1
|
Coopmans L, Larsson A, Joneborg U, Lok C, van Trommel N. Surgical Management of Gestational Trophoblastic Disease. Gynecol Obstet Invest 2023; 89:214-229. [PMID: 37788661 DOI: 10.1159/000534065] [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: 01/10/2023] [Accepted: 09/04/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Gestational trophoblastic disease (GTD) is a rare pregnancy-related condition consisting of premalignant and malignant forms arising from proliferation of trophoblastic cells. The malignant forms are collectively referred to as gestational trophoblastic neoplasia (GTN) and are highly sensitive to chemotherapy. However, surgical procedures remain indispensable in the diagnosis and treatment of GTD. OBJECTIVES The aim of this review was to summarize surgical interventions in the treatment of GTD and GTN. We reviewed indications, efficacy, possible complications, and oncological outcomes of surgery. METHODS Three searches were performed in the databases of PubMed, Embase, and the Cochrane Library to create an up-to-date overview of existing literature on the following subjects: (1) the role of primary hysterectomy in GTD and GTN; (2) the role of second curettage in GTD and GTN; (3) fertility sparing surgery in GTN; (4) surgical management of metastases. Included articles originated from the time period 1952-2022. Articles written in English, Spanish, and French were included. OUTCOMES Thirty-eight articles were found and selected. Surgical evacuation through suction curettage is most used and advised in the treatment of GTD. A second curettage could be beneficial in patients with low hCG levels and low FIGO scores. In women who have completed their families, primary hysterectomy might be considered as the risk of subsequent GTN is lower than after suction curettage. In case of the rare forms of GTN (epithelioid trophoblastic tumor or placental site trophoblastic tumor) surgical tumor resection remains the most important step in treatment. Data on fertility sparing surgery in GTN are scarce and this treatment should be considered experimental. CONCLUSION AND OUTLOOK Surgery remains an important part of treatment of GTD and is sometimes indispensable to achieve curation. Further collection of evidence is needed to determine treatment steps.
Collapse
Affiliation(s)
- Leonoor Coopmans
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands,
| | - Agnes Larsson
- Department of Gynecologic Cancer Surgery, Karolinska University Hospital and Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Ulrika Joneborg
- Department of Gynecologic Cancer Surgery, Karolinska University Hospital and Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Christianne Lok
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nienke van Trommel
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Kong Y, Wang W, Lin J, Wan X, Feng F, Ren T, Zhao J, Yang J, Xiang Y. Management and Predictors of Treatment Failure in Patients with Chemo-Resistant/Relapsed Gestational Trophoblastic Neoplasia with Lung Metastasis. J Clin Med 2022; 11:jcm11247270. [PMID: 36555889 PMCID: PMC9784534 DOI: 10.3390/jcm11247270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/26/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022] Open
Abstract
The aim of the study was to assess the effectiveness of a combined treatment modality of salvage chemotherapy and pulmonary resection in chemo-resistant/relapsed gestational trophoblastic neoplasia (GTN) with lung metastasis and identify predictors of treatment failure. Data of patients with chemo-resistant/relapsed GTN with lung metastasis who received salvage chemotherapy combined with pulmonary resection were retrospectively analyzed. Among 134 included patients, the number of preoperative chemotherapy regimens ranged from 2−8 (median, 3), and courses ranged from 4−37 (median, 14). Pulmonary lobectomies, segmentectomies, wedge resections, and lobectomies plus wedge resections were performed in 84, 5, 35, and 10 patients, respectively. After completion of treatment, 130 (97.0%) patients achieved complete remission. In the entire cohort, the 5-year overall survival (OS) rate was 87.6%. OS rates were similar between stage III and stage IV disease cohorts (89.4% vs. 75.0%, p = 0.137). Preoperative β-human chorionic gonadotropin (β-hCG) levels > 10 IU/L (p = 0.027) and number of preoperative chemotherapy regimens > 3 (p = 0.018) were predictors of treatment failure. The combined treatment modality of salvage chemotherapy and pulmonary resection is effective in patients with chemo-resistant/relapsed GTN with lung metastasis, improving their prognoses. Patients with preoperative serum β-hCG >10 IU/L and those with >3 chemotherapy regimens preoperatively may not benefit from this multidisciplinary treatment.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Junjun Yang
- Correspondence: (J.Y.); (Y.X.); Tel.: +86-6915-5635 (J.Y.); +86-6915-6068 (Y.X.)
| | - Yang Xiang
- Correspondence: (J.Y.); (Y.X.); Tel.: +86-6915-5635 (J.Y.); +86-6915-6068 (Y.X.)
| |
Collapse
|
3
|
Zhao L, Qin Y, Ma D, Liu H. Surgical treatment of lung metastasis in patients with refractory gestational trophoblastic neoplasia: A retrospective study. Gynecol Oncol 2022; 167:37-41. [PMID: 35931469 DOI: 10.1016/j.ygyno.2022.07.030] [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: 06/14/2022] [Revised: 07/23/2022] [Accepted: 07/29/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE The lungs are the most common site of metastasis in patients with gestational trophoblastic neoplasia. We investigated surgical management and prognostic factors of patients with refractory gestational trophoblastic neoplasia to assess the value of lung metastasis resection. PATIENTS AND METHODS The clinical data of patients with refractory gestational trophoblastic neoplasia and lung metastasis treated at Peking Union Medical College Hospital from January 2005 to December 2020 were retrospectively analyzed. Surgical characteristics and survival outcomes were analyzed. RESULTS In total, 213 patients with refractory gestational trophoblastic neoplasia and lung metastasis were screened, and 148 patients who underwent unilateral lung resection were analyzed. Patients' median age was 32 years. Lobectomy was performed in 65.5% of patients, while wedge resection was performed in 34.5%. The rate of postoperative complications was 12.2%. The pathological rate was 66.2%. Video-assisted thoracoscopic surgery showed better surgical characteristics than thoracotomy did. Compared with lobectomy, wedge resection had a shorter operative time, shorter duration of chest tube placement, shorter postoperative hospital stay, and fewer postoperative complications. The median follow-up period was 36 months. During follow-up, 90.5% of patients achieved complete remission. The 5-year disease-free and overall survival rates were 80.4% and 92.6%, respectively. More previous chemotherapy courses and failure to achieve normal β-human chorionic gonadotropin levels postoperatively were predictors of poor prognosis. CONCLUSIONS Surgical treatment of lung metastasis is valuable and safe for patients with refractory gestational trophoblastic neoplasia. The minimally invasive video-assisted thoracoscopic approach and wedge resection are recommended.
Collapse
Affiliation(s)
- Luo Zhao
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, China
| | - Yingzhi Qin
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, China
| | - Dongjie Ma
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, China
| | - Hongsheng Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, China.
| |
Collapse
|
4
|
Wang X, Cheng Y, Li W, Mao R, Zhu T, Lu J, Yue X, Lu X. Management of relapsed gestational trophoblastic neoplasia: What can help to reduce the re-recurrence rate? J Obstet Gynaecol Res 2022; 48:1451-1457. [PMID: 35289459 DOI: 10.1111/jog.15228] [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: 09/02/2021] [Revised: 12/29/2021] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
AIM To explore the risk factors for re-recurrence in relapsed gestational trophoblastic neoplasia (GTN) and therapeutic approaches to reduce the re-recurrence rate. METHODS Data of relapsed GTN treated in the Obstetrics and Gynecology Hospital of Fudan University from January 1, 2015, to December 31, 2020, were reviewed retrospectively. Risk factors associated with re-recurrence were analyzed using Logistic regression analysis. RESULTS A total of 39 relapsed GTN patients were included in our study. At the time of the first relapse, 14 patients received single-agent chemotherapy and 25 patients received multi-agent chemotherapy. Surgery was performed in 19 patients. Complete remission was achieved in all of the patients. Re-recurrence occurred in 21 patients. Univariate analysis suggested that unifocal recurrence was the only factor significantly associated with re-recurrence (OR = 0.25, p = 0.04). Recurrence pattern-based subgroup analysis showed that the proportion of re-recurrence was lower in patients who received both surgery and chemotherapy compared to those who received only chemotherapy in the unifocal recurrence group (3/11 vs. 2/4), but not in the non-unifocal recurrence group (7/8 vs. 9/16). The results of the multivariate analysis showed that there was no significant difference in re-recurrence rates between the surgical approaches and that the non-unifocal recurrence pattern was an independent risk factor for re-recurrence. CONCLUSIONS For relapsed GTN with unifocal recurrence pattern, surgical removal of the lesion can effectively reduce the re-recurrence rate.
Collapse
Affiliation(s)
- Xingran Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yu Cheng
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Wenzhi Li
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Runye Mao
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Tingting Zhu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Jiaqi Lu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xiaoni Yue
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xin Lu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| |
Collapse
|
5
|
Ngu SF, Ngan HYS. Surgery including fertility-sparing treatment of GTD. Best Pract Res Clin Obstet Gynaecol 2020; 74:97-108. [PMID: 33127305 PMCID: PMC7547826 DOI: 10.1016/j.bpobgyn.2020.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 01/01/2023]
Abstract
Gestational trophoblastic disease (GTD) consists of a spectrum of diseases, including hydatidiform moles, invasive mole, metastatic mole, choriocarcinoma, placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). GTD is a relatively uncommon disease occurring in women of reproductive age, with high cure rates. Primary treatment of hydatidiform moles includes uterine evacuation, followed by close monitoring of serial hCG levels to detect for post-molar gestational trophoblastic neoplasia (GTN). In patients with GTN, the main therapy consists of chemotherapy, although some surgical procedures are important in selected patients to achieve curing. Hysterectomy is the mainstay treatment for PSTT or ETT and may be considered in selected patients for management of hydatidiform mole and malignant GTN especially in chemoresistant disease. Resection of metastatic lesions such as in the lung or brain can be considered in selected patients with isolated chemoresistant tumour. Surgical treatment of GTD will be discussed in this chapter.
Collapse
Affiliation(s)
- Siew-Fei Ngu
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Queen Mary Hospital, 6/F Professorial Block, 102 Pokfulam Road, Hong Kong.
| | - Hextan Y S Ngan
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Queen Mary Hospital, 6/F Professorial Block, 102 Pokfulam Road, Hong Kong.
| |
Collapse
|
6
|
Yu H, Li J, Zhu T, Xue X, Lu X. Evaluation and influence of lung metastasis on patient outcome in gestational trophoblastic neoplasia: A 10-year study at a single institution. Eur J Obstet Gynecol Reprod Biol 2020; 251:162-166. [PMID: 32505789 DOI: 10.1016/j.ejogrb.2020.05.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the outcomes and related factors of gestational trophoblastic neoplasia (GTN) with lung metastasis in comparison with GTN without metastasis. STUDY DESIGN GTN is a spectrum of diseases arising from trophoblastic cells, and treatment outcome is promising because of its high sensitivity to chemotherapy. Lung metastasis is not usually considered to be an adverse prognostic factor in the evaluation and treatment of GTN. The clinical records of 48 GTN patients with lung metastasis and 162 GTN patients without metastasis were reviewed and analysed retrospectively from 2003 to 2013. Data were compared between patients with and without metastasis. RESULTS Twenty-five percent of GTN patients with lung metastasis presented with pre-treatment serum human chorionic gonadotropin ≥105 mIU/mL, which was significantly higher compared with GTN patients without metastasis (9.3 %, p < 0.01). Regarding the International Federation of Gynecology and Obstetrics (FIGO) score, 39.6 % of patients with lung metastasis were in the high-risk group (FIGO score ≥ 7), compared with 13.6 % of patients without metastasis (p < 0.01). However, on multi-variate analysis, only a FIGO score ≥7 was associated with lung metastasis. The relapse rate of GTN patients with lung metastasis was significantly higher than that of those without metastasis (8.3 % vs 0.6 %, p < 0.05). In the patients who relapsed, non-postmolar GTN, high-risk GTN and first-line chemoresistance were observed more frequently compared with the patients who did not relapse (p < 0.05). CONCLUSION GTN patients with lung metastasis appear to have increased risk of relapse compared with GTN patients without metastasis. To overcome this, there is a need to consider adjustment of the FIGO scoring system to enable GTN patients with lung metastasis to receive more intensive chemotherapy.
Collapse
Affiliation(s)
- Hailin Yu
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Jun Li
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Tingting Zhu
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Xiaohong Xue
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Xin Lu
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China.
| |
Collapse
|
7
|
Abu-Rustum NR, Yashar CM, Bean S, Bradley K, Campos SM, Chon HS, Chu C, Cohn D, Crispens MA, Damast S, Dorigo O, Eifel PJ, Fisher CM, Frederick P, Gaffney DK, Han E, Huh WK, Lurain JR, Mariani A, Mutch D, Nagel C, Nekhlyudov L, Fader AN, Remmenga SW, Reynolds RK, Sisodia R, Tillmanns T, Ueda S, Wyse E, McMillian NR, Scavone J. Gestational Trophoblastic Neoplasia, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:1374-1391. [PMID: 31693991 DOI: 10.6004/jnccn.2019.0053] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Gestational trophoblastic neoplasia (GTN), a subset of gestational trophoblastic disease (GTD), occurs when tumors develop in the cells that would normally form the placenta during pregnancy. The NCCN Guidelines for Gestational Trophoblastic Neoplasia provides treatment recommendations for various types of GTD including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - David Cohn
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | | | | | | | - John R Lurain
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - David Mutch
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Christa Nagel
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | - Todd Tillmanns
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Stefanie Ueda
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | |
Collapse
|
8
|
Do the Residual Lung Lesions Threaten Gestational Trophoblastic Neoplasia Patients? Int J Gynecol Cancer 2019; 28:1410-1417. [PMID: 30142125 DOI: 10.1097/igc.0000000000001311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Although most gestational trophoblastic neoplasias (GTN) are sensitive to chemotherapy, the treatment strategy of patients who achieve normal β-human chorionic gonadotropin (β-hCG) after the completion of treatment but with residual lung lesions is undefined, let alone whether residual lung lesions threaten GTN patients with acceptable recurrent risk factors. METHODS We observed 73 patients with stage III and stage IV GTN treated at the Department of Obstetrics and Gynecology, Tongji Hospital between September 2007 and August 2016. Among these patients, 46 women confirmed to have residual lung lesions with normalized β-hCG titer levels at 6 weeks after the completion of treatment, and the other 27 were without residual lung lesions. Statistical analysis was used to compare the progression-free survival of these 73 patients. RESULTS The follow-up period of all 73 patients ranged from 6 to 115 months. Six women relapsed with GTN. There were no significant statistical differences (P > 0.05) between the progression-free survival of the patients with residual lung lesions and those without, even in the subgroup of patients with GTN with recurrent risk factors. CONCLUSIONS After the achievement of normalized β-hCG by sufficient chemotherapy, residual lung lesions do not alter the prognosis of patients with GTN, even if the patients are with other recurrent risk factors.
Collapse
|
9
|
Complete Resection Is Essential in the Surgical Treatment of Gestational Trophoblastic Neoplasia. Int J Gynecol Cancer 2018; 28:1453-1460. [PMID: 30157165 DOI: 10.1097/igc.0000000000001348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the utility of surgery in patients with gestational trophoblastic neoplasia (GTN). MATERIALS AND METHODS We performed a retrospective institutional review board-approved analysis of all patients with GTN at a single institution from 1985 to 2015 and compared all patients who underwent surgery as definitive management for their disease to a matched cohort of those who did not. Kaplan-Meier curves were used to estimate progression-free survival (PFS) and overall survival (OS). RESULTS Sixty-nine patients underwent a total of 94 surgeries as definitive treatment for GTN. Nineteen patients had multiple surgeries. Progression-free survival and OS were improved in patients with complete macroscopic surgical resection (n = 61) compared with patients with gross residual disease (n = 33) (median PFS 91.2 months vs 3.3 months, and median OS not reached at 108.8 months vs 66.3 months, respectively; P < 0.05). The nature of the surgery (emergent vs planned) and site of metastatic disease did not influence PFS or OS. Of the 61 patients with no visible residual disease, 17 received adjuvant chemotherapy and 44 did not; there were no observed differences in PFS or OS. Patients who underwent surgery as part of definitive treatment (n = 69 patients) were compared with patients with GTN over the same period who received chemotherapy alone (n = 33 patients). Median PFS was improved in the surgical group (5.9 vs 5.1 months, P < 0.01), but OS was not significantly different (P = 0.37). CONCLUSIONS Complete resection results in improved outcomes in patients who undergo surgery for GTN, whether emergent or planned, independent of disease site, and should be considered as an important component of treatment in some situations.
Collapse
|