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Hassan AR, Itsura PM, Rosen BP, Covens AL, Shaffi AF, Odongo EB, Mburu AW, Smith WL, Moturi SK, Too RK, Ayeah CM, Tonui PK. Mortality factors in high and ultra-high-risk gestational trophoblastic neoplasia at moi teaching & referral hospital: A decade-long observation in kenya. Gynecol Oncol Rep 2024; 53:101392. [PMID: 38694708 PMCID: PMC11061241 DOI: 10.1016/j.gore.2024.101392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 05/04/2024] Open
Affiliation(s)
- Amina R. Hassan
- Moi University/ Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Peter M. Itsura
- Moi University/ Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | - Allan L. Covens
- University of Toronto, Sunnybrook Health Sciences Center, Toronto, Canada
| | - Afrin F. Shaffi
- Moi University/ Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | | | - Wilmot L. Smith
- Moi University/ Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Sharon K. Moturi
- Moi University/ Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Ronald K. Too
- Moi University/ Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Chia M. Ayeah
- Moi University/ Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Philiph K. Tonui
- Moi University/ Moi Teaching and Referral Hospital, Eldoret, Kenya
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2
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Huang W, Zheng Z, Bao Z, Xiao X, Li L, Sun Z, Kang L. A poor prognostic male choriocarcinoma with multiple systemic metastases: a case report and the literature review. Front Med (Lausanne) 2024; 11:1382672. [PMID: 38572155 PMCID: PMC10989191 DOI: 10.3389/fmed.2024.1382672] [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: 02/06/2024] [Accepted: 03/08/2024] [Indexed: 04/05/2024] Open
Abstract
Background Non-gestational choriocarcinoma, also known as primary choriocarcinoma, is extremely rare in men, manifesting with specific signs such as breast feminization, testicular atrophy, and loss of libido. The presentation typically includes elevated serum β-hCG levels, widespread metastatic disease, and a rapid progression of the condition. Case report We present a rare case of a 41-year-old man diagnosed with choriocarcinoma, exhibiting a unique combination of multiple metastases, including lung, brain, bone, and retroperitoneal lymph node metastases, as confirmed by 18F-FDG PET/CT imaging. The patient was treated with aggressive chemotherapy and pembrolizumab, and the prognosis remained poor. The patient's overall survival was a mere 5 months following diagnosis. Conclusion Non-gestational choriocarcinoma represents a rare entity in clinical practice and should be considered in young men presenting with gynaecomastia and elevated β-hCG levels alongside normal gonads. Thus, we advocate for a more comprehensive inquiry into medical history and a systematic examination. The 18F-FDG PET/CT examination not only visually delineates the lesion's location and extent but also serves as a cornerstone for clinical tumor staging, providing valuable support for treatment monitoring and subsequent follow-up.
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Affiliation(s)
- Wenpeng Huang
- Department of Nuclear Medicine, Peking University First Hospital, Beijing, China
| | - Zuohuan Zheng
- Department of Traditional Chinese Medicine, The Seventh People’s Hospital of Chongqing, Chongqing, China
| | - Zheng Bao
- Department of Nuclear Medicine, Peking University First Hospital, Beijing, China
| | - Xiaoyan Xiao
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Liming Li
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhaonan Sun
- Department of Medical Imaging, Peking University First Hospital, Beijing, China
| | - Lei Kang
- Department of Nuclear Medicine, Peking University First Hospital, Beijing, China
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3
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Li J, He L, Zhou L, Li T. Successful treatment of primary mediastinal choriocarcinoma with lung metastasis in a 13-year-old male. Pediatr Blood Cancer 2024; 71:e30765. [PMID: 37953465 DOI: 10.1002/pbc.30765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Jian Li
- Department of Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lulu He
- Department of Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Li Zhou
- Department of Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Tao Li
- Department of Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
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4
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Shahzadi M, Khan SR, Tariq M, Baloch SS, Shahid A, Moosajee M, Samon Z. Review of current literature on gestational trophoblastic neoplasia. J Egypt Natl Canc Inst 2023; 35:37. [PMID: 38008872 DOI: 10.1186/s43046-023-00195-y] [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: 03/29/2023] [Accepted: 10/28/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND Gestational Trophoblastic Neoplasia (GTN) is a disease of the reproductive age group with an incidence rate of <1% among all tumors involving the female reproductive tract. It occurs because of aberrant fertilization. Patients are diagnosed early because of aggravated symptoms during pregnancy. Moreover, patients also bleed from the tumor sites, which leads to early presentation. A cure rate of 100% can be achieved with adequate treatment. MAIN BODY In this literature review, the authors have brought to attention the risk factors, classification, and various treatment options in GTN patients according to their stratification as per the WHO scoring system. Patients are categorized into low and high risk based on the FIGO scoring system. Patients with low risk are treated with single-agent methotrexate or actinomycin-D. Despite the superiority of actinomycin-D in terms of efficacy, methotrexate remains the first choice of therapy in low-risk patients due to its better toxicity profile. Multi-agent chemotherapy with etoposide, methotrexate, actinomycin-D, cyclophosphamide and vincristine (EMA-CO) leads to complete remission in 93% of high-risk GTN patients. Around 40% of patients with incomplete responses are salvaged with platinum-based multi-agent chemotherapy. Isolated chemo-resistant clones can be salvaged with surgical interventions. CONCLUSION The mortality in patients with GTN has significantly reduced over time. With adequate multi-disciplinary support, patients with GTN can ultimately be cured and can spend every day healthy reproductive life.
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Affiliation(s)
- Mehwish Shahzadi
- Department of Medical Oncology, Aga Khan University Hospital, Karachi, Pakistan
| | - Saqib Raza Khan
- Department of Medical Oncology, Aga Khan University Hospital, Karachi, Pakistan.
| | - Muhammad Tariq
- Department of Medical Oncology, Khyber Teaching Hospital, Peshawar, Pakistan
| | | | - Aisha Shahid
- Department of internal medicine, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Munira Moosajee
- Department of Medical Oncology, Aga Khan University Hospital, Karachi, Pakistan
| | - Zarka Samon
- Department of Oncology, Monash Health, Bentleigh East, Australia
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5
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Bogani G, Ray-Coquard I, Mutch D, Vergote I, Ramirez PT, Prat J, Concin N, Ngoi NYL, Coleman RL, Enomoto T, Takehara K, Denys H, Lorusso D, Takano M, Sagae S, Wimberger P, Segev Y, Kim SI, Kim JW, Herrera F, Mariani A, Brooks RA, Tan D, Paolini B, Chiappa V, Longo M, Raspagliesi F, Benedetti Panici P, Di Donato V, Caruso G, Colombo N, Pignata S, Zannoni G, Scambia G, Monk BJ. Gestational choriocarcinoma. Int J Gynecol Cancer 2023; 33:1504-1514. [PMID: 37758451 DOI: 10.1136/ijgc-2023-004704] [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] [Indexed: 10/03/2023] Open
Abstract
Gestational choriocarcinoma accounts for 5% of gestational trophoblastic neoplasms. Approximately 50%, 25%, and 25% of gestational choriocarcinoma occur after molar pregnancies, term pregnancies, and other gestational events, respectively. The FIGO scoring system categorizes patients into low (score 0 to 6) and high risk (score 7 or more) choriocarcinoma. Single-agent and multi-agent chemotherapy are used in low- and high-risk patients, respectively. Chemotherapy for localized disease has a goal of eradication of disease without surgery and is associated with favorable prognosis and fertility preservation. Most patients with gestational choriocarcinoma are cured with chemotherapy; however, some (<5.0%) will die as a result of multi-drug resistance, underscoring the need for novel approaches in this group of patients. Although there are limited data due to its rarity, the treatment response with immunotherapy is high, ranging between 50-70%. Novel combinations of immune checkpoint inhibitors with targeted therapies (including VEGFR-2 inhibitors) are under evaluation. PD-L1 inhibitors are considered a potential important opportunity for chemo-resistant patients, and to replace or de-escalate chemotherapy to avoid or minimize chemotherapy toxicity. In this review, the Rare Tumor Working Group and the European Organization for Research and Treatment of Cancer evaluated the current landscape and further perspective in the management of patients diagnosed with gestational choriocarcinoma.
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Affiliation(s)
- Giorgio Bogani
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Isabelle Ray-Coquard
- Centre Leon Berard, LYON CEDEX 08, France
- Hesper lab, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - David Mutch
- Washington University in Saint Louis, St Louis, Missouri, USA
| | - Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium
| | - Pedro T Ramirez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas, USA
| | - Jaime Prat
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Nicole Concin
- Department of Gynecology and Obstetrics; Innsbruck Medical Univeristy, Innsbruck, Austria
| | | | | | - Takayuki Enomoto
- Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Belgium
| | - Kazuhiro Takehara
- Department of Gynecologic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | | | | | - Masashi Takano
- Department of Obstetrics and Gynecology, National Defense Medical College, Tokorozawa, Japan
| | - Satoru Sagae
- Gynecologic Oncology, Tokeidai Kinen Byoin, Sapporo, Japan
| | - Pauline Wimberger
- Gyncology and Obstetrics, Technische Universitat Dresden Medizinische Fakultat Carl Gustav Carus, Dresden, Germany
| | - Yakir Segev
- Obstetrics and Gynecology, Carmel Hospital, Haifa, Israel
| | - Se Ik Kim
- Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Jae-Weon Kim
- Obstetrics and gynecology, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Fernanda Herrera
- Centre Hospitalier Universitaire Vaudois Departement doncologie CHUV-UNIL, Lausanne, Switzerland
| | - Andrea Mariani
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Rebecca A Brooks
- Section of Gynecologic Oncology, University of Chicago Medicine, Chicago, Illinois, USA
| | - David Tan
- National University Cancer Institute, Singapore
| | - Biagio Paolini
- Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italy
| | - Valentina Chiappa
- Department of Gynecologic Oncology, IRCCS National Cancer Institute, Milan, Italy
| | | | | | | | | | | | - Nicoletta Colombo
- Medical Gynecologic Oncology Unit; University of Milan Bicocca; Milan; Italy, European Institute of Oncology, Milano, Italy
| | - Sandro Pignata
- Gynaecological Oncology, National Cancer Institute Napels, Naples, Italy
| | - Gianfranco Zannoni
- Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Bradley J Monk
- Virginia G Piper Cancer Center - Biltmore Cancer Center, Phoenix, Arizona, USA
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6
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Albright BB, Ellett T, Knochenhaur HE, Goins EC, Monuszko KA, Kaplan SJ, Previs RA, Moss HA, Havrilesky LJ, Davidson BA. Treatments and outcomes in high-risk gestational trophoblastic neoplasia: A systematic review and meta-analysis. BJOG 2023; 130:443-453. [PMID: 36648416 PMCID: PMC10066712 DOI: 10.1111/1471-0528.17374] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND High-risk gestational trophoblastic neoplasia (GTN) is rare and treated with diverse approaches. Limited published institutional data has yet to be systematically reviewed. OBJECTIVES To compile global high-risk GTN (prognostic score ≥7) cohorts to summarise treatments and outcomes by disease characteristics and primary chemotherapy. SEARCH STRATEGY MEDLINE, Embase, Scopus, ClinicalTrials.gov and Cochrane were searched through March 2021. SELECTION CRITERIA Full-text manuscripts reporting mortality among ≥10 high-risk GTN patients. DATA COLLECTION AND ANALYSIS Binomial proportions were summed, and random-effects meta-analyses performed. MAIN RESULTS From 1137 records, we included 35 studies, representing 20 countries. Among 2276 unique high-risk GTN patients, 99.7% received chemotherapy, 35.8% surgery and 4.9% radiation. Mortality was 10.9% (243/2236; meta-analysis: 10%, 95% confidence interval [CI] 7-12%) and likelihood of complete response to primary chemotherapy was 79.7% (1506/1890; meta-analysis: 78%, 95% CI: 74-83%). Across 24 reporting studies, modern preferred chemotherapy (EMA/CO or EMA/EP) was associated with lower mortality (overall: 8.8 versus 9.5%; comparative meta-analysis: 8.1 versus 12.4%, OR 0.42, 95% CI: 0.20-0.90%, 14 studies) and higher likelihood of complete response (overall: 76.6 versus 72.8%; comparative meta-analysis: 75.9 versus 60.7%, OR 2.98, 95% CI: 1.06-8.35%, 14 studies), though studies focused on non-preferred regimens reported comparable outcomes. Mortality was increased for ultra-high-risk disease (30 versus 7.5% high-risk; meta-analysis OR 7.44, 95% CI: 4.29-12.9%) and disease following term delivery (20.8 versus 7.3% following molar pregnancy; meta-analysis OR 2.64, 95% CI: 1.10-6.31%). Relapse rate estimates ranged from 3 to 6%. CONCLUSIONS High-risk GTN is responsive to several chemotherapy regimens, with EMA/CO or EMA/EP associated with improved outcomes. Mortality is increased in patients with ultra-high-risk, relapsed and post-term pregnancy disease.
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Affiliation(s)
- Benjamin B. Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Tressa Ellett
- Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC, USA
| | - Hope E. Knochenhaur
- Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC, USA
| | - Emily C. Goins
- Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC, USA
| | - Karen A. Monuszko
- Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC, USA
| | - Samantha J. Kaplan
- Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC, USA
| | - Rebecca A. Previs
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Haley A. Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
| | - Brittany A. Davidson
- Department of Obstetrics and Gynecology, Duke University Medical Center, 20 Duke Medicine Circle, Durham, NC, USA
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7
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Jareemit N, Therasakvichya S, Freitas F, Paiva G, Ramírez LAC, Berkowitz RS, Horowitz NS, Maestá I, Fülöp V, Braga A, Elias KM. EMACO for treatment of gestational trophoblastic neoplasia: A multinational multicenter study. Gynecol Oncol 2023; 170:114-122. [PMID: 36682089 DOI: 10.1016/j.ygyno.2022.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To investigate the efficacy and toxicity of etoposide, methotrexate, actinomycin D alternating with cyclophosphamide, and vincristine (EMACO) for treatment of gestational trophoblastic neoplasia, and for factors independently associated with EMACO resistance and disease-specific death in an international cohort. METHODS Medical records of GTN patients who received EMACO during 1986-2019 from gestational trophoblastic disease centers from four countries including the USA, Thailand, Hungary, and Brazil, were retrospectively reviewed. Among 335 GTN patients, 266 patients who received EMACO as primary chemotherapy were included in the primary treatment group, and 69 patients who received EMACO after relapse/resistance to single-agent chemotherapy were included in the prior treatment group. RESULTS Three-quarters (76.1%) of all patients achieved remission, and the survival rate was 89%. The prior treatment group had better outcomes than the primary treatment group relative to remission rate (87.0% vs. 73.3%, p = 0.014) and number of EMACO cycles to achieve remission (3 vs. 6 cycles, p < 0.001). Sustained remission increased to 87.2% in EMACO-resistant patients treated with later-line chemotherapy. Number of metastatic organs ≥2 (adjusted odds ratio [aOR]: 2.33, p = 0.049) was the only independent predictor of EMACO resistance among overall patients. Interval from index pregnancy ≥7 months (aOR: 4.34, p = 0.001), and pretreatment hCG >100,000 IU/L (aOR: 2.85, p = 0.028) were independent predictors of EMACO resistance in the high-risk subgroup. The only factor independently associated with disease-specific death was EMACO resistance (aOR: 176.04, p < 0.001). CONCLUSIONS EMACO is an effective treatment for GTN. Number of metastatic organs and EMACO resistance were the independent predictors of EMACO resistance and disease-specific death, respectively.
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Affiliation(s)
- Nida Jareemit
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suwanit Therasakvichya
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Fernanda Freitas
- Rio de Janeiro Trophoblastic Disease Centre, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Gabriela Paiva
- Rio de Janeiro Trophoblastic Disease Centre, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Luz Angela Correa Ramírez
- Postgraduation Program in Tocoginecology, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, SP, Brazil; Clinical Department, University of Caldas, Manizales, Caldas, Colombia
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Izildinha Maestá
- Botucatu Trophoblastic Disease Center of the Clinical Hospital of Botucatu Medical School, Department of Gynecology and Obstetrics, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Vilmos Fülöp
- Department of Obstetrics and Gynecology, Medical Centre Hungarian Defense Forces, Semmelweis University, National Trophoblastic Disease Center, Budapest, Faculty of Health Sciences, University of Miskolc, Miskolc, Hungary
| | - Antonio Braga
- Rio de Janeiro Trophoblastic Disease Centre, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, Rio de Janeiro, Brazil; Postgraduate Program in Applied Health Sciences, Vassouras University, Rio de Janeiro, RJ, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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8
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Sirimusika N, Boonyapipat S. Serum human chorionic gonadotropin ratios for the detection of etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine resistance in high‐risk gestational trophoblastic neoplasia. Health Sci Rep 2022; 5:e729. [PMID: 35873390 PMCID: PMC9301295 DOI: 10.1002/hsr2.729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Nathapol Sirimusika
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology Faculty of Medicine, Prince of Songkla University, Hat Yai Songkhla Thailand
| | - Sathana Boonyapipat
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology Faculty of Medicine, Prince of Songkla University, Hat Yai Songkhla Thailand
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9
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Ji M, Jiang S, Zhao J, Wan X, Feng F, Ren T, Yang J, Xiang Y. Efficacies of FAEV and EMA/CO regimens as primary treatment for gestational trophoblastic neoplasia. Br J Cancer 2022; 127:524-530. [PMID: 35459802 PMCID: PMC9345879 DOI: 10.1038/s41416-022-01809-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Guidelines recommend etoposide, methotrexate, actinomycin D (EMA)/cyclophosphamide, vincristine (CO) as first-line treatment for high-risk gestational trophoblastic neoplasia (GTN). However, the floxuridine, actinomycin D, etoposide and vincristine (FAEV) regimen is commonly used to treat these patients in China. We conducted a randomised controlled trial to compare the efficacies and toxicities of FAEV and EMA/CO. METHODS Ninety-four patients with GTN were enrolled between May 2015 and April 2019 and randomly assigned to the FAEV or EMA/CO regimen. The rates of complete remission and relapse and the toxicities were compared in August 2021. RESULTS Five patients were excluded from the analysis. There were 46 patients in the FAEV group and 43 patients in the EMA/CO group. The complete remission rates following primary treatment were 89.1% and 79.1% (P = 0.193), respectively. The relapse rates were 8.7% and 9.3% (P = 0.604). The apparent incidences of grade 4 myelosuppression were 60.9% and 32.6% (P = 0.008), respectively; however, they became both 32.6% (P = 0.996) after granulocyte colony-stimulating factor support. Other adverse reactions were similar in the two groups. No patient died of disease. CONCLUSION FAEV has comparable efficacy and toxicity to EMA/CO as the primary treatment for high-risk GTN, and may thus be another first-line choice of chemotherapy. CLINICAL TRIAL REGISTRATION chictr.org.cn: ChiCTR1800017423.
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Affiliation(s)
- Mingliang Ji
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Shiyang Jiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jun Zhao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China. .,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China.
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Tong Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China. .,National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China.
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Li Y, Chen D, Yu H, Xia R, Zhang X, Zheng W. The efficacy evaluation of initial chemotherapy for high-risk gestational trophoblastic neoplasm. Curr Probl Cancer 2022; 46:100861. [PMID: 35421635 DOI: 10.1016/j.currproblcancer.2022.100861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 11/19/2022]
Abstract
In clinical practice, a large number of patients have failed to receive chemotherapy or combination therapy because of drug resistance, recurrence and metastasis of specific sites. Therefore, how to choose the initial chemotherapy individually and reduce the occurrence of drug resistance is the key to cure high-risk GTN. This study investigated the efficacy of chemotherapy based on 5-fluorouracil (5-FU) regimen and EMA/CO regimen as the initial chemotherapy regimen in the treatment of high-risk gestational trophoblastic neoplasms (high-risk GTN). The treatment status of high-risk GTN patients who received primary chemotherapy using 5-Fu regimens (FAV and FA regimens) or EMA/CO regimens at Cancer Hospital of China Medical University from 2002 to 2019 was retrospective analyzed. Regular follow-up was conducted to evaluate its efficacy and to analyze prognostic factors. There were a total of 87 high-risk patients, 75 in the 5-FU-based group and 12 in the EMA/CO group. The clinical characteristics of patients in both groups were not statistically significant (P > 0.05). The overall survival rate of all patients was 87.4%, the rate of serological complete remission (SCR) was 87.4%, the SCR rate of initial treatment was 75.9%, the recurrence rate was 7.9%, and the mortality rate was 12.6%. There were no statistical differences in overall survival rate, SCR rate, SCR rate of initial treatment, drug resistance rate, recurrence rate and mortality in the 5-FU group and the EMA/CO group (P > 0.05). The median follow-up was 106 months. Kaplan-Meier analysis showed that the 1-year survival rate, 5-year survival rate and 10-year survival rate in the 5-FU group were 91.9%, 84.3% and 84.3% respectively. The 1-year survival rate, 5-year survival rate and 10-year survival rate of the EMA/CO group were all 91.7%, and there was no statistical difference in the overall survival time between the 2 groups (P > 0.05). COX proportional stepwise regression analysis showed that only clinical staging was an independent risk factor of the prognosis of high-risk GTN (P = 0.003). Conclusion Both 5-FU regimen and EMA / CO regimen can be used as the first-line treatment for high-risk GTN patients, and their effects are similar. For high-risk GTN patients with drug resistance, EMA / CO, FAEV and PEB can be used as second-line salvage chemotherapy.
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Affiliation(s)
- Yitong Li
- Department of Gynecology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, Liaoning Province, China, 110042
| | - Dan Chen
- Department of Gynecology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, Liaoning Province, China, 110042
| | - Huihui Yu
- Liaoning Office for Cancer Control and Research, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, Liaoning Province, China, 110042
| | - Rong Xia
- Department of pain treatment & rehabilitation, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, Liaoning Province, China, 110042
| | - Xin Zhang
- Department of Gynecology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, Liaoning Province, China, 110042
| | - Wei Zheng
- Department of Gynecology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, Liaoning Province, China, 110042.
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11
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Tsai J, Vellayappan B, Venur V, McGranahan T, Gray H, Urban RR, Tseng YD, Palmer J, Foote M, Mayr NA, Combs SE, Sahgal A, Chang EL, Lo SS. The optimal management of brain metastases from gestational trophoblastic neoplasia. Expert Rev Anticancer Ther 2022; 22:307-315. [PMID: 35114862 DOI: 10.1080/14737140.2022.2038566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Gestational trophoblastic diseases and neoplasias (GTDs and GTNs) comprise a spectrum of diseases arising from abnormally proliferating placental/trophoblastic tissue following an antecedent molar or non-molar pregnancy. These can spread to the brain hematogenously in about 10% of patients, mostly in high-risk disease. The optimal management of patients with brain metastases from GTN is unclear, with multiple systemic regimens under use and an uncertain role for radiotherapy. AREAS COVERED Here, we review the epidemiology, workup, and treatment of GTN with central nervous system (CNS) involvement. Literature searches in PubMed and Google Scholar were conducted using combinations of keywords such as "gestational trophoblastic disease," "gestational trophoblastic neoplasia," "choriocarcinoma," and "brain metastases." EXPERT OPINION Systemic therapy is the frontline treatment for GTN with brain metastases, and radiotherapy should only be considered in the context of a clinical trial or for resistant/recurrent disease. Surgery has a limited role in palliating symptoms or relieving intracranial pressure/bleeding. Given the highly specialized care these patients require, treatment at a high-volume referral center with multidisciplinary collaboration likely leads to better outcomes. Randomized trials should be conducted to determine the best systemic therapy option for GTN.
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Affiliation(s)
- Joseph Tsai
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
| | | | - Vyshak Venur
- Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Tresa McGranahan
- Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Heidi Gray
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | - Renata R Urban
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
| | - Joshua Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital, The Ohio State University, Columbus, OH, USA
| | - Matthew Foote
- Princess Alexandra Hospital, University of Queensland, ICON Cancer Care, Brisbane 4072, Australia
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
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12
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Albright BB, Myers ER, Moss HA, Ko EM, Sonalkar S, Havrilesky LJ. Surveillance for gestational trophoblastic neoplasia following molar pregnancy: a cost-effectiveness analysis. Am J Obstet Gynecol 2021; 225:513.e1-513.e19. [PMID: 34058170 PMCID: PMC9941751 DOI: 10.1016/j.ajog.2021.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Historically, published guidelines for care after molar pregnancy recommended monitoring human chorionic gonadotropin levels for the development of gestational trophoblastic neoplasia until normal and then for 6 months after the first normal human chorionic gonadotropin. However, there are little data underlying such recommendations, and recent evidence has demonstrated that gestational trophoblastic neoplasia diagnosis after human chorionic gonadotropin normalization is rare. OBJECTIVE We sought to estimate the cost-effectiveness of alternative strategies for surveillance for gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after complete and partial molar pregnancy. STUDY DESIGN A Markov-based cost-effectiveness model, using monthly cycles and terminating after 36 months/cycles, was constructed to compare alternative strategies for asymptomatic human chorionic gonadotropin surveillance after the first normal (none; monthly testing for 1, 3, 6, and 12 months; or every 3-month testing for 3, 6, and 12 months) for both complete and partial molar pregnancy. The risk of reduced surveillance was modeled by increasing the probability of high-risk disease at diagnosis. Probabilities, costs, and utilities were estimated from peer-reviewed literature, with all cost data applicable to the United States and adjusted to 2020 US dollars. The primary outcome was cost per quality-adjusted life year ($/quality-adjusted life year) with a $100,000/quality-adjusted life year willingness-to-pay threshold. RESULTS Under base-case assumptions, we found no further surveillance after the first normal human chorionic gonadotropin to be the dominant strategy from both the healthcare system and societal perspectives, for both complete and partial molar pregnancy. After complete mole, this strategy had the lowest average cost (healthcare system, $144 vs maximum $283; societal, $152 vs maximum $443) and highest effectiveness (2.711 vs minimum 2.682 quality-adjusted life years). This strategy led to a slightly higher rate of death from gestational trophoblastic neoplasia (0.013% vs minimum 0.009%), although with high costs per gestational trophoblastic neoplasia death avoided (range, $214,000 to >$4 million). Societal perspective costs of lost wages had a greater impact on frequent surveillance costs than rare gestational trophoblastic neoplasia treatment costs, and no further surveillance was more favorable from this perspective in otherwise identical analyses. No further surveillance remained dominant or preferred with incremental cost-effectiveness ratio of <$100,000 in all analyses for partial mole, and most sensitivity analyses for complete mole. Under the assumption of no disutility from surveillance, surveillance strategies were more effective (by quality-adjusted life year) than no further surveillance, and a single human chorionic gonadotropin test at 3 months was found to be cost-effective after complete mole with incremental cost-effectiveness ratio of $53,261 from the healthcare perspective, but not from the societal perspective (incremental cost-effectiveness ratio, $288,783). CONCLUSION Largely owing to the rare incidence of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after molar pregnancy, prolonged surveillance is not cost-effective under most assumptions. It would be reasonable to reduce, and potentially eliminate, current recommendations for surveillance after human chorionic gonadotropin normalization after molar pregnancy, particularly among partial moles. With any reduction in surveillance, patients should be counseled on symptoms of gestational trophoblastic neoplasia and established in routine gynecologic care.
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Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emily M Ko
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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Li Y, Kong Y, Wan X, Feng F, Ren T, Zhao J, Yang J, Xiang Y. Results with Floxuridine, Actinomycin D, Etoposide, and Vincristine in Gestational Trophoblastic Neoplasias with International Federation of Gynecology and Obstetrics Scores ≥5. Oncologist 2021; 26:e2209-e2216. [PMID: 34396643 DOI: 10.1002/onco.13943] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/10/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND 5-fluorouracil-based multiagent chemotherapy has been used as the primary treatment for high-risk gestational trophoblastic neoplasia (GTN) in China for a few decades. This study aims to assess the efficacy and toxicity of floxuridine, actinomycin D, etoposide, and vincristine (FAEV) as a primary treatment for patients with GTN who had International Federation of Gynecology and Obstetrics (FIGO) scores ≥5. MATERIALS AND METHODS A total of 207 patients with GTN who had FIGO scores ≥5 were treated with FAEV as first-line chemotherapy at Peking Union Medical College Hospital between January 2002 and December 2017. Complete remission (CR), resistance, survival, toxicity, and reproductive outcomes were analyzed. RESULTS Of the 207 patients treated with FAEV, 9 (4.3%) required a change of chemotherapy owing to toxicity and 1 (0.5%) died of cerebral hernia 5 weeks after commencing treatment. The remaining 197 patients were assessable to determine the response to FAEV; among them, 168 (85.3%) achieved CR with FAEV and 29 (14.7%) developed resistance to FAEV. The 5-year overall survival rate of the entire cohort was 97.4%. Grade 3-4 neutropenia, thrombocytopenia, and anemia occurred in 28.4%, 6.8%, and 6.2% of cycles, respectively. No acute toxicity-related deaths occurred. Five patients developed acute myeloid leukemia 10-50 months after exposure to chemotherapy; another patient developed duodenal cancer 2 years after completing therapy. Sixty-one patients who preserved fertility wanted to become pregnant; 56 of them conceived. CONCLUSION The FAEV regimen is an effective primary treatment for patients with GTN who have FIGO scores ≥5 and has predictable and manageable toxicity. IMPLICATIONS FOR PRACTICE The most commonly used multiagent chemotherapy for high-risk gestational trophoblastic neoplasia (GTN) is etoposide, methotrexate and actinomycin D/cyclophosphamide and vincristine (EMA/CO) worldwide. However, 5-fluorouracil-based multiagent chemotherapy has been used as a primary treatment for high-risk GTN in China for a few decades. This study evaluated the efficacy and toxicity of floxuridine, actinomycin D, etoposide, and vincristine (FAEV) as a primary treatment for patients with GTN who have International Federation of Gynecology and Obstetrics (FIGO) scores ≥5. The study's data demonstrated that FAEV as a primary treatment achieved favorable outcomes for patients with FIGO scores ≥5. Toxicities that result from the FAEV regimen are predictable and manageable. The FAEV regimen may provide another option for the treatment of GTN.
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Affiliation(s)
- Yuan Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China
| | - Yujia Kong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China
| | - Tong Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China
| | - Jun Zhao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Obstetrics and Gynecologic Diseases, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China
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14
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Real-World Study of Cisplatin, Etoposide, and Bleomycin Chemotherapy Regimen in Gestational Trophoblastic Neoplasia. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6661698. [PMID: 34258277 PMCID: PMC8249144 DOI: 10.1155/2021/6661698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 05/12/2021] [Accepted: 06/15/2021] [Indexed: 11/17/2022]
Abstract
Objective Little observational data exist regarding the use of cisplatin, etoposide, and bleomycin (BEP) chemotherapy regimen in patients with gestational trophoblastic neoplasia (GTN). Methods This is a retrospective study of 95 patients with GTN in our center from June/2010 to June/2018. All patients received at least 2 cycles of BEP chemotherapy. The primary outcomes were the rate of complete remission (CR) and overall survival (OS). The secondary outcomes were disease-free survival (DFS), pregnancy rates after BEP exposure, drug resistance rate, and other adverse events. Results Of the 95 patients included, 66 (69.5%) patients received BEP as primary treatment and 29 (30.5%) were Salvage chemotherapy. The median age at diagnosis was 37 years (range 29.75-46) and 34 years (range 27-40) in two groups, respectively. The median WHO prognostic scores were 6 (range 3.5-8), and 77.32% of patients were FIGO stage III-IV in the primary treatment group. The median WHO prognostic scores were 5 (range 3-9), and 66.55% of patients were FIGO stage III-IV in the salvage treatment group. Median cycles of BEP treatment were 4 (3, 5) and 3 (2, 4) in two groups, respectively. In the primary chemotherapy group, 18.2% received additional hysterectomy, 4.5% received UAE for vaginal bleeding, and 1.52% received whole-brain radiotherapy. In the salvage chemotherapy group, 20.7% received hysterectomy, 6.9% received lobectomy, 3.4% received hysteroscopic lesion resection, and 3.4% received whole-brain radiotherapy. CR rates to initial chemotherapy were 86.4%, including 87.9% in the primary chemotherapy group and 82.8% in the salvage chemotherapy group. No predictive factor of chemotherapy resistance was identified. The rate of 5 year-DFS was 96.52% (95% CI 86.78-99.12) in the primary chemotherapy group and 92.44% (95% CI 73.02-98.06) in the salvage chemotherapy group. The rate of 5 year-OS was 98.31% (95% CI 88.57-99.76) and 95.65% (95% CI 79.93-99.38) in the two groups, respectively. During the treatment, neutropenia, thrombocytopenia, anemia, and liver dysfunction occurred in 80.3%, 6.1%, 25.8%, and 50% primary chemotherapy patients and 82.8%, 31%, 10.3%, and 86.2% salvage chemotherapy patients. In patients with fertility requirements, live birth rates were 100% (10/10) in primary chemotherapy patients and 80% (4/5) in salvage chemotherapy patients. Conclusions BEP regimen was effective in the treatment of GTINs. The treatment was well tolerated, with no safety concerns on patients' fertility.
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15
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Joneborg U, Coopmans L, van Trommel N, Seckl M, Lok CAR. Fertility and pregnancy outcome in gestational trophoblastic disease. Int J Gynecol Cancer 2021; 31:399-411. [PMID: 33649007 DOI: 10.1136/ijgc-2020-001784] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/01/2020] [Indexed: 12/28/2022] Open
Abstract
The aim of this review is to provide an overview of existing literature and current knowledge on fertility rates and reproductive outcomes after gestational trophoblastic disease. A systematic literature search was performed to retrieve all available studies on fertility rates and reproductive outcomes after hydatidiform mole pregnancy, low-risk gestational trophoblastic neoplasia, high- and ultra-high-risk gestational trophoblastic neoplasia, and the rare placental site trophoblastic tumor and epithelioid trophoblastic tumor forms of gestational trophoblastic neoplasia. The effects of single-agent chemotherapy, multi-agent including high-dose chemotherapy, and immunotherapy on fertility, pregnancy wish, and pregnancy outcomes were evaluated and summarized. After treatment for gestational trophoblastic neoplasia, most, but not all, women want to achieve another pregnancy. Age and extent of therapy determine if there is a risk of loss of fertility. Single-agent treatment does not affect fertility and subsequent pregnancy outcome. Miscarriage occurs more often in women who conceive within 6 months of follow-up after chemotherapy. Multi-agent chemotherapy hastens the natural menopause by three years and commonly induces a temporary amenorrhea, but in young women rarely causes permanent ovarian failure or infertility. Subsequent pregnancies have a high chance of ending with live healthy babies. In contrast, high-dose chemotherapy typically induces permanent amenorrhea, and no pregnancies have been reported after high-dose chemotherapy for gestational trophoblastic neoplasia. Immunotherapy is promising and may give better outcomes than multiple schedules of chemotherapy or even high-dose chemotherapy. The first pregnancy after immunotherapy has recently been described. Data on fertility-sparing treatment in placental site trophoblastic tumor and epithelioid trophoblastic tumor are still scarce, and this option should be offered with caution. In general, patients with gestational trophoblastic neoplasia may be reassured about their future fertility and pregnancy outcome. Detailed registration of high-risk gestational trophoblastic neoplasia is still indispensable to obtain more complete data to better inform patients in the future.
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Affiliation(s)
- Ulrika Joneborg
- Department of Pelvic Cancer, Karolinska University Hospital, Karolinska Institute Department of Women's and Children's Health, Stockholm, Sweden
| | - Leonoor Coopmans
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
| | - Nienke van Trommel
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
| | - Michael Seckl
- Department of Medical Oncology, Hammersmith Hospitals; Imperial College London, London, Pennsylvania, UK
| | - Christianne A R Lok
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
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Sekandarzad A, Udi J, Waller CF, Bode C, Biever P. Extracorporeal Membrane Oxygenation Support as a Bridge to Recovery during Chemotherapy in a Young Patient with Metastatic Choriocarcinoma and Severe Acute Respiratory Distress Syndrome. Oncol Res Treat 2020; 43:559-564. [PMID: 32810849 DOI: 10.1159/000509428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/14/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A young woman presented at a local hospital with severe dyspnea directly after childbirth. She was di-agnosed with choriocarcinoma and massive pulmonary metastases. Shortly after administration of polychemotherapy she developed severe acute respiratory distress syndrome (ARDS). CASE PRESENTATION The patient was transferred to the intensive care unit (ICU) and extracorporeal membrane oxygenation (ECMO) center of the university hospital. Venovenous ECMO support was implemented for 28 days while enabling continuous chemotherapy. After 49 days in the ICU, she was transferred to the oncology ward in a stable respiratory state. DISCUSSION/CONCLUSION Although the survival rates of ARDS in the general ICU population have improved lately due to improved management of ARDS and ECMO support, the data on adult cancer patients receiving ECMO support are very limited. Only few small retrospective studies on ECMO support in adult cancer patients have been conducted. Unfortunately the survival rates of patients after allogenic hematopoietic stem cell transplantation and ECMO support were discouraging. Nevertheless, cancer patients with at least stable disease who are eligible for full-code ICU management may be potential candidates for ECMO in case of severe ARDS. Our case report not only shows that patients suffering from choriocarcinoma with pulmonary metastases may develop severe ARDS in the context of polychemotherapy, but also demonstrates that ECMO support enables chemotherapy continuation and complete remission of the underlying choriocarcinoma.
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Affiliation(s)
- Asieb Sekandarzad
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany, .,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany,
| | - Josefina Udi
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Cornelius F Waller
- Department of Haematology, Oncology and Stem Cell Transplantation, Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul Biever
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Jareemit N, Horowitz NS, Goldstein DP, Berkowitz RS, Elias KM. EMA vs EMACO in the treatment of gestational trophoblastic neoplasia. Gynecol Oncol 2020; 158:99-104. [PMID: 32404247 DOI: 10.1016/j.ygyno.2020.04.699] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/23/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare experiences with EMA versus EMACO in the treatment of gestational trophoblastic neoplasia. METHODS The medical records of women diagnosed with GTN at the New England Trophoblastic Disease Center from 1986 to 2019 were reviewed, and women receiving EMA or EMACO as their first multiagent regimen were eligible. Clinical characteristics, treatment, outcomes, and adverse events were compared between the two groups. RESULTS We identified 44 and 39 patients who received EMA and EMACO, respectively. The complete remission rate was significantly higher in the EMA group (97.7%) than in the EMACO group (71.8%) (p = 0.001). However, patients receiving EMACO were more likely to have adverse prognostic factors such as higher median prognostic risk score (8 vs 4, p < 0.001), non-molar antecedent pregnancy (59 vs 27.3%, p = 0.014) and distant metastasis (64.1 vs 47.7%, p = 0.017). Time to complete remission was also similar (p = 0.947) with a median of 12 weeks with EMA and 13.1 weeks with EMACO. There was no significant difference in treatment delays or use of adjuvant surgery. After multivariate analysis, chemotherapy regimen (EMA or EMACO) did not retain prognostic significance for remission. Overall toxicities were more frequent in EMA (60.2 vs 32.7%, p < 0.001), especially neutropenia, but this did not delay treatment and likely resulted from less growth factor support (18.2 vs 48.7%, p = 0.003). CONCLUSIONS When controlling for other prognostic factors, outcomes with EMA appear similar to EMACO. It may be worthwhile to investigate whether EMA, a simpler and less costly regimen, may be as effective as EMACO in the treatment of GTN.
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Affiliation(s)
- Nida Jareemit
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States; New England Trophoblastic Disease Center, Boston, MA, United States
| | - Donald P Goldstein
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States; New England Trophoblastic Disease Center, Boston, MA, United States
| | - Ross S Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States; New England Trophoblastic Disease Center, Boston, MA, United States
| | - Kevin M Elias
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States; New England Trophoblastic Disease Center, Boston, MA, United States.
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Han C, Zhou Y, Ma JA, Liu J, Jiang YN, Zhang HX. A promising treatment option for refractory male primary choriocarcinoma: report of two cases. Transl Cancer Res 2020; 9:3054-3060. [PMID: 35117666 PMCID: PMC8799262 DOI: 10.21037/tcr.2020.02.05] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/18/2020] [Indexed: 12/26/2022]
Abstract
Male primary choriocarcinoma is a rare and invasive malignant neoplasm for which traditional chemotherapy has limited efficacy. Pembrolizumab is a humanized monoclonal anti-programmed death-1 antibody that has antitumor activity in numerous malignancies. The diagnosis and treatment of two cases of advanced male primary choriocarcinoma were retrospectively analyzed and relevant literature was reviewed to discuss the prognosis and the efficacy of different treatments, including pembrolizumab. The first patient, who presented with cough and hemoptysis, was diagnosed with primary mediastinal choriocarcinoma. He initially responded to the first-line chemotherapy of etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine, but eventually developed brain metastases. The patient did not respond to the second-line chemotherapy comprising paclitaxel and cisplatin, and he died 6.5 months after diagnosis. The second patient experienced repeated episodes of abdominal pain and was diagnosed with primary neck choriocarcinoma. He received chemotherapy regimens similar to those of the first patient. However, imaging showed no significant changes and his clinical symptoms were not improved. Immunohistochemistry showed that the expression of programmed death ligand 1 on the tumor cells was 40%, and he was administered pembrolizumab combined with chemotherapy. He achieved complete response and was subsequently switched to pembrolizumab maintenance monotherapy. He is still alive without evidence of disease 36 months after diagnosis. To our knowledge, this is the first case of advanced male primary choriocarcinoma successfully treated with pembrolizumab combined with chemotherapy. Advanced male primary choriocarcinoma is highly aggressive and insensitive to chemotherapy. Pembrolizumab may provide a promising treatment option to improve patient outcomes.
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Affiliation(s)
- Chen Han
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Ying Zhou
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Jin-An Ma
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Jia Liu
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Yu-Na Jiang
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Hai-Xia Zhang
- Department of Oncology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
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Wu X, Qin J, Shen T, Fei W, Chen L, Xie X, Lu W. The 16-year experience in treating low-risk gestational trophoblastic neoplasia patients with failed primary methotrexate chemotherapy. J Gynecol Oncol 2020; 31:e36. [PMID: 32026657 PMCID: PMC7286751 DOI: 10.3802/jgo.2020.31.e36] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/05/2019] [Accepted: 11/10/2019] [Indexed: 12/01/2022] Open
Abstract
Objective To assess the outcomes and toxic effects of 5-day actinomycin D (Act-D) salvage therapy and to explore the predictors of Act-D resistance in patients with low-risk gestational trophoblastic neoplasia (GTN)who failed 5-day methotrexate (MTX) chemotherapy. Methods This retrospective study analyzed patients with low-risk GTN administered Act-D salvage therapy after failing MTX chemotherapy at Women's Hospital, School of Medicine Zhejiang University between January 2000 and December 2015. The clinical parameters of these patients were collected and analyzed. Results The final analysis included 89 cases. Of these, 73 cases (82.02%) responded to salvage Act-D. The remaining 16 resistant cases were switched to etoposide, MTX, Act-D/cyclophosphamide, and vincristine chemotherapy and achieved complete remission. Serum human chorionic gonadotrophin levels before Act-D salvage therapy (hCGAct-D)in the Act-D-resistant cases were significantly higher than those in the Act-D responders (median 605 vs. 103 IU/L, p=0.009). However, the range of hCGAct-D values in Act-D responders was wider than that in Act-D-resistant cases (5.76–16,664 IU/L vs. 11.43–6,732 IU/L). Thus, assigning a general cut-off value was difficult considering the individual setting. Except for 2 cases requiring other salvage regimens due to Act-D toxicity, 97.80% of cases (89/91) tolerated the toxicity. During at least 1-year follow-up, the survival rate was 100.00% and no case developed recurrence. Conclusion Based on the good therapeutic effect and tolerable toxicity, we recommend Act-D salvage therapy for all patients with low-risk GTN who fail primary MTX chemotherapy. The higher serum hCG levels before Act-D salvage therapy may be associated with resistance to this treatment.
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Affiliation(s)
- Xiaodong Wu
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine Zhejiang University, Hangzhou, China
| | - Jiale Qin
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang Province, Hangzhou, China.,Department of Ultrasound, Women's Hospital, School of Medicine Zhejiang University, Hangzhou, China
| | - Tao Shen
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine Zhejiang University, Hangzhou, China
| | - Weidong Fei
- Department of pharmaceutics, Women's Hospital, School of Medicine Zhejiang University, Hangzhou, China
| | - Lili Chen
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine Zhejiang University, Hangzhou, China
| | - Xing Xie
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine Zhejiang University, Hangzhou, China.,Women's Reproductive Health Research Laboratory of Zhejiang Province, Women's Hospital, School of Medicine Zhejiang University, Hangzhou, China
| | - Weiguo Lu
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine Zhejiang University, Hangzhou, China.,Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang Province, Hangzhou, China.,Women's Reproductive Health Research Laboratory of Zhejiang Province, Women's Hospital, School of Medicine Zhejiang University, Hangzhou, China.
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20
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Kong Y, Zong L, Cheng H, Jiang F, Wan X, Feng F, Ren T, Zhao J, Yang J, Xiang Y. Management and risk factors of recurrent gestational trophoblastic neoplasia: An update from 2004 to 2017. Cancer Med 2020; 9:2590-2599. [PMID: 32022487 PMCID: PMC7131839 DOI: 10.1002/cam4.2901] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Yujia Kong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liju Zong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongyan Cheng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fang Jiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tong Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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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.
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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
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22
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Sato S, Yamamoto E, Niimi K, Ino K, Nishino K, Suzuki S, Kotani T, Kajiyama H, Kikkawa F. The efficacy and toxicity of 4-day chemotherapy with methotrexate, etoposide and actinomycin D in patients with choriocarcinoma and high-risk gestational trophoblastic neoplasia. Int J Clin Oncol 2019; 25:203-209. [PMID: 31520175 DOI: 10.1007/s10147-019-01540-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/01/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study aimed to evaluate the efficacy and toxicity of 4-day chemotherapy with methotrexate, etoposide, and actinomycin D (MEA) for patients who were diagnosed with choriocarcinoma and high-risk gestational trophoblastic neoplasia (GTN). METHODS Between January 1999 and December 2015, 29 patients were treated with 4-day MEA after being diagnosed with choriocarcinoma or high-risk GTN. Complete remission to 4-day MEA and adverse effects were retrospectively evaluated. RESULTS The complete remission rates were 79.3% (23/29) and 87.5% (21/24) in all patients and in those who received 4-day MEA as first-line therapy, respectively. Of six patients who developed drug resistance to 4-day MEA, three patients showed complete remission by other treatments, while the other three patients died of the disease. The major adverse effects were leukocytopenia, anemia, and nausea. Of 23 patients who were cured with 4-day MEA, treatment was changed to the etoposide and actinomycin D (EA) regimen in 14 patients, because of leukocytopenia, hepatotoxicity, and stomatitis. Among 20 patients who required hormonal therapy, 15 patients showed normal menstrual cycles after therapy. Five patients had nine conceptions (seven term live births and two spontaneous abortions). No babies were premature or had low birth weight nor did they have congenital anomalies. CONCLUSION The results suggest that the efficacy and the adverse effects of 4-day MEA for choriocarcinoma and high-risk GTN may be the same level as EMA/CO. However, further study will be needed for determining the criteria of changing the treatment regimen from 4-day MEA to the EA regimen.
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Affiliation(s)
- Shizuka Sato
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eiko Yamamoto
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan. .,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiko Ino
- Department of Obstetrics and Gynecology, Wakayama Medical University, Wakayama, Japan
| | - Kimihiro Nishino
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Suzuki
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomomi Kotani
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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23
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Chan Wah Hak C, Coyle C, Kocache A, Short D, Sarwar N, Seckl MJ, Gonzalez MA. Emergency Etoposide-Cisplatin (Em-EP) for patients with germ cell tumours (GCT) and trophoblastic neoplasia (TN). BMC Cancer 2019; 19:770. [PMID: 31382912 PMCID: PMC6683367 DOI: 10.1186/s12885-019-5968-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
Background Etoposide (E) at 100 mg/m2 combined with Cisplatin (P) at 20 mg/m2 represents an induction 2-day regimen embedded in our clinical practice for patients with advanced GCT or TN at high risk of early death. We evaluated 24/7 Em-EP administration to a combined GCT-TN cohort at our Emergency Cancer Treatment Centre (ECTC) to determine its efficacy within the acute setting. Methods Patients who received Em-EP during a five-year interval were identified from electronic databases at Imperial College Healthcare NHS Trust. Data collected included demographics, treatment details and clinical outcome. Results Em-EP was administered in the emergency setting to 104 patients, predominantly young adults (median age 35, range 17–71). Half the cases were GCT (n = 52): 22 male (6 seminomas, 13 non-seminomas); 30 female (2 dysgerminomas, 28 non-dysgerminomas). The other 50% were treated for TN (n = 52): 45 gestational (GTN) and 7 non-gestational. Most patients received Em-EP for a new cancer diagnosis (n = 100, 96%), within 24 h (n = 93, 89%) and out-of-hours (n = 74, 70%). Indications for Em-EP included symptomatic disease (n = 66, 63%), high-burden disease, (n = 51, 49%) and organ failure requiring Intensive Care Unit support (n = 9, 9%). Neutropenic sepsis was observed in 5%. Four-week overall survival after Em-EP administration was 98%. Conclusions Despite the potentially fatal complications encountered in the acute setting, early mortality with Em-EP is low at our ECTC. Specialist units that treat unwell patients with advanced GCT or TN should consider making Em-EP available 24/7 for emergency administration. Its efficacy within a prospective cohort and in other platinum-sensitive malignancies requires evaluation. Electronic supplementary material The online version of this article (10.1186/s12885-019-5968-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Charleen Chan Wah Hak
- Department of Medical Oncology, Imperial College Healthcare National Health Service Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK.
| | - Christopher Coyle
- Department of Medical Oncology, Imperial College Healthcare National Health Service Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - Arwa Kocache
- Department of Medical Oncology, Imperial College Healthcare National Health Service Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - Dee Short
- Department of Medical Oncology, Imperial College Healthcare National Health Service Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - Naveed Sarwar
- Department of Medical Oncology, Imperial College Healthcare National Health Service Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - Michael J Seckl
- Department of Medical Oncology, Imperial College Healthcare National Health Service Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - Michael A Gonzalez
- Department of Medical Oncology, Imperial College Healthcare National Health Service Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
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24
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Dutch Risk Classification and FIGO 2000 for Gestational Trophoblastic Neoplasia Compared. Int J Gynecol Cancer 2016; 26:1712-1716. [DOI: 10.1097/igc.0000000000000812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
ObjectiveOver the years, there has been a wide variety of classification systems in use worldwide to stratify patients between single-agent versus multi-agent chemotherapy, hindering comparison of international research results. The study presents a retrospective comparison of the International Federation of Gynecology and Obstetrics 2000 and Dutch risk classification system for gestational trophoblastic neoplasia.Methods and MaterialsAll patients diagnosed with gestational trophoblastic neoplasia between January 2003 and December 2012 at the trophoblastic disease centre in London were retrospectively scored according to the Dutch classification system (N = 813).ResultsAn extensive overlap between both scoring systems was seen, even though items and relative value of items were quite distinct. The Dutch system seems to be simpler and easier to apply in all situation; a degree of overtreatment can however be presumed with the use of either system.ConclusionsAlthough it is likely that outcome is indeed affected by the individual factors used in both systems, many factors relate to tumor bulk and may not be independently prognostic. We therefore believe that further refinement of the classification systems and their underlying prognostic items plus any new items that seem promising would be useful.
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Yang J, Xiang Y, Wan X, Feng F, Ren T. Primary treatment of stage IV gestational trophoblastic neoplasia with floxuridine, dactinomycin, etoposide and vincristine (FAEV): A report based on our 10-year clinical experiences. Gynecol Oncol 2016; 143:68-72. [PMID: 27426306 DOI: 10.1016/j.ygyno.2016.07.099] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 06/27/2016] [Accepted: 07/10/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the efficacy and toxicity profile of floxuridine, dactinomycin, etoposide and vincristine (FAEV) regimen as primary treatment in stage IV gestational trophoblastic neoplasia (GTN). METHODS From 2004 to 2014, FAEV was given to 30 stage IV GTNs as the primary treatment (at least two cycles) in Peking Union Medical College Hospital. Remission/resistance/recurrence rate, the cause of treatment failure, and the toxicity profile were analyzed. RESULTS A total of 190cycles of FAEV were administered to 30 patients; the median number of the cycles was 6 (range 3-11). The median follow up was 52.3months (range 8-120). Of all the patients received FAEV primarily, 24 achieved complete remission after only received FAEV, with no recurrence; 6 patients later switched to EMA-CO treatment due to FAEV resistance. Among the 6 patients, 2 died of progressive disease after multiple lines of chemotherapy, the other 4 achieved complete remission after second-line or third-line chemotherapy and 1 of them relapsed 15months later. FAEV was well tolerated. No one died from toxicity. Severe grade 4 neutropenia and thrombocytopenia were noted in 8 (26.7%) and 2 (6.7%) cases. No secondary malignancy was observed with follow-ups from 8 to120 months. Patients treated with FAEV showed good reproductive outcomes. CONCLUSIONS FAEV regimen might be considered as an alternative to other chemotherapy regimen in the primary treatment of stage IV GTN, where it had a high rate of remission and a tolerable toxicity.
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Affiliation(s)
- Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China.
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China.
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China.
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China.
| | - Tong Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China.
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Alazzam M, Tidy J, Osborne R, Coleman R, Hancock BW, Lawrie TA. Chemotherapy for resistant or recurrent gestational trophoblastic neoplasia. Cochrane Database Syst Rev 2016; 2016:CD008891. [PMID: 26760424 PMCID: PMC6768657 DOI: 10.1002/14651858.cd008891.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Gestational trophoblastic neoplasia (GTN) is a highly curable group of pregnancy-related tumours; however, approximately 25% of GTN tumours will be resistant to, or will relapse after, initial chemotherapy. These resistant and relapsed lesions will require salvage chemotherapy with or without surgery. Various salvage regimens are used worldwide. It is unclear which regimens are the most effective and the least toxic. OBJECTIVES To determine which chemotherapy regimen/s for the treatment of resistant or relapsed GTN is/are the most effective and the least toxic. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 4), MEDLINE and EMBASE up to October 2011. In addition, we handsearched the relevant society conference proceedings and study reference lists. For the updated review, we searched Cochrane Group Specialised Register, CENTRAL, MEDLINE and EMBASE to 16 Novemeber 2015. In addition, we searched online clinical trial registries for ongoing trials. SELECTION CRITERIA Only randomised controlled trials (RCTs) were included. DATA COLLECTION AND ANALYSIS We designed a data extraction form and planned to use random-effects methods in Review Manager 5.1 for meta-analyses. MAIN RESULTS The search identified no RCTs; therefore we were unable to perform any meta-analyses. AUTHORS' CONCLUSIONS RCTs in GTN are scarce owing to the low prevalence of this disease and its highly chemosensitive nature. As chemotherapeutic agents may be associated with substantial side effects, the ideal treatment should achieve maximum efficacy with minimal side effects. For methotrexate-resistant or recurrent low-risk GTN, a common practice is to use sequential five-day dactinomycin, followed by MAC (methotrexate, dactinomycin, cyclophosphamide) or EMA/CO (etoposide, methotrexate, dactinomycin, cyclophosphamide, vinblastine) if further salvage therapy is required. However, five-day dactinomycin is associated with more side effects than pulsed dactinomycin, therefore an RCT comparing the relative efficacy and safety of these two regimens in the context of failed primary methotrexate treatment is desirable.For high-risk GTN, EMA/CO is the most commonly used first-line therapy, with platinum-etoposide combinations, particularly EMA/EP (etoposide, methotrexate, dactinomycin/etoposide, cisplatin), being favoured as salvage therapy. Alternatives, including TP/TE (paclitaxel, cisplatin/ paclitaxel, etoposide), BEP (bleomycin, etoposide, cisplatin), FAEV (floxuridine, dactinomycin, etoposide, vincristine) and FA (5-fluorouracil (5-FU), dactinomycin), may be as effective as EMA/EP and associated with fewer side effects; however, this is not clear from the available evidence and needs testing in well-designed RCTs. In the UK, an RCT comparing interventions for resistant/recurrent GTN will be very challenging owing to the small numbers of patients with this scenario. International multicentre collaboration is therefore needed to provide the high-quality evidence required to determine which salvage regimen/s have the best effectiveness-to-toxicity ratio in low- and high-risk disease. Future research should include economic evaluations and long-term surveillance for secondary neoplasms.
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Affiliation(s)
- Mo'iad Alazzam
- Beacon HospitalGynaecological Oncology DivisionSandyfordDublinIreland18
| | - John Tidy
- Sheffield Teaching Hospitals Foundation NHS TrustObstetrics & GynaecologyRoyal Hallamshire HospitalGlossop RoadSheffieldUKS10 2JF
| | - Raymond Osborne
- Toronto‐Sunnybrook Regional Cancer CentreDivision of Gynecology‐Oncology2075 Bayview AveTorontoONCanadaM4N 3M5
| | - Robert Coleman
- Sheffield UniversitySchool of Medicine and Biomedical SciencesWestern BankSheffieldUKS10 2TN
| | - Barry W Hancock
- Sheffield UniversitySchool of Medicine and Biomedical SciencesWestern BankSheffieldUKS10 2TN
| | - Theresa A Lawrie
- 1st Floor Education Centre, Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupCombe ParkBathUKBA1 3NG
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YAO KUN, GAN YU, TANG YUXIN, TANG JIN, HE LEYE, DAI YINGBO. An invasive mole with bilateral kidney metastases: A case report. Oncol Lett 2015; 10:3407-3410. [PMID: 26788142 PMCID: PMC4665133 DOI: 10.3892/ol.2015.3768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 09/14/2015] [Indexed: 11/24/2022] Open
Abstract
Clinical reports of kidney metastases derived from an invasive mole (IM) are rare. The present study presents the case of a 42-year-old woman who exhibited IM and bilateral kidneys metastases in what may be, to the best of our knowledge, the first report of such a case. Following an induced abortion, the patient initially experienced irregular vaginal bleeding and subsequently presented with left-sided waist and abdominal pain. The patient was admitted to hospital and was clinically diagnosed with gestational trophoblastic neoplasia (GTN), as well as bilateral kidney metastases and a spontaneous rupture of the left kidney. This diagnosis was based on the patient's medical history, which comprised increased levels of human chorionic gonadotropin β and aberrant results on computed tomography (CT) scans. The patient subsequently received conservative management to prevent renal damage, and a standard etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine chemotherapy regimen for GTN was administered. Following eight cycles of chemotherapy, a follow-up CT examination indicated that the damage in the patient's left kidney could not be corrected with conservative treatments, therefore the left kidney was excised and a laparoscopic hysterectomy was performed. The pathological results were consistent with the clinical diagnosis and allowed further classification of the primary tumor as an IM. The present case demonstrated that it is possible for IM to metastasize to the kidney, and furthermore, that this type of metastatic tumor may be fragile and possess the potential to cause spontaneous kidney rupture.
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Affiliation(s)
- KUN YAO
- Department of Urology, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
| | - YU GAN
- Department of Urology, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
| | - YUXIN TANG
- Department of Urology, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
| | - JIN TANG
- Department of Urology, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
| | - LEYE HE
- Department of Urology, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
| | - YINGBO DAI
- Department of Urology, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
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Faaborg L, Niemann I, Ostenfeld EB, Hansen ES, Sunde L, Lindegaard JC. A 30-year experience in using oral methotrexate as initial treatment for gestational trophoblastic neoplasia regardless of risk group. Acta Oncol 2015; 55:234-9. [PMID: 26106854 DOI: 10.3109/0284186x.2015.1059486] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Treatment of postmolar gestational trophoblastic neoplasia (GTN) is often stratified according to FIGO score using methotrexate (MTX) for low-risk patients and first-line multi-agent chemotherapy (e.g. EMA-CO) for high-risk patients. In contrast, oral MTX may be given as first-line therapy to all GTN patients regardless of risk group. The aim was to examine the efficacy of oral MTX and a response-adapted treatment policy, which has been used for three decades at Aarhus University Hospital (AUH). MATERIAL AND METHODS Seventy-one consecutive postmolar GTN patients treated 1981-2011 were included. Data were obtained from medical records, using histopathology and human choriogonadotropin (hCG) to verify the diagnosis. All patients received oral MTX as first-line chemotherapy. Second- and third-line chemotherapy was given according to response. RESULTS Sixty-four (90%) patients were retrospectively categorized as FIGO low-risk disease, whereas seven patients (10%) had high-risk disease. Complete response to first-line oral MTX chemotherapy was observed in 35/71 (49%) patients, while 62/71 (87%) had complete remission on MTX (first-line) and/or MTX plus dactinomycin (second-line), without the use of multi-agent therapy. Nine patients (13%) received third-line multi-agent chemotherapy, six low-risk (67%) and three high-risk (33%) patients. There were no recurrences and no patients died as a consequence of toxicity or disease. CONCLUSION Fifty percent of all patients can be cured on oral MTX alone. By adding dactinomycin, about 90% are cured without use of multi-agent chemotherapy. The use of oral MTX as initial treatment can minimize the number of patients receiving multi-agent chemotherapy.
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Affiliation(s)
- Louise Faaborg
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Isa Niemann
- b Department of Obstetrics and Gynecology , Aarhus University Hospital , Aarhus , Denmark
| | - Eva B Ostenfeld
- c Department of Clinical Epidemiology , Aarhus University Hospital , Aarhus , Denmark
| | - Estrid S Hansen
- d Department of Pathology , Aarhus University Hospital , Aarhus , Denmark
| | - Lone Sunde
- e Department of Clinical Genetics Aarhus University Hospital , Aarhus , Denmark
- f Department of Biomedicine , Aarhus University Hospital , Aarhus , Denmark
| | - Jacob C Lindegaard
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
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Cyclophosphamide, Hydroxyurea, Actinomycin D, Methotrexate, and Vincristine in the Treatment of Gestational Trophoblastic Neoplasia. Int J Gynecol Cancer 2015; 25:498-503. [DOI: 10.1097/igc.0000000000000383] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Chimiothérapie des tumeurs trophoblastiques gestationnelles à haut risque. ONCOLOGIE 2014. [DOI: 10.1007/s10269-014-2402-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Feng F, Xiang Y. Surgical management of chemotherapy-resistant gestational trophoblastic neoplasia. Expert Rev Anticancer Ther 2014; 10:71-80. [DOI: 10.1586/era.09.169] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ngu SF, Chan KKL. Management of Chemoresistant and Quiescent Gestational Trophoblastic Disease. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2014; 3:84-90. [PMID: 24533232 PMCID: PMC3920061 DOI: 10.1007/s13669-013-0071-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Gestational trophoblastic neoplasia (GTN) is highly chemosensitive and has a high cure rate. Since the introduction of chemotherapy, reliable measurement of human chorionic gonadotropin (hCG) levels, and individualised risk-based therapy into the management of GTN, almost all low-risk and more than 80 % of high-risk GTN cases are curable. However, approximately 25 % of high-risk GTN developed resistance to chemotherapy or relapsed after completion of initial therapy, which often necessitate salvage combination chemotherapy. On the other end of the spectrum, a proportion of patients with gestational trophoblastic disease (GTD) have persistently low levels of hCG, without clinical or radiological evidence of disease, a condition called quiescent GTD. Recently, measurement of hyperglycosylated hCG has been proposed for the management of patients with quiescent GTD. Although representing a small proportion of GTD cases, the management of patients with chemoresistant and quiescent GTD often poses challenges to medical practitioners.
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Affiliation(s)
- Siew-Fei Ngu
- Department of Obstetrics and Gynecology, The University of Hong Kong, 102 Pokfulam Road, Hong Kong, Hong Kong SAR
| | - Karen K L Chan
- Department of Obstetrics and Gynecology, The University of Hong Kong, 102 Pokfulam Road, Hong Kong, Hong Kong SAR
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Exudative Retinal Detachment Caused by Metastatic Choriocarcinoma to the Choroid. J Emerg Med 2013; 44:617-9. [DOI: 10.1016/j.jemermed.2012.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 06/27/2011] [Accepted: 05/06/2012] [Indexed: 11/20/2022]
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Deng L, Zhang J, Wu T, Lawrie TA. Combination chemotherapy for primary treatment of high-risk gestational trophoblastic tumour. Cochrane Database Syst Rev 2013:CD005196. [PMID: 23440800 DOI: 10.1002/14651858.cd005196.pub4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND This is an update of the original review that was published in The Cochrane Database of Systematic Reviews, 2009, Issue 2. Gestational trophoblastic neoplasia (GTN) are malignant disorders of the placenta that include invasive hydatidiform mole, choriocarcinoma, placental-site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). Choriocarcinoma and invasive hydatidiform mole respond well to chemotherapy: low-risk tumours are treated with single-agent chemotherapy (e.g. methotrexate or actinomycin D), whereas high-risk tumours are treated with combination chemotherapy (e.g. EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine)). Various drug combinations may be used for high-risk tumours; however, the comparative efficacy and safety of these regimens is not clear. OBJECTIVES To determine the efficacy and safety of combination chemotherapy in treating high-risk GTN. SEARCH METHODS For the original review, we searched the Cochrane Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL; Issue 2, 2008), MEDLINE, EMBASE and CBM in May 2008. For the updated review, we searched Cochrane Group Specialised Register, CENTRAL, MEDLINE and EMBASE to September 2012. In addition, we searched online clinical trial registries for ongoing trials. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing first-line combination chemotherapy interventions in women with high-risk GTN. DATA COLLECTION AND ANALYSIS Two review authors independently collected data using a data extraction form. Meta-analysis could not be performed as we included only one study. MAIN RESULTS We included one RCT of 42 women with high-risk GTN who were randomised to MAC (methotrexate, actinomycin D and chlorambucil) or the modified CHAMOCA regimen (cyclophosphamide, hydroxyurea, actinomycin D, methotrexate, doxorubicin, melphalan and vincristine). There were no statistically significant differences in efficacy of the two regimens; however women in the MAC group experienced statistically significantly less toxicity overall and less haematological toxicity than women in the CHAMOCA group. During the study period, six women in the CHAMOCA group died compared with one in the MAC group. This study was stopped early due to unacceptable levels of toxicity in the CHAMOCA group. We identified no RCTs comparing EMA/CO with MAC or other chemotherapy regimens. AUTHORS' CONCLUSIONS CHAMOCA is not recommended for GTN treatment as it is more toxic and not more effective than MAC. EMA/CO is currently the most widely used first-line combination chemotherapy for high-risk GTN, although this regimen has not been rigorously compared to other combinations such as MAC or FAV in RCTs. Other regimens may be associated with less acute toxicity than EMA/CO; however, proper evaluation of these combinations in high-quality RCTs that include long-term surveillance for secondary cancers is required. We acknowledge that, given the low incidence of GTN, RCTs in this field are difficult to conduct, hence multicentre collaboration is necessary.
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Affiliation(s)
- Linyu Deng
- National Key Laboratory of Biotherapy and Cancer Centre,West ChinaHospital, Sichuan University, Chengdu, China
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Alazzam M, Tidy J, Osborne R, Coleman R, Hancock BW, Lawrie TA. Chemotherapy for resistant or recurrent gestational trophoblastic neoplasia. Cochrane Database Syst Rev 2012; 12:CD008891. [PMID: 23235667 DOI: 10.1002/14651858.cd008891.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Gestational trophoblastic neoplasia (GTN) is a highly curable group of pregnancy-related tumours; however, approximately 25% of GTN tumours will be resistant to, or will relapse after, initial chemotherapy. These resistant and relapsed lesions will require salvage chemotherapy with or without surgery. Various salvage regimens are used worldwide. It is unclear which regimens are the most effective and the least toxic. OBJECTIVES To determine which chemotherapy regimen/s for the treatment of resistant or relapsed GTN is/are the most effective and the least toxic. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 4), MEDLINE and EMBASE up to October 2011. In addition, we handsearched the relevant society conference proceedings and study reference lists. SELECTION CRITERIA Only randomised controlled trials (RCTs) were included. DATA COLLECTION AND ANALYSIS We designed a data extraction form and planned to use random-effects methods in Review Manager 5.1 for meta-analyses. MAIN RESULTS The search identified no RCTs; therefore we were unable to perform any meta-analyses. AUTHORS' CONCLUSIONS RCTs in GTN are scarce owing to the low prevalence of this disease and its highly chemosensitive nature. As chemotherapeutic agents may be associated with substantial side effects, the ideal treatment should achieve maximum efficacy with minimal side effects. For methotrexate-resistant or recurrent low-risk GTN, a common practice is to use sequential five-day dactinomycin, followed by MAC (methotrexate, dactinomycin, cyclophosphamide) or EMA/CO (etoposide, methotrexate, dactinomycin, cyclophosphamide, vinblastine) if further salvage therapy is required. However, five-day dactinomycin is associated with more side effects than pulsed dactinomycin, therefore an RCT comparing the relative efficacy and safety of these two regimens in the context of failed primary methotrexate treatment is desirable.For high-risk GTN, EMA/CO is the most commonly used first-line therapy, with platinum-etoposide combinations, particularly EMA/EP (etoposide, methotrexate, dactinomycin/etoposide, cisplatin), being favoured as salvage therapy. Alternatives, including TP/TE (paclitaxel, cisplatin/ paclitaxel, etoposide), BEP (bleomycin, etoposide, cisplatin), FAEV (floxuridine, dactinomycin, etoposide, vincristine) and FA (5-fluorouracil (5-FU), dactinomycin), may be as effective as EMA/EP and associated with fewer side effects; however, this is not clear from the available evidence and needs testing in well-designed RCTs. In the UK, an RCT comparing interventions for resistant/recurrent GTN will be very challenging owing to the small numbers of patients with this scenario. International multicentre collaboration is therefore needed to provide the high-quality evidence required to determine which salvage regimen/s have the best effectiveness-to-toxicity ratio in low- and high-risk disease. Future research should include economic evaluations and long-term surveillance for secondary neoplasms.
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Affiliation(s)
- Mo'iad Alazzam
- Department of Gynaecology, The Galway Clinic, Doughiska, Galway, Ireland.
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Lybol C, Thomas CMG, Blanken EA, Sweep FCGJ, Verheijen RH, Westermann AM, Boere IA, Reyners AKL, Massuger LFAG, van Hoesel RQGCM, Ottevanger PB. Comparing cisplatin-based combination chemotherapy with EMA/CO chemotherapy for the treatment of high risk gestational trophoblastic neoplasia. Eur J Cancer 2012; 49:860-7. [PMID: 23099004 DOI: 10.1016/j.ejca.2012.09.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 09/10/2012] [Accepted: 09/15/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Cisplatin-based chemotherapy (etoposide 100 mg/m(2) days 1-5, methotrexate 300 mg/m(2) day 1, cyclophosphamide 600 mg/m(2) day 1, actinomycin D 0.6 mg/m(2) day 2 and cisplatin 60 mg/m(2) day 4, EMACP) was compared to EMA/CO (etoposide 100 mg/m(2) days 1-2, methotrexate 300 mg/m(2) day 1 and actinomycin D 0.5 mg i.v. bolus day 1 and 0.5 mg/m(2) day 2, alternating with cyclophosphamide 600 mg/m(2) day 8 and vincristine 1 mg/m(2) day 8) for the treatment of high-risk gestational trophoblastic neoplasia (GTN). PATIENTS AND METHODS In the Netherlands, 83 patients were treated with EMACP and 103 patients with EMA/CO. Outcome measures were remission rate, median number of courses to achieve normal human chorionic gonadotrophin (hCG) concentrations, toxicity, recurrent disease rate and disease specific survival. RESULTS Remission rates were similar (EMACP 91.6%, EMA/CO 85.4%). The median number of courses of EMA/CO to reach hCG normalisation for single-agent resistant disease and primary high-risk disease was three and five courses, respectively, compared to 1.5 (p=0.001) and three (p<0.001) courses of EMACP. Patients treated with EMACP more often developed fever, renal toxicity, nausea and diarrhoea compared to patients treated with EMA/CO. Patients treated with EMA/CO more often had anaemia, neuropathy and hepatotoxicity. CONCLUSION EMACP combination chemotherapy is an effective treatment for high-risk GTN, with a remission rate comparable to EMA/CO. However, the difference in duration of treatment is only slightly shorter with EMACP. Cisplatin-based chemotherapy in the form of EMACP in this study was not proven more effective than EMA/CO.
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Affiliation(s)
- C Lybol
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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Lybol C, Centen DW, Thomas CMG, ten Kate-Booij MJ, Verheijen RHM, Sweep FCGJ, Ottevanger PB, Massuger LFAG. Fatal cases of gestational trophoblastic neoplasia over four decades in the Netherlands: a retrospective cohort study. BJOG 2012; 119:1465-72. [DOI: 10.1111/j.1471-0528.2012.03480.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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A case of pulmonary choriocarcinoma metastasis with unusual FDG-PET and CT findings: correlation with pathology. Ann Nucl Med 2012; 26:835-9. [DOI: 10.1007/s12149-012-0644-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 07/23/2012] [Indexed: 10/28/2022]
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Goldstein DP, Berkowitz RS. Current Management of Gestational Trophoblastic Neoplasia. Hematol Oncol Clin North Am 2012; 26:111-31. [DOI: 10.1016/j.hoc.2011.10.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Cyriac S, Rajendranath R, Sridevi V, Sagar TG. Etoposide, cisplatin-etoposide, methotrexate, actinomycin-D as primary treatment for management of very-high-risk gestational trophoblastic neoplasia. Int J Gynaecol Obstet 2011; 115:37-9. [DOI: 10.1016/j.ijgo.2011.04.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 04/17/2011] [Accepted: 07/05/2011] [Indexed: 11/25/2022]
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Feng F, Xiang Y, Wan X, Geng S, Wang T. Salvage combination chemotherapy with floxuridine, dactinomycin, etoposide, and vincristine (FAEV) for patients with relapsed/chemoresistant gestational trophoblastic neoplasia. Ann Oncol 2011; 22:1588-1594. [PMID: 21239399 DOI: 10.1093/annonc/mdq649] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Although most patients with gestational trophoblastic neoplasia (GTN) are cured by conventional chemotherapy, some develop drug resistance or relapse. The use of new combination drugs has been studied to treat those with resistant or relapsed disease. We evaluated the results of floxuridine, dactinomycin, etoposide, and vincristine (FAEV) chemotherapy in patients with relapsed/chemoresistant GTN. PATIENTS AND METHODS Clinical data and outcome of the patients with relapsed/chemoresistant GTN from 1 January 2005 to 30 June 2008 were retrospectively reviewed. Eligible patients had received at least one cycle of FAEV chemotherapy. The primary end points were response rate and toxicity of FAEV regimen; the secondary end point was assessment of clinical predictors of response. RESULTS In total, 91 patients were included. Fifty-five of these patients (60.4%) achieved serologic complete remission (SCR), 29 patients had no response, 7 patients experienced recurrent grade ≥3 or intolerable toxicity. SCR of FAEV chemotherapy was significantly associated with number of previous chemotherapy regimens (≤2) in multivariate analysis (P = 0.005). The most serious adverse events were greater than or equal to grade 3 neutropenia (26.4%), febrile neutropenia (6.6%), and greater than or equal to grade 3 thrombocytopenia (3.3%). CONCLUSION FAEV is an effective regimen with manageable toxicity for patients with relapsed/chemoresistant GTN. Further studies of this regimen are warranted.
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Affiliation(s)
- F Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Y Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - X Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - S Geng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - T Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Lurain JR. Gestational trophoblastic disease II: classification and management of gestational trophoblastic neoplasia. Am J Obstet Gynecol 2011; 204:11-8. [PMID: 20739008 DOI: 10.1016/j.ajog.2010.06.072] [Citation(s) in RCA: 241] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 06/30/2010] [Indexed: 12/11/2022]
Abstract
Gestational trophoblastic neoplasia (GTN) includes invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. The overall cure rate in treating these tumors is currently >90%. Thorough evaluation and staging allow selection of appropriate therapy that maximizes chances for cure while minimizing toxicity. Nonmetastatic (stage I) and low-risk metastatic (stages II and III, score <7) GTN can be treated with single-agent chemotherapy resulting in a survival rate approaching 100%. High-risk GTN (stages II-IV, score ≥7) requires initial multiagent chemotherapy with or without adjuvant radiation and surgery to achieve a survival rate of 80-90%.
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Affiliation(s)
- John R Lurain
- John I. Brewer Trophoblastic Disease Center, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Abstract
Gestational trophoblastic disease encompasses a range of pregnancy-related disorders, consisting of the premalignant disorders of complete and partial hydatidiform mole, and the malignant disorders of invasive mole, choriocarcinoma, and the rare placental-site trophoblastic tumour. These malignant forms are termed gestational trophoblastic tumours or neoplasia. Improvements in management and follow-up protocols mean that overall cure rates can exceed 98% with fertility retention, whereas most women would have died from malignant disease 60 years ago. This success can be explained by the development of effective treatments, the use of human chorionic gonadotropin as a biomarker, and centralisation of care. We summarise strategies for management of gestational trophoblastic disease and address some of the controversies and future research directions.
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Affiliation(s)
- Michael J Seckl
- Department of Cancer Medicine, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, UK.
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Abstract
STUDY DESIGN A case of lumbar metastasis of a choriocarcinoma is presented. OBJECTIVE To present and review a rare case of metastatic choriocarcinoma in the lumbar spine. SUMMARY OF BACKGROUND DATA Choriocarcinoma is a highly anaplastic malignancy derived from trophoblastic cells characterized by the secretion of human chorionic gonadotropin (hCG) and early hematogenous metastasis. However, metastatic choriocarcinoma in the spine is extremely rare. Although 2 cases of metastasis in lumbar and/or sacral vertebra have been reported, the efficacy of surgical treatment for the spinal metastasis of choriocarcinoma is not yet known. METHODS The clinical course, radiologic features, pathology, and outcome of the treatment of metastatic choriocarcinoma of the lumbar spine is reported. RESULTS A 38-year-old female patient with abnormal uterine bleeding 6 weeks after a normal-term delivery showed high serum levels of hCG. A whole body image analysis revealed a lesion in the L2 vertebra. After computed tomography-guided needle biopsy, a clinical and pathologic diagnosis of lumbar metastasis of choriocarcinoma was made. Surgical resection of the localized L2 vertebra lesion was performed by total en bloc spondylectomy after a poor response to initial chemotherapy with methotrexate. Postsurgically, the serum level of hCG explosively increased and local recurrences around the original L2 vertebra and epidural metastasis abruptly developed. Lung metastases also occurred concurrently and progressed and the patient eventually died to the disease. CONCLUSION We have reported a rare case of lumbar metastasis of choriocarcinoma after a normal-term pregnancy. This is the first report of lumbar metastasis of choriocarcinoma treated by spinal surgery. Because surgical resection of a lumbar metastasis of choriocarcinoma involves a substantial risk of profuse hemorrhage, local recurrence and the spread of metastasis, multiagent chemotherapy in combination with radiotherapy should be preformed before surgical resection.
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Chalouhi GE, Golfier F, Soignon P, Massardier J, Guastalla JP, Trillet-Lenoir V, Schott AM, Raudrant D. Methotrexate for 2000 FIGO low-risk gestational trophoblastic neoplasia patients: efficacy and toxicity. Am J Obstet Gynecol 2009; 200:643.e1-6. [PMID: 19393597 DOI: 10.1016/j.ajog.2009.03.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 01/16/2009] [Accepted: 03/06/2009] [Indexed: 11/30/2022]
Abstract
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.
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Abstract
Gestational trophoblastic neoplasia (GTN) includes invasive mole, choriocarcinoma, and placental site trophoblastic tumors. The overall cure rate in treating these tumors currently exceeds 90%. Thorough evaluation and staging allow selection of appropriate therapy that maximizes chances for cure while minimizing toxicity. Nonmetastatic (stage I) and low-risk metastatic (stages II and III, World Health Organization score < 7) GTN can be treated with single-agent chemotherapy, resulting in a survival rate approaching 100%. High-risk metastatic GTN (stage IV, WHO score > or = 7) requires initial multiagent chemotherapy with or without adjuvant radiation and surgery to achieve a survival rate of 80% to 90%.
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Affiliation(s)
- Jacqueline M Morgan
- John I. Brewer Trophoblastic Disease Center, Northwestern University Feinberg School of Medicine, 250 East Superior Street, Suite 05-2168, Chicago, IL 60611, USA
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Braga A, Maestá I, Michelin OC, Delmanto LRG, Consonni M, Rudge MVC, Belfort P. Maternal and perinatal outcomes of first pregnancy after chemotherapy for gestational trophoblastic neoplasia in Brazilian women. Gynecol Oncol 2008; 112:568-71. [PMID: 19108876 DOI: 10.1016/j.ygyno.2008.10.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 10/18/2008] [Accepted: 10/31/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate maternal and perinatal outcomes of first pregnancy after chemotherapy for gestational trophoblastic neoplasia (GTN) in Brazilian patients. METHODS This study included 252 subsequent pregnancies after chemotherapy for GTN treated between 1960-2005. Correlations of maternal and perinatal outcomes with chemotherapy regimen (single or multiagent) and the time interval between chemotherapy completion and first subsequent pregnancy were investigated. RESULTS There was a significant increase in adverse maternal outcomes in women who conceived <6 months than 6-12 months (76.2% and 19.6%; p<0.0001; OR=13.12; CI 95%=3.87-44.40) and >12 months (76.2% and 21.7%; p<0.0001; OR=11.56; CI 95%=3.98-33.55) after chemotherapy. Spontaneous abortion frequency was higher <6 months (71.4%) than 6-12 months (17.6%; p<0.0001; OR=11.66; CI 95%=3.55-38.22) and >12 months (9.4%; p<0.0001; OR=23.97; CI 95%=8.21-69.91) after chemotherapy. There was no difference in adverse perinatal outcomes (stillbirth, fetal malformation, and preterm birth) related to the interval after chemotherapy and subsequent pregnancy. The overall occurrence of adverse maternal and perinatal outcomes did not significantly differ between patients on single or multiagent regimens. CONCLUSION Adverse maternal outcomes and spontaneous abortion were more frequent among patients who conceived within 6 months of chemotherapy completion. In these cases, careful prenatal monitoring and hCG level measurement 6 weeks after the completion of any new pregnancy are recommended.
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Affiliation(s)
- Antônio Braga
- Department of Gynecology and Obstetrics, Botucatu Medical School, UNESP - Sao Paulo State University, Botucatu/SP, Brazil
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