Reproductive outcomes after hydatiform mole and gestational trophoblastic neoplasia

Gestational and Non-gestational Trophoblastic Neoplasia. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 032/049, April 2022)

Purpose The aim was to develop and update a guideline which would improve the quality of care offered to women with gestational and non-gestational trophoblastic disease, a group of diseases characterized by their rarity and biological heterogeneity.

Methods In accordance with the method used to compile S2k-guidelines, the guideline authors carried out a search of the literature (MEDLINE) for the period 1/2020 to 12/2021 and evaluated the recent literature. No key questions were formulated. No structured literature search with methodical evaluation and assessment of the level of evidence was carried out. The text of the precursor version of the guideline from 2019 was updated based on the most recent literature, and new statements and recommendations were drafted.

Recommendations The updated guideline contains recommendations for the diagnosis and therapy of women with hydatidiform mole (partial and complete moles), gestational trophoblastic neoplasia after pregnancy or without prior pregnancy, persistent trophoblastic disease after molar pregnancy, invasive moles, choriocarcinoma, placental site nodules, placental site trophoblastic tumor, hyperplasia at the implantation site und epithelioid trophoblastic tumor. Separate chapters cover the determination and assessment of human chorionic gonadotropin (hCG), histopathological evaluation of specimens, and the appropriate molecular pathological and immunohistochemical diagnostic procedures. Separate chapters on immunotherapy, surgical therapy, multiple pregnancies with simultaneous trophoblastic disease, and pregnancy after trophoblastic disease were formulated, and the corresponding recommendations agreed upon.

Avelumab in Patients With Gestational Trophoblastic Tumors With Resistance to Single-Agent Chemotherapy: Cohort A of the TROPHIMMUN Phase II Trial

PURPOSE

Women with gestational trophoblastic tumors (GTT) resistant to single-agent chemotherapy receive alternative chemotherapy regimens, which, although effective, cause considerable toxicity. All GTT subtypes express programmed death-ligand 1 (PD-L1), and natural killer (NK) cells are involved in trophoblast immunosurveillance. Avelumab (anti-PD-L1) induces NK cell-mediated cytotoxicity. The TROPHIMMUN trial assessed avelumab in women with chemotherapy-resistant GTT.

METHODS

In this phase II multicenter trial (ClinicalTrials.gov identifier: NCT03135769), women with GTT who experienced disease progression after single-agent chemotherapy received avelumab 10 mg/kg intravenously every 2 weeks until human chorionic gonadotropin (hCG) normalization, followed by 3 consolidation cycles. Rate of hCG normalization was the primary endpoint (2-step Simon design).

RESULTS

Between December 2016 and September 2018, 15 patients were treated. Median age was 34 years; disease stage was I or III in 53.3% and 46.7% of women, respectively; and International Federation of Gynecology and Obstetrics (FIGO) score was 0-4 in 33.3%, 5-6 in 46.7%, and ≥ 7 in 20% of patients. Prior treatment included methotrexate (100%) and actinomycin D (7%). Median follow-up was 25 months, and median number of avelumab cycles was 8 (range, 2-11). Grade 1-2 treatment-related adverse events occurred in 93% of patients, most commonly (≥ 25%) fatigue (33.3%), nausea/vomiting (33.3%), and infusion-related reaction (26.7%). One patient had grade 3 uterine bleeding (treatment unrelated). Eight patients (53.3%) had hCG normalization after a median of 9 avelumab cycles; none subsequently relapsed. Probability of normalization was not associated with disease stage, FIGO score, or baseline hCG. One patient subsequently had a healthy pregnancy. In avelumab-resistant patients (46.7%), hCG was normalized with actinomycin D (42.3%) or combination chemotherapy/surgery (57.1%).

CONCLUSION

In patients with single-agent chemotherapy-resistant GTT, avelumab had a favorable safety profile and cured approximately 50% of patients. Avelumab could be a new therapeutic option, particularly in patients who would otherwise receive combination chemotherapy.

A rare cause of tumour lysis syndrome and acute kidney injury

Tumour lysis syndrome is rare in solid malignancies. Here, we report a case of tumour lysis syndrome and acute kidney injury in a 23-year-old female with gestational trophoblastic neoplasia. Hydration and early dialysis therapy were started with good recovery. On follow up she progressed to chronic kidney disease. After 6 years of follow up, the patient conceived and delivered successfully.

A comprehensive analysis of gestational trophoblastic neoplasia trials posted at online clinical trial registries

OBJECTIVE

We conducted a comprehensive analysis of gestational trophoblastic neoplasia (GTN) trials posted at online registries and aimed to provide useful information for future GTN trial designs.

STUDY DESIGN

We searched ClinicalTrials.gov, EU Clinical Trials Register, WHO International Clinical Trials Registry Portal (ICTRP) Search Portal, Australian New Zealand Clinical Trial Registry, ISRCTN Register, and Chinese Clinical Trial Register for all the clinical trials reporting GTN treatments. The general information of each trial was extracted.

RESULTS

Twenty trials meeting the inclusion criteria were included in the final analysis. In total, 6 trials were phase II trials, 2 were phase II/III trials, 7 were phase III trials, and 1 was a phase IV trial; and the phase type of 4 trials were not reported. The conditions included low-risk GTN (n = 15), high-risk GTN (n = 2), and mixed GTN (n = 3). Randomization was performed in 15 trials, and the remaining 5 trials were single-arm trials. The median enrollment size for randomized clinical trials (RCTs) and single-arm trials was 80 and 38, respectively. Among the RCTs, parallel assignment was used in 12 trials, crossover assignment was used in 1, and the intervention models of 2 were not reported. For masking, 15 trials were open-label, 2 were single-blinded, 2 were double-blinded, and the masking status of 1 was not reported. Ovarian functions and pregnancy outcome after chemotherapy were evaluated in only 2 trials. Regarding sponsorship, 2 trials had industry sponsorship.

CONCLUSION

Conducting RCTs for GTN is challenging, and international collaboration and smarter clinical trial designs are required for future GTN trials.

Fertility-sparing uterine lesion resection for young women with gestational trophoblastic neoplasias: single institution experience

Purpose

To evaluate the oncological safety and pregnant outcomes of fertility-sparing uterine lesion resection in treating gestational trophoblastic neoplasias.

Results

After the treatment of surgery and chemotherapy, all the patients achieved complete remission. With a median follow-up time of 44 months (range, 6-188), 3 patients (3.85%) relapsed within 3-26 months. Multivariate analysis showed that tumor size was the independent risk factor of recurrence and the cutoff value was 4.2cm. Among 37 patients who attempted to conceive, 31 achieved clinical pregnancy. The rate of pregnancy and live birth were 83.8% and 77.4%. Uterine rupture did not occurred no matter in cesarean section or vaginal delivery. No congenital abnormalities were reported among the live births.

Methods

From January 1995 to December 2014, 78 patients with gestational trophoblastic neoplasias who underwent fertility-sparing uterine lesion resection at Peking Union Medical College Hospital were reviewed. The complete remission rate, fertility rate, pregnant outcomes and risk factors of recurrence were analyzed.

Conclusions

Fertility-sparing uterine lesion resection might be considered as a safe and reasonable alternative for high-selected young women to remove uterine lesion in the treatment of gestational trophoblastic neoplasias.

Early pregnancy following multidrug regimen chemotherapy in a gestational trophoblastic neoplasia patient: A case report

RATIONALE

Gestational trophoblastic neoplasia is a group of rare tumors that can be cured using chemotherapy. The use of artificial contraception for at least 1 year is recommended not only due to the high recurrence rate in the first year after treatment, but also because of the unclear genetic toxic effects of multidrug regimen chemotherapy on reproductive cells. There is no consensus about the contraception duration, but most patients want to have children.

PATIENT CONCERNS

This case involved a 33-year-old female suffering from gestational trophoblastic neoplasia and 5-fluorouracil + actinomycin-D chemotherapy. She became pregnant 1 month after finishing the chemotherapy.

DIAGNOSIS

Gestational trophoblastic neoplasia.

INTERVENTIONS

No treatment during pregnancy.

OUTCOMES

The patient had a full-term normal delivery, and the baby showed normal development and growth after a follow-up of 48 months.

LESSONS

Pregnancy soon after chemotherapy can be viable with rigorous prenatal care.