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Horne AW, Tong S, Moakes CA, Middleton LJ, Duncan WC, Mol BW, Whitaker LHR, Jurkovic D, Coomarasamy A, Nunes N, Holland T, Clarke F, Doust AM, Daniels JP. Combination of gefitinib and methotrexate to treat tubal ectopic pregnancy (GEM3): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet 2023; 401:655-663. [PMID: 36738759 DOI: 10.1016/s0140-6736(22)02478-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 10/26/2022] [Accepted: 11/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Tubal ectopic pregnancies can cause substantial morbidity or even death. Current treatment is with methotrexate or surgery. Methotrexate treatment fails in approximately 30% of women who subsequently require rescue surgery. Gefitinib, an epidermal growth factor receptor inhibitor, might improve the effects of methotrexate. We assessed the efficacy of oral gefitinib with methotrexate, versus methotrexate alone, to treat tubal ectopic pregnancy. METHODS We performed a multicentre, randomised, double-blind, placebo-controlled trial across 50 UK hospitals. Participants diagnosed with tubal ectopic pregnancy were administered a single dose of intramuscular methotrexate (50 mg/m2) and randomised (1:1 ratio) to 7 days of additional oral gefitinib (250 mg daily) or placebo. The primary outcome, analysed by intention to treat, was surgical intervention to resolve the ectopic pregnancy. Secondary outcomes included time to resolution of ectopic pregnancy and serious adverse events. This trial is registered at the ISRCTN registry, ISCRTN 67795930. FINDINGS Between Nov 2, 2016, and Oct 6, 2021, 328 participants were allocated to methotrexate and gefitinib (n=165) or methotrexate and placebo (n=163). Three participants in the placebo group withdrew. Surgical intervention occurred in 50 (30%) of 165 participants in the gefitinib group and in 47 (29%) of 160 participants in the placebo group (adjusted risk ratio 1·15, 95% CI 0·85 to 1·58; adjusted risk difference -0·01, 95% CI -0·10 to 0·09; p=0·37). Without surgical intervention, median time to resolution was 28·0 days in the gefitinib group and 28·0 days in the placebo group (subdistribution hazard ratio 1·03, 95% CI 0·75 to 1·40). Serious adverse events occurred in five (3%) of 165 participants in the gefitinib group and in six (4%) of 162 participants in the placebo group. Diarrhoea and rash were more common in the gefitinib group. INTERPRETATION In women with a tubal ectopic pregnancy, adding oral gefitinib to parenteral methotrexate does not offer clinical benefit over methotrexate and increases minor adverse reactions. FUNDING National Institute of Health Research.
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Affiliation(s)
- Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK.
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Catherine A Moakes
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - W Colin Duncan
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Lucy H R Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Davor Jurkovic
- Institute for Women's Health, University College Hospital, London, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, University of Birmingham, Birmingham, UK
| | - Natalie Nunes
- Department of Obstetrics and Gynaecology, West Middlesex University Hospital, Chelsea and Westminster Hospital Foundation Trust, London, UK
| | - Tom Holland
- Department of Obstetrics and Gynaecology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fiona Clarke
- Department of Obstetrics and Gynaecology, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - Ann M Doust
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Jane P Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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2
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Leziak M, Żak K, Frankowska K, Ziółkiewicz A, Perczyńska W, Abramiuk M, Tarkowski R, Kułak K. Future Perspectives of Ectopic Pregnancy Treatment-Review of Possible Pharmacological Methods. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192114230. [PMID: 36361110 PMCID: PMC9656791 DOI: 10.3390/ijerph192114230] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/22/2022] [Accepted: 10/26/2022] [Indexed: 06/03/2023]
Abstract
Ectopic pregnancy, that is, a blastocyst occurring outside the endometrial cavity of the uterus, affects nearly 2% of pregnancies. The treatment of ectopic pregnancy is surgical or pharmacological. Since surgical management is associated with numerous serious side effects, conservative treatment is sought. The treatment of choice in the majority of cases is based on pharmacotherapy with methotrexate (MTX) in a single- or multi-dose regimen. Although the efficacy of methotrexate reaches between 70 and 90%, its use requires specific conditions regarding both the general condition of the patient and the characteristic features of the ectopic pregnancy. Moreover, MTX can cause severe adverse effects, including stomatitis, hepatotoxicity and myelosuppression. Therefore, clinicians and researchers are still looking for a less toxic, more effective treatment, which could prevent surgeries as a second-choice treatment. Some studies indicate that other substances might constitute a good alternative to methotrexate in the management of ectopic pregnancies. These substances include aromatase inhibitors, especially letrozole. Another promising substance in EP treatment is gefitinib, an inhibitor of EGFR tyrosine domain which, combined with MTX, seems to constitute a more effective alternative in the management of tubal ectopic pregnancies. Other substances for local administration include KCl and absolute ethanol. KCl injections used in combination with MTX may be used when foetal heart function is detected in cervical ectopic pregnancies, as well as in heterotopic pregnancy treatment. Absolute ethanol injections proved successful and safe in caesarean scar pregnancies management. Thus far, little is known about the use of those substances in the treatment of ectopic pregnancies, but already conducted studies seem to be promising.
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Affiliation(s)
- Milena Leziak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Klaudia Żak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Karolina Frankowska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Aleksandra Ziółkiewicz
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Weronika Perczyńska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Monika Abramiuk
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
| | - Rafał Tarkowski
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
| | - Krzysztof Kułak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
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3
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Effects of Gefitinib, an Epidermal Growth Factor Receptor Inhibitor, on Human Placental Cell Growth: Correction. Obstet Gynecol 2021; 137:962. [PMID: 33878056 DOI: 10.1097/aog.0000000000004380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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4
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Shu C, Yu X, Cheng S, Jing J, Hu C, Pang B. Pristimerin Suppresses Trophoblast Cell Epithelial-Mesenchymal Transition via miR-542-5p/EGFR Axis. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:4659-4670. [PMID: 33173276 PMCID: PMC7646443 DOI: 10.2147/dddt.s274595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/18/2020] [Indexed: 12/31/2022]
Abstract
Background Ectopic pregnancy (EP) is an ectopic embryo implantation occurred outside the uterine cavity. Nowadays, more attention have garnered in fast and effective treatment with less side effects. Pristimerin is known as the clinical application for anti-cancer, and the effect on EP therapy is still unclear. Materials and Methods Trophoblast cell line HTR-8/SVneo was used; then, we performed cell counting kit-8 assay, wound healing assay, flow cytometry and real-time polymerase chain reaction analysis (RT-PCR) to detect the cell viability, migration ability, apoptosis and epithelial–mesenchymal transition (EMT) under pristimerin treatment. In addition, public bioinformatic database was used to discover the connection between molecular and genes. Finally, we used miRNA transfection and RT-PCR techniques to determine the underlying molecular mechanism. Results We revealed that pristimerin inhibited trophoblast cells proliferation, migration and EMT, while induced trophoblast cell apoptosis. Furthermore, expression of miR-542-5p, AGO2 and EGFR was suppressed in HTR-8/SVneo cells post pristimerin treatment, and miR-542-5p silence showed the same effect. Combing pristimerin treatment and miR-542-5p silence showed a synergistic action. Conclusion Pristimerin could be an effective treatment to block embryo implantation by miR-542-5p and EGFR down-regulation.
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Affiliation(s)
- Chang Shu
- Department of Obstetrics and Gynecology, The First Hospital of Jilin University, Changchun, Jilin 130021, People's Republic of China
| | - Xiaowei Yu
- Centre for Reproductive Medicine, Centre for Prenatal Diagnosis, The First Hospital of Jilin University, Changchun, Jilin 130021, People's Republic of China
| | - Shihuan Cheng
- Department of Rehabilitation, The First Hospital of Jilin University, Changchun, Jilin 130021, People's Republic of China
| | - Jili Jing
- Centre for Reproductive Medicine, Centre for Prenatal Diagnosis, The First Hospital of Jilin University, Changchun, Jilin 130021, People's Republic of China
| | - Cong Hu
- Centre for Reproductive Medicine, Centre for Prenatal Diagnosis, The First Hospital of Jilin University, Changchun, Jilin 130021, People's Republic of China.,Department of Rehabilitation, The First Hospital of Jilin University, Changchun, Jilin 130021, People's Republic of China
| | - Bo Pang
- Central Laboratory, The First Hospital of Jilin University, Changchun, Jilin 130021, People's Republic of China.,Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130021, People's Republic of China
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5
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Targeting colony stimulating factor-1 receptor signalling to treat ectopic pregnancy. Sci Rep 2020; 10:15638. [PMID: 32973322 PMCID: PMC7519033 DOI: 10.1038/s41598-020-72785-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/07/2020] [Indexed: 11/08/2022] Open
Abstract
1–2% of pregnancies are ectopic, the majority implanting in the Fallopian tube. A single, systemic dose of methotrexate, a DNA-synthesis (S phase) inhibitor, has been used since 1991 for outpatient treatment of women with stable EP. However, methotrexate has limited clinical and cost effectiveness, restricting its use to 25–30% of these women. There is an unmet need for better medical treatment for EP. Colony stimulating factor-1 (CSF-1) promotes placentation and creates a pro-inflammatory environment that is fundamental for the maintenance of a normal pregnancy. We hypothesised that CSF-1 is also involved in the placentation and maintenance of an EP. Herein, we demonstrate the immunolocalisation of the CSF-1 receptor (CSF-1R) as well as its ligand (CSF-1) in immortalised first trimester trophoblast cells. We show that a specific CSF-1R kinase inhibitor, GW2580, abolishes CSF-1 induced trophoblast cell proliferation and migration and can be cytotoxic. We then demonstrate the expression of CSF-1R and CSF-1 in the cytotrophoblast and syncytiotrophoblast within ectopic implantation sites from women with EP. Our data suggests that CSF-1 is involved in the survival and proliferation of trophoblast cells in EP. This suggests that pharmacological disruption of CSF-1/CSF-1R signaling axis could be the basis of a new therapeutic for EP.
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6
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The untapped potential of placenta-enriched molecules for diagnostic and therapeutic development. Placenta 2019; 84:28-31. [PMID: 30745114 DOI: 10.1016/j.placenta.2019.02.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/19/2019] [Accepted: 02/02/2019] [Indexed: 12/27/2022]
Abstract
Pregnancy complications such as fetal growth restriction and preeclampsia are diseases with limited biomarkers for prediction, and a complete lack of therapeutic options. We define placenta-enriched molecules as those that are highly expressed in the placenta relative to all other human tissues. Many exist including mRNAs, miRNAs and proteins. It is now well established that placenta-enriched mRNAs are found within the maternal circulation and are cleared rapidly after birth. Similarly, distinct clusters of miRNAs that are placenta-enriched have been identified and are measurable within the circulation. However, perhaps the most established potential diagnostics thus far are circulating placental proteins such as placental growth factor (PlGF), pregnancy associated pregnancy protein-A (PAPP-A) and soluble FMS-like tyrosine kinase 1 (sFlt-1). There has also been much interest in targeting placenta-enriched molecules as a means to treat diseases of pregnancy. We have shown promising results in targeting placenta-enriched epidermal growth factor receptor (EGFR) to treat ectopic pregnancy. Others have focused on using placenta-enriched molecules as a means of homing therapeutic-filled nanoparticles to the placenta, or to directly target sFlt-1 to improve disease outcomes. Importantly, many placenta-enriched molecules remain largely unstudied. We propose that a better understanding of their biology, and potential contribution to the pathogenesis of diseases, may yield more predictive diagnostic and therapeutic targets.
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7
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May J, Duncan C, Mol B, Bhattacharya S, Daniels J, Middleton L, Hewitt C, Coomarasamy A, Jurkovic D, Bourne T, Bottomley C, Peace-Gadsby A, Doust A, Tong S, Horne AW. A multi-centre, double-blind, placebo-controlled, randomised trial of combination methotrexate and gefitinib versus methotrexate alone to treat tubal ectopic pregnancies (GEM3): trial protocol. Trials 2018; 19:643. [PMID: 30458863 PMCID: PMC6247635 DOI: 10.1186/s13063-018-3008-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/20/2018] [Indexed: 11/12/2022] Open
Abstract
Background Tubal ectopic pregnancy (tEP) is the most common life-threatening condition in gynaecology. Treatment options include surgery and medical management. Stable women with tEPs with pre-treatment serum human chorionic gonadotrophin (hCG) levels < 1000 IU/L respond well to outpatient medical treatment with intramuscular methotrexate. However, tEPs with hCG > 1000 IU/L can take significant time to resolve with methotrexate and require multiple outpatient monitoring visits. In pre-clinical studies, we found that tEP implantation sites express high levels of epidermal growth factor receptor. In early-phase trials, we found that combination therapy with gefitinib, an orally active epidermal growth factor receptor antagonist, and methotrexate resolved tEPs without the need for surgery in over 70% of cases, did not cause significant toxicities, and was well tolerated. We describe the protocol of a randomised trial to assess the efficacy of combination gefitinib and methotrexate, versus methotrexate alone, in reducing the need for surgical intervention for tEPs. Methods and analysis We propose to undertake a multi-centre, double-blind, placebo-controlled, randomised trial (around 70 sites across the UK) and recruit 328 women with tEPs (with pre-treatment serum hCG of 1000–5000 IU/L). Women will be randomised in a 1:1 ratio by a secure online system to receive a single dose of intramuscular methotrexate (50 mg/m2) and either oral gefitinib or matched placebo (250 mg) daily for 7 days. Participants and healthcare providers will remain blinded to treatment allocation throughout the trial. The primary outcome is the need for surgical intervention for tEP. Secondary outcomes are the need for further methotrexate treatment, time to resolution of the tEP (serum hCG ≤ 15 IU/L), number of hospital visits associated with treatment (until resolution or scheduled/emergency surgery), and the return of menses by 3 months after resolution. We will also assess adverse events and reactions until day of resolution or surgery, and participant-reported acceptability at 3 months. Discussion A medical intervention that reduces the need for surgery and resolves tEP faster would be a favourable treatment alternative. If effective, we believe that gefitinib and methotrexate could become standard care for stable tEPs. Trial registration ISRCTN Registry ISRCTN67795930. Registered 15 September 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-3008-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James May
- Simpsons Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Colin Duncan
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Ben Mol
- Monash Health, Monash Medical Centre, Melbourne, Australia
| | - Siladitya Bhattacharya
- Obstetrics and Gynaecology, Division of Applied Clinical Sciences, University of Aberdeen, Aberdeen Maternity Hospital, Aberdeen, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen's Medical Centre, Nottingham, UK
| | - Lee Middleton
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Catherine Hewitt
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Birmingham Women's Hospital, Birmingham, UK
| | - Davor Jurkovic
- Gynaecology Diagnostic and Treatment Unit, University College Hospital, London, UK
| | - Tom Bourne
- Obstetrics and Gynaecology, Chelsea and Westminster NHS Hospital Foundation Trust, London, UK
| | | | | | - Ann Doust
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Stephen Tong
- University of Melbourne, Mercy Hospital for Women, Melbourne, Australia
| | - Andrew W Horne
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4SA, UK.
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8
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Jachymski T, Moczulska H, Guzowski G, Pomorski M, Piątek S, Zimmer M, Rokita W, Wielgoś M, Sieroszewski P. Conservative treatment of abnormally located intrauterine pregnancies (cervical and cesarean scar pregnancies): a multicenter analysis (Polish series). J Matern Fetal Neonatal Med 2018; 33:993-998. [PMID: 30122076 DOI: 10.1080/14767058.2018.1514009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objectives: To analyze the effectiveness and outcome of conservative treatment in cases of abnormally located intrauterine pregnancies (cervical and cesarean scar).Study design: A retrospective analysis was performed of 30 pregnant women hospitalized due to abnormally located intrauterine pregnancies. The analyzed group comprised 24 pregnant women with abnormally located pregnancies. The patients were divided into two groups: the first group consisted of patients treated systemically with methotrexate, while the second of those treated locally by administration of methotrexate (MTX) and/or potassium chloride (KCl) by gestational sac puncture.Results: The analyzed group comprised 24 pregnant women with abnormally located pregnancies. Eight patients were diagnosed with cervical pregnancy (CP) and 16 patients were diagnosed with cesarean scar pregnancy (CSP). Six patients were excluded from the study: two with spontaneous abortions, two heterotopic pregnancies, and two cornual pregnancies. Twelve analyzed patients underwent MTX systemic administration (five patients with CP, seven with CSP). In five patients, systemic treatment was ineffective; they were qualified for additional local therapy with gestational sac (GS) puncture and MTX or KCl administration to the sac and additional administration of MTX to the trophoblast area. In second group of 12 patients (three CP, nine CSP), local treatment (GS puncture with MTX or MTX + KCl) was used as the first line treatment. One patient underwent combined treatment (local + systemic).Conclusions: Conservative treatment should be the gold standard procedure in abnormally located intrauterine pregnancies. It is noticeable that MTX / KCl is more effective in a direct administration to the GS. In four cases, systemic MTX did not produce the desired effects. In these cases, the treatment was assisted by local administration of MTX or KCl, resulting in the termination of an abnormally located pregnancy.
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Affiliation(s)
- Tomasz Jachymski
- Department of Fetal Medicine and Gynaecology, Medical University of Lodz, Lodz, Poland
| | - Hanna Moczulska
- Department of Fetal Medicine and Gynaecology, Medical University of Lodz, Lodz, Poland.,Department of Clinical Genetics, Medical University of Lodz, Lodz, Poland
| | - Grzegorz Guzowski
- Department of Fetal Medicine and Gynaecology, Medical University of Lodz, Lodz, Poland
| | - Michał Pomorski
- II Department of Gynaecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Szymon Piątek
- 1st Department of Obstetrics and Gynaecology, Medical University of Warsaw, Warsaw, Poland
| | - Mariusz Zimmer
- II Department of Gynaecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Wojciech Rokita
- Department of Obstetrics and Gynaecology, the Jan Kochanowski University in Kielce, Kielce, Poland
| | - Mirosław Wielgoś
- 1st Department of Obstetrics and Gynaecology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Sieroszewski
- Department of Fetal Medicine and Gynaecology, Medical University of Lodz, Lodz, Poland
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9
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Skubisz MM, Tong S, Doust A, Mollison J, Johns TG, Neil P, Robinson M, Bhattacharya S, Wallace E, Krzys N, Colin Duncan W, Horne AW. Gefitinib and Methotrexate to Treat Ectopic Pregnancies with a Pre-Treatment Serum hCG 1000-10,000 IU/L: Phase II Open Label, Single Arm Multi-Centre Trial. EBioMedicine 2018; 33:276-281. [PMID: 29941341 PMCID: PMC6085507 DOI: 10.1016/j.ebiom.2018.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 06/05/2018] [Accepted: 06/12/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Ectopic pregnancies are a leading cause of maternal mortality. Most are treated surgically. We evaluated the efficacy and safety of combining oral gefitinib (epidermal growth factor receptor inhibitor) with methotrexate to treat larger ectopic pregnancies. METHODS We performed a phase II, single arm, open label study across four hospitals in Edinburgh and Melbourne. We recruited women with a stable tubal ectopic pregnancy and a pre-treatment serum hCG between 1000 and 10,000 IU/L. We administered intramuscular methotrexate (50 mg/m2) once, and oral gefitinib (250 mg) for seven days. The primary outcome was the percentage successfully treated without needing surgery. To show the treatment is at least 70% effective, 28 participants were required, and 24 or more successfully treated without surgery. Secondary outcomes were safety, tolerability, and time to resolution. This study is registered (ACTRN12611001056987). FINDINGS 30 participants with stable tubal ectopic pregnancies were recruited but two withdrew, leaving 28 participants. The median (± range) pre-treatment serum hCG was 2039 (1031-8575) IU/L and nine had pre-treatment hCGs levels >3000 IU/L. The treatment successfully resolved 86% (24/28) cases with a median (±range) time to resolution of 32 (18-67) days. The treatment caused transient rash and diarrhoea, but no serious adverse events. INTERPRETATION Combination gefitinib and methotrexate is at least 70% effective in resolving ectopic pregnancies with a pre-treatment serum hCG 1000-10,000 IU/L. This may be a new way to treat most stable ectopic pregnancies, but needs to be validated via a randomised clinical trial.
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Affiliation(s)
- Monika M Skubisz
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg 3084, Victoria, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia; The Hudson Institute, Clayton 3168, Australia; Monash Health, Clayton 3168, Victoria, Australia
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg 3084, Victoria, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia.
| | - Ann Doust
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom
| | - Jill Mollison
- University of Oxford, Nuffield Department of Primary Health Sciences, Oxford OX2 6GG, United Kingdom
| | | | - Peter Neil
- Monash Health, Clayton 3168, Victoria, Australia
| | - Miranda Robinson
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia
| | - Siladitya Bhattacharya
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, United Kingdom
| | - Euan Wallace
- The Hudson Institute, Clayton 3168, Australia; Monash Health, Clayton 3168, Victoria, Australia
| | - Nicole Krzys
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg 3084, Victoria, Australia
| | - W Colin Duncan
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom
| | - Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom
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10
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Eliesen GAM, van den Broek P, van den Heuvel JJ, Bilos A, Pertijs J, van Drongelen J, Russel FGM, Greupink R. Editor's Highlight: PlacentalDisposition and Effects of Crizotinib: An Ex Vivo Study in the Isolated Dual-Side Perfused Human Cotyledon. Toxicol Sci 2018; 157:500-509. [PMID: 28369651 DOI: 10.1093/toxsci/kfx063] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs) play an important role in cancer pharmacotherapy, yet there is limited data on their use during pregnancy. We studied placental disposition and placental toxicity of crizotinib, a TKI used to treat nonsmall cell lung cancer. Term placentas were perfused for 3 h with crizotinib (1 µM) using the ex vivo dual-side cotyledon perfusion technique. Interference of TKIs with trophoblast viability was studied using BeWo cells. Expression of P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP) in placental tissue was assessed by immunohistochemistry and inhibition of these transporters was determined in vitro by transport studies with membrane vesicles overexpressing human P-gp or BCRP. We found that crizotinib rapidly and strongly accumulates in cotyledon perfusion experiments, reaching a concentration of 3.1 ± 0.4 µM in placental tissue. Final drug concentrations in the maternal and foetal reservoirs were 0.2 ± 0.05 and 0.08 ± 0.01 µM, respectively. Furthermore, crizotinib inhibited BeWo cell viability (IC50: 234 nM, 95% CI: 167-328 nM) 10 times more potently than other TKIs tested. In vitro transport studies revealed that crizotinib is a potent inhibitor of the transport activities of BCRP (IC50: 5.7 µM, 95% CI: 2.7-11.8 µM) and P-gp (IC50: 7.8 µM, 95% CI: 3.4-18.0 µM). In conclusion, crizotinib strongly accumulated in placental tissue at clinically relevant concentrations. IC50 values for transporter inhibition and trophoblast cell viability were similar to the tissue concentrations reached, suggesting that crizotinib can inhibit placental BCRP and P-gp function and possibly affect trophoblast viability.
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Affiliation(s)
- Gaby A M Eliesen
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Petra van den Broek
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Jeroen J van den Heuvel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Albert Bilos
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Jeanne Pertijs
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frans G M Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Rick Greupink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
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11
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Hastie R, Lim E, Sluka P, Campbell L, Horne AW, Ellett L, Hannan NJ, Brownfoot F, Kaitu'u-Lino TJ, Tong S. Vinorelbine Potently Induces Placental Cell Death, Does Not Harm Fertility and is a Potential Treatment for Ectopic Pregnancy. EBioMedicine 2018; 29:166-176. [PMID: 29429891 PMCID: PMC5925452 DOI: 10.1016/j.ebiom.2018.01.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/15/2018] [Accepted: 01/31/2018] [Indexed: 11/30/2022] Open
Abstract
Ectopic pregnancies complicate 1–2 pregnancies and are a leading cause of maternal death. An effective oral drug therapy that replaces surgery might make its treatment safer, cheaper, simpler and therefore more widely accessible. The only current medical treatment offered to women is intramuscular methotrexate, but this only reliably resolves smaller ectopic pregnancies. As such, many ectopic pregnancies require surgical excision. We show that vinorelbine, an orally available chemotherapeutic agent, potently induced placental cell death but did not harm fertility in mice. Vinorelbine was 100–1000 times more potent than methotrexate in inducing placental cell death in vitro, and more potent than combination methotrexate and gefitinib (another proposed treatment for ectopic pregnancy being evaluated in phase III trials). Mechanistically, it caused microtubule condensation, blocked mitosis and activated the apoptosis cascade in placental cells. Vinorelbine was more efficacious than methotrexate ± gefitinib in reducing the volume of placental cell tumors xenografted subcutaneously in SCID mice. Mice exposed to vinorelbine and allowed to breed, following a four week washout period, displayed normal fertility, however long-term fertility was not assessed. Human Fallopian tubes treated with vinorelbine did not exhibit up-regulation of apoptosis molecules. Our findings show that placental cells appear sensitive to vinorelbine and it has potential as a tablet-only approach to treat ectopic pregnancy. We have identified vinorelbine, a well tolerated chemotherapeutic, as a potential therapeutic for ectopic pregnancy. Vinorelbine potently reduced placental cell viability in-vitro and in-vivo and proved more efficacious than the current medical therapeutic. Vinorelbine did not impact upon subsequent fertility in a mouse breeding model.
Ectopic pregnancy occurs when a conceptus implants outside of the womb. They are life threating and are a leading cause of maternal death in early pregnancy. Currently, the large majority of ectopic pregnancies are removed surgical, partly owing to the limited efficacy of the only available medical therapeutic, methotrexate. Here, we have identified a potential new medical therapeutic for ectopic pregnancy, vinorelbine. Vinorelbine, which is orally available chemotherapeutic, reduced placental cell viability both in-vitro and in-vivo and did not impact upon mice fertility in a breeding model. As such, vinorelbine may be an efficacious treatment for ectopic pregnancy and further human studies into its application are warranted.
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Affiliation(s)
- Roxanne Hastie
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia.
| | - Elgene Lim
- Connie Johnson Breast Cancer Research Group, Garvan Institute of Medical Research, Sydney, Australia
| | - Pavel Sluka
- Uro-Oncology Laboratory, Monash University, Eastern Health Clinical School, Melbourne, Australia
| | - Lisa Campbell
- MRC Centre for Reproductive Health, The University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Andrew W Horne
- MRC Centre for Reproductive Health, The University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | | | - Natalie J Hannan
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
| | - Fiona Brownfoot
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
| | - Tu'uhevaha J Kaitu'u-Lino
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
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12
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Liu JL, Zhao M. Prioritization of Susceptibility Genes for Ectopic Pregnancy by Gene Network Analysis. Int J Mol Sci 2016; 17:ijms17020191. [PMID: 26840308 PMCID: PMC4783925 DOI: 10.3390/ijms17020191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/14/2016] [Accepted: 01/27/2016] [Indexed: 01/25/2023] Open
Abstract
Ectopic pregnancy is a very dangerous complication of pregnancy, affecting 1%–2% of all reported pregnancies. Due to ethical constraints on human biopsies and the lack of suitable animal models, there has been little success in identifying functionally important genes in the pathogenesis of ectopic pregnancy. In the present study, we developed a random walk–based computational method named TM-rank to prioritize ectopic pregnancy–related genes based on text mining data and gene network information. Using a defined threshold value, we identified five top-ranked genes: VEGFA (vascular endothelial growth factor A), IL8 (interleukin 8), IL6 (interleukin 6), ESR1 (estrogen receptor 1) and EGFR (epidermal growth factor receptor). These genes are promising candidate genes that can serve as useful diagnostic biomarkers and therapeutic targets. Our approach represents a novel strategy for prioritizing disease susceptibility genes.
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Affiliation(s)
- Ji-Long Liu
- College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China.
| | - Miao Zhao
- College of Veterinary Medicine, South China Agricultural University, Guangzhou 510642, China.
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13
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Hirbo J, Eidem H, Rokas A, Abbot P. Integrating Diverse Types of Genomic Data to Identify Genes that Underlie Adverse Pregnancy Phenotypes. PLoS One 2015; 10:e0144155. [PMID: 26641094 PMCID: PMC4671692 DOI: 10.1371/journal.pone.0144155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/14/2015] [Indexed: 11/18/2022] Open
Abstract
Progress in understanding complex genetic diseases has been bolstered by synthetic approaches that overlay diverse data types and analyses to identify functionally important genes. Pre-term birth (PTB), a major complication of pregnancy, is a leading cause of infant mortality worldwide. A major obstacle in addressing PTB is that the mechanisms controlling parturition and birth timing remain poorly understood. Integrative approaches that overlay datasets derived from comparative genomics with function-derived ones have potential to advance our understanding of the genetics of birth timing, and thus provide insights into the genes that may contribute to PTB. We intersected data from fast evolving coding and non-coding gene regions in the human and primate lineage with data from genes expressed in the placenta, from genes that show enriched expression only in the placenta, as well as from genes that are differentially expressed in four distinct PTB clinical subtypes. A large fraction of genes that are expressed in placenta, and differentially expressed in PTB clinical subtypes (23–34%) are fast evolving, and are associated with functions that include adhesion neurodevelopmental and immune processes. Functional categories of genes that express fast evolution in coding regions differ from those linked to fast evolution in non-coding regions. Finally, there is a surprising lack of overlap between fast evolving genes that are differentially expressed in four PTB clinical subtypes. Integrative approaches, especially those that incorporate evolutionary perspectives, can be successful in identifying potential genetic contributions to complex genetic diseases, such as PTB.
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Affiliation(s)
- Jibril Hirbo
- Department of Biological Sciences, Vanderbilt University, Box 35164 Station B, Nashville, TN, 37235–1634, United States of America
| | - Haley Eidem
- Department of Biological Sciences, Vanderbilt University, Box 35164 Station B, Nashville, TN, 37235–1634, United States of America
| | - Antonis Rokas
- Department of Biological Sciences, Vanderbilt University, Box 35164 Station B, Nashville, TN, 37235–1634, United States of America
| | - Patrick Abbot
- Department of Biological Sciences, Vanderbilt University, Box 35164 Station B, Nashville, TN, 37235–1634, United States of America
- * E-mail:
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14
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Capmas P, Fernandez H. Effectiveness of gefitinib in combination with methotrexate in the treatment of ectopic pregnancy. Int J Womens Health 2015; 7:673-6. [PMID: 26170723 PMCID: PMC4498725 DOI: 10.2147/ijwh.s55556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Medical management for ectopic pregnancy is subject to substantial variations with different protocols and various routes of administration. Regardless the protocol used, methotrexate is currently the medical treatment of choice for ectopic pregnancy. The risk of a rescue surgery is a main concern. Recently, some studies suggested combining gefitinib and methotrexate to improve medical treatment and to decrease the need for reinjection and for additional surgery. Gefitinib is an orally administered EGF receptor-tyrosine kinase inhibitor. For tubal ectopic pregnancy, median recovery time was shorter after combination treatment with gefitinib and methotrexate. Toxicity reported with combination treatment was acneiform rash in 67% of cases and diarrhea in 42%. They were always transient and are known side effects of gefitinib previously described in lung cancer. These preliminary results are very promising but need to be explored further before wide distribution. For ectopic pregnancy, combining treatment seems to be interesting but results of the first randomized trial have to be evaluated first. For other indications, such as non-tubal ectopic pregnancy or choriocarcinoma, randomized studies are needed before wide use of the combination in current practice.
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Affiliation(s)
- Perrine Capmas
- Inserm, Centre of Research in Epidemiology and Population Health (CESP), Bicetre Hospital, GHU Sud, AP-HP, Le Kremlin Bicêtre, France
| | - Hervé Fernandez
- Department of Gynecology, Bicetre Hospital, GHU Sud, AP-HP, Le Kremlin Bicêtre, France
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15
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Misme H, Agostini A, Dubernard G, Tourette C. [Indications for methotrexate in gynecology outside the first-line treatment of ectopic tubal pregnancies]. J Gynecol Obstet Hum Reprod 2015; 44:220-229. [PMID: 25666162 DOI: 10.1016/j.jgyn.2014.12.015] [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: 11/13/2014] [Accepted: 12/02/2014] [Indexed: 06/04/2023]
Abstract
The objective of this work is to discuss the indications for methotrexate in gynecology outside the first-line treatment of tubal ectopic pregnancy. In tubal ectopic pregnancy, the prophylactic use of systemic methotrexate can be discussed when performing laparoscopic salpingotomy. In case of failure of salpingotomy, administration seems justified especially if it avoids re-intervention. The combination of methotrexate with other therapies such as mifepristone, potassium chloride or gefitinib is not recommended in the treatment of ectopic pregnancy. For non-tubal ectopic pregnancy, the intramuscular or local administration of methotrexate is an acceptable treatment for uncomplicated interstitial pregnancies. For uncomplicated cervical or cesarean scar pregnancies, the local administration of methotrexate should be considered as a first-line treatment. For ovarian pregnancies, methotrexate should not be a first-line treatment, surgical treatment remains the standard. Asymptomatic women presenting with a pregnancy of unknown location and plateauing serum hCG concentration<2000 UI/L can be managed expectantly: it is recommended to take an additional quantitative hCG serum level after 48 hours. Thus, methotrexate is not recommended in the first intention. Other gynecological indications were discussed: methotrexate is not recommended in the management of first-trimester miscarriages or in the management of placenta accreta.
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Affiliation(s)
- H Misme
- Service de gynécologie-obstétrique de l'hôpital de la Croix-Rousse, hospices civils de Lyon, 103, Grand rue de la Croix-rousse, 69004 Lyon, France.
| | - A Agostini
- Service de gynécologie-obstétrique, CHU de La Conception, 147, boulevard Baille, 13385 Marseille cedex 05, France
| | - G Dubernard
- Service de gynécologie-obstétrique de l'hôpital de la Croix-Rousse, hospices civils de Lyon, 103, Grand rue de la Croix-rousse, 69004 Lyon, France
| | - C Tourette
- Service de gynécologie-obstétrique, CHU de La Conception, 147, boulevard Baille, 13385 Marseille cedex 05, France.
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Tong S, Skubisz MM, Horne AW. Molecular diagnostics and therapeutics for ectopic pregnancy. Mol Hum Reprod 2014; 21:126-35. [PMID: 25232044 DOI: 10.1093/molehr/gau084] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Ectopic pregnancies are a serious gynaecological emergency that can be fatal. As such, prompt diagnosis and safe timely treatment is essential. Here, we review the literature on the development of molecularly targeted diagnostics and therapeutics for ectopic pregnancy. A blood-based biomarker that accurately identifies an ectopic pregnancy could be used to offer early diagnostic certainty in cases where ultrasound cannot determine the location of the embryo ('a pregnancy of unknown location'). Molecules examined so far can be broadly grouped into biological themes of relevance to reproduction: (i) Fallopian tube (dys)function, (ii) embryo/trophoblast growth, (iii) corpus luteum function, (iv) inflammation, (v) uterine function and (vi) angiogenesis. While a sensitive and specific biomarker for ectopic pregnancy has yet to be identified, it is possible that improvements in platform technologies or a multi-modal biomarker approach may yield an accurate diagnostic biomarker test. Furthermore, with the advent of better imaging technology, the need for a blood-based biomarker test may be superseded by improvements in ultrasound or magnetic resonance imaging technology. There have been some recent preclinical studies describing molecularly targeted therapeutic approaches for ectopic pregnancy. Notably, bench-to-bedside studies have examined the use of combination gefitinib (orally available epidermal growth factor receptor inhibitor) and methotrexate. Preclinical studies suggest that combination gefitinib and methotrexate is highly effective in inducing placental cell death, and is significantly more effective than methotrexate alone. In early human trials, encouraging preliminary efficacy data have shown that combination gefitinib and methotrexate can rapidly resolve tubal ectopic pregnancies, and large extra-tubal ectopic pregnancies. If a large clinical randomized controlled trial confirms these findings, combination gefitinib and methotrexate could become a new medical treatment option for ectopic pregnancy.
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Affiliation(s)
- Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, Mercy Hospital for Women, University of Melbourne, 163 Studley Rd, Heidelberg 3084, Australia
| | - Monika M Skubisz
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, Mercy Hospital for Women, University of Melbourne, 163 Studley Rd, Heidelberg 3084, Australia
| | - Andrew W Horne
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh EH16 4TJ, UK
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17
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Horne A, Skubisz M, Tong S, Duncan W, Neil P, Wallace E, Johns T. Combination gefitinib and methotrexate treatment for non-tubal ectopic pregnancies: a case series. Hum Reprod 2014; 29:1375-9. [PMID: 24812320 PMCID: PMC4059335 DOI: 10.1093/humrep/deu091] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Non-tubal ectopic pregnancies are a rare subgroup of ectopic pregnancies implanted at sites other than the Fallopian tube. Mortality from non-tubal ectopic pregnancies is higher compared with that for tubal ectopic pregnancies, and they are becoming more common, partly due to the rising incidence of Caesarean sections and use of assisted reproductive technologies. Non-tubal ectopic pregnancies can be especially difficult to treat. Surgical treatment is complex, and follow-up after medical treatment is usually protracted. There is therefore a need for more effective medical therapies to resolve non-tubal ectopic pregnancies and reduce operative intervention. We have recently reported successful use of combination gefitinib (an orally available epidermal growth factor receptor inhibitor) and methotrexate for treatment of tubal pregnancies. To our knowledge, this combination has not been used to treat non-tubal pregnancies. Here we report the use of combination gefitinib and methotrexate to treat eight women with stable, non-tubal ectopic pregnancies at two tertiary academic teaching hospitals (Edinburgh, UK and Melbourne, Australia); five interstitial and three Caesarean section scar ectopic pregnancies. Pretreatment serum hCG levels ranged from 2458 to 48 550 IU/l, and six women had pretreatment hCG levels >5000 IU/l. The women were co-administered 1-2 doses of i.m. methotrexate (50 mg/m² on Day 1, ± Day 4 or Day 7) with seven once daily doses of oral gefitinib (250 mg). The women were monitored until complete resolution of the ectopic pregnancy, defined as a serum hCG <15 IU/l. Time to resolution (days from first methotrexate dose until serum hCG <15 IU/l), safety and tolerability, complication rates and subsequent fertility outcomes were also recorded. All eight women were successfully treated with combination gefitinib and methotrexate. The most common side effects were transient acne/rash and diarrhoea, known side effects of gefitinib. All women promptly resumed menstruation and importantly, three women subsequently conceived spontaneously. Two have delivered a healthy infant at term and the third is currently in her second trimester of pregnancy. Hence, our case series supports a future clinical trial to determine the efficacy of combination gefitinib and methotrexate to treat non-tubal ectopic pregnancies.
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Affiliation(s)
- A.W. Horne
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh EH16 4TJ, UK
- Correspondence address. MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh EH16 4TJ, UK. Tel: +44-131-242-2694; Fax: +44-131-242-3441; E-mail:
| | - M.M. Skubisz
- Translational Obstetrics Group, University of Melbourne, Mercy Hospital for Women, Heidelberg, VIC 3084, Australia
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, VIC 3168, Australia
| | - S. Tong
- Translational Obstetrics Group, University of Melbourne, Mercy Hospital for Women, Heidelberg, VIC 3084, Australia
| | - W.C. Duncan
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, Edinburgh EH16 4TJ, UK
| | - P. Neil
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, VIC 3168, Australia
| | - E.M. Wallace
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, VIC 3168, Australia
| | - T.G. Johns
- Centre for Cancer Research, Monash Institute of Medical Research, Monash University, Clayton, VIC 3168, Australia
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18
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Capmas P, Bouyer J, Fernandez H. Treatment of ectopic pregnancies in 2014: new answers to some old questions. Fertil Steril 2014; 101:615-20. [DOI: 10.1016/j.fertnstert.2014.01.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/16/2014] [Accepted: 01/16/2014] [Indexed: 10/25/2022]
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20
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Skubisz MM, Horne AW, Johns TG, Nilsson UW, Duncan WC, Wallace EM, Critchley HOD, Tong S. Combination gefitinib and methotrexate compared with methotrexate alone to treat ectopic pregnancy. Obstet Gynecol 2013; 122:745-751. [PMID: 24084530 DOI: 10.1097/aog.0b013e3182a14cfb] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine the safety, tolerability, and efficacy of combination gefitinib and methotrexate to treat ectopic pregnancy. METHODS We performed a phase I, single-arm (nonrandomized), open-label study. Twelve women with ectopic pregnancies were administered methotrexate (50 mg/m, intramuscular) and 250 mg oral gefitinib in a dose-escalation protocol: one dose (day 1) n=3; three doses (days 1-3) n=3; seven doses (days 1-7) n=6. Efficacy was examined by comparing human chorionic gonadotrophin (hCG) decline and time to resolution with historic controls administered methotrexate only. RESULTS Common side effects were transient acneiform rash in 67% (8/12) and diarrhea in 42% (5/12) of participants. There was no clinical or biochemical evidence of serious pulmonary, renal, hepatic, or hematologic toxicity. Of six participants with a pretreatment serum hCG level between 1,000 and 3,000 international units/L, hCG levels declined significantly faster than in the control group. Median serum hCG levels by day 7 after treatment were less than one fifth of levels observed among 71 historic controls treated with methotrexate alone (median [interquartile range] hCG in participants 261 [55-1,445] international units/L compared with controls 1,426 [940-2,573]; P=.008). Median time for the ectopic pregnancies to resolve with combination therapy was 34% shorter compared with methotrexate alone (21 days compared with 32 days; P=.018). CONCLUSION Combination gefitinib and methotrexate has potential as a treatment for ectopic pregnancy but is commonly associated with minor side effects such as transient rash and diarrhea. The treatment requires validation of safety and efficacy in a larger trial. CLINICAL TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, www.anzctr.org, AC'TRN12610000684022. LEVEL OF EVIDENCE : II.
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Affiliation(s)
- Monika M Skubisz
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Heidelberg, and the Ritchie Centre and the Centre for Cancer Research, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia; and the MRC Centre for Reproductive Health, the Queen's Medical Research Institute, Edinburgh, United Kingdom
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21
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Horne AW, Skubisz MM, Doust A, Duncan WC, Wallace E, Critchley HOD, Johns TG, Norman JE, Bhattacharya S, Mollison J, Rassmusen M, Tong S. Phase II single arm open label multicentre clinical trial to evaluate the efficacy and side effects of a combination of gefitinib and methotrexate to treat tubal ectopic pregnancies (GEM II): study protocol. BMJ Open 2013; 3:bmjopen-2013-002902. [PMID: 23872290 PMCID: PMC3717468 DOI: 10.1136/bmjopen-2013-002902] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Tubal ectopic pregnancy (tEP) is the most common life-threatening condition in gynaecology. tEPs with pretreatment serum human chorionic gonadotrophin (hCG) levels <1000 IU/L respond well to outpatient medical treatment with intramuscular methotrexate (MTX). TEPs with hCG >1000 IU/L take a significant time to resolve with MTX and require multiple outpatient monitoring visits. Gefitinib is an orally active epidermal growth factor receptor (EGFR) antagonist. In preclinical studies, we found that EP implantation sites express high levels of EGFR and that gefitinib augments MTX-induced regression of pregnancy-like tissue. We performed a phase I toxicity study administering oral gefitinib and intramuscular MTX to 12 women with tEPs. The combination therapy did not cause significant toxicities and was well tolerated. We noted that combination therapy resolved the tEPs faster than MTX alone. We now describe the protocol of a larger single arm trial to estimate the efficacy and side effects of combination gefitinib and MTX to treat stable tEPs with hCG 1000-10 000 IU/L METHODS AND ANALYSIS: We propose to undertake a single-arm multicentre open label trial (in Edinburgh and Melbourne) and recruit 28 women with tEPs (pretreatment serum hCG 1000-10 000 IU/L). We intend to give a single dose of intramuscular MTX (50 mg/m(2)) and oral gefitinib (250 mg) daily for 7 days. Our primary outcome is the resolution of EP to non-pregnant hCG levels <15 IU/L without requirement of surgery. Our secondary outcomes are comparison of time to resolution against historical controls given MTX only, and safety and tolerability as determined by clinical/biochemical assessment. ETHICS AND DISSEMINATION Ethical approval has been obtained from Scotland A Research Ethics Committee (MREC 11/AL/0350), Southern Health Human Research Ethics Committee B (HREC 11180B) and the Mercy Health Human Research Ethics Committee (R12/25). Data will be presented at international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ACTRN12611001056987.
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Affiliation(s)
- Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
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