Role of surgical therapy in the management of gestational trophoblastic neoplasia

The role of surgery in gestational trophoblastic disease: an overview

Gestational trophoblastic disease comprises a group of rare, and potentially malignant, conditions that arise from abnormal trophoblastic proliferation. When there is invasion and evidence of metastatic disease, gestational trophoblastic neoplasia is used. While chemotherapy is the mainstay of treatment for gestational trophoblastic neoplasia, the role of surgery has come full circle in recent years. Before the introduction of highly effective systemic treatment options, surgery was the default treatment. Surgery for gestational trophoblastic neoplasia often yielded unsatisfactory results and mortality remained high. In recent years, the role of adjuvant surgery in the management of gestational trophoblastic neoplasia has been examined with great interest. We aim to provide an overview of the various surgical approaches employed in managing gestational trophoblastic neoplasia, including their indications, techniques, and outcomes. Additionally, we discuss whether there is a role to do less in surgery for gestational trophoblastic neoplasia and describe our experience with a modified surgical technique for its treatment. By summarizing the current evidence, this article highlights the significant contributions of surgery to the holistic management of patients with gestational trophoblastic neoplasia and provides a framework on which to base management and treatment programs.

Splenic Metastatic Choriocarcinoma with Nontraumatic Splenic Rupture: A Case Report and Literature Review

Choriocarcinoma is a highly malignant trophoblastic tumor that occurs mostly in women of childbearing age. The main mode of metastasis is hematogenous metastasis. The most common sites of metastasis are the lung, vagina and brain, while splenic metastasis is rare. Because of its rapid development, extensive metastasis can occur in a short period, and some patients only show metastatic symptoms, which are often missed or misdiagnosed as ectopic pregnancy or other diseases. We describe a rare case of splenic metastatic choriocarcinoma with acute abdominal pain caused by nontraumatic splenic rupture. In addition, we review the previous literature on splenic metastasis of choriocarcinoma and summarize the clinical manifestations, management measures and prognoses. Our case and literature review indicate that splenic metastatic choriocarcinoma is rare and difficult to distinguish from splenic ectopic pregnancy and other diseases. Clinicians should strengthen their understanding of this disease and avoid misdiagnosis.

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

The aim of the study was to assess the effectiveness of a combined treatment modality of salvage chemotherapy and pulmonary resection in chemo-resistant/relapsed gestational trophoblastic neoplasia (GTN) with lung metastasis and identify predictors of treatment failure. Data of patients with chemo-resistant/relapsed GTN with lung metastasis who received salvage chemotherapy combined with pulmonary resection were retrospectively analyzed. Among 134 included patients, the number of preoperative chemotherapy regimens ranged from 2−8 (median, 3), and courses ranged from 4−37 (median, 14). Pulmonary lobectomies, segmentectomies, wedge resections, and lobectomies plus wedge resections were performed in 84, 5, 35, and 10 patients, respectively. After completion of treatment, 130 (97.0%) patients achieved complete remission. In the entire cohort, the 5-year overall survival (OS) rate was 87.6%. OS rates were similar between stage III and stage IV disease cohorts (89.4% vs. 75.0%, p = 0.137). Preoperative β-human chorionic gonadotropin (β-hCG) levels > 10 IU/L (p = 0.027) and number of preoperative chemotherapy regimens > 3 (p = 0.018) were predictors of treatment failure. The combined treatment modality of salvage chemotherapy and pulmonary resection is effective in patients with chemo-resistant/relapsed GTN with lung metastasis, improving their prognoses. Patients with preoperative serum β-hCG >10 IU/L and those with >3 chemotherapy regimens preoperatively may not benefit from this multidisciplinary treatment.

Predictors of chemotherapy resistance & relapse in gestational trophoblastic neoplasia

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).

Transcatheter Artery Embolization for Postoperative Haemorrhage after Arterio-Venous Malformation - Safer Option

Summary. Introduction:

Hemorrhage is one of the commonest and dreaded complications especially with pelvic surgeries. Gestational trophoblastic neoplasias (GTN) are notorious for their propensity to bleed torrentially and metastasis to vital organs. GTN is associated with an arterio-venous malformation (AVM) about 10-15% of the time, which can lead to bleeding after surgery or after complete remission. After the failure of conventional management with chemotherapy or surgery one is compelled to take another modality of management. One of such methods is the use of transcatheter artery embolization in cases of GTN or post-hysterectomy cases of GTN. Transcatheter arteryembolization (TAE) was effective in controlling bleeding due to arterio-venous malformation in 96% of cases.

Case:

46 years P2L2A5 (para 2, living issue 2, abortion 5) post-hysterectomy patient presented with bleeding from the vagina after surgery. Twice she underwent vaginal vault repair after hysterectomy but failed. Ultrasonography (USG) showed arterio-venous malformation (AVM); angiography revealed massive extravasation from (left internal iliac artery and abnormal vascularity from the right internal iliac. She was taken up for bilateral internal iliac arteries embolization but again had a heavy bout of bleeding after one week. CT scan confirmed a residual lesion and she underwent a repeat embolization after which the bleeding stopped. Serum BHCG was advised during workup and it was 1997 IU/ml. A diagnosis of GTN was confirmed. The patient was discharged after two cycles of chemotherapy with advice to review for the third one on an outpatient department basis.

Conclusion:

We concluded that TAE is an effective and safer alternative to surgery in postoperative bleeding from AV malformation in the case of GTN. It can be repeated and should be made to more liberal use in emergency settings.

A promising therapeutic strategy for metastatic gestational trophoblastic disease: Engineered anticancer gene-expressing stem cells to selectively target choriocarcinoma

Gestational trophoblastic disease (GTD) is an unusual disease occurring in pregnancy that originates from abnormal trophoblastic cells and comprises a group of diseases with different properties of invasion, metastasis and recurrence. The GTD group includes hydatidiform moles and gestational trophoblastic neoplasms (GTNs), with GTNs being divided into invasive moles, choriocarcinoma, placental site trophoblastic tumors and epithelioid trophoblastic tumors. The present review focuses on current effective treatments for GTD, including conventional and novel promising direct enzyme prodrug therapies (DEPTs). Conventional therapies, such as chemotherapy and hysterectomy, are currently used in a clinical setting; however, the use of diverse DEPTs, including antibody-DEPT and gene-DEPT is also being attempted to cure GTNs. In addition, gene delivery tools using genetically engineered neural stem cells (NSCs) are presently being examined for the treatment of GTNs. The tumor-tropism of NSCs by chemoattractant factors is a unique characteristic of these cells and can serve as a vehicle to deliver anticancer agents. Previous studies have demonstrated that injection with NSC-expressing suicide genes into xenograft animal models has a significant inhibitory effect on tumor growth. Stem cells can be genetically engineered to express anticancer genes, which migrate to the metastatic sites and selectively target cancer cells, and are considered to effectively target metastatic GTNs. However, the safety issue of stem cell therapy, such as tumorigenesis, remains a challenge. Novel therapies comprising a combination of conventional and novel promising treatments are anticipated to be definitive treatments for metastasized and/or recurrent patients with GTNs.

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.

Identification and treatment of gestational trophoblastic neoplasia located in the cesarean scar

OBJECTIVE

To identify the clinical characteristics of, and the diagnostic and therapeutic strategies for, gestational trophoblastic neoplasia (GTN) located in the cesarean scar.

METHODS

The present retrospective analysis was conducted among patients diagnosed with GTN located in the cesarean scar at Peking Union Medical College Hospital, Beijing, China, between June 1, 2006, and May 31, 2016. Clinical features, diagnostic and therapeutic procedures, and outcomes were reviewed.

RESULTS

Of 938 women diagnosed with GTN, 31 (3.3%) patients had GTN located in the cesarean scar. Irregular vaginal bleeding was the main clinical manifestation. Twenty (65%) patients received an accurate diagnosis based on a history of molar pregnancy/a high β-human chorionic gonadotropin level/typical imaging presentations. The remaining 11 patients were initially misdiagnosed; the definitive diagnosis was made by pathology. All patients received chemotherapy; 22 (71%) women also underwent hysterectomy or localized uterine lesion resection because of chemoresistant lesions. All patients had a complete remission; at a median follow-up of 35 months, only 1 (3%) woman had a relapse.

CONCLUSION

Owing to its rarity and nonspecific symptoms, GTN located in the cesarean scar is prone to misdiagnosis. In patients without typical manifestations, the definitive diagnosis often relies on pathology. For treatment, uterine lesion resection is a useful adjunct to chemotherapy.

Postmolar choriocarcinoma after an interval of 7 years: Case report and literature review

Choriocarcinoma is a rare pregnancy-related malignancy. The majority is arising from non-molar pregnancy. Here we report a patient who was diagnosed with postmolar choriocarcinoma after an interval of 7 years. Before surgery, we suspected the diagnosis of the patient was intramural pregnancy or choriocarcinoma. Laparoscopy was performed and hysterectomy was carried out. Postoperative pathological evaluation of the surgical specimen confirmed the case was choriocarcinoma. Hysterectomy through laparoscopy was feasible and safe for selected patients.

Comparing and evaluating the efficacy of methotrexate and actinomycin D as first-line single chemotherapy agents in low risk gestational trophoblastic disease

OBJECTIVE

The aim of this study was to compare responses to single-agent chemotherapies and evaluate the predictive factors of resistance in low risk (LR) gestational trophoblastic disease (GTD). The chemotherapy agents included methotrexate (MTX) and actinomycin D (ACT-D).

METHODS

We conducted a retrospective study of 126 patients with GTD who were treated between 2000 and 2013. A total of 71 patients with LR GTD were treated with MTX (8-day regimen or weekly regimen, n=53) or ACT-D (bi-weekly pulsed regimen or 5-day regimen, n=18). The successful treatment group and the failed treatment group were compared and analyzed to identify prognostic factors.

RESULTS

The complete response rates were 83.3% for ACT-D and 62.2% for MTX, with no statistically significant difference. There was no severe adverse effect reported for either group. Longer interval durations from the index pregnancy (>2 months, p=0.040) and larger tumor size (>3 cm, p=0.020) were more common in non-responders than in responders; these results were statistically significant.

CONCLUSION

Based on our results, ACT-D may be a better option than MTX as a first-line single chemotherapy agent for LR GTD. The bi-weekly pulsed ACT-D regimen had minimal, or at least the same, toxicities compared with MTX. However, due to the lack of strong supporting evidence, it cannot be conclusively stated that this is the best single agent for first-line chemotherapy in LR GTD patients. Further larger controlled trials will be necessary to establish the best guidelines for GTD treatment.

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

Objective

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

Methods

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

Results

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

Conclusions

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