Surgical resection in the management of pulmonary metastatic disease of gestational trophoblastic neoplasia

Effect of lung metastasis on the treatment and prognosis of patients with gestational trophoblastic neoplasia: A systematic review and meta-analysis

INTRODUCTION

Gestational trophoblastic neoplasia (GTN) is a highly invasive tumor, mainly spreading to the lungs. However, lung metastasis in GTN is usually not considered as an adverse prognostic factor. Therefore, the aim of this study was to summarize the results of previous studies and evaluate the effects of lung metastasis on the treatment and prognosis of GTN.

MATERIAL AND METHODS

The study was prospectively registered in PROSPERO (CRD42023372371). Electronic databases including PubMed, Embase, the Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang, and China Biomedical Literature Database were used for a systematical search of relevant studies published up to November 21, 2022. The observational studies reporting the clinical outcomes of GTN patients with and without lung metastasis were selected. The incidences of resistance, relapse, and mortality of GTN patients were extracted and successively grouped based on the presence of lung metastasis. The pooled relative risks (RRs) and 95% confidence interval (95% CI) of the eligible studies were calculated. The qualities of included studies were assessed with the Newcastle-Ottawa Scale and the certainty of evidence was graded based on the GRADE. The meta-analysis was performed using Stata 12.0 and GradePro software.

RESULTS

Five publications with 3629 GTN patients were included. The meta-analysis revealed that the GTN with lung metastasis was strongly correlated with first-line chemoresistance (pooled RR = 1.40, 95% CI: 1.22 to 1.61, p < 0.001), recurrence (pooled RR = 3.03, 95% CI: 1.21 to 7.62, p = 0.018), and disease-specific death (pooled RR = 22.11, 95% CI: 3.37 to 145.08, p = 0.001). Ethnicity was also an important factor and Caucasian GTN patients with lung metastasis showed a higher risk of recurrence as revealed by the subgroup analysis (pooled RR = 5.10, 95% CI: 2.38 to 10.94, p < 0.001).

CONCLUSIONS

GTN patients with lung metastasis exhibited a higher risk of chemoresistance, relapse, and disease-specific death. Patients with lung metastasis among the Caucasian population had a higher risk of recurrence than Asian populations. Therefore, the presence of lung metastases might be considered as a high-risk factor for prognosis of GTN and deserves more attention in the choice of first-line chemotherapy regimens and follow-up.

Surgical Management of Gestational Trophoblastic Disease

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.

Pulmonary resection of residual lesions of pulmonary metastasis from gestational trophoblastic neoplasia

OBJECTIVE

To evaluate the prognosis and recurrence in patients with residual lesions of pulmonary metastasis from gestational trophoblastic neoplasia after initial treatment, and to explore the clinical significance of pulmonary resection.

METHODS

A retrospective analysis was performed on 606 patients with residual lesions from pulmonary metastasis after receiving standardized chemotherapy as initial treatment in Peking Union Medical College Hospital from January 2002 to December 2018. Patients were divided into surgery (51 patients) and non-surgery (555 patients) groups. The prognosis of these patients was compared. Risk factors affecting recurrence were analyzed to explore the effect of pulmonary resection.

RESULTS

Among low risk patients, complete remission rate was 100% and recurrence rate was <1% in both groups. Among high risk patients, complete remission and recurrence rates were 93.5% and 10.3% in the surgery group and 94.7% and 14.3% in the non-surgery group, respectively. There was no significant difference in prognostic features between the two groups (all p>0.05). No significant difference was found in recurrence rates based on recurrence risk factors (≥3.2 cm residual lung lesions, prognosis score ≥9.0, and drug resistance) between the two groups (all p>0.05).

CONCLUSION

After standardized chemotherapy, pulmonary resection was not necessary for initially treated stage III gestational trophoblastic neoplasia patients whose blood β human chorionic gonadotropin levels normalized and residual lung lesions remained stable. These patients should be closely monitored during follow-up, regardless of the size of the residual lung lesions or high/low risk score, especially within a year after complete remission.

Management and Predictors of Treatment Failure in Patients with Chemo-Resistant/Relapsed Gestational Trophoblastic Neoplasia with Lung Metastasis

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.

Role of Salvage Surgery in Gestational Trophoblastic Neoplasia: a Regional Cancer Centre Experience

Gestational trophoblastic neoplasia (GTN) is a curable cancer with chemotherapy. However, some develop chemoresistance to standard chemotherapy and surgery can be a useful option in them. Our study aimed to assess the role of salvage surgery in GTN with chemoresistance. It is a retrospective hospital-based study from 2000 to 2021. Case sheets of women who underwent salvage surgery for chemoresistance were reviewed and clinical parameters like preoperative hCG, antecedent pregnancy, WHO risk score, multiple chemotherapy regimens prior surgery, presence of > 1 disease site, and presence of residual choriocarcinoma that predicted the effect of surgery on serological response were assessed using Fisher's exact test. A total of 19 patients with high-risk GTN developed chemoresistance and underwent salvage surgery. Eight underwent hysterectomy, 3 underwent hysterectomy plus adnexal tumour resection, six received fertility-sparing surgery, and two underwent segmental resection of the lung. Histopathological examination revealed viable tumour in 7/19 patients, but significant fall in median hCG level from 161.5 mIU/ml (preoperatively) to 15.5 mIU/ml (postoperatively) was noted. Preoperative hCG < 100 mIU/ml (p = 0.019) was the most important determinant of complete response to surgery. All the patients who had disease confined to the uterus and/or lungs at the time of surgery achieved remission after completion of treatment. Our study concludes that in the case of chemoresistant high-risk GTN, carefully selected cases with low hCG levels and disease confined to the uterus and/or lungs get the most benefit of surgery. The use of postoperative chemotherapy after complete response is essential to maintain remission and prevent relapse.

Surgical treatment of lung metastasis in patients with refractory gestational trophoblastic neoplasia: A retrospective study

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.

High-intensity focused ultrasound ablation as an adjuvant surgical salvage procedure in gestational trophoblastic neoplasia chemotherapy with chemoresistance or recurrence: two case reports

BACKGROUND

Chemotherapy is the main treatment strategy for gestational trophoblastic neoplasia (GTN). Surgical resection is crucial to deal with chemoresistance and recurrence following chemotherapy. The aim of this study was to explore if high-intensity focused ultrasound (HIFU) can be used as a complementary technique to surgical procedures in the management of GTN.

CASE REPORT

This case report described two females who previously developed chemoresistance or recurrence during chemotherapy and then underwent HIFU as an adjuvant surgical salvage procedure. For high-risk GTN patients with chemoresistance, HIFU treatment decreased the risk of chemoresistance and shortened the course of chemotherapy. It also reduced the dosage of chemotherapeutic agents used for the patient who suffered a recurrence.

CONCLUSION

For patients with GTN who desire to preserve their uterus, HIFU may be used as a complementary technique to surgical resection in the management of GTN.

Doppler-based predictive model for methotrexate resistance in low-risk gestational trophoblastic neoplasia with myometrial invasion: prospective study of 147 patients

OBJECTIVES

This prospective clinical study aimed to evaluate the vascularization characteristics of low-risk gestational trophoblastic neoplasia (GTN) using Doppler imaging and to develop a predictive model for resistance to methotrexate (MTX).

METHODS

Patients with low-risk GTN receiving primary MTX treatment were enrolled from the Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China, from September 2012 to August 2018. The primary endpoint was to develop and internally validate a predictive model for resistance to MTX therapy in these patients. In the training set, clinical features and Doppler hemodynamic parameters before MTX therapy were analyzed using logistic regression to identify independent predictors of MTX resistance, which were integrated into the model. The predictive performance of the model was evaluated by leave-one-out cross-validation in the training dataset and internal validation in an independent-sample test dataset.

RESULTS

The entire imaging protocol was completed by 147 eligible patients, of which 110 comprised the training set and 37 the test set. In the training set, cases with myometrial invasion (81.8%; 90/110) showed vascular-enriched areas in the myometrium and high velocity and low impedance ratios of the uterine artery (UtA) compared to cases without myometrial invasion (18.2%; 20/110). On multivariate logistic regression analysis, time-averaged mean velocity in UtA (UtA-TAmean) and the International Federation of Gynecology and Obstetrics (FIGO) score were identified as independent predictors (P = 0.009 and P = 0.043, respectively) of MTX resistance. The Doppler-based predictive model, developed based on the 90 cases with myometrial invasion, was y = -2.95332 + 0.41696 × FIGO score + 0.03551 × UtA-TAmean. The model showed an area under the curve of 0.757 (95% CI, 0.653-0.862) and the optimal cut-off value was 0.50622, which had 45.2% sensitivity and 96.6% specificity. The model stratified patients with low-risk GTN into low (< 10%), intermediate (10-90%) and high (> 90%) probability of MTX resistance, based on the threshold values of -1.59544 and 0.10046. The model had an accuracy of 74.4% (95% CI, 64.5-82.3%) in the cross-validation and 72.7% (95% CI, 55.8-84.9%) in the internal validation.

CONCLUSIONS

The Doppler-based predictive model, combining a non-invasive marker of tumor vascularity with the FIGO scoring system, can differentiate cases with low from those with high probability of developing MTX resistance and therefore has the potential to guide treatment options in patients with low-risk GTN and myometrial invasion. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Following chemotherapy for gestational trophoblastic neoplasia, do residual lung lesions increase the risk of relapse?

BACKGROUND

There remains uncertainty about the prognostic significance of residual lung lesion on imaging after completion of treatment of low- or high-risk gestational trophoblastic neoplasia (GTN). Here, we determine if such residual lung lesions are associated with an increased risk of relapse.

METHODS

We retrospectively screened our electronic database to identify patients with low- or high-risk GTN and lung metastases between 2004 and 18. Recurrences among patients with or without residual lung lesions on imaging were compared. Chi square analysis and Kaplan-Meier survival curves were constructed. As the numbers of cases were low, we combined this data with our previously published and non-overlapping patient cohort (1995-2004).

RESULTS

Of 1304 GTN patients treated at our centre between 2004 and 18, 99 had lung metastases without other distant sites. There were 40 patients (40.4%) with residual lung lesions. Whilst an increased rate of relapse was observed among patients with residual lung lesions (4/40; 10.0%) compared to without such lesions (3/59; 5.1%), this difference was not statistically significant (p = .35). By combining the data with our previous cohort, there was an increase in relapse rate of patients with residual lung lesions (5/63; 7.9%) compared to those without such lesions (4/112; 3.6%). However, this difference was also not statistically significant (p = .21).

CONCLUSION

Residual lung lesions on imaging after completion of GTN treatment are common. However, this finding did not statistically increase relapse rate. Due to low number of recurrent events, a multi-centre, larger dataset would be needed to provide more definitive evidence.

Thoracoscopic Surgery to Treat Lung Metastases from Refractory Choriocarcinoma

Purpose

To assess the use of video-assisted thoracoscopic surgery to treat lung metastases from refractory choriocarcinoma.

Patients and Methods

We reviewed patients diagnosed with refractory choriocarcinoma who underwent lung resection by video-assisted thoracoscopic surgery combined with chemotherapy between October 2013 and August 2019 at the Peking Union Medical College Hospital. The surgical records, pathologic findings and survival rates were analyzed.

Results

The study included 73 patients who underwent 78 thoracoscopic surgeries. Most patients underwent lobectomy (48.7%), and 17 patients (21.8%) underwent resection of more than one lobe. The median operation time and bleeding volume were 95 minutes and 50 mL, respectively. The median duration of chest tube use and hospital stay were 3 days and 4 days, respectively. Postoperative complications were documented in 6 patients (7.7%). The thoracic lymph nodes were harvested in 51 patients (65.4%), but none of these patients had positive nodes. A total of 69.2% of the patients had positive pathologic findings. The mean follow-up time was 30 months. During follow-up, 11 patients experienced disease relapse, and 2 of them died because of brain metastasis. The overall disease-free rate was 83.6%, and the survival rate was 97.0% after excluding those lost to follow-up. Patients with decreased postoperative β-hCG showed a higher disease-free rate during follow up (P<0.05).

Conclusion

The minimally invasive video-assisted thoracoscopic approach is a valuable and safe treatment for refractory choriocarcinoma patients with lung metastases. Lymphadenectomy is not suggested for these patients. Patients with decreased postoperative β-hCG levels may achieve a much better prognostic result.

Evaluation and influence of lung metastasis on patient outcome in gestational trophoblastic neoplasia: A 10-year study at a single institution

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.

Management and risk factors of recurrent gestational trophoblastic neoplasia: An update from 2004 to 2017

OBJECTIVE

We investigated the clinical characteristics, treatments, and survival of patients with gestational trophoblastic neoplasia (GTN) who experienced recurrence. Factors predictive of recurrence were also investigated.

METHODS

Patients with GTN who recurred after completing chemotherapy at Peking Union Medical College Hospital Trophoblastic Disease Center were identified between January 2004 and December 2017. Logistic regression analysis was used to identify factors predictive of GTN recurrence.

RESULTS

A total of 1827 patients with GTN achieved complete remission (CR) at our center, of whom 118 (6.5%) experienced recurrence during follow-up. The recurrence rates for patients initially treated at our center and those referred to us were 2.7% and 14.6%, respectively. The majority of recurrent patients received floxuridine-based multiagent chemotherapy (n = 64). Patients who underwent surgery achieved a significantly higher CR rate than those who did not (88.6% vs 61.1%, P = .001). Although 94.1% of recurrent patients reachieved CR, 33.3% of them recurred for a second time. The 5-year survival rate of the entire cohort was 80.4%. An interval between antecedent pregnancy and chemotherapy >12 months (OR: 6.600, 95% CI [3.217-13.540], P < .001), and an interval from first chemotherapy to achieving β-human chorionic gonadotropin (β-hCG) normalization >14 weeks (OR: 2.226, 95% CI [1.080-4.588], P = .030) were predictors of recurrence.

CONCLUSIONS

Patients with recurrent GTN are prone to recurring for a second time. Surgery plays a beneficial role in the management of recurrent GTN. An interval between antecedent pregnancy and chemotherapy >12 months, and an interval from first chemotherapy to achieving β-hCG normalization >14 weeks were predictors of recurrence.

Do the Residual Lung Lesions Threaten Gestational Trophoblastic Neoplasia Patients?

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.

Pulmonary Resection in the Management of High-Risk Gestational Trophoblastic Neoplasia

Objective

The aim of this study was to evaluate the role of pulmonary resection in the management of high-risk gestational trophoblastic neoplasia (GTN).

Methods

Patients who underwent pulmonary resection as part of their treatment for chemotherapy-resistant high-risk GTN from 1986 and 2014 were retrospectively analyzed. All patients had received 1 or more multiagent chemotherapy regimens preoperatively. Patient and disease characteristics were evaluated with respect to outcome.

Results

Fifteen (26%) of 58 patients treated for high-risk GTN underwent pulmonary resection with curative intent. Mean age of patients was 29 years (range, 19–37 years). International Federation of Gynecology and Obstetrics stage was III in 12 and IV in 3. International Federation of Gynecology and Obstetrics scores ranged from 5 to 20 (mean, 10). Antecedent pregnancy was nonmolar in 11 patients (73%). Adjuvant surgical procedures other than pulmonary resection were performed in 8 patients (53%). Preoperative chemotherapy regimens ranged from 1 to 10 (median, 4) and courses numbered from 2 to 32 (median, 14). Preoperative human chorionic gonadotropin (hCG) levels ranged from 2 to 2786 mIU/mL (median, 177 mIU/mL). Pulmonary wedge resections or lobectomies were performed via video-assisted thoracoscopic surgery (11) or thoracotomy (4). Two patients underwent pulmonary resections on 2 separate occasions. No patient had complications as a result of these procedures. Eleven patients (73%) were cured. In these 11 patients, hCG levels decreased to less than 2 mIU/mL within 6 to 52 days (mean, 22 days) postoperatively.

Conclusions

Pulmonary resection of chemotherapy-resistant GTN was an important component of treatment in 26% of high-risk patients, 73% of whom were cured. Ideal candidates have disease isolated to the lungs and low hCG levels.

Primary pulmonary cancer colliding with metastatic choriocarcinoma

Collision tumors are rare in nature. Although lung is one of the main organs where metastatic tumors may occur, collision neoplasms consisting of a primary lung cancer and metastatic choriocarcinoma have never been reported so far. Here we describe a case of primary squamous-cell lung carcinoma (SCC) colliding with metastatic choriocarcinoma in a 55-year-old woman.

Analysis of the prognosis and related factors for patients with stage IV gestational trophoblastic neoplasia

OBJECTIVE

This study aimed to investigate and analyze the treatments and prognoses of patients with stage IV gestational trophoblastic neoplasia (GTN).

METHODS

Between January 1990 and January 2010, 105 patients with stage IV GTN were treated in our hospital (Peking Union Medical College Hospital). A retrospective study is presented herein to report the prognoses of these patients and to statistically analyze the risk factors that affected the prognoses of patients with stage IV GTN.

RESULTS

After the treatments, of the 105 patients, 71 (67.6%) patients achieved complete remission, 15 (14.3%) patients exhibited partial remission, and 19 (18.1%) patients exhibited progression of the disease. In total, of the 105 patients, 30 (28.6%) patients died. Our statistical analyses have revealed that a previously failed multidrug chemotherapy history, multiorgan metastasis concomitant with renal metastasis, and surgical intervention all affected the prognoses of patients with stage IV GTN. In addition, patients with stage IV GTN with International Federation of Gynecology and Obstetrics scores below 12 were relatively more likely to obtain complete remission.

CONCLUSIONS

Multidrug, multiroute chemotherapy, assisted by surgery when necessary, is the predominant strategy for patients with stage IV GTN. Fluorouracil-based multidrug chemotherapy can produce good outcomes for patients with stage IV GTN who were treated primarily. Adequate attention should be given to patients who have previously failed multidrug chemotherapy, have experienced multiorgan metastasis concomitant with renal metastasis, or have International Federation of Gynecology and Obstetrics scores of more than 12.

Thoracotomy in refractory gestational trophoblastic neoplasia with lung metastasis after normalization of serum beta human chorionic gonadotropin (β-hCG) with salvage chemotherapy

Objective

To assess the need for pulmonary surgery in the treatment of refractory gestational trophoblastic neoplasia with lung metastasis after normalization of serum beta human chorionic gonadotropin (β-hCG) level with salvage chemotherapy.

Materials and methods

A review of medical records of patients with refractory gestational trophoblastic neoplasia who underwent pulmonary surgery and received combined chemotherapy between January 1995 and December 2008 at the Peking Union Medical College Hospital was retrospectively performed. The positive pathologic findings in surgical specimens were defined as trophoblastic cells documented in the specimen. Pathologic findings were reported.

Results

There were 21 patients with preoperative normal β-hCG. Of 21 patients, six (28.6%) had positive pathologic findings. The positive pathologic findings remained at 27.3% in 11 patients who had received no less than two cycles of consolidation chemotherapy before pulmonary surgery. Univariate analysis found that no variables in patient characteristics were associated with pathologic findings. At the median follow-up of 78 months (9–186 months), 85.7% (18 of 21) patients were alive, and no statistical difference was observed in the disease-free survival between the patients with positive and negative pathologic findings. The 5-year overall survival was 72.2%.

Conclusion

Pulmonary surgery is valuable in the treatment of refractory patients with lung metastasis after normalization of serum β-hCG level following salvage chemotherapy, irrespective of viable trophoblasts in surgical specimens. Further study will be necessary to clarify the importance of this observation.

[Progress of the diagnosis and treatment of pulmonary metastasis of gestational choriocarcinoma]

妊娠绒毛膜癌（简称绒癌）是最常见的妊娠滋养细胞肿瘤，极易发生血行转移，常出现肺转移。自一系列有效化疗药物用于绒癌治疗之后，绒癌已成为可治愈的恶性肿瘤之一，但耐药及复发仍是治疗失败的主要原因，特别是肺转移灶的处理。如何掌握手术指征和时机成为治疗难点。本文就绒癌肺转移的诊断、化疗、手术指征及时机、手术方式等治疗进展进行综述。