Early identification of persistent trophoblastic disease with serum hCG concentration ratios

Serum human chorionic gonadotropin ratios for the detection of etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine resistance in high‐risk gestational trophoblastic neoplasia

Aims

This study aimed to identify the optimal human chorionic gonadotropin (hCG) ratio in predicting etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine resistance in women diagnosed with high‐risk gestational trophoblastic neoplasia (GTN) and to compare the chemoresistant disease detection rate by using the optimal hCG ratio and traditional criteria.

Methods

Seventy‐six women with primary high‐risk GTN treated with etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine in a tertiary‐care center were included. The hCG ratio was determined by its serum pretreatment level divided by that before each cycle of chemotherapy. The traditional criteria for chemoresistance included plateau or rising of hCG or presence of new metastasis. The optimal hCG ratio was determined using receiver operating characteristics (ROC) curve analysis.

Results

Among the specificities of 90%, 92.5%, and 95%, the 90% specificity yielded the best ROC curve. At 90% specificity, the best area under curve value was at the fourth cycle with 75% sensitivity. The hCG ratio at the fourth cycle was 31.92. Using the ratio at the fourth cycle, chemoresistant disease was detected in six out of eight patients, compared to one in the traditional criteria. When combining the two diagnostic tools, the cumulative detection rate in the fourth cycle was 10/12 (83.3%) of total drug resistance. Among patients who developed drug resistance at the fourth cycle or thereafter, the use of the ratio at the fourth cycle could diagnose chemoresistance approximately two cycles earlier than that with the traditional criteria.

Conclusions

A hCG ratio of <31.9 at the fourth cycle should be considered a high‐risk for etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine resistance and may need second‐line chemotherapy. The ratio increases the detection rate of resistance to these drugs more than the traditional criteria.

Early prediction of post-molar gestational trophoblastic neoplasia and resistance to methotrexate, based on a single serum human chorionic gonadotropin measurement

BACKGROUND

Clinicians are unable to provide individualized counseling regarding risk of progression for patients with a complete hydatidiform mole (CHM). We developed nomograms enabling early prediction of post-molar gestational trophoblastic neoplasia (GTN) and resistance to methotrexate (MTX) based on a single serum human chorion gonadotropin (hCG) measurement.

METHODS

We generated two nomograms with logistic regression: to predict post-molar GTN, and MTX resistance. For patients with high probability to progress to post-molar GTN or MTX resistance, we determined hCG cut-offs at 97.5% specificity to select patients for additional- or adjustments in current treatment.

RESULTS

The nomograms had a good to excellent ability to distinguish either between patients with uneventful hCG regression versus progression to post molar GTN, or between patients cured by MTX versus patients in whom resistance would occur. At 97.5% specificity, we identified 66% (95%CI 56-75) of the 149 patients who would progress to post-molar GTN, four weeks after initial curettage. For patients treated with MTX, we identified 55% (95%CI 23-83) of the 43 patients who would become resistant, preceding their third course at 97.5% specificity.

CONCLUSION

The nomograms and cut-off levels can be used to assist in counseling for patients diagnosed with CHM.

Risk factors for second-line dactinomycin failure after methotrexate treatment for low-risk gestational trophoblastic neoplasia: a retrospective study

OBJECTIVE

To find risk factors for second-line dactinomycin failure in patients with low-risk gestational trophoblastic neoplasia (GTN).

DESIGN

Retrospective multicentre study.

SETTING

Tertiary reference centre.

POPULATION

Patients with low-risk GTN, treated with dactinomycin after methotrexate (MTX) failure.

METHODS

Retrospective analysis of 45 patients with low-risk GTN treated with dactinomycin after MTX failure, registered between 2006 and 2018.

MAIN OUTCOME MEASURES

Treatment outcome and risk factors for second-line dactinomycin failure.

RESULTS

Thirty patients (66.7%) were cured and 15 patients (33.3%) required third-line therapy. Type of antecedent pregnancy and hCG levels pre-dactinomycin were risk factors for failure in univariate analysis (odds ratio [OR] 19.30, 95% CI 2.04-182.60, P = 0.01 and OR 2.77, 95% CI 1.18-6.50, P = 0.02, respectively). Level of hCG pre-dactinomycin remained a significant risk factor in multivariate analysis (OR 2.93, 95% CI 1.02-8.40, P = 0.045). Complete remission (CR) was achieved in 83.3% of patients with pre-dactinomycin hCG levels <10 ng/ml, in 75% with hCG levels between 10 and 20 ng/ml, in 66.7% with hCG levels between 20 and 30 ng/ml, and in 50% with hCG levels between 30 and 40 ng/ml. No patients with hCG levels >40 ng/ml achieved CR. Patients with dactinomycin failure were treated surgically and/or with multi-chemotherapy; all except one achieved CR.

CONCLUSIONS

Treatment with dactinomycin after MTX failure in patients with low-risk GTN resulted in CR in 66.7%. Chance of curative treatment with dactinomycin is strongly related to the hCG level.

TWEETABLE ABSTRACT

Chance of curative treatment with dactinomycin after MTX failure in GTN patients is strongly related to the level of hCG pre-dactinomycin.

Human Chorionic Gonadotropin (hCG) Regression Curve for Predicting Response to EMA/CO (Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide and Vincristine) Regimen in Gestational Trophoblastic Neoplasia

BACKGROUND

An hCG regression curve has been used to predict the natural history and response to chemotherapy in gestational trophoblastic disease. We constructed hCG regression curves in high-risk gestational trophoblastic neoplasia (GTN) treated with EMA/CO and identified an optimal hCG level to detect EMA/CO resistance in GTN.

MATERIALS AND METHODS

Eighty-one women with GTN treated with EMA/CO were classified as primary high-risk GTN (n=65) and single agent-resistance GTN (n=16). The hCG levels prior to each course of chemotherapy were plotted in the 10th, 50th, and 90th percentiles to construct the hCG regression curves. Diagnostic performance was evaluated for an optimal cut-off value.

RESULTS

The median hCG levels were 264,482 mIU/mL mIU/mL and 495.5 mIU/mL mIU/mL for primary high-risk GTN and single agent-resistance GTN, respectively. The 50th percentile of the hCG level in primary high-risk GTN and single agent-resistance turned to normal before the 4th and the 2nd course of chemotherapy, respectively. The 90th percentile of the hCG level in primary high-risk GTN and single agent-resistance turned to normal before the 9th and the 2nd course of chemotherapy, respectively. The hCG level of ≥118.6 mIU/mL mIU/mL at the 5thcourse of EMA/CO predicted the EMA/CO resistance in primary high-risk GTN patients with a sensitivity of 85.7% and a specificity of 100%.

CONCLUSION

EMA/CO resistance in primary high-risk GTN can be predicted by using an hCG regression curve in combination with the cut-off value of 118.6 mIU/mL at the 5thcourse of chemotherapy.

Linear regression of postevacuation serum human chorionic gonadotropin concentrations predicts postmolar gestational trophoblastic neoplasia

OBJECTIVE

Currently, human chorionic gonadotropin (hCG) follow-up after evacuation of hydatidiform moles is essential to identify patients requiring chemotherapeutic treatment for gestational trophoblastic neoplasia (GTN). We propose a model based on linear regression of postevacuation serum hCG concentrations for the prediction of GTN.

METHODS

One hundred thirteen patients with at least 3 serum samples from days 7 to 28 after evacuation were selected from the Dutch Central Registry for Hydatidiform Moles (1994-2009). The slopes of the linear regression lines of the first 3 log-transformed serum hCG and free β-hCG values were calculated. Receiver operating characteristic curves were constructed to calculate areas under curve (AUCs).

RESULTS

The slope of the hCG regression line showed an AUC of 0.906 (95% confidence interval, 0.845-0.967). Gestational trophoblastic neoplasia could be predicted in 52% of patients with GTN at 97.5% specificity (cutoff, -0.020). Twenty-one percent of patients with GTN could be predicted before diagnosis according to the International Federation of Gynecology and Obstetrics 2000 criteria. The slope of free β-hCG showed an AUC of 0.844 (95% confidence interval, 0.752-0.935), 69% sensitivity at 97.5% specificity, and 38% of patients with GTN could be predicted before diagnosis according to the International Federation of Gynecology and Obstetrics criteria.

CONCLUSIONS

The slope of the linear regression line of hCG proved to be a good test to discriminate between patients who will achieve spontaneous disease remission and patients developing GTN. The slope of free β-hCG seems to be a better predictor for GTN than the slope of hCG. Although this model needs further validation for different assays, it seems a promising way to predict the more aggressive cases of GTN.

An Immunonanosilver Surface-Enhnaced Resonance Raman Scattering Method for Determination of Human Chorionic Gonadotrophin

In pH 6.6 Na2HPO4-citric acid buffer solution and in the presence of KCl, the nanosilver-labeled rabbit anti-hCG (Ag-RAhCG) was aggregated un-specifically to the aggregations. Upon addition of rhodamine 6G (RhG) molecular probe, it adsorb on the surface of Ag-RAhCG aggregations that exhibited the strongest surface-enhnaced resonance Raman scattering (SERRS) peak at 613 cm-1. In the optimal condition, the decreased SERRS intensity responds linearly with the concentration of hCG over 0.05-1.75 µg/mL. Based on this, a new and simple SERRS method has been proposed for the determination of hCG in serum samples, with satisfactory results.

An Immunonanosilver Resonance Rayleigh Scattering Spectral Probe for Rapid Assay of Human Chorionic Gonadotrophin

In pH 6.6 Na2HPO4- citric acid buffer solution and in the presence of KCl, the immunoreaction between hCG and nanosilver-labeled anti-hCG took place, the immunonanosilver-complex was formed and deposited, caused the resonance Rayleigh scattering (RRS) intensity at 510 nm decreased. In the optimal condition, the decreased RRS intensity responds linearly with the concentration of hCG over 0.125-1.75 µg/mL. Based on this, a new and simple RRS method has been proposed for the determination of hCG in serum samples, with satisfactory results.

Predicting gestational trophoblastic neoplasia (GTN): is urine hCG the answer?

BACKGROUND

Previous studies on the significance of hCG to predict gestational trophoblastic neoplasia (GTN) have been too small for robust conclusions to be reached. Our aim in this study was to analyse the significance of urine hCG in predicting GTN in a large population.

METHODS

Details of 3926 patients were available for analysis. Information regarding age, dates of diagnosis and registration, urine hCG levels, antecedent pregnancy and chemotherapy were prospectively collected and used for analyses. Patients were stratified into different groups according to urine hCG level (IU/L); < 50, 50-99, 100-249, 250-499, 500-999, 1000-9999 and ≥10,000. Multivariate analyses were used to identify the prognostic indicators of GTN.

RESULTS

Urine hCG and antecedent pregnancy were the most powerful indicators for developing GTN (P<0.01). None of the patients with partial mole and urine hCG <50 IU/L (Normal level=40 IU/L) developed GTN. The risk of GTN was >35% in all patients with urine hCG ≥500 IU/L. GTN developed in 70% of patients with complete mole and urine hCG ≥10,000 IU/L.

CONCLUSION

Urine hCG is sensitive test for GTN. Urine hCG level is a powerful prognostic indicator for the GTN. Patients with partial mole could be safely discharged from the surveillance programme once their hCG have normalised. Patients with urine hCG ≥249 IU/L, whether partial or complete molar pregnancy, appear to benefit from intensive surveillance. Prophylactic chemotherapy could be considered when there are problems with surveillance.

Methotrexate for 2000 FIGO low-risk gestational trophoblastic neoplasia patients: efficacy and toxicity

OBJECTIVE

We sought to review efficacy and toxicity of an 8-day methotrexate (MTX) regimen in the treatment of patients with low-risk gestational trophoblastic neoplasia (GTN) from the French Trophoblastic Disease Reference Center.

STUDY DESIGN

Between 1999 and 2006, 142 low-risk GTNs were diagnosed according to International Federation of Gynecology and Obstetrics (FIGO) criteria for GTN and to the FIGO scoring system. We report their characteristics, remission/resistance/recurrence rates, and treatment toxicity.

RESULTS

The 8-day MTX regimen achieved a 77.5% remission rate. All patients but 1 (99.9%) achieved remission and remained disease free until the time of analysis. Severe (grade 3 or 4) blood/bone marrow toxicity and metabolic/laboratory toxicity was noted in 4.2% of cases, of which 2 (1.4%) were grade 4.

CONCLUSION

For patients with GTN diagnosed according to FIGO criteria and considered low risk according to the FIGO scoring system, an 8-day MTX regimen is an adequate treatment associating a high rate of remission to a low rate of toxicity.