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Branco-Silva M, Maestá I, Horowitz N, Elias K, Seckl M, Berkowitz R. Recurrence and resistance risk factors in low-risk gestational trophoblastic neoplasia. Int J Gynecol Cancer 2024:ijgc-2024-005770. [PMID: 39375166 DOI: 10.1136/ijgc-2024-005770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2024] Open
Abstract
Gestational trophoblastic neoplasia (GTN) is a group of rare but highly curable pregnancy-related tumors, especially in low-risk cases. However, around 25% of patients with GTN develop either resistant or recurrent disease after initial chemotherapy. To enhance the understanding of the mechanisms driving treatment failures and to develop more personalized and effective therapeutic strategies, this review explored diverse factors influencing low-risk GTN prognosis. These factors include FIGO (International Federation of Gynecology and Obstetrics) risk score, histology, patient age, pregnancy type, human chorionic gonadotropin (hCG) levels, disease duration, tumor characteristics, metastasis, Doppler ultrasonography, and consolidation chemotherapy. Additionally, the review examined independent risk determinants for disease recurrence and resistance to single-agent chemotherapy in patients with low-risk GTN. In most previous studies on the risk factors related to low-risk GTN, resistance and recurrence have typically been examined independently, despite their overlapping and interrelated nature. Furthermore, they often involve small sample sizes, suffer from methodological shortcomings, and exhibit limited statistical power.Studies utilizing multivariate analysis have shown that independent risk determinants for resistance to first-line treatment include FIGO score, metastatic disease, pre-treatment hCG level, interval between antecedent pregnancy and GTN diagnosis, tumor size, uterine artery pulsatility index (UAPI), choriocarcinoma, lung metastases, lung nodule size, and clearance hCG quartile. The independent predictive factors associated with recurrence include lung metastases, lung nodule size, interval between antecedent pregnancy and chemotherapy, interval from first chemotherapy to hCG normalization, post-delivery low-risk GTN, number of chemotherapy courses to achieve hCG normalization, and number of consolidation chemotherapy cycles. However, while these identified predictive factors offer valuable guidance, the variability in definitions and populations across studies may have implications for the generalizability of their findings. A comprehensive approach using clear definitions and taking into account multiple predictive factors may be necessary for accurately assessing the risk of resistance and recurrence in patients with low-risk GTN.
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Affiliation(s)
- Mariza Branco-Silva
- Postgraduate Program in Tocogynecology, Botucatu Medical School, Universidade Estadual Paulista Júlio de Mesquita Filho Faculdade de Medicina - Câmpus de Botucatu, Botucatu, Brazil
| | - Izildinha Maestá
- Botucatu Trophoblastic Disease Center, Botucatu Medical School Hospital, Department of Gynecology and Obstetrics, Sao Paulo State University Julio de Mesquita Filho, Botucatu, Brazil
| | - Neil Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Division of Gynecologic Oncology,Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kevin Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Division of Gynecologic Oncology,Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Seckl
- Trophoblastic Tumour Screening and Treatment Centre, Imperial College London - Charing Cross Campus, London, UK
| | - Ross Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Division of Gynecologic Oncology,Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Ghorani E, Seckl MJ. Future Directions for Gestational Trophoblastic Disease. Hematol Oncol Clin North Am 2024:S0889-8588(24)00115-1. [PMID: 39322464 DOI: 10.1016/j.hoc.2024.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
Gestational trophoblastic disease encompasses a spectrum of premalignant and malignant conditions. While centralized care models significantly improve survival rates, many countries still lack such specialized centers, leading to preventable deaths. Current research focuses on refining diagnostic and treatment methods, aiming to better predict the risk of malignancy and reduce the need for aggressive therapies. Immunotherapy has emerged as a promising treatment modality, offering high cure rates with fewer side effects compared to traditional chemotherapy. Global efforts must continue to expand access to specialized care and integrate new therapies to improve outcomes and reduce treatment-related harm.
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Affiliation(s)
- Ehsan Ghorani
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK
| | - Michael J Seckl
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK.
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Ngu SF, Ngan HYS. GTN Diagnosis and Staging. Hematol Oncol Clin North Am 2024:S0889-8588(24)00079-0. [PMID: 39155174 DOI: 10.1016/j.hoc.2024.07.002] [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: 08/20/2024]
Abstract
Majority of gestational trophoblastic neoplasia (GTN) follows molar pregnancies where diagnosis is mostly based on persistent or rising serum human chorionic gonadotrophin (hCG). Diagnosis of GTN could be based on clinical presentation, serum hCG measurement, imaging, histology, and genotyping. A high index of suspicion in women of reproductive age presenting with abnormal vaginal bleeding or unusual systematic presentation is important. An accurate staging and classification system for GTN is crucial to evaluate the risk and the prognosis of patients, and to optimize treatment. GTN is staged using the International Federation of Gynecology and Obstetrics 2000 staging and the modified World Health Organization prognostic scoring system.
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Affiliation(s)
- Siew-Fei Ngu
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, 6/F Professorial Block, 102 Pokfulam Road, Hong Kong SAR.
| | - Hextan Y S Ngan
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, 6/F Professorial Block, 102 Pokfulam Road, Hong Kong SAR
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Parker VL, Winter MC, Tidy JA, Palmer JE, Sarwar N, Singh K, Aguiar X, Hancock BW, Pacey AA, Seckl MJ, Harrison RF. PREDICT-GTN 2: Two-factor streamlined models match FIGO performance in gestational trophoblastic neoplasia. Gynecol Oncol 2024; 180:152-159. [PMID: 38091775 DOI: 10.1016/j.ygyno.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/07/2023] [Accepted: 11/15/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE The International Federation of Gynecology and Obstetrics (FIGO) scoring system uses the sum of eight risk-factors to predict single-agent chemotherapy resistance in Gestational Trophoblastic Neoplasia (GTN). To improve ease of use, this study aimed to generate: (i) streamlined models that match FIGO performance and; (ii) visual-decision aids (nomograms) for guiding management. METHODS Using training (n = 4191) and validation datasets (n = 144) of GTN patients from two UK specialist centres, logistic regression analysis generated two-factor models for cross-validation and exploration. Performance was assessed using true and false positive rate, positive and negative predictive values, Bland-Altman calibration plots, receiver operating characteristic (ROC) curves, decision-curve analysis (DCA) and contingency tables. Nomograms were developed from estimated model parameters and performance cross-checked upon the training and validation dataset. RESULTS Three streamlined, two-factor models were selected for analysis: (i) M1, pre-treatment hCG + history of failed chemotherapy; (ii) M2, pre-treatment hCG + site of metastases and; (iii) M3, pre-treatment hCG + number of metastases. Using both training and validation datasets, these models showed no evidence of significant discordance from FIGO (McNemar's test p > 0.78) or across a range of performance parameters. This behaviour was maintained when applying algorithms simulating the logic of the nomograms. CONCLUSIONS Our streamlined models could be used to assess GTN patients and replace FIGO, statistically matching performance. Given the importance of imaging parameters in guiding treatment, M2 and M3 are favoured for ongoing validation. In resource-poor countries, where access to specialist centres is problematic, M1 could be pragmatically implemented. Further prospective validation on a larger cohort is recommended.
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Affiliation(s)
- Victoria L Parker
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Level 4 The Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK.
| | - Matthew C Winter
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Level 4 The Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK; Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - John A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Julia E Palmer
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Naveed Sarwar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Kamaljit Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Xianne Aguiar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Barry W Hancock
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Level 4 The Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK
| | - Allan A Pacey
- Faculty of Biology, Medicine and Health, Core Technology Facility, 46 Grafton Street, University of Manchester, Manchester, M13 9NT, UK
| | - Michael J Seckl
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Robert F Harrison
- Department of Automatic Control and Systems Engineering, The University of Sheffield, Mappin Street, Sheffield S1 3JD, UK
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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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Winter MC, Tidy JA, Singh K, Sarwar N, Aguiar X, Seckl MJ. Efficacy analysis of single-agent carboplatin AUC4 2-weekly as second-line therapy for methotrexate-resistant (MTX-R) low risk gestational trophoblastic neoplasia (GTN). Gynecol Oncol 2023; 175:66-71. [PMID: 37327541 DOI: 10.1016/j.ygyno.2023.05.072] [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: 04/06/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Approximately one-third of patients with low-risk Gestational Trophoblastic Neoplasia (WHO 0-6) develop methotrexate-resistance (MTX-R). In the UK, subsequent treatment with either actinomycin-D (ActD) or multi-agent combination chemotherapy has depended on whether the hCG was above or below an hCG threshold. To reduce exposure to combination chemotherapy (CC), over the years the UK service has raised this threshold as well as using single-agent carboplatin AUC6 3-weekly at MTX-R instead of CC. Updated results for carboplatin demonstrate an 86% complete hCG response (hCG CR) but associated with haematological dose-limiting toxicity. METHODS In 2017, single-agent carboplatin became the national standard second-line treatment following MTX-R at hCG of >3000 IU/L. Carboplatin was changed to two-weekly AUC4 scheduling and continued until normal hCG plus 3 consolidation cycles. For patients failing to respond, CC (Etoposide-Actinomycin-D or EMA-CO) was introduced. RESULTS 22 evaluable patients with a median hCG at MTX-R of 10,147 IU/L (IQR 5527-19,639) received carboplatin AUC4 2-weekly (median no. of cycles = 6, IQR 2-8). Of these, 36% achieved a hCG CR. All 14 non-CR patients were cured with subsequent CC; 11 and 2 patients with 3rd line and 4th line CC respectively and 1 patient following 5th line CC and hysterectomy. Overall survival remains 100%. CONCLUSION Carboplatin is not sufficiently active in the second-line treatment of low-risk MTX-resistant GTN. New strategies are required to increase hCG CR and spare more toxic CC regimens.
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Affiliation(s)
- Matthew C Winter
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK; Department of Oncology and Metabolism, The University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK.
| | - John A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Kam Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Naveed Sarwar
- Gestational Trophoblastic Tumour Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W6 8RF, UK
| | - Xianne Aguiar
- Gestational Trophoblastic Tumour Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W6 8RF, UK
| | - Michael J Seckl
- Gestational Trophoblastic Tumour Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W6 8RF, UK
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Parker VL, Winter MC, Tidy JA, Hancock BW, Palmer JE, Sarwar N, Kaur B, McDonald K, Aguiar X, Singh K, Unsworth N, Jabbar I, Pacey AA, Harrison RF, Seckl MJ. PREDICT-GTN 1: Can we improve the FIGO scoring system in gestational trophoblastic neoplasia? Int J Cancer 2023; 152:986-997. [PMID: 36346113 PMCID: PMC10108153 DOI: 10.1002/ijc.34352] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022]
Abstract
Gestational trophoblastic neoplasia (GTN) patients are treated according to the eight-variable International Federation of Gynaecology and Obstetrics (FIGO) scoring system, that aims to predict first-line single-agent chemotherapy resistance. FIGO is imperfect with one-third of low-risk patients developing disease resistance to first-line single-agent chemotherapy. We aimed to generate simplified models that improve upon FIGO. Logistic regression (LR) and multilayer perceptron (MLP) modelling (n = 4191) generated six models (M1-6). M1, all eight FIGO variables (scored data); M2, all eight FIGO variables (scored and raw data); M3, nonimaging variables (scored data); M4, nonimaging variables (scored and raw data); M5, imaging variables (scored data); and M6, pretreatment hCG (raw data) + imaging variables (scored data). Performance was compared to FIGO using true and false positive rates, positive and negative predictive values, diagnostic odds ratio, receiver operating characteristic (ROC) curves, Bland-Altman calibration plots, decision curve analysis and contingency tables. M1-6 were calibrated and outperformed FIGO on true positive rate and positive predictive value. Using LR and MLP, M1, M2 and M4 generated small improvements to the ROC curve and decision curve analysis. M3, M5 and M6 matched FIGO or performed less well. Compared to FIGO, most (excluding LR M4 and MLP M5) had significant discordance in patient classification (McNemar's test P < .05); 55-112 undertreated, 46-206 overtreated. Statistical modelling yielded only small gains over FIGO performance, arising through recategorisation of treatment-resistant patients, with a significant proportion of under/overtreatment as the available data have been used a priori to allocate primary chemotherapy. Streamlining FIGO should now be the focus.
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Affiliation(s)
- Victoria L Parker
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Matthew C Winter
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK.,Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Barry W Hancock
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Julia E Palmer
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Naveed Sarwar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Baljeet Kaur
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Katie McDonald
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Xianne Aguiar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kamaljit Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nick Unsworth
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Imran Jabbar
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Allan A Pacey
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Robert F Harrison
- Department of Automatic Control and Systems Engineering, The University of Sheffield, Sheffield, UK
| | - Michael J Seckl
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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Winarno GNA, Mulyantari AI, Kurniadi A, Suardi D, Zulvayanti Z, Trianasari N. Predicting Chemotherapy Resistance in Gestational Trophoblastic Neoplasia: Ratio of Neutrophils, Lymphocytes, Monocytes, and Platelets. Med Sci Monit 2022; 28:e938499. [PMID: 36477073 PMCID: PMC9745950 DOI: 10.12659/msm.938499] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) have recently been used as inflammatory biomarkers for cancer patients. This study aims to determine the role of pretreatment NLR, LMR, and PLR in predicting chemoresistance in gestational trophoblastic neoplasia (GTN) patients. MATERIAL AND METHODS A total of 129 low-risk and high-risk GTN patients who had received first-line chemotherapy were enrolled in this historical cohort study. The pretreatment NLR, LMR, and PLR values were analyzed to predict the resistance to first-line chemotherapy in low-risk and high-risk GTN patients. RESULTS Chemoresistant patients had significantly higher NLR than chemosensitive patients in low-risk and high-risk GTN patients (P<0.05). In high-risk GTN, patients with lower LMR and higher PLR tended to have chemoresistance to first-line chemotherapy (P=0.008, P=0.001). Univariate analysis revealed that the NLR, LMR, and PLR cut-off points of 2.654, 3.8, and 192.174, respectively, were associated with chemoresistance in high-risk GTN (P=0.0001, P=0.011, P=0.0001). The combination of NLR, PLR, and FIGO score in high-risk GTN was the best combination among other combinations with cut-off value >17 (P=0.001). CONCLUSIONS Higher NLR, lower LMR, and higher PLR were associated with chemoresistance for high-risk GTN patients. Furthermore, NLR, LMR, and PLR can improve the accuracy of predicting resistance to first-line chemotherapy in high-risk GTN.
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Affiliation(s)
| | - Ayu Insafi Mulyantari
- Department of Obstetrics and Gynecology, Dr. Hasan Sadikin Central General Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Andi Kurniadi
- Department of Obstetrics and Gynecology, Dr. Hasan Sadikin Central General Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Dodi Suardi
- Department of Obstetrics and Gynecology, Dr. Hasan Sadikin Central General Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Zulvayanti Zulvayanti
- Department of Obstetrics and Gynecology, Dr. Hasan Sadikin Central General Hospital, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
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Weng Y, Liu Y, Benjoed C, Wu X, Tang S, Li X, Xie X, Lu W. Evaluation and simplification of risk factors in FIGO 2000 scoring system for gestational trophoblastic neoplasia: a 19-year retrospective analysis. J Zhejiang Univ Sci B 2022; 23:218-229. [PMID: 35261217 DOI: 10.1631/jzus.b2100895] [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: 11/11/2022]
Abstract
OBJECTIVES The International Federation of Gynecology and Obstetrics (FIGO) 2000 scoring system classifies gestational trophoblastic neoplasia (GTN) patients into low- and high-risk groups, so that single- or multi-agent chemotherapy can be administered accordingly. However, a number of FIGO-defined low-risk patients still exhibit resistance to single-agent regimens, and the risk factors currently adopted in the FIGO scoring system possess inequable values for predicting single-agent chemoresistance. The purpose of this study is therefore to evaluate the efficacy of risk factors in predicting single-agent chemoresistance and explore the feasibility of simplifying the FIGO 2000 scoring system for GTN. METHODS The clinical data of 578 GTN patients who received chemotherapy between January 2000 and December 2018 were retrospectively reviewed. Univariate and multivariate logistic regression analyses were carried out to identify risk factors associated with single-agent chemoresistance in low-risk GTN patients. Then, simplified models were built and compared with the original FIGO 2000 scoring system. RESULTS Among the eight FIGO risk factors, the univariate and multivariate analyses identified that pretreatment serum human chorionic gonadotropin (hCG) level and interval from antecedent pregnancy were consistently independent predictors for both first-line and subsequent single-agent chemoresistance. The simplified model with two independent factors showed a better performance in predicting single-agent chemoresistance than the model with the other four non-independent factors. However, the addition of other co-factors did improve the efficiency. Overall, simplified models can achieve favorable performance, but the original FIGO 2000 prognostic system still features the highest discrimination. CONCLUSIONS Pretreatment serum hCG level and interval from antecedent pregnancy were independent predictors for both first-line and subsequent single-agent chemoresistance, and they had greater weight than other non-independent factors in predicting single-agent chemoresistance. The simplified model composed of certain selected factors is a promising alternative to the original FIGO 2000 prognostic system, and it shows comparable performance.
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Affiliation(s)
- Yang Weng
- Women's Reproductive Health Key Research Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Yuanyuan Liu
- Women's Reproductive Health Key Research Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Chitapa Benjoed
- Women's Reproductive Health Key Research Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Xiaodong Wu
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Sangsang Tang
- Women's Reproductive Health Key Research Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Xiao Li
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China.,Center for Uterine Cancer Diagnosis and Therapy Research of Zhejiang Province, Hangzhou 310006, China
| | - Xing Xie
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China.,Center for Uterine Cancer Diagnosis and Therapy Research of Zhejiang Province, Hangzhou 310006, China
| | - Weiguo Lu
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China. .,Center for Uterine Cancer Diagnosis and Therapy Research of Zhejiang Province, Hangzhou 310006, China. .,Cancer Center of Zhejiang University, Hangzhou 310058, China.
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Guo Z, Zhu C, Wang Y, Li Z, Wang L, Fan J, Xu Y, Zou N, Kong Y, Li D, Sui L. miR-30a targets STOX2 to increase cell proliferation and metastasis in hydatidiform moles via ERK, AKT, and P38 signaling pathways. Cancer Cell Int 2022; 22:103. [PMID: 35246136 PMCID: PMC8895545 DOI: 10.1186/s12935-022-02503-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 01/31/2022] [Indexed: 11/15/2022] Open
Abstract
Background A hydatidiform mole is a condition caused by abnormal proliferation of trophoblastic cells. MicroRNA miR-30a acts as a tumor suppressor gene in most tumors and participates in the development of various cancers. However, its role in hydatidiform moles is not clear. Methods Quantitative real-time reverse transcription PCR was used to verify the expression level of miR-30a and STOX2 (encoding storkhead box 2). Flow cytometry assays were performed to detect the cell cycle in cell with different expression levels of miR-30a and STOX2. Cell Cycle Kit-8, 5-ethynyl-2′-deoxyuridine, and colony formation assays were used to detect cell proliferation and viability. Transwell assays was used to test cell invasion and migration. Dual-luciferase reporter assays and western blotting were used to investigate the potential mechanisms involved. Result Low miR-30a expression promoted the proliferation, migration, and invasion of trophoblastic cells (JAR and HTR-8). Dual luciferase assays confirmed that STOX2 is a target of miR-30a and resisted the effect of upregulated miR-30a in trophoblastic cells. In addition, downregulation of STOX2 by miR-30a could activate ERK, AKT, and P38 signaling pathways. These results revealed a new mechanism by which ERK, AKT, and P38 activation by miR-30a/STOX2 results in excessive proliferation of trophoblast cells in the hydatidiform mole. Conclusions In this study, we found that miR-30a plays an important role in the development of the hydatidiform mole. Our findings indicate that miR-30a might promote the malignant transformation of human trophoblastic cells by regulating STOX2, which strengthens our understanding of the role of miR-30a in regulating trophoblastic cell transformation. Supplementary Information The online version contains supplementary material available at 10.1186/s12935-022-02503-3.
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Affiliation(s)
- Zhenzhen Guo
- Core Lab Glycobiol & Glycoengn, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Chenyu Zhu
- Core Lab Glycobiol & Glycoengn, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Youhui Wang
- Core Lab Glycobiol & Glycoengn, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Zhen Li
- Core Lab Glycobiol & Glycoengn, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Lu Wang
- Core Lab Glycobiol & Glycoengn, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Jianhui Fan
- Core Lab Glycobiol & Glycoengn, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Yuefei Xu
- Core Lab Glycobiol & Glycoengn, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Na Zou
- Department of Pathology, Dalian Municipal Women And Children's Medical Center, Dalian, 116044, Liaoning, People's Republic of China
| | - Ying Kong
- Core Lab Glycobiol & Glycoengn, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, Liaoning, China
| | - Dong Li
- Department of Pathology, Dalian Municipal Women And Children's Medical Center, Dalian, 116044, Liaoning, People's Republic of China
| | - Linlin Sui
- Core Lab Glycobiol & Glycoengn, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, Liaoning, China.
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11
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Meakin C, Barrett ES, Aleksunes LM. Extravillous trophoblast migration and invasion: Impact of environmental chemicals and pharmaceuticals. Reprod Toxicol 2022; 107:60-68. [PMID: 34838982 PMCID: PMC8760155 DOI: 10.1016/j.reprotox.2021.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/09/2021] [Accepted: 11/22/2021] [Indexed: 01/03/2023]
Abstract
During pregnancy, the migration and invasion of extravillous trophoblasts (EVTs) into the maternal uterus is essential for proper development of the placenta and fetus. During the first trimester, EVTs engraft and remodel maternal spiral arteries allowing for efficient blood flow and the transfer of essential nutrients and oxygen to the fetus. Aberrant migration of EVTs leading to either shallow or deep invasion into the uterus has been implicated in a number of gestational pathologies including preeclampsia, fetal growth restriction, and placenta accreta spectrum. The migration and invasion of EVTs is well-coordinated to ensure proper placentation. However, recent data point to the ability of xenobiotics to disrupt EVT migration. These xenobiotics include heavy metals, endocrine disrupting chemicals, and organic contaminants and have often been associated with adverse pregnancy outcomes. In most instances, xenobiotics appear to reduce EVT migration; however, there are select examples of enhanced motility after chemical exposure. In this review, we provide an overview of the 1) current experimental approaches used to evaluate EVT migration and invasion in vitro, 2) ability of environmental chemicals and pharmaceuticals to enhance or retard EVT motility, and 3) signaling pathways responsible for altered EVT migration that are sensitive to disruption by xenobiotics.
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Affiliation(s)
- Cassandra Meakin
- Department of Pharmacology and Toxicology, Rutgers University, Piscataway, NJ
| | - Emily S. Barrett
- Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, NJ,Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
| | - Lauren M. Aleksunes
- Department of Pharmacology and Toxicology, Rutgers University, Piscataway, NJ,Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, NJ,Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ,Center for Lipid Research, New Jersey Institute for Food, Nutrition, and Health, Rutgers University, New Brunswick, NJ
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12
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Jiang F, Lin JK, Xiang Y, Xu ZF, Wan XR, Feng FZ, Ren T, Yang JJ, Zhao J. The impact of pulmonary metastases on therapeutic response and prognosis in malignant gestational trophoblastic neoplasia patients: a retrospective cohort study. Eur J Cancer 2021; 161:119-127. [PMID: 34911640 DOI: 10.1016/j.ejca.2021.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/31/2021] [Accepted: 11/07/2021] [Indexed: 11/03/2022]
Abstract
AIM The lung is the most common site of metastasis for gestational trophoblastic neoplasia (GTN). However, the level of influence of lung metastases on the prognosis of GTN and the degree to which lung metastases are considered in assessments of disease treatment options are unclear. Moreover, it is unclear which characteristics of lung metastases impact the disease. In this study, we evaluated the influence of lung metastases on the clinical course of GTN and identified lung imaging characteristics that impact treatment outcomes. METHODS A retrospective cohort study was conducted on GTN patients treated at Peking Union Medical College Hospital between 2002 and 2018. The baseline characteristics, first-line treatment outcomes and final outcomes of patients with lung metastases (Group 1) and those without lung metastases (Group 2) were compared. RESULTS The emergence of resistance occurred significantly more frequently in Group 1 (n = 994) than in Group 2 (n = 570) (19.52% versus 14.56%, p = 0.019), and the death rate was higher in Group 1 (0.91% versus 0%, p = 0.031). Among the patients treated with multi-agent chemotherapy, the rate of resistance and the number of treatment courses were significantly higher in Group 1 than in Group 2 (p = 0.002 and < 0.001, respectively). The lung imaging characteristics that impacted prognosis included the number of nodules, whether there were multiple nodules or a single nodule, and the number of nodules sized >1 cm. Multivariate analysis showed that a nodule measuring ≥1.8 cm was an independent risk factor for first-line treatment resistance and recurrence. CONCLUSION Although pulmonary metastases do not affect overall survival in GTN patients, the presence of lung metastases before treatment is associated with increased risk of disease recurrence and resistance to first-line multidrug chemotherapy, especially when pulmonary nodules are larger than 1.8 cm. CLINICAL TRIAL REGISTRATION N.A.
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Affiliation(s)
- Fang Jiang
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Jin-Kai Lin
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Yang Xiang
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China.
| | - Zhuo-Fan Xu
- School of Medicine, Tsinghua University, 30 Shuangqing Road, Haidian District, Beijing, China
| | - Xi-Run Wan
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Feng-Zhi Feng
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Tong Ren
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Jun-Jun Yang
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
| | - Jun Zhao
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China
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13
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Taira Y, Shimoji Y, Nakasone T, Arakaki Y, Nakamoto T, Kinjo T, Kudaka W, Mekaru K, Aoki Y. A high-risk gestational trophoblastic neoplasia derived from a complete hydatidiform mole with coexisting fetus identified by short tandem repeats analysis: A case report. Case Rep Womens Health 2021; 31:e00336. [PMID: 34195021 PMCID: PMC8233190 DOI: 10.1016/j.crwh.2021.e00336] [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: 04/02/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 11/30/2022] Open
Abstract
A complete hydatidiform mole coexisting with a fetus (CHMCF) is a rare form of twin pregnancy. High-risk gestational trophoblastic neoplasia (GTN) can occur after a CHMCF pregnancy, although the frequency is low. In cases of GTN, the clinical diagnosis and that based on the International Federation of Gynecology and Obstetrics (FIGO) scoring system can differ. This case report concerns a patient with a choriocarcinoma that was initially diagnosed and treated as a low-risk stage III GTN following a live birth from a CHMCF pregnancy. We used short tandem repeat (STR) analysis to identify the causative pregnancy as the patient's earlier complete hydatidiform mole. Clinicians should anticipate a high-risk GTN when treating persistent trophoblastic disease (PTD) in patients with a non-typical course. A fetus and a complete hydatidiform mole can coexist as a twin pregnancy. A complete hydatidiform mole coexisting with a fetus can rarely cause choriocarcinoma. Short tandem repeat analysis can be used to identify causative pregnancies. Causative pregnancy is a risk factor for persistent trophoblastic disease.
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14
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Winter MC. Treatment of low-risk gestational trophoblastic neoplasia. Best Pract Res Clin Obstet Gynaecol 2021; 74:67-80. [PMID: 33741258 DOI: 10.1016/j.bpobgyn.2021.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/08/2021] [Indexed: 12/20/2022]
Abstract
Low-risk gestational trophoblastic neoplasia (GTN), defined as FIGO/WHO score 0-6, is highly curable with an overall survival rate, which is approximately 100%. For most low-risk GTN patients, first-line single-agent chemotherapy with either methotrexate or actinomycin-D is recommended with overall complete human chorionic gonadotrophin (hCG) response rates of 60%-90% in mostly retrospective, non-randomised studies. The few randomised trials that exist are not appropriately powered or designed to define the optimal first-line treatment. Approximately 25%-30% of low-risk patients will develop resistance to initial single-agent chemotherapy with an increase in the FIGO score, a diagnosis of choriocarcinoma, higher pre-treatment hCG and the presence of metastatic disease being associated with an increase in the risk of resistance. The optimal treatment of patients scoring WHO 5 and 6 remains poorly defined given that approximately 70%-80% of these patients develop resistance to first-line single-agent chemotherapy, and there is an urgent need to refine the FIGO/WHO scoring system so that these patients can be identified for more intensive therapy from the outset. Despite this, almost all low-risk patients who experience treatment failure with first-line monotherapy will be cured with either sequential single-agent chemotherapy or multiagent chemotherapy with or without surgery. Given the associated increased short and longer-term toxicities associated with multi-agent chemotherapy, promising strategies to reduce the exposure of women to combination chemotherapy in low-risk disease have been investigated, including the use of carboplatin and immune check-point inhibitors. Further evaluation is required to define optimal patient selection, particularly with the use of immunotherapeutic agents given their significant increased costs and lack of longer-term safety data. Although there is a clear need to revise the FIGO/WHO (2000) scoring system, consistent international use of this is recommended to facilitate the comparison of data along with future focus in the development of international collaborative translational and clinical research, including randomised controlled trials.
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Affiliation(s)
- Matthew C Winter
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, S10 2SJ, United Kingdom.
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15
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Wang K, Chen Y. Management and prognostic analysis of patients with gestational trophoblastic neoplasia (GTN) in FIGO stage IV and its special type. Clin Exp Metastasis 2020; 38:47-59. [PMID: 33219408 PMCID: PMC7882548 DOI: 10.1007/s10585-020-10064-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/08/2020] [Indexed: 11/17/2022]
Abstract
GTN is a group malignant diseases from placental trophoblastic cells. There are very few cases of GTN with FIGO (International Federation of Gynecology and Obstetrics) stage IV all over the world, and the special types (patients with metastatic lesions and with no evidence of GTN neither in genitalia nor in lungs) have rarely been reported. It is necessary to conduct large retrospective studies aimed at exploring the diagnosis, treatment and outcomes of this disease. In this retrospective study, 716 patients with GTN were treated at Zhejiang University School of Medicine Women’s Hospital between January 1999 and September 2019; 26 patients were diagnosed as stage IV GTN; Among the 26 stage IV GTN patients, 5 were defined as the special types. The 5-year OS rate of the total 26 FIGO stage IV GTN patients was 69.0%. There was no significant difference of survival rate between stage IV GTN and its special type. And no significant differences in blood type, antecedent pregnancy type, the interval from last known pregnancy, pretreatment serum HCG (human chorionic gonadotropin) level, maximum diameter of tumors, FIGO score, underwent surgery or not and pathological pattern by the outcomes. Age, number of tumor lesions, primary chemotherapy regimen was EMA-CO or EP-EMA protocol and chemoresponse affected the prognosis significantly. Only number of tumor lesions > 8 was independent prognostic factors associated with poorer OS.
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Affiliation(s)
- Kai Wang
- Department of Oncology, Zhejiang University School of Medicine Women's Hospital, No. 1 Xueshi Road, Hangzhou, China
| | - Yaxia Chen
- Department of Oncology, Zhejiang University School of Medicine Women's Hospital, No. 1 Xueshi Road, Hangzhou, China.
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16
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Epstein E, Joneborg U. Sonographic characteristics of post-molar gestational trophoblastic neoplasia at diagnosis and during follow-up, and relationship with methotrexate resistance. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:759-765. [PMID: 31909527 DOI: 10.1002/uog.21971] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/06/2019] [Accepted: 12/20/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To describe the sonographic characteristics of post-molar gestational trophoblastic neoplasia (GTN) at diagnosis and during follow-up, and to assess their association with methotrexate (MTX) resistance (R) as first-line chemotherapy. METHODS This was a retrospective study of all women treated for post-molar GTN at Karolinska University Hospital, Stockholm, Sweden, between October 2010 and December 2017, who had undergone expert transvaginal ultrasound assessment ≤ 2 weeks prior to, or ≤ 1 week after, the start of first-line MTX treatment. Women with a detectable uterine lesion were followed up with repeat scans during treatment, as well as after treatment in cases of persistent lesions. The association between MTX-R and sonographic findings at inclusion was assessed. RESULTS Of 47 eligible women, 36 were included in the analysis after excluding those who had not undergone structured transvaginal ultrasound assessment and those who started treatment at another center. The median age at diagnosis was 33 (interquartile range (IQR), 27-43) years and 35/36 (97%) women were in the FIGO low-risk group (risk score, 0-6). At inclusion, no uterine lesions were found in eight (22%) women, focal lesions in 24 (67%) women and global lesions in four (11%) women. Median maximum lesion diameter was 40.4 (IQR, 31.3-49.4) mm and 26/28 (93%) lesions had a color score of 3 or 4. Arteriovenous fistulas were found in 9/28 (32%) women and theca lutein cysts in 4/36 (11%) women. Four women with GTN lesion at inclusion underwent hysterectomy prior to the first follow-up ultrasound scan and a fifth woman with a growing lesion underwent hysterectomy, which revealed persistent viable trophoblastic tissue. All remaining women reached complete remission and median time to human chorionic gonadotropin normalization was 2.7 (IQR, 1.4-3.7) months. During ultrasound follow-up, 88% (21/24) of lesions resolved completely. Two women with a persisting lesion remained in complete remission. Median time to disappearance of vascularity was 5.8 (IQR, 3.7-9.3) months and median time to resolution of the lesion was 6.8 (IQR, 3.7-9.3) months. MTX-R developed in 12/31 (39%) women. Uterine tumors ≥ 4 cm (73% vs 17%; P = 0.008) and global lesions (25% vs 0%; P = 0.03) were significantly more common in women with compared to those without MTX-R. CONCLUSION Uterine lesions were detected at the time of diagnosis in 78% of women with post-molar GTN. The vast majority of the lesions resolved completely during follow-up, after a median of 7 months. MTX-R was more common in uterine tumors of 4 cm, or larger, and in global lesions. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Epstein
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Sodersjukhuset, Stockholm, Sweden
| | - U Joneborg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
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17
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Qiu Q, Zheng X. Comparison of effects of methotrexate/calcium folinate and actinomycin D on trophoblastic tumors. ALL LIFE 2020. [DOI: 10.1080/26895293.2020.1830186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Qian Qiu
- Fujian Maternal and Child Health Hospital, Fuzhou, People’s Republic of China
| | - Xiangqing Zheng
- Fujian Maternal and Child Health Hospital, Fuzhou, People’s Republic of China
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18
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Koźmiński P, Halik PK, Chesori R, Gniazdowska E. Overview of Dual-Acting Drug Methotrexate in Different Neurological Diseases, Autoimmune Pathologies and Cancers. Int J Mol Sci 2020; 21:ijms21103483. [PMID: 32423175 PMCID: PMC7279024 DOI: 10.3390/ijms21103483] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 02/07/2023] Open
Abstract
Methotrexate, a structural analogue of folic acid, is one of the most effective and extensively used drugs for treating many kinds of cancer or severe and resistant forms of autoimmune diseases. In this paper, we take an overview of the present state of knowledge with regards to complex mechanisms of methotrexate action and its applications as immunosuppressive drug or chemotherapeutic agent in oncological combination therapy. In addition, the issue of the potential benefits of methotrexate in the development of neurological disorders in Alzheimer’s disease or myasthenia gravis will be discussed.
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19
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Sharami SRY, Saffarieh E. A review on management of gestational trophoblastic neoplasia. J Family Med Prim Care 2020; 9:1287-1295. [PMID: 32509606 PMCID: PMC7266251 DOI: 10.4103/jfmpc.jfmpc_876_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The rare presence of malignant cancerous cells afar any type of pregnancy is known as gestational trophoblastic neoplasia (GTN). GTN are benign lesions which mostly happen due to the activity of extravillous trophoblast cells and the placental villous tree development. These kinds of diseases would be occurring mainly due to the following clinicopathologic conditions: (I) existence of epithelioid trophoblastic tumor (ETT), (II) rare type of choriocarcinoma cancer, (III) gestational trophoblastic tumor of mole, and (IV) the rare malignant tumor of placental site trophoblastic tumor. OBJECTIVE This comprehensive study is trying to review the most recent approaches in comprehension of pathogenesis, more precise diagnosis, and also the most effective therapeutic procedures for patients who suffer from GTN disorders. MATERIALS AND METHOD A comprehensive research was carried out on scientific databases of Science Citation Index (SCI), MEDLINE, EMBASE, HMIC, PubMed, CINAHL, Google Scholar, Cochrane Database of Systematic Reviews (CDSR), and PsycINFO over the time period of 2005 to 2019. The keywords which applied for discovering more related records were including: Gestational trophoblastic diseases (GTD), Gestational trophoblastic neoplasia (GTN), molar pregnancy, choriocarcinoma, human chorionic gonadotropin (hCG), diagnosis, management and treatment. CONCLUSION In spite of the fact that GTN patients are treated with conventional surgical therapies or/and chemotherapy, in some patients with resistant disease, these therapies may not be effective and patients may die. Some novel remedial agents are required for decreasing the level of toxicity caused through administering conventional chemotherapy and also treating the patients who suffer from refractory or resistant disease. The newest issues are related to GTN diagnosis, process of progression of hydatidiform mole (HM) to GTN, and the issue of GTN drug resistance. In this regard, we should have a comprehensive knowledge on GTN genetics for answering all the available questions about this disorder.
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Affiliation(s)
| | - Elham Saffarieh
- Abnormal Uterine Bleeding Research Center, Semnan University of Medical Science, Semnan, Iran
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20
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Batti R, Mokrani A, Rachdi H, Raies H, Touhami O, Ayadi M, Meddeb K, Letaief F, Yahiaoui Y, Chraiet N, Mezlini A. Gestational trophoblastic neoplasia: experience at Salah Azaiez Institute. Pan Afr Med J 2019; 33:121. [PMID: 31489099 PMCID: PMC6711693 DOI: 10.11604/pamj.2019.33.121.13897] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 04/14/2019] [Indexed: 02/07/2023] Open
Abstract
Gestational trophoblastic disease (GTD) develops from abnormal cellular proliferation of trophoblasts following fertilization. It includes benign trophoblastic disease (hydatidiform moles (HM)) and the malignant trophoblastic diseases or gestational trophoblastic neoplasia (GTN). The frequency of the GTD in Tunisia is one per 918 deliveries. The aim of this study is to analyze the clinical characteristics, treatment and outcomes of GTD at Salah Azaiez Institute (ISA). Medical records of women diagnosed with GTD at ISA from January 1st, 1981 to December 31st, 2012 were retrospectively reviewed. FIGO score was determined retrospectively for patients treated before 2002. One hundred and nine patients with GTN were included. Patients presented with metastases at 43% of cases. The most common metastatic sites were lung (30%) and vagina (13%). Fifty six (56 (51%) patients had low-risk and 21 (19%) cases had high-risk, the FIGO score was not assessed in 32 cases. After a median follow-up of 46 months, 21 patients were lost to follow-up, 12 patients died, 19 progressed and 8 relapsed. At 10 years, the OS rate was 85% and the PFS rate 79%. OS was significantly influenced by the presence of metastases at presentation (M0 100 % vs. Metastatic 62 %; p < 0.0001), FIGO stage (I-II 100% VS 61% and 65% for stage III and IV; p < 0.001), FIGO score (low-risk 99 % vs. high-risk 78 %; p < 0.001). GTN is a significant source of maternal morbidity with increased risk of mortality from complications if not detected early and treated promptly.
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Affiliation(s)
- Rim Batti
- Department of Medical Oncology at Salah Azaiz Institute, Tunis, Tunisia
| | - Amina Mokrani
- Department of Medical Oncology at Salah Azaiz Institute, Tunis, Tunisia
| | - Haifa Rachdi
- Department of Medical Oncology at Salah Azaiz Institute, Tunis, Tunisia
| | - Henda Raies
- Department of Medical Oncology at Salah Azaiz Institute, Tunis, Tunisia
| | - Omar Touhami
- "C" Department of Obstetrics and Gynecology, Tunis Maternity and Neonatology Center, Tunis, Tunisia
| | - Mouna Ayadi
- Department of Medical Oncology at Salah Azaiz Institute, Tunis, Tunisia
| | - Khadija Meddeb
- Department of Medical Oncology at Salah Azaiz Institute, Tunis, Tunisia
| | - Feryel Letaief
- Department of Medical Oncology at Salah Azaiz Institute, Tunis, Tunisia
| | - Yosra Yahiaoui
- Department of Medical Oncology at Salah Azaiz Institute, Tunis, Tunisia
| | - Nesrine Chraiet
- Department of Medical Oncology at Salah Azaiz Institute, Tunis, Tunisia
| | - Amel Mezlini
- Department of Medical Oncology at Salah Azaiz Institute, Tunis, Tunisia
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21
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Abstract
Gestational trophoblastic disease or neoplasia covers a spectrum of benign and malignant conditions arising from pregnancies with highly abnormal development of trophoblastic tissue. In this brief review, we discuss the different features of these different conditions and their origins and risk factors and introduce some of the more novel and controversial treatment options currently being explored.
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Affiliation(s)
- Fen Ning
- Guangzhou Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Houmei Hou
- Guangzhou Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Abraham N. Morse
- Guangzhou Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Gendie E. Lash
- Guangzhou Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
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22
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Braga A, Mora P, de Melo AC, Nogueira-Rodrigues A, Amim-Junior J, Rezende-Filho J, Seckl MJ. Challenges in the diagnosis and treatment of gestational trophoblastic neoplasia worldwide. World J Clin Oncol 2019; 10:28-37. [PMID: 30815369 PMCID: PMC6390119 DOI: 10.5306/wjco.v10.i2.28] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/12/2018] [Accepted: 01/01/2019] [Indexed: 02/06/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) is a rare tumor that originates from pregnancy that includes invasive mole, choriocarcinoma (CCA), placental site trophoblastic tumor and epithelioid trophoblastic tumor (PSTT/ETT). GTN presents different degrees of proliferation, invasion and dissemination, but, if treated in reference centers, has high cure rates, even in multi-metastatic cases. The diagnosis of GTN following a hydatidiform molar pregnancy is made according to the International Federation of Gynecology and Obstetrics (FIGO) 2000 criteria: four or more plateaued human chorionic gonadotropin (hCG) concentrations over three weeks; rise in hCG for three consecutive weekly measurements over at least a period of 2 weeks or more; and an elevated but falling hCG concentrations six or more months after molar evacuation. However, the latter reason for treatment is no longer used by many centers. In addition, GTN is diagnosed with a pathological diagnosis of CCA or PSTT/ETT. For staging after a molar pregnancy, FIGO recommends pelvic-transvaginal Doppler ultrasound and chest X-ray. In cases of pulmonary metastases with more than 1 cm, the screening should be complemented with chest computed tomography and brain magnetic resonance image. Single agent chemotherapy, usually Methotrexate (MTX) or Actinomycin-D (Act-D), can cure about 70% of patients with FIGO/World Health Organization (WHO) prognosis risk score ≤ 6 (low risk), reserving multiple agent chemotherapy, such as EMA/CO (Etoposide, MTX, Act-D, Cyclophosphamide and Oncovin) for cases with FIGO/WHO prognosis risk score ≥ 7 (high risk) that is often metastatic. Best overall cure rates for low and high risk disease is close to 100% and > 95%, respectively. The management of PSTT/ETT differs and cure rates tend to be a bit lower. The early diagnosis of this disease and the appropriate treatment avoid maternal death, allow the healing and maintenance of the reproductive potential of these women.
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Affiliation(s)
- Antonio Braga
- Postgraduate Program of Medical Sciences, Fluminense Federal University, Niterói 24033-900, Brazil
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Paulo Mora
- Postgraduate Program of Medical Sciences, Fluminense Federal University, Niterói 24033-900, Brazil
- Brazilian National Cancer, Hospital do Câncer 2, Rio de Janeiro 20220-410, Brazil
| | | | - Angélica Nogueira-Rodrigues
- Department of Internal Medicine, Faculty of Medicine, Minas Gerais Federal University, Belo Horizonte 30130-100, Brazil
| | - Joffre Amim-Junior
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Jorge Rezende-Filho
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, United Kingdom
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