1
|
Elias KM, Berkowitz RS, Horowitz NS. Ultra High-risk Gestational Trophoblastic Neoplasia. Hematol Oncol Clin North Am 2024:S0889-8588(24)00109-6. [PMID: 39341707 DOI: 10.1016/j.hoc.2024.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
Ultra high-risk gestational trophoblastic neoplasia (GTN) refers to patients with World Health Organization prognostic risk scores of at least 13. The mortality risk for these patients averages 30%. Ultra high-risk GTN more frequently presents with higher tumor volume, liver and/or brain metastases, and very high human chorionic gonadotropin levels. The diagnostic evaluation must include a thorough evaluation for central nervous system disease. Prompt initiation of cisplatin - etoposide induction chemotherapy reduces the risks of early death. Collaborative services such as neurosurgery, radiation oncology, and interventional radiology may be required to manage hemorrhagic lesions.
Collapse
Affiliation(s)
- Kevin M Elias
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA; New England Trophoblastic Disease Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Ross S Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA; New England Trophoblastic Disease Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Dana-Farber Cancer Institute, Boston, MA, USA
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA; New England Trophoblastic Disease Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Dana-Farber Cancer Institute, Boston, MA, USA
| |
Collapse
|
2
|
Braga A, Paiva G, Alevato R, Saldanha P, Elias KM, Horowitz NS, Berkowitz RS. Treatment of High-Risk Gestational Trophoblastic Neoplasia. Hematol Oncol Clin North Am 2024:S0889-8588(24)00108-4. [PMID: 39322460 DOI: 10.1016/j.hoc.2024.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
High-risk gestational trophoblastic neoplasia encompasses patients with high volumes of disease or diffuse metastatic involvement who are unlikely to achieve remission with single-agent chemotherapy. Etoposide-based multi-drug regimens form the core of high-risk therapy. Second-line therapy includes platinum-based regimens. Increasingly, third-line therapy uses immunotherapy. Surgical intervention may be required to resect foci of resistant disease or manage complications. Treatment should continue until the hCG is less that the reference range for normal, followed by at least 3 cycles of consolidation therapy. At least 2 years of hCG surveillance are advisable for most patients requiring multiagent therapy to encompass 95% of relapses.
Collapse
Affiliation(s)
- Antonio Braga
- Postgraduate Program in Medical Sciences, Faculty of Medicine, Fluminense Federal University, Rua Ataíde Parreiras, 100, Bairro de Fátima, Niterói, RJ, 24070-090, Rio de Janeiro, Brazil; Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Rua Laranjeiras, 180, Laranjeiras, Rio de Janeiro, RJ, 22240-003, Brazil; Postgraduate Program in Applied Health Sciences, Vassouras University, Av. Expedicionário Osvaldo de Almeida Ramos, 250, Bloco 03, 2 andar, Centro, Vassouras, RJ, 27700-000, Brazil.
| | - Gabriela Paiva
- Postgraduate Program in Medical Sciences, Faculty of Medicine, Fluminense Federal University, Rua Ataíde Parreiras, 100, Bairro de Fátima, Niterói, RJ, 24070-090, Rio de Janeiro, Brazil
| | - Raphael Alevato
- Postgraduate Program in Medical Sciences, Faculty of Medicine, Fluminense Federal University, Rua Ataíde Parreiras, 100, Bairro de Fátima, Niterói, RJ, 24070-090, Rio de Janeiro, Brazil
| | - Penélope Saldanha
- Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Rua Laranjeiras, 180, Laranjeiras, Rio de Janeiro, RJ, 22240-003, 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, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, 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, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| |
Collapse
|
3
|
Yaoxing X, Fangfang Z, Wenzhi L, Xianrong Z, Xin L, Xiang T. Morphological Diversity of the Endometrium in Choriocarcinoma Specimens and its Role in Differential Diagnosis. Int J Surg Pathol 2024; 32:935-942. [PMID: 37993989 DOI: 10.1177/10668969231211336] [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: 11/24/2023]
Abstract
Introduction: The morphological characteristics of the endometrium in patients with choriocarcinoma have not been well described. We described the endometrial morphology patterns in 46 choriocarcinomas and analyzed their relationship with the clinicopathological characteristics of these patients. Methods: Forty-six patients diagnosed with choriocarcinoma that had sufficient endometrial tissues for histopathological diagnosis were selected. Diagnoses of choriocarcinoma and secretory status of endometrium were reviewed. LHCGR expression of endometrium was evaluated by immunostaining. Results: Endometrial morphology was classified as secretory or nonsecretory. The 15 secretory specimens included 2 highly secretory and 13 common secretory specimens. The 31 nonsecretory patterns included 1 hyperplasia without atypia, 7 disordered proliferations, 13 typical proliferations, and 10 resting endometria. Among these, 11 specimens with overall nonsecretory patterns showed focally weak secretory changes surrounding the choriocarcinoma lesion. Secretory patterns were observed in classic choriocarcinomas (8/17) and monomorphic choriocarcinomas (7/21) but not in scanty-trophoblast choriocarcinomas (0/8). Secretory changes appeared significantly less frequently in patients who received multi-agent chemotherapy (4/25) than in those who did not (7/14) or received single-agent chemotherapy (4/7) (P = 0.030). The differences in age, months since the last pregnancy, pregnancy type, recurrence, specimen type, gross diameter, human chorionic gonadotropin (hCG) levels, and expression of hCG receptors were not statistically significant. Conclusions: The endometrial morphologies in choriocarcinoma were diverse, including various proliferative and secretory changes, but rarely hypersecretory changes, compared to the prevailing hypersecretory endometrium in hydatidiform moles. The variety in endometrial morphology was the consequence of ovarian hormonal disturbances of the hypothalamic-pituitary-gonadal axis by hCG from choriocarcinoma. Therefore, the endometrium may serve as a clue for histopathological diagnosis of choriocarcinoma. Our study presents the largest cohort reported to date to describe the diverse spectrum of endometrial changes in choriocarcinoma patients.
Collapse
Affiliation(s)
- Xiao Yaoxing
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Zhong Fangfang
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Li Wenzhi
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Zhou Xianrong
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Lu Xin
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Tao Xiang
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| |
Collapse
|
4
|
Sait HK, Alghamdi F, Ragab Y, Aljadani S, Sait KH. Non-gestational Choriocarcinoma of the Ovary: A Report of a Rare Case From Saudi Arabia. Cureus 2024; 16:e66487. [PMID: 39246853 PMCID: PMC11381097 DOI: 10.7759/cureus.66487] [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] [Accepted: 08/08/2024] [Indexed: 09/10/2024] Open
Abstract
Non-gestational choriocarcinoma of the ovary is extremely rare and presents diagnostic and therapeutic challenges. Early recognition, appropriate surgical intervention, and adjuvant chemotherapy are essential for successful management. This case underscores the importance of considering choriocarcinoma in the differential diagnosis of ovarian tumors, especially in perimenopausal women with vascular mass. We present the case of a 47-year-old sexually active woman with a history of pelvic pain, diagnosed with non-gestational choriocarcinoma of the ovary. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy with successful management using the bleomycin, etoposide, and platinum (BEP) regimen. This case highlights the importance of early detection and appropriate management of this rare entity.
Collapse
Affiliation(s)
- Hesham K Sait
- Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
- Obstetrics and Gynecology, Tom Baker Cancer Centre, University of Calgary, Calgary, CAN
| | - Fahad Alghamdi
- Pathology, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Yaser Ragab
- Radiology, Dr. Erfan and Bagedo General Hospital, Jeddah, SAU
| | - Sarah Aljadani
- Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Khalid H Sait
- Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| |
Collapse
|
5
|
Mangla M, Palo S, Kanikaram P, Kaur H. Non-gestational choriocarcinoma: unraveling the similarities and distinctions from its gestational counterpart. Int J Gynecol Cancer 2024; 34:926-934. [PMID: 38123189 DOI: 10.1136/ijgc-2023-004906] [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: 12/23/2023] Open
Abstract
Choriocarcinoma is a highly vascular and invasive tumor of anaplastic trophoblast, predominantly made up of cytotrophoblasts and syncytiotrophoblasts without villi. Based on its origin, choriocarcinoma can be either gestational or non-gestational. Non-gestational choriocarcinoma can be of germ cell origin, or can be seen in association with a somatic high-grade malignancy. It is difficult to differentiate gestational from non-gestational choriocarcinoma, especially in the reproductive age group. It is important to distinguish between the two, for accurate staging and prognostication, deciding the primary treatment modality, (ie, surgery or chemotherapy), and tailoring follow-up timeframes after diagnosis. An extensive literature search was performed regarding all cases of non-gestational choriocarcinoma, published before March 2023. A note was made of whether the origin of choriocarcinoma was ascertained and how gestational choriocarcinoma was differentiated from non-gestational choriocarcinoma. The keywords used for literature search were "non-gestational choriocarcinoma", "primary choriocarcinoma", "ovarian choriocarcinoma", "ovarian germ cell tumors", or "choriocarcinomatous differentiation". This review aims to summarize the similarities and differences in the epidemiology, pathogenesis, clinical presentation, and management guidelines between gestational and non-gestational choriocarcinoma, which can form an important educational resource for clinicians and laboratory physicians dealing with such cases.
Collapse
Affiliation(s)
- Mishu Mangla
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences - Bibinagar, Hyderabad, Telangana, India
| | - Seetu Palo
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences - Bibinagar, Hyderabad, Telangana, India
| | - Poojitha Kanikaram
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences - Bibinagar, Hyderabad, Telangana, India
| | - Harpreet Kaur
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences - Bilaspur, Bilaspur, Himachal Pradesh, India
| |
Collapse
|
6
|
Peyle M, Massoud M, Patrier S, Gaillot-Durand L, Side G, Devouassoux-Shisheboran M, Massardier J, Descargues P, Msika A, Hajri T, Rousset P, Haesebaert J, Lotz JP, Jamelot M, You B, Golfier F, Eiriksson L, Allias F, Bolze PA. Impact of molecular genotyping on the diagnosis and treatment of human chorionic gonadotropin-producing tumors. J Gynecol Obstet Hum Reprod 2024; 53:102704. [PMID: 38040333 DOI: 10.1016/j.jogoh.2023.102704] [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: 09/05/2023] [Revised: 11/19/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVES To assess the use of molecular genotyping to accurately diagnose and treat human chorionic gonadotropin (hCG)-producing tumors and to evaluate the discriminating capacity of molecular testing on prognosis and overall survival. METHODS We conducted a retrospective descriptive study of patients registered with the French Reference Center for Trophoblastic Disease between 1999 and 2021. We included all patients with hCG-producing tumors for whom results of molecular genotyping were available. RESULTS Fifty-five patients with molecular genotyping were included: 81.2 % (n = 45) had tumors of gestational origin, 12.7 % (n = 7) of non-gestational origin and 5.5 % (n = 3) of undetermined origin. The results of molecular genotyping influenced the treatment decisions for 17 % of patients in this cohort. Overall survival was 93.3 % for patients with gestational tumors (after a median follow-up of 74 months) compared to 71.4 % for patients with non-gestational tumors (after a median follow-up of 23 months). CONCLUSION In atypical presentations of hCG-producing tumors, molecular genotyping is a valuable tool to guide diagnosis and tailor treatment recommendations.
Collapse
Affiliation(s)
- M Peyle
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France
| | - M Massoud
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France
| | - S Patrier
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service d'anatomie et cytologie pathologique, Centre Hospitalier Universitaire de Rouen, 76000, Rouen, France
| | - L Gaillot-Durand
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Pathologie - Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France
| | - G Side
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service d'anatomie et cytologie pathologique, Centre Hospitalier Universitaire de Rouen, 76000, Rouen, France
| | - M Devouassoux-Shisheboran
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Pathologie - Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France
| | - J Massardier
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Gynécologie Obstétrique, Unité de Diagnostic Anténatal, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69500 Bron, France
| | - P Descargues
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France
| | - A Msika
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France
| | - T Hajri
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France
| | - P Rousset
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Radiologie, Hôpital Lyon Sud, Hospices Civils de Lyon, 165, Chemin du Grand Revoyet, 69495 Pierre-Bénite, France; Université Lyon 1, Centre pour l'Innovation en Cancérologie de Lyon (CICLY), EA3738, Faculté de Médecine Lyon Sud Charles Mérieux, France
| | - J Haesebaert
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Pôle de Santé Publique, service de recherche et d'épidémiologie cliniques, Hospices Civils de Lyon, Lyon, France; Université Claude Bernard Lyon 1, U1290 Reshape, Lyon, France
| | - J P Lotz
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Hôpital Tenon, Pôle Onco-Hématologie Hôpitaux Universitaires de l'Est Parisien, Assistance Publique-Hôpitaux de Paris, 4 Rue de la Chine, 75020 Paris, France; Sorbonne Université, Faculté de Médecine, 91-105 Bd de l'Hôpital, 75013 Paris, France
| | - M Jamelot
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Hôpital Tenon, Pôle Onco-Hématologie Hôpitaux Universitaires de l'Est Parisien, Assistance Publique-Hôpitaux de Paris, 4 Rue de la Chine, 75020 Paris, France; Sorbonne Université, Faculté de Médecine, 91-105 Bd de l'Hôpital, 75013 Paris, France
| | - B You
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Université Lyon 1, Centre pour l'Innovation en Cancérologie de Lyon (CICLY), EA3738, Faculté de Médecine Lyon Sud Charles Mérieux, France; Service d'oncologie médicale, Institut de Cancérologie des Hospices Civils de Lyon (IC-HCL), CITOHL EPSILYON, Hospices Civils de Lyon, 69495 Pierre-Bénite, France
| | - F Golfier
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Université Lyon 1, Centre pour l'Innovation en Cancérologie de Lyon (CICLY), EA3738, Faculté de Médecine Lyon Sud Charles Mérieux, France
| | - L Eiriksson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - F Allias
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Pathologie - Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France
| | - P A Bolze
- Centre Français de Référence des Maladies Trophoblastiques, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Hospices Civils de Lyon, Hôpital Lyon Sud, 69495 Pierre Bénite, France; Université Lyon 1, Centre pour l'Innovation en Cancérologie de Lyon (CICLY), EA3738, Faculté de Médecine Lyon Sud Charles Mérieux, France.
| |
Collapse
|
7
|
Raffin D, Descargues P, Hajri T, Massardier J, You B, Lotz JP, Rousset P, Tordo J, Devouassoux-Shisheboran M, Golfier F, Bolze PA. Morbidity, mortality, and prognostic factors in gestational trophoblastic neoplasia with liver metastasis. J Gynecol Obstet Hum Reprod 2023; 52:102636. [PMID: 37500013 DOI: 10.1016/j.jogoh.2023.102636] [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: 12/27/2022] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Liver metastases of gestational trophoblastic neoplasia (GTN) are rare, but associated with poor prognosis. The additional concomitant presence of brain or intra-abdominal metastases, with liver metastases has been described as worsening factors, but the literature on this topic is reduced. OBJECTIVE To estimate the overall mortality, specific hepatic morbidity, and mortality, and to identify prognostic factors for patients with GTN and liver metastases. METHOD The medical records of 26 GTN patients with liver metastases registered in the French Center for Trophoblastic Diseases and treated between November 1999 and December 2019 were reviewed. Overall survival was described using Kaplan-Meier estimates. Prognostic factors were identified using univariate and multivariate Cox analyses. RESULTS The 5-year overall survival rate was 60.7% for all patients with liver metastasis. The survival rate was higher in patients who achieved complete remission after first-line chemotherapy than in those who did not (100% vs 20%, p = 0.001). The only factor independently associated with prognosis was the presence of 6 or more liver metastases (5-year survival, 16.7% vs. 82.4% otherwise; HR =11.1, 95%CI, 2.3-53.1; p = 0.003). None of the five patients with a single liver metastasis died. CONCLUSION GTN with liver metastasis is very rare (1.6%). The prognosis of patients seems to be improving. The results of this study are also reassuring for patients with complete remission after first-line combination chemotherapy, as well as for those with a single liver metastasis.
Collapse
Affiliation(s)
- Delphine Raffin
- University of Lyon 1, Hospices Civils de Lyon, University Hospital Lyon Sud, Department of Gynecological Surgery and Oncology, Obstetrics, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France.
| | - Pierre Descargues
- University of Lyon 1, Hospices Civils de Lyon, University Hospital Lyon Sud, Department of Gynecological Surgery and Oncology, Obstetrics, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France; French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France
| | - Touria Hajri
- French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France
| | - Jérôme Massardier
- University of Lyon 1, University Hospital Femme Mere Enfant, Department of Obstetrics and Gynecology, 51, boulevard Pinel, 69500 Bron, France
| | - Benoit You
- University of Lyon 1, Hospices Civils de Lyon, University Hospital Lyon Sud, Medical Oncology Department, Investigational Center for Treatments in Oncology and Hematology of Lyon (CITOHL), CICLY EA3738, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France; Université Lyon-1, EA 3738 CICLY, Oullins cedex F-69921, France
| | - Jean-Pierre Lotz
- Sorbonne University, AP-HP, Tenon Hospital, Department of medical oncology, 4 rue de la Chine, 75020 Paris, France
| | - Pascal Rousset
- Université Lyon-1, EA 3738 CICLY, Oullins cedex F-69921, France; University of Lyon 1, Hospices Civils de Lyon, University Hospital Lyon Sud, Department of Radiology, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France
| | - Jérémie Tordo
- University of Lyon 1, Hospices Civils de Lyon, University Hospital Lyon Sud, Nuclear Medicine Department, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France
| | - Mojgan Devouassoux-Shisheboran
- University of Lyon 1, Hospices Civils de Lyon, University Hospital Lyon Sud, Department of Pathology, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France
| | - François Golfier
- University of Lyon 1, Hospices Civils de Lyon, University Hospital Lyon Sud, Department of Gynecological Surgery and Oncology, Obstetrics, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France; French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France; Université Lyon-1, EA 3738 CICLY, Oullins cedex F-69921, France
| | - Pierre-Adrien Bolze
- University of Lyon 1, Hospices Civils de Lyon, University Hospital Lyon Sud, Department of Gynecological Surgery and Oncology, Obstetrics, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France; French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 chemin du grand Revoyet, 69495 Pierre Bénite, France; Université Lyon-1, EA 3738 CICLY, Oullins cedex F-69921, France
| |
Collapse
|
8
|
Barcellini A, Fodor A, Charalampopoulou A, Cassani C, Locati LD, Cioffi R, Bergamini A, Pignata S, Orlandi E, Mangili G. Radiation Therapy for Gestational Trophoblastic Neoplasia: Forward-Looking Lessons Learnt. Cancers (Basel) 2023; 15:4817. [PMID: 37835511 PMCID: PMC10571950 DOI: 10.3390/cancers15194817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) includes several rare malignant diseases occurring after pregnancy: invasive moles, choriocarcinoma, placental site trophoblastic tumours, and epithelioid trophoblastic tumours. Multidisciplinary protocols including multi-agent chemotherapy, surgery, and occasionally radiotherapy achieve good outcomes for some high-risk metastatic patients. In this narrative review of the published studies on the topic, we have tried to identify the role of radiotherapy. The available studies are mainly small, old, and retrospective, with incomplete data regarding radiotherapy protocols delivering low doses (which can make this disease appear radioresistant in some cases despite high response rates with palliative doses) to wide fields (whole-brain, whole-liver, etc.), which can increase toxicity. Studies considering modern techniques are needed to overcome these limitations and determine the full potential of radiotherapy beyond its antihemorrhagic and palliative roles.
Collapse
Affiliation(s)
- Amelia Barcellini
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy;
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy;
| | - Andrei Fodor
- Department of Radiation Oncology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
| | - Alexandra Charalampopoulou
- Radiobiology Unit, Research and Development Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy;
- Hadron Academy PhD Course, Istituto Universitario di STUDI Superiori (IUSS), 27100 Pavia, Italy
| | - Chiara Cassani
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Unit of Obstetrics and Gynecology, IRCCS, Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Laura Deborah Locati
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy;
- Translational Oncology Unit, Maugeri Clinical Research Institutes IRCCS, 27100 Pavia, Italy
| | - Raffaella Cioffi
- Unit of Gynaecology and Obstetrics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (R.C.); (A.B.); (G.M.)
| | - Alice Bergamini
- Unit of Gynaecology and Obstetrics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (R.C.); (A.B.); (G.M.)
| | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori, IRCCS-Fondazione G. Pascale Napoli, 80131 Naples, Italy;
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100 Pavia, Italy;
| | - Giorgia Mangili
- Unit of Gynaecology and Obstetrics, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (R.C.); (A.B.); (G.M.)
| |
Collapse
|
9
|
Baas IO, Westermann AM, You B, Bolze PA, Seckl M, Ghorani E. Immunotherapy for Gestational Trophoblastic Neoplasia: A New Paradigm. Gynecol Obstet Invest 2023; 89:230-238. [PMID: 37703867 PMCID: PMC11152029 DOI: 10.1159/000533972] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/27/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Immune checkpoint immunotherapy (CPI) targeting programmed cell death 1 (PD-1)/ligand (PD-L1) has been shown to be an effective treatment for gestational trophoblastic neoplasia (GTN). This includes those with multidrug resistance, ultra-high-risk disease, and epithelioid trophoblastic tumour/placental site trophoblastic tumour subtypes that are inherently chemotherapy resistant, but there is also emerging evidence in low-risk disease. OBJECTIVES We set out to generate an overview of the current data supporting the use of CPI for GTN in both high-risk and low-risk disease and to consider future research goals and directions in order to implement CPI in current treatment guidelines. METHODS We identified and reviewed the published data on the use of CPI agents in GTN. OUTCOME 133 patients were identified who had been treated with CPI for GTN with pembrolizumab (23), avelumab (22), camrelizumab (57), toripalimab (15), or other anti-PD-1 agents (16), of whom 118 had high-risk diseases, relapse or multi-drug resistant disease, and 15 low-risk diseases. Overall 85 patients achieved complete remission, 77 (of 118) with high-risk disease, and 8 (of 15) with low-risk disease. 1 patient with complete remission in the high-risk group developed a relapse 22 months after anti-PD-1 treatment had been stopped. Treatment was generally well tolerated across studies. CONCLUSIONS AND OUTLOOK The majority of high-risk patients (77/118) treated with CPI are cured and this is particularly relevant amongst those with chemotherapy resistant disease who otherwise have very limited treatment options. Priorities for future research include determining whether these agents have a role earlier in the disease course, the utility of combination with chemotherapy, and effects on future fertility. Treatment availability remains a concern due to the high price of these agents.
Collapse
Affiliation(s)
- Inge O Baas
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands,
| | - Anneke M Westermann
- Department of Medical Oncology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Benoit You
- Université Lyon 1, Hospices Civils De Lyon, Centre Français De Référence Des Maladies Trophoblastiques, Hôpital Lyon Sud, CITOHL, EA 3738 CICLY, Univ Lyon 1, Lyon, France
| | - Pierre-Adrien Bolze
- Université Lyon 1, Hospices Civils De Lyon, Centre Français De Référence Des Maladies Trophoblastiques, Hôpital Lyon Sud, CITOHL, EA 3738 CICLY, Univ Lyon 1, Lyon, France
| | - Michael Seckl
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Ehsan Ghorani
- Department of Medical Oncology, Gestational Trophoblastic Disease Centre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| |
Collapse
|
10
|
Khadraoui H, Herzog TJ, Jackson A, Billingsley C. Acute pulmonary complications in the setting of high risk gestational trophoblastic neoplasia and induction of chemotherapy. Gynecol Oncol Rep 2023; 48:101224. [PMID: 37346459 PMCID: PMC10279533 DOI: 10.1016/j.gore.2023.101224] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 06/23/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) consists of rare malignancies of the placenta with a known propensity to metastasize to the lungs. GTN is treated with chemotherapeutic agents known to cause lung injury, further placing patients at risk for serious pulmonary events. In the literature, only a few reports of these complications and their management have been described. Here, we present two cases of GTN with pulmonary complications in the hopes of providing guidance in management. Management of these acute complications had to be balanced between continuation of life-saving therapy to reduce disease burden versus further exacerbation existing pulmonary disease. A review of the English language literature on pulmonary complications in GTN and chemotherapy was performed. In these two cases, we identified key steps that were critical in management: inpatient chemotherapy, early intervention and transfer to an intensive unit when needed, multidisciplinary teams, and altering regimens to reduce lung toxicity. Sequelae of pulmonary injury secondary to chemotherapy can be similar to those secondary to metastases. Because consistent criteria for chemotherapy-induced lung injury has not been established, the true incidence of lung injury that is directly related to chemotherapy versus metastatic disease cannot always be parsed out, making management of these complications difficult. There is also a lack of centralized care for a rare disease like GTN and regional differences in incidence, which can lead to inconsistent treatment decisions. It therefore remains important to illuminate rarely seen complications and their management in the hopes of providing guidance to future clinicians.
Collapse
Affiliation(s)
- Hanaa Khadraoui
- University of Cincinnati Department of Obstetrics & Gynecology, 231 Albert Sabin Way MSB 4408, Cincinnati, OH 45267, USA
| | - Thomas J. Herzog
- University of Cincinnati Department of Obstetrics & Gynecology: Division of Gynecologic Oncology, 234 Goodman Street, Cincinnati, OH 45219, USA
| | - Amanda Jackson
- University of Cincinnati Department of Obstetrics & Gynecology: Division of Gynecologic Oncology, 234 Goodman Street, Cincinnati, OH 45219, USA
| | - Caroline Billingsley
- University of Cincinnati Department of Obstetrics & Gynecology: Division of Gynecologic Oncology, 234 Goodman Street, Cincinnati, OH 45219, USA
| |
Collapse
|
11
|
Deleuze A, Massard C, Le Du F, You B, Lefeuvre-Plesse C, Bolze PA, de la Motte Rouge T. Management of trophoblastic tumors : review of evidence, current practice, and future directions. Expert Rev Anticancer Ther 2023; 23:699-708. [PMID: 37198729 DOI: 10.1080/14737140.2023.2215438] [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: 02/19/2023] [Accepted: 05/15/2023] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Gestational trophoblastic neoplasia (GTN) is a group of rare tumors characterized by abnormal trophoblastic proliferation following pregnancy including invasive moles, choriocarcinomas, and intermediate trophoblastic tumors (ITT). Although the treatment and follow-up of GTN has been heterogeneous, globally the emergence of expert networks has helped to harmonize its management. AREAS COVERED We provide an overview of the current knowledge, diagnosis, and management strategies in GTN and discuss innovative therapeutic options under investigation. While chemotherapy has been the historical backbone of GTN treatment, promising drugs such as immune checkpoint inhibitors targeting the PD-1/PD-L1 pathway and anti-angiogenic tyrosine kinase inhibitors are currently being investigated remodeling the therapeutical landscape of trophoblastic tumors. EXPERT OPINION Chemotherapy regimens for GTN have potential long-term effects on fertility and quality of life, making innovative and less toxic therapeutic approaches necessary. Immune checkpoint inhibitors have shown promise in reversing immune tolerance in GTN and have been evaluated in several trials. However, immunotherapy is associated with rare but life-threatening adverse events and evidence of immune-related infertility in mice, highlighting the need for further research and careful consideration of its use. Innovative biomarkers could help personalize GTN treatments and reduce chemotherapy burden in some patients.
Collapse
Affiliation(s)
- Antoine Deleuze
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | | | - Fanny Le Du
- Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
| | - Benoit You
- Department of Gynecological Oncological, and Obstetrics Department, Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
- French Reference Center for Trophoblastic Diseases, University Hospital Lyon Sud, Lyon, France
- Institute of Cancerology, Hospices Civils de Lyon, CITOHL, Lyon, UR, France
| | | | - Pierre-Adrien Bolze
- Department of Gynecological Oncological, and Obstetrics Department, Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
- Institute of Cancerology, Hospices Civils de Lyon, CITOHL, Lyon, UR, France
| | | |
Collapse
|
12
|
He X, Chang Z, Yan H, Weng Y. Pulmonary aspergillus infection with abnormal imaging successfully treated with omalizumab: A case report. Medicine (Baltimore) 2023; 102:e33845. [PMID: 37327273 PMCID: PMC10270481 DOI: 10.1097/md.0000000000033845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/04/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Pulmonary aspergillosis is a pulmonary infectious disease that is clinically difficult to diagnose and treat. When the lower respiratory tract is invaded by Aspergillus, the clinical manifestations and imaging features vary among patients with different immune states. The use of antifungal drugs and glucocorticoids are important, but some patients do not respond satisfactorily to treatment. CASE PRESENTATION A 59-year-old female had a long history of asthma and poor symptom control, with long-term use of long-acting inhaled glucocorticoids combined with a long-acting β2 receptor agonists (ICS + LABA) (salmeterol fluticasone inhalation powder). The ground glass shadow, tree-in-bud sign, and bronchiectasis in the middle lobe of the right lung and the lower lobe of both lungs were first detected by chest CT over 5 years ago. Atelectasis in the middle lobe of the right lung was detected over 3 years ago. Over 2 years ago, the patient was hospitalized and a repeat chest CT showed persistent atelectasis in the middle lobe of the right lung, and more lesions in bilateral lower lungs than before. Aspergillus fumigatus was detected in alveolar lavage fluid and sputum pathogenic culture, which confirmed the diagnosis of pulmonary aspergillosis. After treatment with voriconazole and amphotericin B, the middle lobe of the right lung partially reopened, but the lesions in bilateral lower lungs persisted. After 21 weeks of treatment, the antifungal drugs were stopped because the patient refused to use oral/intravenous glucocorticoids, and omalizumab was finally chosen for treatment. After 1 month of treatment, the patient's clinical symptoms began to ease. After 1 year of treatment, imaging reexamination of lung showed that the lesions were completely cleared, accompanied by significant improvement in nutritional status and airway function. CONCLUSIONS We reported the case of a patient with pulmonary Aspergillus infection who was treated with omalizumab and showed significant improvement in clinical symptoms and imaging abnormalities, which provides a new option for patients with pulmonary Aspergillus infection who show unsatisfactory response with first-line drugs.
Collapse
Affiliation(s)
- Xing He
- Department of Pulmonary and Critical Care Medicine, Cheng Du Qing Cheng Mt. Hospital, Chongzhou City, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Zhenzhen Chang
- Department of Pulmonary and Critical Care Medicine, Cheng Du Qing Cheng Mt. Hospital, Chongzhou City, Chengdu, China
| | - Haiying Yan
- Department of Pulmonary and Critical Care Medicine, Cheng Du Qing Cheng Mt. Hospital, Chongzhou City, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yang Weng
- School of Mathematics, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
13
|
Zhang Z, Zhao Z, Wang J, Cui R, Feng F. Endometrial clear cell carcinoma with non-gestational choriocarcinoma differentiation: use of rapamycin maintenance. Int J Gynecol Cancer 2023; 33:988-994. [PMID: 37277138 DOI: 10.1136/ijgc-2023-004320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Affiliation(s)
- Zhibo Zhang
- Department of Obstetrics and Gynaecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, People's Republic of China
| | - Zichen Zhao
- Department of Obstetrics and Gynaecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, People's Republic of China
| | - Jing Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Ruixue Cui
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Fengzhi Feng
- Department of Obstetrics and Gynaecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, People's Republic of China
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Gupta A, Kapoor A, Mishra BK, Kashyap L, Choudhary A, Singh A, Singh N, Sansar B. Gestational Trophoblastic Neoplasia-A Retrospective Analysis of Patients Treated at a Tertiary Care Oncology Center in North India. South Asian J Cancer 2023; 12:153-158. [PMID: 37969673 PMCID: PMC10635767 DOI: 10.1055/s-0042-1758356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
Anuj GuptaObjectives The aim of this study was to do a retrospective analysis of patients of gestational trophoblastic neoplasia (GTN) treated at our center concerning their clinical features and treatment outcomes. Materials and Methods Patients diagnosed and treated from May 2018 to December 2021 were included. All relevant information pertaining to eligible patients was retrieved from the electronic medical records. Patients were risk-stratified based on the World Health Organization (WHO) risk scoring system with a score of seven and above being classified into the high-risk category. Patients were monitored for response by measuring β-human chorionic gonadotrophin (β-HCG) levels before each consecutive cycle. Statistical Analysis Appropriate statistical analysis was performed using SPSS version 26. Results Records of 39 eligible patients were analyzed for clinical features out of which 38 were eligible for response assessment. The median age of presentation was 28 years with the majority of patients (79.4%) diagnosed based on β-HCG levels and clinical history alone. The most common symptom was bleeding per vagina (64%), while the majority of antecedent pregnancies were abortions (59%). Of the 14 low-risk category patients, 12 received single-agent methotrexate/actinomycin D, while 2 received etoposide, methotrexate actinomycin D (EMACO) regimen. Overall response rates were 85.7% with the others responding to the second-line EMACO regimen. Five patients in this group had a WHO score of 5 or 6 and all of them responded to single-agent treatment. Among the 25 high-risk category patients, all received the EMACO regimen with high-dose methotrexate added to those with brain metastasis. The response rate was 87.5% with all the nonresponders having features of ultra-high risk of liver/brain metastasis and/or a WHO score of more than 12. While one nonresponder had expired despite treatment, the other two responded to the etoposide methotrexate and actinomycin D/ etoposide and cisplatin regimen. Conclusion Our results are in consonance with other reported studies. The subcategories of low-risk GTN with a WHO score of 5 and 6 and high-risk GTN with ultra-high-risk features deserve further research in the form of multicenter prospective studies.
Collapse
Affiliation(s)
- Anuj Gupta
- Department of Medical Oncology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malviya Cancer Center, Varanasi, Uttar Pradesh, India
| | - Akhil Kapoor
- Department of Medical Oncology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malviya Cancer Center, Varanasi, Uttar Pradesh, India
| | - Bal Krishna Mishra
- Department of Medical Oncology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malviya Cancer Center, Varanasi, Uttar Pradesh, India
| | - Lakhan Kashyap
- Department of Medical Oncology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malviya Cancer Center, Varanasi, Uttar Pradesh, India
| | - Amit Choudhary
- Department of Medical Oncology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malviya Cancer Center, Varanasi, Uttar Pradesh, India
| | - Arpita Singh
- Department of Medical Oncology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malviya Cancer Center, Varanasi, Uttar Pradesh, India
| | - Neha Singh
- Department of Oncopathology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malviya Cancer Center, Varanasi, Uttar Pradesh, India
| | - Bipinesh Sansar
- Department of Medical Oncology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malviya Cancer Center, Varanasi, Uttar Pradesh, India
| |
Collapse
|
16
|
Hapuarachi B, Tidy JA, Romanowski C, Singh K, Gillett S, Ireson J, Winter MC. Leptomeningeal disease as a presenting feature of gestational trophoblastic neoplasia: A review and recommendations for management. Gynecol Oncol 2023; 172:47-53. [PMID: 36934478 DOI: 10.1016/j.ygyno.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/25/2023] [Accepted: 03/07/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVES Gestational Trophoblastic Neoplasia (GTN) is a rare group of malignant placental-related tumours requiring systemic anti-cancer treatment. Leptomeningeal disease (LMD) related to GTN is not well reported with no consensus in optimal treatment. We offer recommendations for management of these patients. METHODS We discuss five patients with GTN who presented with features of LMD and were diagnosed with gadolinium-enhanced MRI brain, all of whom received low dose induction etoposide-cisplatin (EP) followed by either EP-etoposide, methotrexate (CNS) and actinomycin-D (EMA) or EMA(CNS)-cyclophosphamide and vincristine (CO). RESULTS Four out of the five patients additionally received intrathecal methotrexate. Four patients had complete hCG response to first line multi-agent chemotherapy, one patient required second line paclitaxel, cisplatin alternating with paclitaxel, etoposide (TP/TE), where paclitaxel was substituted with nab-paclitaxel due to anaphylaxis, followed by hysterectomy. One of the four initial complete hCG responders relapsed in the lung requiring further systemic treatment with subsequent lobectomy. Patient reported outcomes indicate persistent neurological symptoms are mild and do not affect functionality and quality of life. CONCLUSION With a follow-up range of 2-6 years, all five patients remain cured demonstrating excellent survival outcomes with the avoidance of whole-brain radiotherapy in all cases.
Collapse
Affiliation(s)
- B Hapuarachi
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - J A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - C Romanowski
- Department of Neuroradiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2JF, UK
| | - K Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - S Gillett
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - J Ireson
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - M C Winter
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK; Yorkshire Cancer Research Connects NHS Academy Fellow, Department of Oncology and Metabolism, The University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK.
| |
Collapse
|
17
|
Braga A, Paiva G, Cattai CJ, Elias KM, Horowitz NS, Berkowitz RS. Current chemotherapeutic options for the treatment of gestational trophoblastic disease. Expert Opin Pharmacother 2023; 24:245-258. [PMID: 36399723 DOI: 10.1080/14656566.2022.2150075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Gestational trophoblastic neoplasia (GTN) is a rare tumor that arises from trophoblastic tissues with high remission rates after chemotherapy treatment. GTN can develop from any gestational events, such as miscarriage, ectopic pregnancy, and preterm/term pregnancy, but is more frequent after hydatidiform mole. The sensitivity of this tumor to chemotherapy and the presence of an exceptional tumor marker allow high remission rates, especially when patients are treated in referral centers. AREAS COVERED Observational, retrospective, prospective, systematic reviews, and meta-analysis studies focusing on GTN treatment. We searched PubMed, Medline, and the Library of Congress from January 1965 to May 2022. EXPERT OPINION Early GTN diagnosis allows low-toxic and highly effective treatment. Even multimetastatic disease has high rates of remission with multiagent regimen chemotherapy. Surgery is reserved for uterine disease in patients who have completed childbearing, in cases of chemoresistance to multiagent regimens or in the rare cases of placental site trophoblastic tumor or epithelioid trophoblastic tumor. While resistance is managed by salvage chemotherapy, cases with limited clinical response to sequential regimens have been successfully treated with immunotherapy.
Collapse
Affiliation(s)
- Antonio Braga
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil.,Department of Medicine, Vassouras Medical School, Postgraduate Program in Applied Health Sciences, Vassouras University, Vassouras, RJ, Brazil.,National Academy of Medicine, Young Leadership Physician Program, Rio de Janeiro, RJ, Brazil
| | - Gabriela Paiva
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil
| | - Cassia Juliana Cattai
- , Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, 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, Dana Farber Cancer Institute, 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, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
18
|
Kurniadi A, Zulvayanti Z, Suardi D, Mantilidewi K, Irsyad BI, Reswari A, Purwara BH, Winarno GNA. Risk Factors That Correlate with Resistance to First-Line Chemotherapy on High-risk Gestational Trophoblastic Neoplasia. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND: Gestational trophoblastic neoplasia (GTN) is a condition arising from abnormal proliferation of the trophoblastic cells. GTN incidence in Indonesia, precisely in Hasan Sadikin General Hospital, as many as 730 cases are reported per year. GTN is generally highly sensitive to chemotherapy, and multiagent chemotherapy regimens are recommended for high-risk GTN. Multiagent chemotherapy regimens for GTN treatment at Hasan Sadikin General Hospital are EMCO, with no other literature study describing chemotherapy resistance with EMCO today.
AIM: This study aimed to identify risk factors associated with first-line chemotherapy resistance at Hasan Sadikin General Hospital.
METHODS: In this cross-sectional study, medical records of 81 patients with high-risk GTN presented in the period from January 2018 to June 2021 who received EMCO chemotherapy at Hasan Sadikin General Hospital were retrieved from the archives, and medical data were reviewed and analyzed. Bivariate analysis was performed using the Chi-square test with Fisher’s exact alternative, and multivariate analysis using the binary logistic regression test. p < 0.05 was considered statistically significant.
RESULTS: From 81 samples that received EMCO chemotherapy, 15 (18.5%) cases were resistant to EMCO, and 66 (81.5%) cases were responsive to EMCO. The risk factors associated with EMCO resistance were histopathological features and appropriate with EMCO chemotherapy interval (p < 0.05). Variables of age, previous pregnancy, GTN stage, FIGO prognostic score, stage, beta-hCG level, and side effects of EMCO did not significantly correlate with resistance to EMCO (p > 0.05).
CONCLUSION: Histopathological features and appropriate chemotherapy intervals were associated with the incidence of resistance to EMCO in Hasan Sadikin General Hospital.
Collapse
|
19
|
Weikel K, Watkins E. Gestational Trophoblastic Disease and Neoplasia. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
20
|
Abstract
The nitrogen mustards are powerful cytotoxic and lymphoablative agents and have been used for more than 60 years. They are employed in the treatment of cancers, sarcomas, and hematologic malignancies. Cyclophosphamide, the most versatile of the nitrogen mustards, also has a place in stem cell transplantation and the therapy of autoimmune diseases. Adverse effects caused by the nitrogen mustards on the central nervous system, kidney, heart, bladder, and gonads remain important issues. Advances in analytical techniques have facilitated the investigation of the pharmacokinetics of the nitrogen mustards, especially the oxazaphosphorines, which are prodrugs requiring metabolic activation. Enzymes involved in the metabolism of cyclophosphamide and ifosfamide are very polymorphic, but a greater understanding of the pharmacogenomic influences on their activity has not yet translated into a personalized medicine approach. In addition to damaging DNA, the nitrogen mustards can act through other mechanisms, such as antiangiogenesis and immunomodulation. The immunomodulatory properties of cyclophosphamide are an area of current exploration. In particular, cyclophosphamide decreases the number and activity of regulatory T cells, and the interaction between cyclophosphamide and the intestinal microbiome is now recognized as an important factor. New derivatives of the nitrogen mustards continue to be assessed. Oxazaphosphorine analogs have been synthesized in attempts to both improve efficacy and reduce toxicity, with varying degrees of success. Combinations of the nitrogen mustards with monoclonal antibodies and small-molecule targeted agents are being evaluated. SIGNIFICANCE STATEMENT: The nitrogen mustards are important, well-established therapeutic agents that are used to treat a variety of diseases. Their role is continuing to evolve.
Collapse
Affiliation(s)
- Martin S Highley
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Bart Landuyt
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Hans Prenen
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Peter G Harper
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Ernst A De Bruijn
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| |
Collapse
|
21
|
Current Evidence on Immunotherapy for Gestational Trophoblastic Neoplasia (GTN). Cancers (Basel) 2022; 14:cancers14112782. [PMID: 35681761 PMCID: PMC9179472 DOI: 10.3390/cancers14112782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 05/26/2022] [Accepted: 06/01/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Gestational trophoblastic neoplasia (GTN) is a rare tumor group that arises from the malignant transformation of placental tissue. Based on the evaluation of International Federation of Gynecology and Obstetrics (FIGO) anatomic staging and FIGO prognostic score, GTN is divided into low-, high-, and ultra-high-risk groups if the score obtained is less than or equal to 6, greater than 6 or greater than 12, respectively. The standard treatment is chemotherapy, using a single agent in low-risk disease and multiagent chemotherapy in high- and ultra-high-risk GTN. In chemoresistant forms of GTN, the use of immune checkpoint inhibitors, such as anti-PD-1 or anti-PD-L1/2, could represent a new therapeutic strategy. In this study, we evaluate the available evidence on immune checkpoint inhibitors for GTN treatment. Abstract Background: Gestational trophoblastic disease includes a rare group of benign and malignant tumors derived from abnormal trophoblastic proliferation. Malignant forms are called gestational trophoblastic neoplasia (GTN) and include invasive mole, choriocarcinoma, placental site trophoblastic tumor and epithelioid trophoblastic tumor. Standard treatment of GTN is chemotherapy. The regimen of choice mainly depends on the FIGO prognostic score. Low-risk and high-risk GTN is treated with single-agent or multiagent chemotherapy, respectively. In the case of chemoresistance, immunotherapy may represent a new therapeutic strategy. Methods: Literature obtained from searches on PubMed concerning GTN and immunotherapy was reviewed. Results: Programmed cell death 1 (PD-1) and its ligands (PD-L1/2) are expressed in GTN. Published data on PD-1/PD-L1 inhibitors alone in GTN were available for 51 patients. Pembrolizumab is an anti-PD-1 inhibitor used in chemoresistant forms of GTN. In the TROPHIMMUN trial, Avelumab, a monoclonal antibody inhibiting PD-L1, showed promising results only in patients with GTN resistant to monochemotherapy. Conversely, in patients with resistance to multiagent chemotherapy, treatment with Avelumab was discontinued due to severe toxicity and disease progression. The association of Camrelizumab and Apatinib could represent a different treatment for forms of GTN refractory to polychemotherapy or for relapses. Conclusions: Anti-PD-1 or anti-PD-L1 might represent an important new treatment strategy for the management of chemoresistant/refractory GTN.
Collapse
|
22
|
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.
Collapse
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.
| |
Collapse
|
23
|
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.
Collapse
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.
| |
Collapse
|
24
|
Non-Gestational Ovarian Choriocarcinoma: A Rare Ovarian Cancer Subtype. Diagnostics (Basel) 2022; 12:diagnostics12030560. [PMID: 35328112 PMCID: PMC8947355 DOI: 10.3390/diagnostics12030560] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/07/2022] [Accepted: 02/15/2022] [Indexed: 12/04/2022] Open
Abstract
Non-Gestational Ovarian Choriocarcinoma (NGOC) is an extremely rare ovarian tumor, with an incidence of less than 0.6% of malignant ovarian germ cell tumors. Its close pathologic resemblance to Gestational Ovarian Choriocarcinoma (GOC), however, requires special attention as the treatments differ greatly. NGOC typically affects patients in late adolescence or early reproductive years. As a result, NGOCs are often misdiagnosed as ectopic pregnancies due to their common presentation of bleeding, abdominal pain, adnexal mass, and positive serum beta-HCG. On pathologic examination, the tumor is indistinguishable from GOC, and only after review of tissue for paternal genetic components can the diagnosis of NGOC be made. Imaging studies often show highly vascular lesions with further investigation with computer topography (CT) sometimes showing metastatic lesions in the lungs, pelvis, vagina, and liver. These lesions are often hemorrhagic and can lead to catastrophic bleeding. Treatment is vastly different from GOC; NGOC requires treatment with both surgical resection and chemotherapy, with Bleomycin, Etoposide, and Cisplatin (BEP) being the most used regimen. With correct diagnosis and treatment, patients can often receive fertility sparing treatment with long term survival.
Collapse
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Wang Z, Han P, Zhu X, Ying J, Qian J. Role of Emergency Surgery for Fatal Complications of Gestational Trophoblastic Neoplasia: A Single-Center Experience. Cancer Manag Res 2022; 14:851-861. [PMID: 35250312 PMCID: PMC8893144 DOI: 10.2147/cmar.s346421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/11/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose High-risk gestational trophoblastic neoplasia (GTN) can lead to fatal complications; however, few reports have assessed emergency surgery as a treatment option for such complications. Thus, this study aimed to analyze the clinical features and prognosis of patients with GTN who underwent emergency surgery. Patients and Methods Thirteen patients with high-risk or ultra-high-risk GTN who underwent emergency surgery for fatal complications in the First Affiliated Hospital of Zhejiang University, School of Medicine from 2013 to 2020 were analyzed, and their medical records were reviewed. The patients’ characteristics and treatment were evaluated with respect to outcomes. Results Thirteen patients with GTN who underwent 15 emergency surgical procedures were identified in our center. The mean International Federation of Gynecology and Obstetrics score of these patients was 14.8 (range, 11–19). Of the 13 patients, six underwent brain surgeries, such as tumor resection (n = 5) and conservative surgery (n = 1). All the patients received multi-agent chemotherapy after emergency surgery, and the mean time from emergency surgery to subsequent chemotherapy was 12.7 days. Of the 13 patients, 10 (77%) were cured and disease-free, with a follow-up period ranging from 3 months to 8 years. All the patients (n = 6) who underwent emergency brain surgery survived and achieved complete remission. Conclusion For patients with high-risk GTN with fatal complications, especially brain lesions, emergency surgery combined with subsequent chemotherapy may provide a favorable prognosis.
Collapse
Affiliation(s)
- Zhe Wang
- Department of Gynecology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Peilin Han
- Department of Gynecology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Xiaoxu Zhu
- Department of Gynecology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Jun Ying
- Department of Gynecology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Jianhua Qian
- Department of Gynecology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Correspondence: Jianhua Qian, Tel +86 13858028056, Email
| |
Collapse
|
27
|
Ding W, Zhang N, Rao Y, Xu X, Nie T, Qu P. A Successfully Treated Multiple Metastatic Choriocarcinoma Coexistent With Live Fetus: A Case Report and Literature Review. Front Oncol 2022; 11:777707. [PMID: 35174067 PMCID: PMC8841587 DOI: 10.3389/fonc.2021.777707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/06/2021] [Indexed: 11/28/2022] Open
Abstract
Management of metastatic choriocarcinoma coexistent with live fetus is tricky for gynecologists. There is no consensus on treatment because of its rarity. We present a unique case of gestational choriocarcinoma with multiple metastases, who received EP chemotherapy in the third trimester. At 31 + 5 weeks, a healthy male baby was delivered by cesarean section. Then, she received six cycles of EMA/CO as postpartum chemotherapy. Her beta-human chorionic gonadotropin (β-hCG) level decreased to the normal range, and the metastases vanished. The patient had no clinical symptoms 4 years after discharge, and the baby was also free from this disease. Short tandem repeat polymorphism (STR) analysis was performed to determine the genotype of the choriocarcinoma, placenta, and normal curettage tissue of the maternal uterine. Comparing the polymorphic genetic markers revealed that the tumor was gestational choriocarcinoma, but did not originate from the coexistent pregnancy. In spite of extensive metastases, antepartum chemotherapy is an effective and safe treatment for patients with gestational choriocarcinoma concurrent with pregnancy. STR analysis can be useful in distinguishing gestational choriocarcinoma from non-gestational, as well as the causative pregnancy, and serve as a helpful examination tool for guiding clinical management.
Collapse
Affiliation(s)
- Wei Ding
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
- Department of Gynecological Oncology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
| | - Na Zhang
- Department of Gynecological Oncology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
| | - Yang Rao
- Department of Gynecological Oncology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
| | - Xiaoning Xu
- Institute of Forensic Science, Tianjin Municipal Public Security Bureau, Tianjin, China
| | - Tonggang Nie
- Institute of Forensic Science, Tianjin Municipal Public Security Bureau, Tianjin, China
| | - Pengpeng Qu
- Department of Gynecological Oncology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin, China
- Clinical School of Obstetrics and Gynecology Center, Tianjin Medical University, Tianjin, China
- *Correspondence: Pengpeng Qu,
| |
Collapse
|
28
|
Wu A, Zhu Q, Tan C, Chen L, Tao Y. Invasive Mole Resulting in Uterine Rupture: A Case Report. Front Surg 2022; 8:798640. [PMID: 35155552 PMCID: PMC8831237 DOI: 10.3389/fsurg.2021.798640] [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: 10/20/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022] Open
Abstract
Uterine surgery is a common predisposing factor for uterine rupture, while an invasive mole that leads to uterine rupture is a rare clinical occurrence. Here, we report a case of a 31-year-old childless woman who underwent abortion after 53 days of pregnancy. She still experienced abdominal pain and scanty vaginal bleeding after the abortion. Her levels of human chorionic gonadotropin (HCG) were high, while ultrasound and MRI results revealed an enlarged uterus and a mass in the myometrium. During preparation for treatment, the gynecologist ruptured the uterus of the patient, leaving her shocked. Eventually the patient's uterus was removed the uterus and pathologically diagnosed as result is the an invasive mole.
Collapse
|
29
|
Ghorani E, Seckl MJ. Emergency craniotomy: a life-saving procedure as part of multi-modal therapy of GTN. J Gynecol Oncol 2022; 33:e52. [PMID: 35443295 PMCID: PMC9024186 DOI: 10.3802/jgo.2022.33.e52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/13/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Ehsan Ghorani
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Hospitals NHS Trust, London, UK
| | - Michael J Seckl
- Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial College Hospitals NHS Trust, London, UK
| |
Collapse
|
30
|
Li Y, Wang W, Wan X, Feng F, He YL, Yang J, Xiang Y. Effectiveness of craniotomy and long-term survival in 35 patients with gestational trophoblastic neoplasia with brain metastases: a clinical retrospective analysis. J Gynecol Oncol 2022; 33:e33. [PMID: 35128861 PMCID: PMC9024194 DOI: 10.3802/jgo.2022.33.e33] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 01/02/2022] [Accepted: 01/10/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Methods Results Conclusion Decompressive craniotomy is a life-saving option for patients with GTN at risk of cerebral hernia. Craniotomy combined with timely standard chemotherapy could help improve survival in certain patients. Previous chemotherapy failure is an independent risk factor for poor survival.
Collapse
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 Obstetric & Gynecologic Diseases, Beijing, PR, China
| | - Weidi Wang
- 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 Obstetric & Gynecologic Diseases, Beijing, PR, 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 Obstetric & Gynecologic Diseases, Beijing, PR, 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 Obstetric & Gynecologic Diseases, Beijing, PR, China
| | - Yong-Lan He
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR, 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 Obstetric & Gynecologic Diseases, Beijing, PR, 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 Obstetric & Gynecologic Diseases, Beijing, PR, China
| |
Collapse
|
31
|
Horowitz NS, Eskander RN, Adelman MR, Burke W. Epidemiology, diagnosis, and treatment of gestational trophoblastic disease: A Society of Gynecologic Oncology evidenced-based review and recommendation. Gynecol Oncol 2021; 163:605-613. [PMID: 34686354 DOI: 10.1016/j.ygyno.2021.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/28/2021] [Accepted: 10/04/2021] [Indexed: 12/22/2022]
Affiliation(s)
- N S Horowitz
- Brigham & Women's Hospital/Dana Farber Cancer Institute, Boston, MA, USA.
| | - R N Eskander
- University of California, San Diego, Moores Cancer Center, La Jolla, CA, USA
| | | | - W Burke
- Stony Brook Medicine, Long Island, NY, USA
| |
Collapse
|
32
|
Smith NJ, Nance BA, Durham LA, McAlarnen LA, Bishop EA, Zundel MT. Extracorporeal Membrane Oxygenator Failure in a Patient With Gestational Trophoblastic Neoplasm: Possible Mechanisms and Considerations in Critical Care. J Cardiothorac Vasc Anesth 2021; 36:2583-2587. [PMID: 34649807 DOI: 10.1053/j.jvca.2021.09.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Nathan J Smith
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI.
| | - Beth A Nance
- Department of Anesthesiology, Division of Critical Care Anesthesia, Medical College of Wisconsin, Milwaukee, WI
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Lindsey A McAlarnen
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Erin A Bishop
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - M Tracy Zundel
- Department of Anesthesiology, Division of Critical Care Anesthesia, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
33
|
Frega G, Kepp O, Turchetti D, Rizzo A, Pantaleo MA, Brandi G. Hypothesis on the possible relevance of the immunogenic cell death in the treatment of gestational trophoblastic neoplasms. Transl Oncol 2021; 14:101224. [PMID: 34592590 PMCID: PMC8482038 DOI: 10.1016/j.tranon.2021.101224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/31/2021] [Accepted: 09/10/2021] [Indexed: 11/30/2022] Open
Abstract
The genetic background and the antigenic landscape of cancer cells play a critical role in the response to immunotherapies. A high tumor antigenicity, together with an increased adjuvanticity potentially induced by a peculiar type of cell death, namely immunogenic cell death (ICD), could foster the response to immunogenic therapies. The gestational trophoblastic neoplasm (GTN) is a one-of-a-kind cancer in the oncological landscape due to its exclusive genomic makeup. The prognosis of GTN is significantly better than non-gestational trophoblastic neoplasm (nGTN). Due to its peculiar genetic inheritance, GTN potentially constitutes a singular archetype in the immuno-oncological field.
Collapse
Affiliation(s)
- G Frega
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Italy; Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni n.15, 40138 Bologna, Italy.
| | - O Kepp
- Equipe labellisée par la Ligue contre le cancer, INSERM UMR1138, Centre de Recherche des Cordeliers, Université de Paris, Sorbonne Université, Paris, France; Metabolomics and Cell Biology Platforms, Gustave Roussy, Villejuif, France
| | - D Turchetti
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Italy; U.O. Genetica Medica, Policlinico S. Orsola-Malpighi, Centro di Ricerca sui Tumori Ereditari, Bologna Italy
| | - A Rizzo
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Italy; Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni n.15, 40138 Bologna, Italy
| | - M A Pantaleo
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Italy; Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni n.15, 40138 Bologna, Italy
| | - G Brandi
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Italy; Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni n.15, 40138 Bologna, Italy
| |
Collapse
|
34
|
Zhang W, Gou P, Dupret JM, Chomienne C, Rodrigues-Lima F. Etoposide, an anticancer drug involved in therapy-related secondary leukemia: Enzymes at play. Transl Oncol 2021; 14:101169. [PMID: 34243013 PMCID: PMC8273223 DOI: 10.1016/j.tranon.2021.101169] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 01/13/2023] Open
Abstract
Etoposide is a semi-synthetic glycoside derivative of podophyllotoxin, also known as VP-16. It is a widely used anticancer medicine in clinics. Unfortunately, high doses or long-term etoposide treatment can induce therapy-related leukemia. The mechanism by which etoposide induces secondary hematopoietic malignancies is still unclear. In this article, we review the potential mechanisms of etoposide induced therapy-related leukemia. Etoposide related leukemogenesis is known to depend on reactive oxidative metabolites of etoposide, notably etoposide quinone, which interacts with cellular proteins such as topoisomerases II (TOP2), CREB-binding protein (CREBBP), and T-Cell Protein Tyrosine Phosphatase (TCPTP). CYP3A4 and CYP3A5 metabolize etoposide to etoposide catechol, which readily oxidizes to etoposide quinone. As a poison of TOP2 enzymes, etoposide and its metabolites induce DNA double-stranded breaks (DSB), and the accumulation of DSB triggers cell apoptosis. If the cell survives, the DSB gives rise to the likelihood of faulty DNA repair events. The gene translocation could occur in mixed-lineage leukemia (MLL) gene, which is well-known in leukemogenesis. Recently, studies have revealed that etoposide metabolites, especially etoposide quinone, can covalently bind to cysteines residues of CREBBP and TCPTP enzymes, . This leads to enzyme inhibition and further affects histone acetylation and phosphorylation of the JAK-STAT pathway, thus putatively altering the proliferation and differentiation of hematopoietic stem cells (HSC). In brief, current studies suggest that etoposide and its metabolites contribute to etoposide therapy-related leukemia through TOP2 mediated DSB and impairs specific enzyme activity, such as CREBBP and TCPTP.
Collapse
Affiliation(s)
- Wenchao Zhang
- Université de Paris, BFA, UMR 8251, CNRS, Paris F-75013, France.
| | - Panhong Gou
- Inserm UMR-S1131, Université de Paris, IRSL, Hôpital Saint-Louis, Paris, France
| | | | - Christine Chomienne
- Inserm UMR-S1131, Université de Paris, IRSL, Hôpital Saint-Louis, Paris, France; Service de Biologie Cellulaire, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Saint Louis, Paris, France
| | | |
Collapse
|
35
|
Ngan HYS, Seckl MJ, Berkowitz RS, Xiang Y, Golfier F, Sekharan PK, Lurain JR, Massuger L. Diagnosis and management of gestational trophoblastic disease: 2021 update. Int J Gynaecol Obstet 2021; 155 Suppl 1:86-93. [PMID: 34669197 PMCID: PMC9298230 DOI: 10.1002/ijgo.13877] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Gestational trophoblastic disease (GTD) arises from abnormal placenta and is composed of a spectrum of premalignant to malignant disorders. Changes in epidemiology of GTD have been noted in various countries. In addition to histology, molecular genetic studies can help in the diagnostic pathway. Earlier detection of molar pregnancy by ultrasound has resulted in changes in clinical presentation and decreased morbidity from uterine evacuation. Follow-up with human chorionic gonadotropin (hCG) is essential for early diagnosis of gestational trophoblastic neoplasia (GTN). The duration of hCG monitoring varies depending on histological type and regression rate. Low-risk GTN (FIGO Stages I-III: score <7) is treated with single-agent chemotherapy but may require additional agents; although scores 5-6 are associated with more drug resistance, overall survival approaches 100%. High-risk GTN (FIGO Stages II-III: score ≥7 and Stage IV) is treated with multiagent chemotherapy, with or without adjuvant surgery for excision of resistant foci of disease or radiotherapy for brain metastases, achieving a survival rate of approximately 90%. Gentle induction chemotherapy helps reduce early deaths in patients with extensive tumor burden, but late mortality still occurs from recurrent treatment-resistant tumors.
Collapse
Affiliation(s)
- Hextan Y. S. Ngan
- Department of Obstetrics and GynecologyUniversity of Hong KongQueen Mary HospitalHong KongChina
| | - Michael J. Seckl
- Department of Medical OncologyCharing Cross Trophoblastic Disease CenterCharing Cross Campus of Imperial College LondonLondonUK
| | - Ross S. Berkowitz
- Department of Obstetrics and GynecologyDivision of Gynecologic OncologyBrigham and Women's HospitalDana‐Farber Cancer InstituteHarvard Medical SchoolBostonMassachusettsUSA
| | - Yang Xiang
- Department of Obstetrics and GynecologyPeking Union Medical College HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - François Golfier
- Department of Obstetrics and GynecologyFrench Trophoblastic Disease Reference CentreLyon University HospitalClaude Bernard Lyon 1 UniversityLyonFrance
| | - Paradan K. Sekharan
- Department of Obstetrics and GynecologyInstitute of Maternal and Child HealthMedical CollegeCalicutIndia
| | - John R. Lurain
- John I. Brewer Trophoblastic Disease CenterNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Leon Massuger
- Department of Obstetrics and GynecologyDivision of Gynecologic OncologyRadboud University Medical Centre NijmegenNijmegenThe Netherlands
| |
Collapse
|
36
|
Acute cardiopulmonary failure in a young woman with high-risk gestational trophoblastic neoplasia: A case of induction chemotherapy during extracorporeal membrane oxygenation. Gynecol Oncol Rep 2021; 37:100849. [PMID: 34458540 PMCID: PMC8379276 DOI: 10.1016/j.gore.2021.100849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 11/20/2022] Open
Abstract
Early use of extracorporeal membrane oxygenation (ECMO) is valuable when pulmonary tumor burden from GTN is high. Induction chemotherapy of cisplatin and etoposide was administered during ECMO successfully. The induction chemotherapy regimen led to exponential decline in beta-HCG after 1 cycle. Collaboration of subspecialists is necessary to treat coexisting malignancy and cardiopulmonary failure associated with GTN.
Collapse
|
37
|
Škubník J, Pavlíčková VS, Ruml T, Rimpelová S. Vincristine in Combination Therapy of Cancer: Emerging Trends in Clinics. BIOLOGY 2021; 10:849. [PMID: 34571726 PMCID: PMC8468923 DOI: 10.3390/biology10090849] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 02/07/2023]
Abstract
Treatment of blood malignancies and other cancer diseases has been mostly unfeasible, so far. Therefore, novel treatment regimens should be developed and the currently used ones should be further elaborated. A stable component in various cancer treatment regimens consists of vincristine, an antimitotic compound of natural origin. Despite its strong anticancer activity, mostly, it cannot be administered as monotherapy due to its unspecific action and severe side effects. However, vincristine is suitable for combination therapy. Multidrug treatment regimens including vincristine are standardly applied in the therapy of non-Hodgkin lymphoma and other malignancies, in which it is combined with drugs of different mechanisms of action, mainly with DNA-interacting compounds (for example cyclophosphamide), or drugs interfering with DNA synthesis (for example methotrexate). Besides, co-administration of vincristine with monoclonal antibodies has also emerged, the typical example of which is the anti-CD20 antibody rituximab. Although in some combination anticancer therapies, vincristine has been replaced with other drugs exhibiting lesser side effects, though, in most cases, it is still irreplaceable. This is strongly evidenced by the number of active clinical trials evaluating vincristine in combination cancer therapy. Therefore, in this article, we have reviewed the most common cancer treatment regimens employing vincristine and bring an overview of current trends in the clinical development of this compound.
Collapse
Affiliation(s)
| | | | | | - Silvie Rimpelová
- Department of Biochemistry and Microbiology, University of Chemistry and Technology Prague, Technická 3, 166 28 Prague, Czech Republic; (J.Š.); (V.S.P.); (T.R.)
| |
Collapse
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
Tsakiridis I, Giouleka S, Kalogiannidis I, Mamopoulos A, Athanasiadis A, Dagklis T. Diagnosis and Management of Gestational Trophoblastic Disease: A Comparative Review of National and International Guidelines. Obstet Gynecol Surv 2021; 75:747-756. [PMID: 33369685 DOI: 10.1097/ogx.0000000000000848] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Gestational trophoblastic disease (GTD) is associated with increased mortality and morbidity in women of reproductive age, if managed in a suboptimal way, left untreated, or diagnosed after the development of extensive metastases. Objective The aims of this study were to review and compare the recommendations from published guidelines on these tumors of placental origin. Evidence Acquisition A descriptive review of guidelines from the Royal College of Obstetricians and Gynecologists, the International Federation of Gynecology and Obstetrics, the European Society for Medical Oncology, and the Royal Australian and New Zealand College of Obstetricians and Gynecologists on GTD was carried out. Results All the guidelines agree that suction evacuation is the optimal management for hydatidiform molar pregnancy and that chemotherapy, either single-agent (for low risk) or multiagent (for high risk), is the preferred treatment modality for choriocarcinoma. There is also a consensus that a future pregnancy should be avoided during follow-up; therefore, an effective contraception method should be used. All medical societies recommend the registration of such patients to GTD screening centers, endorse the use of International Federation of Gynecology and Obstetrics 2000 scoring system, and mention that the diagnosis of gestational trophoblastic neoplasia (GTN) should be based on the clinical presentation (from the genital tract and the metastatic sites) and the human chorionic gonadotropin evaluation. Additionally, all 4 medical societies recommend the surgical management of placental site trophoblastic tumors or epithelioid trophoblastic tumors, as chemotherapy is less effective in these cases. However, there is controversy regarding the appropriate follow-up after the treatment of hydatidiform mole, the administration of anti-D immunoglobulin, the time of oxytocin infusion, and the salvage regimens that may be used in cases of resistant or recurrent GTN. Conclusions There is need for consistent international practice protocols, which will lead to an earlier diagnosis and eventually to a more effective management of GTD worldwide and decrease in the recurrence rate and in the associated morbidity and mortality.
Collapse
Affiliation(s)
| | | | | | - Apostolos Mamopoulos
- Professor, Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Professor, Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | |
Collapse
|
40
|
Singhal S, Kumar L, Kumar S, Khurana S, Bhatla N. Predictors of chemotherapy resistance & relapse in gestational trophoblastic neoplasia. Indian J Med Res 2021; 152:595-606. [PMID: 34145099 PMCID: PMC8224147 DOI: 10.4103/ijmr.ijmr_2585_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background & objectives: Gestational trophoblastic neoplasia (GTN) is a chemosensitive malignancy with an excellent cure rate. The primary objective of the present study was to determine the predictors of chemoresistance and disease relapse, and the secondary objective was to appraise the WHO/FIGO risk scoring and course of disease in women with GTN. Methods: In this retrospective study, case records of women treated for GTN from January 2011 to June 2019 were reviewed. For the purpose of comparison, sub-stratification of FIGO/WHO low risk group (≤6) into low (0-4) and intermediate (5-6) risk was done. Similarly, WHO high risk (≥7) group was sub-stratified into high (7-12) and ultra-high risk (≥13) groups. Results: Case records of 116 patients were included: 51.7 per cent (60/116) were of low risk disease and 48.2 per cent (56/116) were of high risk disease. Chemoresistance developed in 28.4 per cent (33/116) and relapse in 10.3 per cent (12/116) cases. Risk of chemoresistance was higher in low risk (0-6) while risk of relapse was more in high risk (≥7) group. On sub-stratification, chemoresistance was more with intermediate [0-4: 28.5% (10/35), 5-6: 44% (11/25), 7-12: 22.5% (9/40), ≥13: 18.7% (3/16)] and relapse with ultra-high risk score [0-4: 5.7% (2/35), 5-6: 4% (1/25), 7-12:10% (4/40), ≥13: 31.2% (5/16)]. Age, myometrial invasion, serum beta-human chorionic gonadotropin and tumour size were not related to chemoresistance or relapse. Interpretation & conclusions: WHO risk score and presence of metastatic disease predict the probability of developing chemotherapy resistance and disease relapse. Risk of chemotherapy resistance was higher in women with intermediate-risk score (5-6), and risk of relapse was more in those with ultra-high risk score (≥13).
Collapse
Affiliation(s)
- Seema Singhal
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology, Dr BR Ambedkar IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Sunesh Kumar
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Khurana
- Department of Medical Oncology, Dr BR Ambedkar IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Neerja Bhatla
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
41
|
Eiriksson L, Dean E, Sebastianelli A, Salvador S, Comeau R, Jang JH, Bouchard-Fortier G, Osborne R, Sauthier P. Guideline No. 408: Management of Gestational Trophoblastic Diseases. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:91-105.e1. [PMID: 33384141 DOI: 10.1016/j.jogc.2020.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/02/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This guideline reviews the clinical evaluation and management of gestational trophoblastic diseases, including surgical and medical management of benign, premalignant, and malignant entities. The objective of this guideline is to assist health care providers in promptly diagnosing gestational trophoblastic diseases, to standardize treatment and follow-up, and to ensure early specialized care of patients with malignant or metastatic disease. INTENDED USERS General gynaecologists, obstetricians, family physicians, midwives, emergency department physicians, anaesthesiologists, radiologists, pathologists, registered nurses, nurse practitioners, residents, gynaecologic oncologists, medical oncologists, radiation oncologists, surgeons, general practitioners in oncology, oncology nurses, pharmacists, physician assistants, and other health care providers who treat patients with gestational trophoblastic diseases. This guideline is also intended to provide information for interested parties who provide follow-up care for these patients following treatment. TARGET POPULATION Women of reproductive age with gestational trophoblastic diseases. OPTIONS Women diagnosed with a gestational trophoblastic disease should be referred to a gynaecologist for initial evaluation and consideration for primary surgery (uterine evacuation or hysterectomy) and follow-up. Women diagnosed with gestational trophoblastic neoplasia should be referred to a gynaecologic oncologist for staging, risk scoring, and consideration for primary surgery or systemic therapy (single- or multi-agent chemotherapy) with the potential need for additional therapies. All cases of gestational trophoblastic neoplasia should be discussed at a multidisciplinary cancer case conference and registered in a centralized (regional and/or national) database. EVIDENCE Relevant studies from 2002 onwards were searched in Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and Cochrane Systematic Reviews using the following terms, either alone or in combination: trophoblastic neoplasms, choriocarcinoma, trophoblastic tumor, placental site, gestational trophoblastic disease, hydatidiform mole, drug therapy, surgical therapy, radiotherapy, cure, complications, recurrence, survival, prognosis, pregnancy outcome, disease outcome, treatment outcome, and remission. The initial search was performed in April 2017 and updated in May 2019. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional significant articles were identified through cross-referencing the identified reviews. The total number of studies identified was 673, with 79 studies cited in this review. VALIDATION METHODS The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of Directors of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of Directors for the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework. See the online appendix tables for key to grading and interpretation of recommendations. BENEFITS These guidelines will assist physicians in promptly diagnosing gestational trophoblastic diseases and urgently referring patients diagnosed with gestational trophoblastic neoplasia to gynaecologic oncology for specialized management. Treating gestational trophoblastic neoplasia in specialized centres with the use of centralized databases allows for capturing and comparing data on treatment outcomes of patients with these rare tumours and for optimizing patient care. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES) RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
Collapse
|
42
|
Di Fiore R, Suleiman S, Felix A, O’Toole SA, O’Leary JJ, Ward MP, Beirne J, Sabol M, Ozretić P, Yordanov A, Vasileva-Slaveva M, Kostov S, Nikolova M, Said-Huntingford I, Ayers D, Ellul B, Pentimalli F, Giordano A, Calleja-Agius J. An Overview of the Role of Long Non-Coding RNAs in Human Choriocarcinoma. Int J Mol Sci 2021; 22:ijms22126506. [PMID: 34204445 PMCID: PMC8235025 DOI: 10.3390/ijms22126506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 02/08/2023] Open
Abstract
Choriocarcinoma (CC), a subtype of trophoblastic disease, is a rare and highly aggressive neoplasm. There are two main CC subtypes: gestational and non-gestational, (so called when it develops as a component of a germ cell tumor or is related to a somatic mutation of a poorly differentiated carcinoma), each with very diverse biological activity. A therapeutic approach is highly effective in patients with early-stage CC. The advanced stage of the disease also has a good prognosis with around 95% of patients cured following chemotherapy. However, advancements in diagnosis and treatment are always needed to improve outcomes for patients with CC. Long non-coding (lnc) RNAs are non-coding transcripts that are longer than 200 nucleotides. LncRNAs can act as oncogenes or tumor suppressor genes. Deregulation of their expression has a key role in tumor development, angiogenesis, differentiation, migration, apoptosis, and proliferation. Furthermore, detection of cancer-associated lncRNAs in body fluids, such as blood, saliva, and urine of cancer patients, is emerging as a novel method for cancer diagnosis. Although there is evidence for the potential role of lncRNAs in a number of cancers of the female genital tract, their role in CC is poorly understood. This review summarizes the current knowledge of lncRNAs in gestational CC and how this may be applied to future therapeutic strategies in the treatment of this rare cancer.
Collapse
Affiliation(s)
- Riccardo Di Fiore
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta;
- Center for Biotechnology, Sbarro Institute for Cancer Research and Molecular Medicine, College of Science and Technology, Temple University, Philadelphia, PA 19122, USA;
- Correspondence: (R.D.F.); (J.C.-A.); Tel.: +356-2340-3871 (R.D.F.); +356-2340-1892 (J.C.-A.)
| | - Sherif Suleiman
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta;
| | - Ana Felix
- Department of Pathology, Campo dos Mártires da Pátria, Instituto Portugues de Oncologia de Lisboa, NOVA Medical School, UNL, 130, 1169-056 Lisboa, Portugal;
| | - Sharon A. O’Toole
- Departments of Obstetrics and Gynaecology and Histopathology, Trinity St James’s Cancer Institute, Trinity College Dublin, 8 Dublin, Ireland;
| | - John J. O’Leary
- Department of Histopathology, Trinity College Dublin, Trinity St James’s Cancer Institute, 8 Dublin, Ireland; (J.J.O.); (M.P.W.)
| | - Mark P. Ward
- Department of Histopathology, Trinity College Dublin, Trinity St James’s Cancer Institute, 8 Dublin, Ireland; (J.J.O.); (M.P.W.)
| | - James Beirne
- Department of Gynaecological Oncology, Trinity St James Cancer Institute, St James Hospital, 8 Dublin, Ireland;
| | - Maja Sabol
- Laboratory for Hereditary Cancer, Division of Molecular Medicine, Ruđer Bošković Institute, 10000 Zagreb, Croatia; (M.S.); (P.O.)
| | - Petar Ozretić
- Laboratory for Hereditary Cancer, Division of Molecular Medicine, Ruđer Bošković Institute, 10000 Zagreb, Croatia; (M.S.); (P.O.)
| | - Angel Yordanov
- Department of Gynecologic Oncology, Medical University Pleven, 5800 Pleven, Bulgaria;
| | | | - Stoyan Kostov
- Department of Gynecology, Medical University Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria;
| | - Margarita Nikolova
- Saint Marina University Hospital—Pleven, Medical University Pleven, 5800 Pleven, Bulgaria;
| | - Ian Said-Huntingford
- Department of Histopathology, Mater Dei Hospital, Birkirkara Bypass, MSD 2090 Msida, Malta;
| | - Duncan Ayers
- Centre for Molecular Medicine & Biobanking, University of Malta, MSD 2080 Msida, Malta; (D.A.); (B.E.)
- Faculty of Biology, Medicine and Human Sciences, The University of Manchester, Manchester M1 7DN, UK
| | - Bridget Ellul
- Centre for Molecular Medicine & Biobanking, University of Malta, MSD 2080 Msida, Malta; (D.A.); (B.E.)
| | - Francesca Pentimalli
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Napoli, Italy;
| | - Antonio Giordano
- Center for Biotechnology, Sbarro Institute for Cancer Research and Molecular Medicine, College of Science and Technology, Temple University, Philadelphia, PA 19122, USA;
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy
| | - Jean Calleja-Agius
- Department of Anatomy, Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta;
- Correspondence: (R.D.F.); (J.C.-A.); Tel.: +356-2340-3871 (R.D.F.); +356-2340-1892 (J.C.-A.)
| |
Collapse
|
43
|
Nakamura B, Cowan M, Griffin BB, Victoria Fischer J, Lurain JR, Strohl AE. Successful management of stage IV epithelioid trophoblastic tumor using multimodality treatment: A case report. Gynecol Oncol Rep 2021; 37:100802. [PMID: 34195329 PMCID: PMC8239721 DOI: 10.1016/j.gore.2021.100802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/27/2021] [Indexed: 11/18/2022] Open
Abstract
ETT is a rare variant of GTN that is more chemoresistant than choriocarcinoma. Approximately 25–35% of patients with ETT present with metastatic disease. Chemotherapy for ETT should consist of an etoposide/platinum-based regimen. Multimodality treatment can result in successful management of stage IV ETT.
Epithelioid trophoblastic tumor (ETT) is a rare variant of gestational trophoblastic neoplasia (GTN) that develops from chorionic-type intermediate trophoblast, is more resistant to chemotherapy than choriocarcinoma, and presents with metastatic disease in 25–35% of cases. We report a case of a 32-year-old who presented one week postpartum with severe abdominal pain and was found to have profound anemia and an elevated hCG level. CT scans and MRI revealed bleeding from hepatic masses, multiple hemorrhagic pulmonary nodules, a 7 cm uterine mass, and brain metastases. She underwent emergent hepatic embolization, was started on induction chemotherapy with weekly low-dose etoposide and cisplatin followed by a transition to etoposide, high-dose methotrexate, actinomycin D, etoposide, and cisplatin (HD EMA-EP), received stereotactic brain radiotherapy, and subsequently underwent minimally-invasive hysterectomy. She remains disease free over one year after the completion of treatment. An aggressive multimodal treatment approach employing etoposide/cisplatin-based chemotherapy as well as surgical procedures to control hemorrhage or excise resistant disease, and radiotherapy for brain metastases can result in successful treatment of stage IV ETT.
Collapse
Affiliation(s)
- Brad Nakamura
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew Cowan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brannan B. Griffin
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jean Victoria Fischer
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John R. Lurain
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- John I. Brewer Trophoblastic Disease Center, USA
| | - Anna E. Strohl
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- John I. Brewer Trophoblastic Disease Center, USA
- Robert H. Lurie Comprehensive Cancer Center, USA
- Corresponding author at: 250 E. Superior St. Suite 05-2175, Chicago, IL 60611, USA.
| |
Collapse
|
44
|
Seckl MJ, Ghorani E. Progress to international harmonisation of care and future developments. Best Pract Res Clin Obstet Gynaecol 2021; 74:159-167. [PMID: 34119435 DOI: 10.1016/j.bpobgyn.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/18/2021] [Indexed: 01/01/2023]
Abstract
Considerable differences exist in the management of gestational trophoblastic disease (GTD) both nationally and internationally despite numerous efforts to harmonise patient care. This partly reflects differences in healthcare systems and availability of resources. However, even in first world equivalent economies with similar healthcare systems differences remain, which appear to impact survival. Recently, new international guidelines have been established in Europe through a series of consensus meetings. Improvement of outcomes will depend on the establishment of dedicated centres with appropriate patient pathways according to these guidelines. This review will highlight some of the differences and efforts to unify the management of GTD across the globe and discuss areas for future development.
Collapse
Affiliation(s)
- Michael J Seckl
- Dept Medical Oncology, Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W68RF, UK.
| | - Ehsan Ghorani
- Dept Medical Oncology, Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Rd, London W68RF, UK
| |
Collapse
|
45
|
Zhang TJ, Shen Z, Li M, Zhu J, Li YB, Wei W, Zhou HC, Zhao WD, Wu DB, Zhou Y. Emergency craniotomy in patient with intracranial metastatic choriocarcinoma: a case report. J Int Med Res 2021; 49:300060520987725. [PMID: 33530802 PMCID: PMC7871072 DOI: 10.1177/0300060520987725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Choriocarcinoma is a highly malignant gynaecological tumour. This disease becomes life-threatening once brain haemorrhage or brain herniation occurs. Timely and accurate brain surgery can gain treatment time for patients that have a large number of cerebral haemorrhages and/or brain herniation. This current report describes a case of choriocarcinoma secondary to a hydatidiform mole in a 55-year-old woman that presented with neurological symptoms. Following admission to hospital, computed tomography examination found that lung and brain metastases were accompanied by cerebral haemorrhage. Cerebral hernia occurred during induction chemotherapy treatment and emergency surgery was performed. The patient recovered after individual chemotherapy and rehabilitation treatment. Patients with a very high risk of choriocarcinoma with brain metastasis should be referred to a comprehensive medical centre. Necessary surgical treatment and individualized chemotherapy can reduce the mortality of patients with choriocarcinoma brain metastasis.
Collapse
Affiliation(s)
- Tian-Jiao Zhang
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of University of Science & Technology of China, Anhui Provincial Hospital, Hefei, Anhui Province, China
| | - Zhen Shen
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of University of Science & Technology of China, Anhui Provincial Hospital, Hefei, Anhui Province, China
| | - Min Li
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of University of Science & Technology of China, Anhui Provincial Hospital, Hefei, Anhui Province, China
| | - Jing Zhu
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of University of Science & Technology of China, Anhui Provincial Hospital, Hefei, Anhui Province, China
| | - Yue-Bo Li
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of University of Science & Technology of China, Anhui Provincial Hospital, Hefei, Anhui Province, China
| | - Wei Wei
- Department of Radiology, The First Affiliated Hospital of University of Science & Technology of China, Anhui Provincial Hospital, Hefei, Anhui Province, China
| | - Hang-Cheng Zhou
- Department of Pathology, The First Affiliated Hospital of University of Science & Technology of China, Anhui Provincial Hospital, Hefei, Anhui Province, China
| | - Wei-Dong Zhao
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of University of Science & Technology of China, Anhui Provincial Hospital, Hefei, Anhui Province, China
| | - Da-Bao Wu
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of University of Science & Technology of China, Anhui Provincial Hospital, Hefei, Anhui Province, China
| | - Ying Zhou
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of University of Science & Technology of China, Anhui Provincial Hospital, Hefei, Anhui Province, China
| |
Collapse
|
46
|
Anjum AS, Maqsood H, Younus S, Anjum S, Fatima M. A Rare Case of Non-Gestational Metastatic Ovarian Choriocarcinoma: Case Report and Literature Review With a Special Emphasis on Imaging. Cureus 2021; 13:e13121. [PMID: 33692915 PMCID: PMC7938442 DOI: 10.7759/cureus.13121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Non-gestational choriocarcinoma of the ovary is a very rare neoplasm. It carries a worse prognosis as compared to gestational choriocarcinoma (GCC). Here, we report a case of non-gestational ovarian choriocarcinoma. The patient initially presented in a medical emergency with abdominal pain, a feeling of heaviness in the lower abdomen, cough, and dyspnea. The patient had four healthy children, and the last childbirth was five years ago. There was no history of any abortion or stillbirth in the past four years. A highly vascular left adnexal mass was observed on ultrasound abdomen and pelvis. Compute CT chest, abdomen, and pelvis were performed, which revealed metastatic left ovarian choriocarcinoma features. It also showed vascular metastases of the carcinoma in the kidneys, liver, and lungs. We report this case specifically emphasizing ultrasound, multidetector computed tomography (MDCT), and CT angiography findings.
Collapse
Affiliation(s)
| | | | - Shifa Younus
- Internal Medicine, Nishtar Medical University, Multan, PAK
| | - Sadia Anjum
- Radiology, Nishtar Medical University, Multan, PAK
| | - Maham Fatima
- Radiology, Nishtar Medical University, Multan, PAK
| |
Collapse
|
47
|
Braga A, Elias KM, Horowitz NS, Berkowitz RS. Treatment of high-risk gestational trophoblastic neoplasia and chemoresistance/relapsed disease. Best Pract Res Clin Obstet Gynaecol 2021; 74:81-96. [PMID: 33622563 DOI: 10.1016/j.bpobgyn.2021.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/05/2020] [Accepted: 01/08/2021] [Indexed: 01/01/2023]
Abstract
High-risk gestational trophoblastic neoplasia (GTN) has an increased risk of developing chemoresistance to single-agent chemotherapy; therefore, the primary treatment should be a multiagent etoposide-based regimen, preferably EMA/CO. After remission (normalization of human chorionic gonadotropin - hCG), at least three consolidation courses of EMA-CO are needed to reduce the risk of relapse. Chemoresistance is diagnosed during treatment if hCG levels plateau/increase, in two consecutive values over a two-week period. When this occurs after remission, in the absence of a new pregnancy, there is a relapse. In both cases, after re-assessment of the extent of disease, EMA-EP is the most common chemotherapy choice. Even in these cases, remission rates are high. After remission is achieved, hCG should be measured monthly for a year. Pregnancy can be allowed after 12 months from remission. The follow-up of these patients in referral centers minimizes the chance of death from this disease and should be encouraged.
Collapse
Affiliation(s)
- Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University and Antonio Pedro University Hospital of Fluminense Federal University), Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, 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
| | - 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
| | - 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
| |
Collapse
|
48
|
Winter MC. Treatment of low-risk gestational trophoblastic neoplasia. Best Pract Res Clin Obstet Gynaecol 2021; 74:67-80. [PMID: 33741258 DOI: 10.1016/j.bpobgyn.2021.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/08/2021] [Indexed: 12/20/2022]
Abstract
Low-risk gestational trophoblastic neoplasia (GTN), defined as FIGO/WHO score 0-6, is highly curable with an overall survival rate, which is approximately 100%. For most low-risk GTN patients, first-line single-agent chemotherapy with either methotrexate or actinomycin-D is recommended with overall complete human chorionic gonadotrophin (hCG) response rates of 60%-90% in mostly retrospective, non-randomised studies. The few randomised trials that exist are not appropriately powered or designed to define the optimal first-line treatment. Approximately 25%-30% of low-risk patients will develop resistance to initial single-agent chemotherapy with an increase in the FIGO score, a diagnosis of choriocarcinoma, higher pre-treatment hCG and the presence of metastatic disease being associated with an increase in the risk of resistance. The optimal treatment of patients scoring WHO 5 and 6 remains poorly defined given that approximately 70%-80% of these patients develop resistance to first-line single-agent chemotherapy, and there is an urgent need to refine the FIGO/WHO scoring system so that these patients can be identified for more intensive therapy from the outset. Despite this, almost all low-risk patients who experience treatment failure with first-line monotherapy will be cured with either sequential single-agent chemotherapy or multiagent chemotherapy with or without surgery. Given the associated increased short and longer-term toxicities associated with multi-agent chemotherapy, promising strategies to reduce the exposure of women to combination chemotherapy in low-risk disease have been investigated, including the use of carboplatin and immune check-point inhibitors. Further evaluation is required to define optimal patient selection, particularly with the use of immunotherapeutic agents given their significant increased costs and lack of longer-term safety data. Although there is a clear need to revise the FIGO/WHO (2000) scoring system, consistent international use of this is recommended to facilitate the comparison of data along with future focus in the development of international collaborative translational and clinical research, including randomised controlled trials.
Collapse
Affiliation(s)
- Matthew C Winter
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, S10 2SJ, United Kingdom.
| |
Collapse
|
49
|
Abstract
PURPOSE OF REVIEW This review demonstrates the evidence for new systemic anticancer treatments and how they integrate within conventional management for gestational trophoblastic neoplasia (GTN). We present the evidence on atypical placental site nodules, and how they incorporate within the GTN spectrum, as well as updates regarding GTN staging and follow-up. RECENT FINDINGS First-line treatment for GTN still lies in conventional chemotherapy, although the introduction of anti-PD1/PD-L1 immune checkpoint inhibitors has shown significant promise in management of relapsed disease, with responses reported in multiple relapsed choriocarcinomas as well as epithelioid trophoblastic tumours and placental site trophoblastic tumours (ETT/PSTT). Following completion of treatment, ETT/PSTT still require life-long surveillance but for other GTN, no recurrences have been detected after 7 years. SUMMARY Checkpoint inhibitors are likely to play an increasing role in the future management of GTN management. Further refinement of prognostic factors to identify those most at risk of GTN recurrence is warranted so that surveillance can be focussed on those most at risk, whilst minimizing unnecessary intervention for those at lower risk.
Collapse
Affiliation(s)
- James Clark
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Road, London W68RF UK
| | - Susanna Slater
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Road, London W68RF UK
| | - Michael J Seckl
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Road, London W68RF UK
| |
Collapse
|
50
|
Soper JT. Gestational Trophoblastic Disease: Current Evaluation and Management. Obstet Gynecol 2021; 137:355-370. [PMID: 33416290 PMCID: PMC7813445 DOI: 10.1097/aog.0000000000004240] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
This review summarizes the current evaluation and management of gestational trophoblastic disease, including evacuation of hydatidiform moles, surveillance after evacuation of hydatidiform mole and the diagnosis and management of gestational trophoblastic neoplasia. Most women with gestational trophoblastic disease can be successfully managed with preservation of reproductive function. It is important to manage molar pregnancies properly to minimize acute complications and to identify gestational trophoblastic neoplasia promptly. Current International Federation of Gynecology and Obstetrics guidelines for making the diagnosis and staging of gestational trophoblastic neoplasia allow uniformity for reporting results of treatment. It is important to individualize treatment based on their risk factors, using less toxic therapy for patients with low-risk disease and aggressive multiagent therapy for patients with high-risk disease. Patients with gestational trophoblastic neoplasia should be managed in consultation with an individual experienced in the complex, multimodality treatment of these patients.
Collapse
Affiliation(s)
- John T Soper
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| |
Collapse
|