
| | - Michael Seckl
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London, UK.
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Alexander AL, Strohl AE, Maniar KP, Lurain JR. Placental site trophoblastic tumor: Successful treatment of 13 cases. Gynecol Oncol Rep 2020; 32:100548. [PMID: 32274412 PMCID: PMC7132153 DOI: 10.1016/j.gore.2020.100548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 01/28/2020] [Accepted: 02/03/2020] [Indexed: 11/29/2022] Open
Abstract
Extent of disease (stage) is the most important predictor of prognosis in PSTT. Prolonged interval from pregnancy to diagnosis of PSTT is an adverse prognostic indicator. Pathologic high-risk features of PSTT are deep invasion, tumor necrosis, and high mitotic rate. Surgery is the most important component in the treatment of PSTT. Platinum/etoposide-containing chemotherapy should be used for high-risk PSTT.
Placental site trophoblastic tumor (PSTT) is a rare variant of gestational trophoblastic neoplasia (GTN) that is characterized by slow growth resulting in mostly uterine-confined disease, low human chorionic gonadotropin (hCG) levels, and resistance to chemotherapy. Our objective was to update our center’s experience with PSTT with respect to presentation, prognostic factors, treatment, and outcomes from 2003 to 2019. Thirteen women with PSTT were identified. Mean age was 32 years. The most frequent presenting symptom was abnormal uterine bleeding (69%). A uterine mass was noted in 62%. The diagnosis was usually established by endometrial biopsy or curettage (62%). Nonmolar pregnancy was the preceding gestation in 85%. Median time from last pregnancy to diagnosis was 13 months (range 0–240 months). Serum hCG levels at diagnosis ranged from 1 to 2606 mIU/mL (median 98 mIU/mL). Three women (23%) presented with metastatic disease. All 13 women underwent surgery: 12 had a hysterectomy, 1 had a fertility-sparing hysteroscopic resection, and 2 underwent pulmonary metastatectomy. Nine women (69%) also received chemotherapy for persistently elevated hCG levels after hysterectomy (2), high-risk factors (4), or metastatic disease (3). Overall survival was 100% with a median survival of 65 months (range 30–167 months). Survival for PSTT increased from 57% to 100%, including from 33% to 100% for metastatic disease, at our center from 1982 to 2003 to 2003–2017. Surgery is the most important component in the treatment of women with PSTT. Multidrug platinum/etoposide- chemotherapy should be used in women with metastatic disease and considered in women with nonmetastatic disease with high-risk features.
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Affiliation(s)
- Amy L Alexander
- John I. Brewer Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Northwestern University Feinberg School of Medicine Chicago, IL, USA
| | - Anna E Strohl
- John I. Brewer Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Northwestern University Feinberg School of Medicine Chicago, IL, USA
| | - Kruti P Maniar
- John I. Brewer Trophoblastic Disease Center, Division of Surgical Pathology, Department of Pathology, Northwestern University Feinberg School of Medicine Chicago, IL, USA
| | - John R Lurain
- John I. Brewer Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Northwestern University Feinberg School of Medicine Chicago, IL, USA
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Frijstein MM, Lok CAR, Trommel NE, ten Kate‐Booij MJ, Massuger LFAG, Werkhoven E, Short D, Aguiar X, Fisher RA, Kaur B, Sarwar N, Sebire NJ, Seckl MJ. Lung metastases in low‐risk gestational trophoblastic neoplasia: a retrospective cohort study. BJOG 2019; 127:389-395. [DOI: 10.1111/1471-0528.16036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2019] [Indexed: 12/01/2022]
Affiliation(s)
- MM Frijstein
- Department of Gynaecological Oncology Centre of Gynaecological Oncology Amsterdam Amsterdam the Netherlands
- Department of Obstetrics and Gynaecology Erasmus University Medical Centre Rotterdam the Netherlands
- Department of Obstetrics and Gynaecology Radboud University Medical Centre Nijmegen the Netherlands
| | - CAR Lok
- Department of Gynaecological Oncology Centre of Gynaecological Oncology Amsterdam Amsterdam the Netherlands
| | - NE Trommel
- Department of Gynaecological Oncology Centre of Gynaecological Oncology Amsterdam Amsterdam the Netherlands
| | - MJ ten Kate‐Booij
- Department of Obstetrics and Gynaecology Erasmus University Medical Centre Rotterdam the Netherlands
| | - LFAG Massuger
- Department of Obstetrics and Gynaecology Radboud University Medical Centre Nijmegen the Netherlands
| | - E Werkhoven
- Department of Biometrics Netherlands Cancer Institute – Antoni van Leeuwenhoek Amsterdam the Netherlands
| | - D Short
- Department of Medical Oncology Charing Cross Hospital London UK
| | - X Aguiar
- Department of Medical Oncology Charing Cross Hospital London UK
| | - RA Fisher
- Department of Medical Oncology Charing Cross Hospital London UK
| | - B Kaur
- Department of Medical Oncology Charing Cross Hospital London UK
| | - N Sarwar
- Department of Medical Oncology Charing Cross Hospital London UK
| | - NJ Sebire
- Department of Medical Oncology Charing Cross Hospital London UK
| | - MJ Seckl
- Department of Medical Oncology Charing Cross Hospital London UK
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37
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Feng X, Wei Z, Zhang S, Du Y, Zhao H. A Review on the Pathogenesis and Clinical Management of Placental Site Trophoblastic Tumors. Front Oncol 2019; 9:937. [PMID: 31850188 PMCID: PMC6893905 DOI: 10.3389/fonc.2019.00937] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/06/2019] [Indexed: 02/05/2023] Open
Abstract
Placental site trophoblastic tumor (PSTT) is a rare type of gestational trophoblastic disease originating from the intermediate trophoblast. Compared with hydatidiform mole, invasive hydatidiform mole and choriocarcinoma, the diagnosis of PSTT is more complicated and lacks specific and sensitive tumor markers. Most PSTT patients demonstrate malignant potential, and the primary treatment of PSTT is hysterectomy. However, metastasis occasionally occurs and even causes death in a small number of PSTT patients. Most PSTT patients are young women hence fertility preservation is an important consideration. The major obstacle for PSTT patient prognosis is chemotherapy resistance. However, the current understanding of the pathogenesis of PSTT and clinical treatment remains elusive. In this review, we summarized the research progress of PSTT in recent years from three aspects: mechanism, clinical presentation, and treatment and prognosis. Well-conducted multi-center studies with sufficient sample sizes are of great importance to better examine the pathological progress and evaluate the prognosis of PSTT patients, so as to develop prevention and early detection programs, as well as novel treatment strategies, and finally improve prognosis for PSTT patients.
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Affiliation(s)
- Xuan Feng
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Zhi Wei
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Sai Zhang
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Yan Du
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Hongbo Zhao
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
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38
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Abu-Rustum NR, Yashar CM, Bean S, Bradley K, Campos SM, Chon HS, Chu C, Cohn D, Crispens MA, Damast S, Dorigo O, Eifel PJ, Fisher CM, Frederick P, Gaffney DK, Han E, Huh WK, Lurain JR, Mariani A, Mutch D, Nagel C, Nekhlyudov L, Fader AN, Remmenga SW, Reynolds RK, Sisodia R, Tillmanns T, Ueda S, Wyse E, McMillian NR, Scavone J. Gestational Trophoblastic Neoplasia, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:1374-1391. [PMID: 31693991 DOI: 10.6004/jnccn.2019.0053] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Gestational trophoblastic neoplasia (GTN), a subset of gestational trophoblastic disease (GTD), occurs when tumors develop in the cells that would normally form the placenta during pregnancy. The NCCN Guidelines for Gestational Trophoblastic Neoplasia provides treatment recommendations for various types of GTD including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor.
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Affiliation(s)
| | | | | | | | | | | | | | - David Cohn
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | | | | | | | - John R Lurain
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - David Mutch
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Christa Nagel
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | - Todd Tillmanns
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Stefanie Ueda
- UCSF Helen Diller Family Comprehensive Cancer Center
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39
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Balachandran K, Salawu A, Ghorani E, Kaur B, Sebire NJ, Short D, Harvey R, Hancock B, Tidy J, Singh K, Sarwar N, Winter MC, Seckl MJ. When to stop human chorionic gonadotrophin (hCG) surveillance after treatment with chemotherapy for gestational trophoblastic neoplasia (GTN): A national analysis on over 4,000 patients. Gynecol Oncol 2019; 155:8-12. [DOI: 10.1016/j.ygyno.2019.07.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/20/2019] [Accepted: 07/23/2019] [Indexed: 01/04/2023]
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