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Parker VL, Winter MC, Tidy JA, Palmer JE, Sarwar N, Singh K, Aguiar X, Hancock BW, Pacey AA, Seckl MJ, Harrison RF. PREDICT-GTN 2: Two-factor streamlined models match FIGO performance in gestational trophoblastic neoplasia. Gynecol Oncol 2024; 180:152-159. [PMID: 38091775 DOI: 10.1016/j.ygyno.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/07/2023] [Accepted: 11/15/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE The International Federation of Gynecology and Obstetrics (FIGO) scoring system uses the sum of eight risk-factors to predict single-agent chemotherapy resistance in Gestational Trophoblastic Neoplasia (GTN). To improve ease of use, this study aimed to generate: (i) streamlined models that match FIGO performance and; (ii) visual-decision aids (nomograms) for guiding management. METHODS Using training (n = 4191) and validation datasets (n = 144) of GTN patients from two UK specialist centres, logistic regression analysis generated two-factor models for cross-validation and exploration. Performance was assessed using true and false positive rate, positive and negative predictive values, Bland-Altman calibration plots, receiver operating characteristic (ROC) curves, decision-curve analysis (DCA) and contingency tables. Nomograms were developed from estimated model parameters and performance cross-checked upon the training and validation dataset. RESULTS Three streamlined, two-factor models were selected for analysis: (i) M1, pre-treatment hCG + history of failed chemotherapy; (ii) M2, pre-treatment hCG + site of metastases and; (iii) M3, pre-treatment hCG + number of metastases. Using both training and validation datasets, these models showed no evidence of significant discordance from FIGO (McNemar's test p > 0.78) or across a range of performance parameters. This behaviour was maintained when applying algorithms simulating the logic of the nomograms. CONCLUSIONS Our streamlined models could be used to assess GTN patients and replace FIGO, statistically matching performance. Given the importance of imaging parameters in guiding treatment, M2 and M3 are favoured for ongoing validation. In resource-poor countries, where access to specialist centres is problematic, M1 could be pragmatically implemented. Further prospective validation on a larger cohort is recommended.
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Affiliation(s)
- Victoria L Parker
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Level 4 The Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK.
| | - Matthew C Winter
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Level 4 The Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK; Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - John A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Julia E Palmer
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Naveed Sarwar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Kamaljit Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield S10 2SJ, UK
| | - Xianne Aguiar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Barry W Hancock
- Division of Clinical Medicine, School of Medicine and Population Health, The University of Sheffield, Level 4 The Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK
| | - Allan A Pacey
- Faculty of Biology, Medicine and Health, Core Technology Facility, 46 Grafton Street, University of Manchester, Manchester, M13 9NT, UK
| | - Michael J Seckl
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Robert F Harrison
- Department of Automatic Control and Systems Engineering, The University of Sheffield, Mappin Street, Sheffield S1 3JD, UK
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Parker VL, Winter MC, Tidy JA, Hancock BW, Palmer JE, Sarwar N, Kaur B, McDonald K, Aguiar X, Singh K, Unsworth N, Jabbar I, Pacey AA, Harrison RF, Seckl MJ. PREDICT-GTN 1: Can we improve the FIGO scoring system in gestational trophoblastic neoplasia? Int J Cancer 2023; 152:986-997. [PMID: 36346113 PMCID: PMC10108153 DOI: 10.1002/ijc.34352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022]
Abstract
Gestational trophoblastic neoplasia (GTN) patients are treated according to the eight-variable International Federation of Gynaecology and Obstetrics (FIGO) scoring system, that aims to predict first-line single-agent chemotherapy resistance. FIGO is imperfect with one-third of low-risk patients developing disease resistance to first-line single-agent chemotherapy. We aimed to generate simplified models that improve upon FIGO. Logistic regression (LR) and multilayer perceptron (MLP) modelling (n = 4191) generated six models (M1-6). M1, all eight FIGO variables (scored data); M2, all eight FIGO variables (scored and raw data); M3, nonimaging variables (scored data); M4, nonimaging variables (scored and raw data); M5, imaging variables (scored data); and M6, pretreatment hCG (raw data) + imaging variables (scored data). Performance was compared to FIGO using true and false positive rates, positive and negative predictive values, diagnostic odds ratio, receiver operating characteristic (ROC) curves, Bland-Altman calibration plots, decision curve analysis and contingency tables. M1-6 were calibrated and outperformed FIGO on true positive rate and positive predictive value. Using LR and MLP, M1, M2 and M4 generated small improvements to the ROC curve and decision curve analysis. M3, M5 and M6 matched FIGO or performed less well. Compared to FIGO, most (excluding LR M4 and MLP M5) had significant discordance in patient classification (McNemar's test P < .05); 55-112 undertreated, 46-206 overtreated. Statistical modelling yielded only small gains over FIGO performance, arising through recategorisation of treatment-resistant patients, with a significant proportion of under/overtreatment as the available data have been used a priori to allocate primary chemotherapy. Streamlining FIGO should now be the focus.
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Affiliation(s)
- Victoria L Parker
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Matthew C Winter
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK.,Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Barry W Hancock
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Julia E Palmer
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Naveed Sarwar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Baljeet Kaur
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Katie McDonald
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Xianne Aguiar
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kamaljit Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nick Unsworth
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Imran Jabbar
- Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Allan A Pacey
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Robert F Harrison
- Department of Automatic Control and Systems Engineering, The University of Sheffield, Sheffield, UK
| | - Michael J Seckl
- Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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Parker VL, Winter MC, Whitby E, Parker WAE, Palmer JE, Tidy JA, Pacey AA, Hancock BW, Harrison RF. Computed tomography chest imaging offers no advantage over chest X-ray in the initial assessment of gestational trophoblastic neoplasia. Br J Cancer 2021; 124:1066-1071. [PMID: 33328608 PMCID: PMC7961138 DOI: 10.1038/s41416-020-01206-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 10/23/2020] [Accepted: 11/26/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The International Federation of Gynaecology and Obstetrics (FIGO) score identifies gestational trophoblastic neoplasia (GTN) patients as low- or high-risk of single-agent chemotherapy resistance (SACR). Computed tomography (CT) has greater sensitivity than chest X-ray (CXR) in detecting pulmonary metastases, but effects upon outcomes remain unclear. METHODS Five hundred and eighty-nine patients underwent both CXR and CT during GTN assessment. Treatment decisions were CXR based. The number of metastases, risk scores, and risk category using CXR versus CT were compared. CT-derived chest assessment was evaluated as impact upon treatment decision compared to patient outcome, incidence of SACR, time-to-normal human chorionic gonadotrophin hormone (TNhCG), and primary chemotherapy resistance (PCR). RESULTS Metastasis detection (p < 0.0001) and FIGO score (p = 0.001) were higher using CT versus CXR. CT would have increased FIGO score in 188 (31.9%), with 43 re-classified from low- to high-risk, of whom 23 (53.5%) received curative single-agent chemotherapy. SACR was higher when score (p = 0.044) or risk group (p < 0.0001) changed. Metastases on CXR (p = 0.019) but not CT (p = 0.088) lengthened TNhCG. Logistic regression analysis found no difference between CXR (area under the curve (AUC) = 0.63) versus CT (AUC = 0.64) in predicting PCR. CONCLUSIONS CT chest would improve the prediction of SACR, but does not influence overall treatment outcome, TNhCG, or prediction of PCR. Lower radiation doses and cost mean ongoing CXR-based assessment is recommended.
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Affiliation(s)
- Victoria L. Parker
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK
| | - Matthew C. Winter
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK ,grid.31410.370000 0000 9422 8284Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield, S10 2SJ UK
| | - Elspeth Whitby
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK
| | - William A. E. Parker
- grid.11835.3e0000 0004 1936 9262School of Medicine, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK
| | - Julia E. Palmer
- grid.31410.370000 0000 9422 8284Department of Gynaecological Oncology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Room H18, Glossop Road, Sheffield, S10 2JF UK
| | - John A. Tidy
- grid.31410.370000 0000 9422 8284Sheffield Centre for Trophoblastic Disease, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield, S10 2SJ UK ,grid.31410.370000 0000 9422 8284Department of Gynaecological Oncology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Room H18, Glossop Road, Sheffield, S10 2JF UK
| | - Allan A. Pacey
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK
| | - Barry W. Hancock
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield, S10 2RX UK
| | - Robert F. Harrison
- grid.11835.3e0000 0004 1936 9262Department of Automatic Control and Systems Engineering, The University of Sheffield, Mappin Street, Sheffield, S1 3JD UK
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Singh K, Gillett S, Ireson J, Hills A, Tidy JA, Coleman RE, Hancock BW, Winter MC. M-EA (methotrexate, etoposide, dactinomycin) and EMA-CO (methotrexate, etoposide, dactinomycin / cyclophosphamide, vincristine) regimens as first-line treatment of high-risk gestational trophoblastic neoplasia. Int J Cancer 2020; 148:2335-2344. [PMID: 33210289 DOI: 10.1002/ijc.33403] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/05/2020] [Accepted: 10/26/2020] [Indexed: 11/06/2022]
Abstract
High-risk gestational trophoblastic neoplasia (GTN) is highly chemosensitive with an excellent prognosis with treatment. Historically in the United Kingdom, the high-risk regimens used have been M-EA (methotrexate, etoposide, dactinomycin) (Sheffield) and EMA-CO (methotrexate, etoposide, dactinomycin / cyclophosphamide, vincristine) (Charing Cross, London) with prior published data suggesting no difference in survival between these. Our Sheffield treatment policy changed in 2014, switching from M-EA to EMA-CO, aiming to reduce time in hospital, and harmonise UK practice. We aimed to report the toxicities, response rates and survival outcomes for 79 patients with high-risk GTN treated in the first-line setting with either M-EA (n = 59) or EMA-CO (n = 20) from 1998 to 2018. Median duration of treatment was similar (M-EA, 17.3 weeks (IQR 13.9-22.6) and 17.6 weeks (IQR 13.4-20.7) with EMA-CO. For M-EA, overall human chorionic gonadotrophin (hCG) complete response (CR) rate was 84.7% (n = 50/59). Two patients died of drug-resistant disease after several lines of multiagent chemotherapy; overall survival is 96.6% (median follow-up 10.4 years). For EMA-CO, overall hCG CR rate was 70%, overall survival is 100% (median follow-up 4 years). In our experience, patients treated with EMA-CO experienced an apparent increased incidence of neutropenia, non-neutropenic Grade 3-4 infection, peripheral neuropathy and more treatment delays and nights in hospital. Granulocyte-colony stimulating factor, after both EMA and CO arms, titrated to baseline neutrophil count improved the toxicity profile. Both treatment regimens are associated with excellent prognosis; selection of regimen may be further guided by individual patients' personal, social and family circumstances. There is further rationale to explore whether these regimens can be refined, such as 2-weekly EMA, to optimise patient experience and reduce toxicity while maintaining efficacy.
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Affiliation(s)
- Kam Singh
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Sarah Gillett
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Jane Ireson
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Anne Hills
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - John A Tidy
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Robert E Coleman
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Barry W Hancock
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Matthew C Winter
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
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Hancock BW, Tidy J. Placental site trophoblastic tumour and epithelioid trophoblastic tumour. Best Pract Res Clin Obstet Gynaecol 2020; 74:131-148. [PMID: 33139212 DOI: 10.1016/j.bpobgyn.2020.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 01/01/2023]
Abstract
Placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT) are the rarest subtypes of gestational trophoblastic disease (GTD). Their diagnosis is complicated and lacks specific and sensitive tumour markers. They are slow-growing tumours and can occur months to years after any type of antecedent pregnancy. The primary treatment for localised disease is hysterectomy. However, extra-uterine invasion and/or metastasis occur in about one-third of cases and still cause death in a small number. Most patients are young; hence, fertility preservation is a consideration. The major obstacle for prognosis is chemotherapy resistance. The current understanding of these tumours remains elusive and no randomized controlled trials have been done. Even those centres treating a large number of patients with GTD will infrequently manage PSTT/ETT. In this review, we assess progress in the understanding of the disease and discuss four main clinical challenges - establishing conformity of practice, devising a risk-adapted approach to clinical management, establishing long-term follow-up data and evaluating therapies for poor prognosis and multi drug-resistant patients.
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Affiliation(s)
| | - John Tidy
- Director, Sheffield Trophoblastic Disease Centre, UK
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Frijstein MM, Lok CAR, Short D, Singh K, Fisher RA, Hancock BW, Tidy JA, Sarwar N, Kanfer E, Winter MC, Savage PM, Seckl MJ. The results of treatment with high-dose chemotherapy and peripheral blood stem cell support for gestational trophoblastic neoplasia. Eur J Cancer 2019; 109:162-171. [PMID: 30731277 DOI: 10.1016/j.ejca.2018.12.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/13/2018] [Accepted: 12/23/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the effect of high-dose chemotherapy (HDC) with peripheral blood stem cell support (PBSCS) on survival of patients with gestational trophoblastic neoplasia (GTN) with either refractory choriocarcinomas or a poor-prognosis placental site/epithelioid trophoblastic tumours (PSTT/ETTs). METHODS Databases of two referral centres for gestational trophoblastic disease were searched, and 32 patients treated with HDC between 1994 and 2015 were identified. Tissue samples were retrieved for genetic evaluation. Cox regression analyses were performed to identify possible predictors of overall survival (OS). RESULTS HDC induced a sustained complete response in 7 patients. Overall, 41% (13/32) of the patients remained disease free after HDC with or without additional treatment. Patients who survived had much lower human chorionic gonadotropin (hCG) values (all ≤12 IU/L) before and after HDC than those who died of disease. Univariable Cox regression analysis demonstrated that hCG >12 IU/L before or after HDC, International Federation of Gynaecology and Obstetrics (FIGO) stage II-IV and presence of metastases at the time of diagnosis were significantly associated with adverse OS. However, only hCG values before HDC remained significant in a multivariable model (p < 0.001). Five of 11 (45%) patients with PSTT/ETT presenting ≥48 months after antecedent pregnancy and 6 of 14 (43%) patients with refractory choriocarcinoma were in remission. Three treatment-related deaths occurred. CONCLUSIONS Despite 3 treatment-induced deaths, HDC with PBSCS appears to be active in salvaging selected patients with poor-prognosis PSTT/ETTs and refractory choriocarcinomas. Low hCG values before HDC seems a beneficial predictor of OS and may suggest that HDC acts more like a consolidation therapy.
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Affiliation(s)
- M M Frijstein
- Department of Gynaecology, Center of Gynaecologic Oncology Amsterdam, the Netherlands
| | - C A R Lok
- Department of Gynaecology, Center of Gynaecologic Oncology Amsterdam, the Netherlands
| | - D Short
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, London, UK
| | - K Singh
- Sheffield Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - R A Fisher
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, London, UK
| | - B W Hancock
- Sheffield Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - J A Tidy
- Sheffield Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - N Sarwar
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, London, UK
| | - E Kanfer
- Dept of Haematology, Hammersmith Hospital Campus of Imperial College, London, UK
| | - M C Winter
- Sheffield Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - P M Savage
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, London, UK
| | - M J Seckl
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, London, UK.
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Frijstein MM, Lok CAR, van Trommel NE, Ten Kate-Booij MJ, Massuger LFAG, van Werkhoven E, Kaur B, Tidy JA, Sarwar N, Golfier F, Winter MC, Hancock BW, Seckl MJ. Management and prognostic factors of epithelioid trophoblastic tumors: Results from the International Society for the Study of Trophoblastic Diseases database. Gynecol Oncol 2018; 152:361-367. [PMID: 30473257 DOI: 10.1016/j.ygyno.2018.11.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/04/2018] [Accepted: 11/11/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Epithelioid Trophoblastic Tumor (ETT) is an extremely rare form of Gestational Trophoblastic Neoplasia (GTN). Knowledge on prognostic factors and optimal management is limited. We identified prognostic factors, optimal treatment, and outcome from the world's largest case series of patients with ETT. METHODS Patients were selected from the international Placental Site Trophoblastic Tumor (PSTT) and ETT database. Fifty-four patients diagnosed with ETT or mixed PSTT/ETT between 2001 and 2016 were included. Cox regression analysis was used to identify prognostic factors for overall survival (OS). RESULTS Forty-five patients with ETT and 9 patients with PSTT/ETT were included. Thirty-six patients had FIGO stage I and 18 had stages II-IV disease. Patients were treated with surgery (n = 23), chemotherapy (n = 6), or a combination of surgery and chemotherapy (n = 25). In total, 39 patients survived, including 22 patients with complete sustained hCG remission for at least 1 year. Patients treated with surgery as first line treatment had early-stage disease and all survived. Most patients treated with chemotherapy with or without surgery had FIGO stages II-IV disease (55%). They underwent multiple lines of chemotherapy. Eleven of them did not survive. Interval since antecedent pregnancy and FIGO stage were prognostic factors of OS (p = 0.012; p = 0.023 respectively). CONCLUSIONS Advanced-stage disease and an interval of ≥48 months since the antecedent pregnancy are poor prognostic factors of ETT. Surgery seems adequate for early-stage disease with a shorter interval. Advanced-stage disease requires a combination of treatment modalities. Because of its rarity, ETT should be treated in a centre with experience in GTN.
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Affiliation(s)
- M M Frijstein
- Department of Gynaecologic Oncology, Centre of Gynaecologic Oncology Amsterdam, the Netherlands.
| | - C A R Lok
- Department of Gynaecologic Oncology, Centre of Gynaecologic Oncology Amsterdam, the Netherlands
| | - N E van Trommel
- Department of Gynaecologic Oncology, Centre of Gynaecologic Oncology Amsterdam, the Netherlands
| | - M J Ten Kate-Booij
- Department of Gynaecologic Oncology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - L F A G Massuger
- Department of Gynaecology and Obstetrics, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - E van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - B Kaur
- Department of Histopathology, Charing Cross Hospital, London, United Kingdom
| | - J A Tidy
- Trophoblastic Disease Centre, Weston Park Hospital, Sheffield, United Kingdom
| | - N Sarwar
- Department of Medical Oncology, Charing Cross Hospital, London, United Kingdom
| | - F Golfier
- Department of Gynaecological Surgery and Oncology, University Hospital Lyon Sud, France
| | - M C Winter
- Trophoblastic Disease Centre, Weston Park Hospital, Sheffield, United Kingdom
| | - B W Hancock
- Trophoblastic Disease Centre, Weston Park Hospital, Sheffield, United Kingdom
| | - M J Seckl
- Department of Medical Oncology, Charing Cross Hospital, London, United Kingdom
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Ireson J, Jones G, Winter MC, Radley SC, Hancock BW, Tidy JA. Systematic review of health-related quality of life and patient-reported outcome measures in gestational trophoblastic disease: a parallel synthesis approach. Lancet Oncol 2018; 19:e56-e64. [DOI: 10.1016/s1470-2045(17)30686-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/15/2017] [Accepted: 08/17/2017] [Indexed: 10/18/2022]
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Winter MC, Tidy JA, Hills A, Ireson J, Gillett S, Singh K, Hancock BW, Coleman RE. Risk adapted single-agent dactinomycin or carboplatin for second-line treatment of methotrexate resistant low-risk gestational trophoblastic neoplasia. Gynecol Oncol 2016; 143:565-570. [PMID: 27756557 DOI: 10.1016/j.ygyno.2016.10.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/21/2016] [Accepted: 10/01/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the outcome of patients treated with second-line chemotherapy for methotrexate-resistant low-risk GTN at the Sheffield Centre, UK between 2001 and 2015, including the novel use of single-agent carboplatin as a strategy to reduce exposure to combination chemotherapy. METHODS 392 low-risk GTN patients were treated with first-line methotrexate. The selection of chemotherapy regimen following methotrexate-resistance depended on the volume of residual disease as indicated by the serum hCG value at the time, with patients switching to either single-agent dactinomycin at an hCG level<150IU/L from 2001-2010 and <300IU/L since 2010, or to combination treatment with etoposide/dactinomycin (EA) above these thresholds. In order to reduce exposure to more toxic combination chemotherapy regimens, our treatment policy was revised in 2011, with the recommendation of single-agent carboplatin as an alternative to EA at hCG levels >300IU/L. RESULTS 136 (35%) of 392 received second-line chemotherapy following methotrexate-resistance. 59 patients received single-agent dactinomycin with 53 (90%) patients achieving complete hCG response, 3 patients requiring combination chemotherapy or surgery, and 3 patients subsequently spontaneously resolving. 56 patients received EA chemotherapy with hCG complete response in 50 (89%) patients, and the remaining 6 patients were cured with further multi-agent chemotherapy or surgery. With carboplatin, 17/21 (81%) achieved an overall complete hCG response rate, with 4 patients requiring third-line EA. Carboplatin was well tolerated with no significant alopecia; myelosuppression was the most significant toxicity. Overall survival for all patients was 100%. CONCLUSION These data show the continued excellent outcomes for methotrexate-resistant low-risk patients treated with single-agent dactinomycin or EA. Our experience with carboplatin is promising and provides an alternative regimen for methotrexate-resistant low-risk disease that avoids alopecia and in-patient treatment.
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Affiliation(s)
- M C Winter
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom.
| | - J A Tidy
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - A Hills
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - J Ireson
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - S Gillett
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - K Singh
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - B W Hancock
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
| | - R E Coleman
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2SJ, United Kingdom
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Macdonald MC, Hancock BW, Winter MC, Coleman RE, Tidy JA. Management and Outcomes of Patients with Stage I and IlIl Low-Risk Gestational Trophoblastic Neoplasia Treated in Sheffield, UK, from 1997-2006. J Reprod Med 2016; 61:341-346. [PMID: 30408379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To review the outcome of patients treated for low-risk gestational trophoblastic neoplasia (GTN) over a 10-year period with the particular aim of assessing response to treatment in Stages I and III disease. Approximately 90% of women requiring treatment for GTN have low-risk disease. Methotrexate is the treat- ment of choice in the UK and achieves complete response rates of 50% and 90%. STUDY DESIGN A retro- spective review of management and outcomes of patients treated for low-risk GTN at the Trophoblastic Disease Centre, Sheffield, UK, from 1997 to 2006. RESULTS Overall 280 patients were treated for low- risk GTN during this time; 8.6% had stage III disease. Single-agent methotrexate was used as first-line therapy in 99% of cases, with a remission rate of 56%. There was no significant difference (p=0.67) in the complete response rate after first-line methotrexate between those with stage I and those with stage III disease. CONCLUSION The overall cure rate for women with low-risk GTN was high (99.6%), and the complete response rate after first-line management was not sig- nificantly different between stages I and III disease.
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Abstract
BACKGROUND This is the second update of a Cochrane review that was first published in 2009, Issue 1, . Gestational trophoblastic neoplasia (GTN) is a rare but curable disease arising in the fetal chorion during pregnancy. Most women with low-risk GTN will be cured by evacuation of the uterus with or without single-agent chemotherapy. However, chemotherapy regimens vary between treatment centres worldwide and the comparable benefits and risks of these different regimens are unclear. OBJECTIVES To determine the efficacy and safety of first-line chemotherapy in the treatment of low-risk GTN. SEARCH METHODS We electronically searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase in September 2008, February 2012, and January 2016. In addition, we searched online trial registers for protocols and ongoing trials. SELECTION CRITERIA For the original review, we included randomised controlled trials (RCTs), quasi-RCTs and non-RCTs that compared first-line chemotherapy for the treatment of low-risk GTN. For this updated versions of the review, we included only RCTs. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and extracted data to a pre-designed data extraction form. Meta-analysis was performed using the random-effects model. MAIN RESULTS We included seven RCTs (667 women) in this updated review. Most studies were at a low or moderate risk of bias and all compared methotrexate with actinomycin D. Three studies compared weekly intramuscular (IM) methotrexate with bi-weekly pulsed intravenous (IV) actinomycin D (393 women), one study compared five-day IM methotrexate with bi-weekly pulsed IV actinomycin D (75 women), one study compared eight-day IM methotrexate-folinic acid (MTX-FA) with five-day IV actinomycin D (49 women), and one study compared eight-day IM MTX-FA with bi-weekly pulsed IV actinomycin D. One study contributed no data. Moderate-certainty evidence indicates that actinomycin D is probably more likely to lead to primary cure than methotrexate (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.57 to 0.75; six trials, 577 participants; I(2) = 26%), and first-line methotrexate treatment is probably more likely to fail than actinomycin D treatment (RR 3.55, 95% CI 1.81 to 6.95; six trials, 577 participants; I(2) = 61%; moderate-certainty evidence) Low-certainty evidence suggests that there may be little or no difference between methotrexate and actinomycin D treatment with respect to nausea (four studies, 466 women; RR 0.61, 95% CI 0.29 to 1.26) or any of the other individual side-effects reported, although data for all of these outcomes were insufficient and too inconsistent to be conclusive. Low-certainty evidence suggests that there may be little or no difference in the risk of severe adverse events (SAEs) between the groups overall (five studies, 515 women; RR 0.35, 95% CI 0.08 to 1.66; I² = 60%); however, the direction of effect favours methotrexate and more evidence is needed. Furthermore, evidence from subgroup analyses suggests that actinomycin D may be associated with a greater risk of SAEs than methotrexate (low-certainty evidence). We found no evidence on the effect of these treatments on future fertility. AUTHORS' CONCLUSIONS Actinomycin D is probably more likely to achieve a primary cure in women with low-risk GTN, and less likely to result in treatment failure, than a methotrexate regimen. There may be little or no difference between the pulsed actinomycin D regimen and the methotrexate regimen with regard to side-effects. However, actinomycin D may be associated with a greater risk of severe adverse events (SAEs) than a methotrexate regimen. Higher-certainty evidence is still needed on treating low-risk GTN and the four ongoing trials are likely to make a significant contribution to this field. Given the variety of treatment regimens, findings from these trials could facilitate a network meta-analysis in the next version of this review to help women and clinicians determine the best treatment options for low-risk GTN.
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Affiliation(s)
- Theresa A Lawrie
- 1st Floor Education Centre, Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupCombe ParkBathUKBA1 3NG
| | - Mo'iad Alazzam
- Beacon HospitalGynaecological Oncology DivisionSandyfordDublinIreland18
| | - John Tidy
- Sheffield Teaching Hospitals Foundation NHS TrustObstetrics & GynaecologyRoyal Hallamshire HospitalGlossop RoadSheffieldUKS10 2JF
| | - Barry W Hancock
- Sheffield UniversitySchool of Medicine and Biomedical SciencesWestern BankSheffieldUKS10 2TN
| | - Raymond Osborne
- Toronto‐Sunnybrook Regional Cancer CentreDivision of Gynecology‐Oncology2075 Bayview AveTorontoONCanadaM4N 3M5
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Taylor F, Short D, Harvey R, Winter MC, Tidy J, Hancock BW, Savage PM, Sarwar N, Seckl MJ, Coleman RE. Late spontaneous resolution of persistent molar pregnancy. BJOG 2016; 123:1175-81. [DOI: 10.1111/1471-0528.13867] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2015] [Indexed: 11/30/2022]
Affiliation(s)
- F Taylor
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - D Short
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - R Harvey
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - MC Winter
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - J Tidy
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - BW Hancock
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
| | - PM Savage
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - N Sarwar
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - MJ Seckl
- Charing Cross Gestational Trophoblastic Disease Centre Department of Medical Oncology Charing Cross Hospital Campus of Imperial College London London UK
| | - RE Coleman
- Sheffield Centre for Trophoblastic Disease Sheffield Cancer Research Centre Weston Park Hospital Sheffield UK
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Abstract
BACKGROUND Gestational trophoblastic neoplasia (GTN) is a highly curable group of pregnancy-related tumours; however, approximately 25% of GTN tumours will be resistant to, or will relapse after, initial chemotherapy. These resistant and relapsed lesions will require salvage chemotherapy with or without surgery. Various salvage regimens are used worldwide. It is unclear which regimens are the most effective and the least toxic. OBJECTIVES To determine which chemotherapy regimen/s for the treatment of resistant or relapsed GTN is/are the most effective and the least toxic. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 4), MEDLINE and EMBASE up to October 2011. In addition, we handsearched the relevant society conference proceedings and study reference lists. For the updated review, we searched Cochrane Group Specialised Register, CENTRAL, MEDLINE and EMBASE to 16 Novemeber 2015. In addition, we searched online clinical trial registries for ongoing trials. SELECTION CRITERIA Only randomised controlled trials (RCTs) were included. DATA COLLECTION AND ANALYSIS We designed a data extraction form and planned to use random-effects methods in Review Manager 5.1 for meta-analyses. MAIN RESULTS The search identified no RCTs; therefore we were unable to perform any meta-analyses. AUTHORS' CONCLUSIONS RCTs in GTN are scarce owing to the low prevalence of this disease and its highly chemosensitive nature. As chemotherapeutic agents may be associated with substantial side effects, the ideal treatment should achieve maximum efficacy with minimal side effects. For methotrexate-resistant or recurrent low-risk GTN, a common practice is to use sequential five-day dactinomycin, followed by MAC (methotrexate, dactinomycin, cyclophosphamide) or EMA/CO (etoposide, methotrexate, dactinomycin, cyclophosphamide, vinblastine) if further salvage therapy is required. However, five-day dactinomycin is associated with more side effects than pulsed dactinomycin, therefore an RCT comparing the relative efficacy and safety of these two regimens in the context of failed primary methotrexate treatment is desirable.For high-risk GTN, EMA/CO is the most commonly used first-line therapy, with platinum-etoposide combinations, particularly EMA/EP (etoposide, methotrexate, dactinomycin/etoposide, cisplatin), being favoured as salvage therapy. Alternatives, including TP/TE (paclitaxel, cisplatin/ paclitaxel, etoposide), BEP (bleomycin, etoposide, cisplatin), FAEV (floxuridine, dactinomycin, etoposide, vincristine) and FA (5-fluorouracil (5-FU), dactinomycin), may be as effective as EMA/EP and associated with fewer side effects; however, this is not clear from the available evidence and needs testing in well-designed RCTs. In the UK, an RCT comparing interventions for resistant/recurrent GTN will be very challenging owing to the small numbers of patients with this scenario. International multicentre collaboration is therefore needed to provide the high-quality evidence required to determine which salvage regimen/s have the best effectiveness-to-toxicity ratio in low- and high-risk disease. Future research should include economic evaluations and long-term surveillance for secondary neoplasms.
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Affiliation(s)
- Mo'iad Alazzam
- Beacon HospitalGynaecological Oncology DivisionSandyfordDublinIreland18
| | - John Tidy
- Sheffield Teaching Hospitals Foundation NHS TrustObstetrics & GynaecologyRoyal Hallamshire HospitalGlossop RoadSheffieldUKS10 2JF
| | - Raymond Osborne
- Toronto‐Sunnybrook Regional Cancer CentreDivision of Gynecology‐Oncology2075 Bayview AveTorontoONCanadaM4N 3M5
| | - Robert Coleman
- Sheffield UniversitySchool of Medicine and Biomedical SciencesWestern BankSheffieldUKS10 2TN
| | - Barry W Hancock
- Sheffield UniversitySchool of Medicine and Biomedical SciencesWestern BankSheffieldUKS10 2TN
| | - Theresa A Lawrie
- 1st Floor Education Centre, Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupCombe ParkBathUKBA1 3NG
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Swerdlow AJ, Cooke R, Bates A, Cunningham D, Falk SJ, Gilson D, Hancock BW, Harris SJ, Horwich A, Hoskin PJ, Linch DC, Lister A, Lucraft HH, Radford J, Stevens AM, Syndikus I, Williams MV. Risk of premature menopause after treatment for Hodgkin's lymphoma. J Natl Cancer Inst 2014; 106:dju207. [PMID: 25139687 DOI: 10.1093/jnci/dju207] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2024] Open
Abstract
BACKGROUND Modern treatment of Hodgkin's lymphoma (HL) has transformed its prognosis but causes late effects, including premature menopause. Cohort studies of premature menopause risks after treatment have been relatively small, and knowledge about these risks is limited. METHODS Nonsurgical menopause risk was analyzed in 2127 women treated for HL in England and Wales at ages younger than 36 years from 1960 through 2004 and followed to 2003 through 2012. Risks were estimated using Cox regression, modified Poisson regression, and competing risks. All statistical tests were two-sided. RESULTS During follow-up, 605 patients underwent nonsurgical menopause before age 40 years. Risk of premature menopause increased more than 20-fold after ovarian radiotherapy, alkylating chemotherapy other than dacarbazine, or BEAM (bis-chloroethylnitrosourea [BCNU], etoposide, cytarabine, melphalan) chemotherapy for stem cell transplantation, but was not statistically significantly raised after adriamycin, bleomycin, vinblastine, dacarbazine (ABVD). Menopause generally occurred sooner after ovarian radiotherapy (62.5% within five years of ≥5 Gy treatment) and BEAM (50.9% within five years) than after alkylating chemotherapy (24.2% within five years of ≥6 cycles), and after treatment at older than at younger ages. Cumulative risk of menopause by age 40 years was 81.3% after greater than or equal to 5Gy ovarian radiotherapy, 75.3% after BEAM, 49.1% after greater than or equal to 6 cycles alkylating chemotherapy, 1.4% after ABVD, and 3.0% after solely supradiaphragmatic radiotherapy. Tables of individualized risk information for patients by future period, treatment type, dose and age are provided. CONCLUSIONS Patients treated with HL need to plan intended pregnancies using personalized information on their risk of menopause by different future time points.
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Affiliation(s)
- Anthony J Swerdlow
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Rosie Cooke
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Andrew Bates
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - David Cunningham
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Stephen J Falk
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Dianne Gilson
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Barry W Hancock
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Sarah J Harris
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Alan Horwich
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Peter J Hoskin
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - David C Linch
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Andrew Lister
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Helen H Lucraft
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - John Radford
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Andrea M Stevens
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Isabel Syndikus
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
| | - Michael V Williams
- Divisions of Genetics and Epidemiology (AJS, RC), Breast Cancer Research (AJS) and Radiotherapy (AH), Institute of Cancer Research, Sutton, UK; University of Manchester and Christie NHS Foundation Trust, Manchester, UK (JR); Gastrointestinal Unit, Royal Marsden Hospital, Sutton, UK (DC); Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK (IS); Cancer Research UK Medical Oncology Unit, St. Bartholomew's Hospital, London, UK (TAL); Cancer Centre, Mount Vernon Hospital, Middlesex, UK (PJH); St. James Institute of Oncology, Leeds, UK (DG); Northern Centre for Cancer Care, Freeman Hospital, Newcastle, UK (HHL); Bristol Haematology and Oncology Centre, Bristol, UK (SJF); Addenbrooke's Hospital, Cambridge, UK (MVW); Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK (BWH); Guy's and St. Thomas, London, UK (SJH); Department of Haematology, University College Hospital, London, UK (DCL); Southampton General Hospital, Southampton, UK (AB); Queen Elizabeth Hospital, Birmingham, UK (AMS). The England and Wales Hodgkin Lymphoma Follow-up Group includes the authors of this article plus: Gabriel Anghel, Lincoln Hospital; Brian Attock, North Devon District Hospital; Jane Barrett, Royal Berkshire Hospital; Andrew Bell, Poole Hospital; Kim Benstead, Cheltenham General Hospital; Eric M. Bessell, Nottingham University Hospital; Ashoke Biswas, Royal Preston Hospital; Norbert Blesing, Great Western Hospital, Swindon; Caroline Brammer, New Cross Hospital, Wolverhampton; Jill Brock, Clatterbridge Centre for Oncology; Alison Brownell, Queens Hospital, Romford; A. Murray Brunt, University Hospital of North Staffordshire; Peter B. Coates, Queen Elizabeth Hospital, King's Lynn; Matthew P. Collinson, Royal Cornwall Hospital; Neville Davidson, Essex County Hospital; Sian Davies, North Middlesex University Hospital; Ian Fentiman, Guy's Hospital; Eve Gallop-Evans, Velindre Hospital; Angel Garcia, Glan Clwyd Hospital; Andrew Goodman, Royal Devon and Exeter Hospital; Ad
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Ireson J, Singh K, Gillett S, Hills A, Everard J, Winter M, Coleman RE, Tidy J, Hancock BW. Evolution of a specialist gestational trophoblastic disease service with a major nursing component: the Sheffield, United Kingdom, experience. J Reprod Med 2014; 59:195-198. [PMID: 24937956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To describe the evolution of a highly regarded and unique model of multidisciplinary care providing support, monitoring, and treatment for all gestational trophoblastic disease (GTD) patients referred to Sheffield Trophoblastic Disease Centre, 1 of the 3 United Kingdom (UK) supraregional GTD centers. BACKGROUND The UK GTD service was first established in 1973 and since its inception has centralized care for GTD patients and played a leading international role in developing therapies, management protocols, and biomarker assays with good outcomes for patients. The service preceded recent trends towards centralization for rare cancers in the U.K. In Sheffield the GTD team has evolved to become a true multidisciplinary team with a strong nursing component, which is set to expand in the future. RESULTS Centralization of care for GTD in the U.K. has been directly associated with the impressive results the service has achieved, with high cure rates (98-100%) and low (5-8%) chemotherapy rates. The addition of GTD nurse specialists has been beneficial to patients as they provide a communication link between patients and their clinicians and ensure that information, support, and advice is available for all GTD patients, both in hospital and at home. CONCLUSION The UK GTD service is an internationally renowned, multidisciplinary organization. The service achieves impressive clinical results and now features a strong nursing component. The addition of nurse specialists has enabled the team to offer both clinical and psychological care and means that specialist advice is available for patients and healthcare professionals involved in giving care to this patient group.
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Agarwal R, Alifrangis C, Everard J, Savage PM, Short D, Tidy J, Fisher RA, Sebire NJ, Harvey R, Hancock BW, Coleman RE, Seckl MJ. Management and survival of patients with FIGO high-risk gestational trophoblastic neoplasia: the U.K. experience, 1995-2010. J Reprod Med 2014; 59:7-12. [PMID: 24597279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To present survival rates of high-risk gestational trophoblastic neoplasia (GTN) (FIGO score > 7) patients treated between 1995 and 2010 in the U.K. Death due to GTN is largely confined to patients with high-risk disease. In the U.K. a national system ensures that all patients are treated at only 2 specialist centers: Charing Cross Hospital (CXH) in London and Weston Park Hospital (WPH) in Sheffield. STUDY DESIGN A total of 196 high-risk patients were identified using the CXH and WPH GTN databases, based on the risk score at the time of presentation. RESULTS In all, 140 CXH and 56 WPH high-risk patients were treated with EMA/CO (etoposide, methotrexate, actinomycin D alternating with cyclophosphamide and vincristine) and MEA (methotrexate, etoposide, actinomycin D), respectively. The FIGO score at presentation ranged from 6-23. Eight patients (7from WPH and 1 from CXH) who were treated prior to 2002 as high-risk based on their pre-2002 scoring scored a 6 using FIGO 2002. Two (1%) patients died within 4 weeks of starting treatment (early death), 12 (6%) relapsed, and 9 patients subsequently died due to drug resistance. The overall survival was 94%, with a median follow-up of 4.69 years. CONCLUSION In the context of a national trophoblastic disease service, patients with high-risk GTN have an excellent prognosis with EMA/CO or MEA.
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Affiliation(s)
- Roshan Agarwal
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - Costi Alifrangis
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - Janet Everard
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - Philip M Savage
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - Dee Short
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - John Tidy
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - Rosemary A Fisher
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - Neil J Sebire
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - Richard Harvey
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - Barry W Hancock
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - Robert E Coleman
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
| | - Michael J Seckl
- Charing Cross Gestational Trophoblastic Disease Centre, Department of Medical Oncology, Charing Cross Hospital, Imperial College Academic Science NHS Trust, UK
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Cooke R, Jones ME, Cunningham D, Falk SJ, Gilson D, Hancock BW, Harris SJ, Horwich A, Hoskin PJ, Illidge T, Linch DC, Lister TA, Lucraft HH, Radford JA, Stevens AM, Syndikus I, Williams MV, Swerdlow AJ. Breast cancer risk following Hodgkin lymphoma radiotherapy in relation to menstrual and reproductive factors. Br J Cancer 2013; 108:2399-406. [PMID: 23652303 PMCID: PMC3681009 DOI: 10.1038/bjc.2013.219] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 04/02/2013] [Accepted: 04/14/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Women treated with supradiaphragmatic radiotherapy (sRT) for Hodgkin lymphoma (HL) at young ages have a substantially increased breast cancer risk. Little is known about how menarcheal and reproductive factors modify this risk. METHODS We examined the effects of menarcheal age, pregnancy, and menopausal age on breast cancer risk following sRT in case-control data from questionnaires completed by 2497 women from a cohort of 5002 treated with sRT for HL at ages <36 during 1956-2003. RESULTS Two-hundred and sixty women had been diagnosed with breast cancer. Breast cancer risk was significantly increased in patients treated within 6 months of menarche (odds ratio (OR) 5.52, 95% confidence interval (CI) (1.97-15.46)), and increased significantly with proximity of sRT to menarche (Ptrend<0.001). It was greatest when sRT was close to a late menarche, but based on small numbers and needing reexamination elsewhere. Risk was not significantly affected by full-term pregnancies before or after treatment. Risk was significantly reduced by early menopause (OR 0.55, 95% CI (0.35-0.85)), and increased with number of premenopausal years after treatment (Ptrend=0.003). CONCLUSION In summary, this paper shows for the first time that sRT close to menarche substantially increases breast cancer risk. Careful consideration should be given to follow-up of these women, and to measures that might reduce their future breast cancer risk.
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Affiliation(s)
- R Cooke
- Division of Genetics and Epidemiology, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey SM2 5NG, UK.
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Abstract
BACKGROUND Gestational trophoblastic neoplasia (GTN) is a highly curable group of pregnancy-related tumours; however, approximately 25% of GTN tumours will be resistant to, or will relapse after, initial chemotherapy. These resistant and relapsed lesions will require salvage chemotherapy with or without surgery. Various salvage regimens are used worldwide. It is unclear which regimens are the most effective and the least toxic. OBJECTIVES To determine which chemotherapy regimen/s for the treatment of resistant or relapsed GTN is/are the most effective and the least toxic. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 4), MEDLINE and EMBASE up to October 2011. In addition, we handsearched the relevant society conference proceedings and study reference lists. SELECTION CRITERIA Only randomised controlled trials (RCTs) were included. DATA COLLECTION AND ANALYSIS We designed a data extraction form and planned to use random-effects methods in Review Manager 5.1 for meta-analyses. MAIN RESULTS The search identified no RCTs; therefore we were unable to perform any meta-analyses. AUTHORS' CONCLUSIONS RCTs in GTN are scarce owing to the low prevalence of this disease and its highly chemosensitive nature. As chemotherapeutic agents may be associated with substantial side effects, the ideal treatment should achieve maximum efficacy with minimal side effects. For methotrexate-resistant or recurrent low-risk GTN, a common practice is to use sequential five-day dactinomycin, followed by MAC (methotrexate, dactinomycin, cyclophosphamide) or EMA/CO (etoposide, methotrexate, dactinomycin, cyclophosphamide, vinblastine) if further salvage therapy is required. However, five-day dactinomycin is associated with more side effects than pulsed dactinomycin, therefore an RCT comparing the relative efficacy and safety of these two regimens in the context of failed primary methotrexate treatment is desirable.For high-risk GTN, EMA/CO is the most commonly used first-line therapy, with platinum-etoposide combinations, particularly EMA/EP (etoposide, methotrexate, dactinomycin/etoposide, cisplatin), being favoured as salvage therapy. Alternatives, including TP/TE (paclitaxel, cisplatin/ paclitaxel, etoposide), BEP (bleomycin, etoposide, cisplatin), FAEV (floxuridine, dactinomycin, etoposide, vincristine) and FA (5-fluorouracil (5-FU), dactinomycin), may be as effective as EMA/EP and associated with fewer side effects; however, this is not clear from the available evidence and needs testing in well-designed RCTs. In the UK, an RCT comparing interventions for resistant/recurrent GTN will be very challenging owing to the small numbers of patients with this scenario. International multicentre collaboration is therefore needed to provide the high-quality evidence required to determine which salvage regimen/s have the best effectiveness-to-toxicity ratio in low- and high-risk disease. Future research should include economic evaluations and long-term surveillance for secondary neoplasms.
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Affiliation(s)
- Mo'iad Alazzam
- Department of Gynaecology, The Galway Clinic, Doughiska, Galway, Ireland.
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Abstract
Lymphomas are solid tumours of the immune system. Hodgkin's lymphoma accounts for about 10% of all lymphomas, and the remaining 90% are referred to as non-Hodgkin lymphoma. Non-Hodgkin lymphomas have a wide range of histological appearances and clinical features at presentation, which can make diagnosis difficult. Lymphomas are not rare, and most physicians, irrespective of their specialty, will probably have come across a patient with lymphoma. Timely diagnosis is important because effective, and often curative, therapies are available for many subtypes. In this Seminar we discuss advances in the understanding of the biology of these malignancies and new, available treatments.
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Affiliation(s)
- Kate R Shankland
- Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK.
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Swerdlow AJ, Cooke R, Bates A, Cunningham D, Falk SJ, Gilson D, Hancock BW, Harris SJ, Horwich A, Hoskin PJ, Linch DC, Lister TA, Lucraft HH, Radford JA, Stevens AM, Syndikus I, Williams MV. Breast Cancer Risk After Supradiaphragmatic Radiotherapy for Hodgkin's Lymphoma in England and Wales: A National Cohort Study. J Clin Oncol 2012; 30:2745-52. [DOI: 10.1200/jco.2011.38.8835] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To investigate breast cancer risk after supradiaphragmatic radiotherapy administered to young women with Hodgkin's lymphoma (HL) in a much larger cohort than previously to provide data for patient follow-up and screening individualized according to treatment type, age, and time point during follow-up. Patients and Methods Breast cancer risk was assessed in 5,002 women in England and Wales treated for HL with supradiaphragmatic radiotherapy at age < 36 years from 1956 to 2003, who underwent follow-up with 97% completeness until December 31, 2008. Results Breast cancer or ductal carcinoma in situ developed in 373 patients, with a standardized incidence ratio (SIR) of 5.0 (95% CI, 4.5 to 5.5). SIRs were greatest for those treated at age 14 years (47.2; 95% CI, 28.0 to 79.8) and continued to remain high for at least 40 years. The maximum absolute excess risk was at attained ages 50 to 59 years. Alkylating chemotherapy or pelvic radiotherapy diminished the risk, but only for women treated at age ≥ 20 years, not for those treated when younger. Cumulative risks were tabulated in detail; for 40-year follow-up, the risk for patients receiving ≥ 40 Gy mantle radiotherapy at young ages was 48%. Conclusion This article provides individualized risk estimates based on large numbers for patients with HL undergoing follow-up after radiotherapy at young ages. Follow-up of such women needs to continue for 40 years or longer and may require more-intensive screening regimens than those in national general population programs. Special consideration is needed of potential measures to reduce breast cancer risk for girls treated with supradiaphragmatic radiotherapy at pubertal ages.
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Affiliation(s)
- Anthony J. Swerdlow
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Rosie Cooke
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Andrew Bates
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - David Cunningham
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Stephen J. Falk
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Dianne Gilson
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Barry W. Hancock
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Sarah J. Harris
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Alan Horwich
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Peter J. Hoskin
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - David C. Linch
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - T. Andrew Lister
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Helen H. Lucraft
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - John A. Radford
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Andrea M. Stevens
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Isabel Syndikus
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
| | - Michael V. Williams
- Anthony J. Swerdlow, Rosie Cooke, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Andrew Bates, Southampton General Hospital, Southampton; Stephen J. Falk, Bristol Haematology and Oncology Centre, Bristol; Dianne Gilson, St James Institute of Oncology, Leeds; Barry W. Hancock, Weston Park Hospital, Sheffield; Sarah J. Harris, Guy's and St Thomas'; David C. Linch, University College Hospital; T. Andrew Lister, St Bartholomew's Hospital, London; Peter J
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Abstract
BACKGROUND This is an update of a Cochrane review that was first published in Issue 1, 2009. Gestational trophoblastic neoplasia (GTN) is a rare but curable disease arising in the fetal chorion during pregnancy. Most women with low-risk GTN will be cured by evacuation of the uterus with or without single-agent chemotherapy. However, chemotherapy regimens vary between treatment centres worldwide and the comparable benefits and risks of these different regimens are unclear. OBJECTIVES To determine the efficacy and safety of first-line chemotherapy in the treatment of low-risk GTN. SEARCH METHODS In September 2008, we electronically searched the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL Issue 3, 2008), MEDLINE and EMBASE. In addition, we searched online trial registers, conference proceedings and reference lists of identified studies. We re-ran these searches in February 2012 for this updated review. SELECTION CRITERIA For the original review, we included randomised controlled trials (RCTs), quasi-RCTs and non-RCTs that compared first-line chemotherapy for the treatment of low-risk GTN. For this updated version of the review, we included only RCTs. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and extracted data to a pre-designed data extraction form. Meta-analysis was performed by pooling the risk ratio (RR) of individual trials. MAIN RESULTS We included five moderate to high quality RCTs (517 women) in the updated review. These studies all compared methotrexate with dactinomycin. Three studies compared weekly intramuscular (IM) methotrexate with bi-weekly pulsed intravenous (IV) dactinomycin (393 women), one study compared five-day IM methotrexate with bi-weekly pulsed IV dactinomycin (75 women) and one study compared eight-day IM methotrexate-folinic acid (MTX-FA) with five-day IV dactinomycin (49 women).Overall, dactinomycin was associated with significantly higher rates of primary cure than methotrexate (five studies, 513 women; RR 0.64, 95% Confidence Interval (CI) 0.54 to 0.76). Methotrexate was associated with significantly more treatment failure than dactinomycin (five studies, 513 women; RR 3.81, 95% CI 1.64 to 8.86). We consider this evidence to be of a moderate quality.There was no significant difference between the two groups with respect to nausea (four studies, 466 women; RR 0.61, 95% CI 0.29 to 1.26) or any of the other individual side-effects reported, although data for all of these outcomes were insufficient and too heterogeneous to be conclusive. No severe adverse effects (SAEs) occurred in either group in three out of the five included studies and there was no significant difference in SAEs between the groups overall (five studies, 515 women; RR 0.35, 95% CI 0.08 to 1.66; I² = 60%), however, there was a trend towards fewer SAEs in the methotrexate group. We considered this evidence to be of a low quality due to substantial heterogeneity and low consistency in the occurrence/reporting of SAEs between trials. AUTHORS' CONCLUSIONS Dactinomycin is more likely to achieve a primary cure in women with low-risk GTN, and less likely to result in treatment failure, compared with methotrexate. There is limited evidence relating to side-effects, however, the pulsed dactinomycin regimen does not appear to be associated with significantly more side-effects than the low-dose methotrexate regimen and therefore should compare favourably to the five- and eight-day methotrexate regimens in this regard.We consider pulsed dactinomycin to have a better cure rate than, and a side-effect profile at least equivalent to, methotrexate when used for first-line treatment of low-risk GTN. Data from a large ongoing trial of pulsed dactinomycin compared with five- and eight-day methotrexate regimens is likely to have an important impact on our confidence in these findings.
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Affiliation(s)
- Mo'iad Alazzam
- Department of Gynaecology, The Galway Clinic, Doughiska, Galway, Ireland.
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Kingdon SJ, Coleman RE, Ellis L, Hancock BW. Deaths from gestational trophoblastic neoplasia: any lessons to be learned? J Reprod Med 2012; 57:293-296. [PMID: 22838243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To review retrospectively the causes of death in unselected patients with gestational trophoblastic neoplasia (GTN). STUDY DESIGN Between 1975 and 2010, 905 patients with GTN were treated at the Sheffield Centre. Twenty-four of them died. The medical records of these patients were reviewed. RESULTS Of the 24 patients, 11 died during initial treatment. A further 8 died from disease relapse and progression of the disease. The cause of death was unrelated in the other 5, who were excluded from analysis. For the remaining 19 patients, death was due to metastatic tumor in 13 and was treatment related in 6. Adverse prognostic features for death from GTN included histology (7 were placental site trophoblastic tumor [PSTT]), risk score (15 were high risk) and chemotherapy resistance. All 5 of the patients who died of acute treatment-related complications (invariably sepsis and/or multiorgan failure) still had active GTN at the time of death; all were treated prior to 1987. One multitreated patient died of acute myeloid leukemia 3 years posttreatment. CONCLUSION Metastatic multidrug-resistant PSTT was and still is the single most important cause of death. Death from choriocarcinoma was with nonpulmonary metastases not responding to initial treatment. Early treatment-related death (from sepsis) is nowadays avoidable.
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Affiliation(s)
- Sarah J Kingdon
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield, UK
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Hassadia A, Kew FM, Tidy JA, Wells M, Hancock BW. Ectopic gestational trophoblastic disease: a case series review. J Reprod Med 2012; 57:297-300. [PMID: 22838244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To highlight the clinical presentation, treatment, histological review and outcome of patients referred to the Sheffield Centre with possible ectopic gestational trophoblastic disease (GTD). STUDY DESIGN A retrospective case note review of patients with possible ectopic GTD referred to the Sheffield Centre between 1997 and 2010 was performed. RESULTS During the 13 years of this retrospective study 6,708 patients were registered at the Centre with GTD, of whom 42 had possible ectopic GTD. Most patients presented with abdominal pain and/or vaginal bleeding (67%). Ectopic pregnancy was diagnosed by ultrasound scan in 19%. Laparoscopic removal of ectopic pregnancy was carried out in 50% of cases; the rest underwent laparotomy for removal of ectopic conceptus. Histological review of slides was performed in 19 cases for whom there was clinical concern. This resulted in 12 confirmed cases of ectopic GTD: 4 choriocarcinomas, 5 partial moles and 3 complete moles. No evidence of metastasis was recorded in any of the cases. Three patients diagnosed with ectopic choriocarcinoma needed chemotherapy. Two responded to methotrexate and 1 needed second-line chemotherapy. All patients are alive and free of disease. CONCLUSION Ectopic GTD is rare and still overdiagnosed. Presentation is the same as for conventional ectopic pregnancy. Central review of the histology should be undertaken, especially in cases where there is clinical, hCG level or histopathologic concern. Conventional chemotherapy for gestational trophoblastic neoplasia is effective. Prognosis remains excellent.
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Affiliation(s)
- Ayman Hassadia
- Department of Gynaecological Oncology, Royal Hallamshire Hospital, Sheffield, UK.
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Killick S, Cook J, Gillett S, Ellis L, Tidy J, Hancock BW. Initial presenting features in gestational trophoblastic neoplasia: does a decade make a difference? J Reprod Med 2012; 57:279-282. [PMID: 22838240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To compare the initial clinical presentation of patients who were treated at our center for gestational trophoblastic neoplasia (GTN) between 1996 and 1998 and between 2006 and 2008. STUDY DESIGN All patients seen at Weston Park Hospitalfor GTN (excluding placental site trophoblastic tumor [PSTT]) between 1996 and 1998 (total, 79) and between 2006 and 2008 (total, 139) were identified and their medical records reviewed. Features from when they first presented with gestational trophoblastic disease (GTD), excluding PSTT, were recorded. During those time periods 1,391 and 1,623 patients, respectively, were registered at our center with GTD. RESULTS The following results were noted: abnormal vaginal bleeding remains the most common presentation; the proportion of abnormal ultrasound scans at initial diagnosis has risen from 1% to 12%; the mean gestational age of the antecedent pregnancy has dropped from 11.3 to 10.1 weeks; the mean number of evacuations has fallen from 1.9 to 1.2, and the proportion of patients having 2 evacuations has more than halved; and the proportion of patients presenting with GTD requiring chemotherapy for GTN was 4.2% (59 of 1,391) for 1996-1998 and 6.7% (109 of 1,623) for 2006-2008. CONCLUSION An improvement in ultrasound technology and expertise in early pregnancy is likely to have contributed to a trend toward a lower gestational age at diagnosis of GTD. We noted a major shift in practice towards a higher threshold for repeat evacuations and an increased proportion of patients with GTN receiving chemotherapy.
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Affiliation(s)
- Stacey Killick
- Sheffield Centre for Trophoblastic Disease, Weston Park Hospital, Sheffield, UK.
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Angelopoulos G, Palmer JE, Hancock BW, Tidy JA. Healthy women with persistently elevated hCG levels: a case series of fourteen women. J Reprod Med 2012; 57:249-253. [PMID: 22696821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To review our own data and that in the literature in order to assess likely morbidity and mortality risks and enhance the information that we can provide to patients suffering with this condition. STUDY DESIGN This was a retrospective case series using data from the Sheffield Trophoblastic Disease Centre Database combined with data from prior publications. RESULTS A diagnosis of elevated human chorionic gonadotropin (hCG) in an otherwise healthy woman carries an 11-19% risk of malignancy and 1-3% risk of mortality. Irrespective of persistently elevated hCG, however, pregnancy appears to be a viable and safe prospect. CONCLUSION Persistently elevated hCG in healthy, nonpregnant women is a rare clinical scenario. Due to the rarity of this condition and potential future malignancy risk, we believe that reporting of future cases is crucial, as is a liaison between national and international trophoblastic disease centers, if we are to gain a more thorough understanding of this possibly premalignant condition.
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Affiliation(s)
- George Angelopoulos
- Department of Gynaecological Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, and the Sheffield Trophoblastic Disease Centre, Weston Park Hospital, Sheffield, South Yorkshire, UK
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Abstract
1 The relationship between serum quinidine levels and rate-corrected QT (QTc) interval after administration of single identical doses of quinidine was assessed. Quinidine concentrations were determined by a modification of Hamfelt & Malers' (1963) method. The significance and clinical application of our findings is discussed. 2 Individual responses (both in quinidine concentration and QTc prolongation) were variable, though the variation was no greater with QTc prolongation response than with serum quinidine levels. A significant peak in QTc prolongation occurred after quinidine administration and this was not accompanied by a similar peak in quinidine levels. There was some correlation (r = 0.53) between serum quinidine levels and QTc interval but a better correlation was found between rate of rise of quinidine concentration and QTc prolongation (r = 0.87). 3 One individual showed marked QTc prolongation with slow rate of rise of quinidine levels. Red cell quinidine levels were lower in this individual and he may be showing increased myocardial sensitivity to quinidine.
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Affiliation(s)
- I R Edwards
- Academic Division of Medicine, Section of Therapeutics, Royal Infirmary, Sheffield
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Swerdlow AJ, Higgins CD, Smith P, Cunningham D, Hancock BW, Horwich A, Hoskin PJ, Lister TA, Radford JA, Rohatiner AZ, Linch DC. Second Cancer Risk After Chemotherapy for Hodgkin's Lymphoma: A Collaborative British Cohort Study. J Clin Oncol 2011; 29:4096-104. [DOI: 10.1200/jco.2011.34.8268] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose We investigated the long-term risk of second primary malignancy after chemotherapy for Hodgkin's lymphoma (HL) in a much larger cohort than any yet published, to our knowledge. Patients and Methods We followed 5,798 patients with HL treated with chemotherapy in Britain from 1963 to 2001—of whom 3,432 also received radiotherapy—to assess second primary malignancy risks compared with general population-based expectations. Results Second malignancies occurred in 459 cohort members. Relative risk (RR) of second cancer was raised after chemotherapy alone (RR, 2.0; 95% CI, 1.7 to 2.4) but was much lower than after combined modalities (RR, 3.9; 95% CI, 3.5 to 4.4). After chemotherapy alone, there were significantly raised risks of lung cancer, non-HL, and leukemia, each contributing approximately equal absolute excess risk. After combined modalities, there were raised risks of these and several other cancers. Second cancer risk peaked 5 to 9 years after chemotherapy alone, but it remained raised for 25 years and longer after combined modalities. Risk was raised after each common chemotherapy regimen except, based on limited numbers and follow-up, adriamycin, bleomycin, vinblastine, and dacarbazine. The age and time-course relations of lung cancer differed between chemotherapy alone and combined modalities. Conclusion Although chemotherapy alone leads to raised risk of second malignancy, this risk is lower and affects fewer anatomic sites than that after combined modalities, and it is slight if at all after 15 years follow-up. The mechanism of lung cancer etiology may differ between chemotherapy and radiotherapy.
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Affiliation(s)
- Anthony J. Swerdlow
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - Craig D. Higgins
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - Paul Smith
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - David Cunningham
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - Barry W. Hancock
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - Alan Horwich
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - Peter J. Hoskin
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - T. Andrew Lister
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - John A. Radford
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - Ama Z.S. Rohatiner
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - David C. Linch
- Anthony J. Swerdlow, Craig D. Higgins, and Alan Horwich, Institute of Cancer Research; David Cunningham, Royal Marsden Hospital, Sutton; Paul Smith and David C. Linch, University College Hospital; T. Andrew Lister and Ama Z.S. Rohatiner, St Bartholomew's Hospital, London; Barry W. Hancock, Weston Park Hospital, Sheffield; Peter J. Hoskin, Mount Vernon Hospital, Middlesex; and John A. Radford, Christie Hospital and University of Manchester, Manchester, United Kingdom
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Johnson PW, Sydes MR, Hancock BW, Cullen M, Radford JA, Stenning SP. Consolidation Radiotherapy in Patients With Advanced Hodgkin's Lymphoma: Survival Data From the UKLG LY09 Randomized Controlled Trial (ISRCTN97144519). J Clin Oncol 2010; 28:3352-9. [DOI: 10.1200/jco.2009.26.0323] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose This study analyzed the outcomes of nonrandomized consolidation radiotherapy (RT) given after chemotherapy in the initial treatment of advanced Hodgkin's lymphoma (HL). The results were collected prospectively within a randomized controlled trial of induction chemotherapy. Patients and Methods Patients were randomly assigned between doxorubicin, bleomycin, vinblastine, and dacarbazine and one of two prespecified multidrug regimens. At least six cycles of chemotherapy were planned, with up to eight for patients showing slower response. Involved-field RT was recommended for incomplete response to chemotherapy or bulk disease at presentation. The primary outcome measure was progression-free survival (PFS), landmarked from the end of chemotherapy. Results Among 807 patients randomly assigned, 702 achieved objective response. Postchemotherapy RT for consolidation was reported in 300 (43%). With median follow-up of 6.9 years, 161 PFS events and 83 deaths were reported. Baseline characteristics showed more patients with bulk disease having RT (190 [63%] v 111 [28%]) and only partial response after chemotherapy (150 [50%] v 36 [9%]). Other baseline characteristics were similar. PFS was superior for patients having RT (hazard ratio [HR], 0.43; 95% CI, 0.30 to 0.60) with 5-year PFS 71% without RT, 86% with RT. A similar advantage was seen for overall survival (HR, 0.47; 95% CI, 0.29 to 0.77). There was no evidence of heterogeneity of treatment effect across subgroups. Conclusion Patients who received consolidation RT apparently had better outcomes, consistently across all prognostic groups which persisted in multivariate analysis. This suggests that RT contributes significantly to the cure rate for advanced HL, although patient selection for combined modality treatment requires better definition in prospective trials.
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Affiliation(s)
- Peter W.M. Johnson
- From the University of Southampton, Medical Research Council (MRC) Clinical Trials Unit, London; Weston Park Hospital, Sheffield; Queen Elizabeth Hospital, Birmingham; The Christie National Health Services Foundation Trust; and The University of Manchester, Manchester, United Kingdom
| | - Matthew R. Sydes
- From the University of Southampton, Medical Research Council (MRC) Clinical Trials Unit, London; Weston Park Hospital, Sheffield; Queen Elizabeth Hospital, Birmingham; The Christie National Health Services Foundation Trust; and The University of Manchester, Manchester, United Kingdom
| | - Barry W. Hancock
- From the University of Southampton, Medical Research Council (MRC) Clinical Trials Unit, London; Weston Park Hospital, Sheffield; Queen Elizabeth Hospital, Birmingham; The Christie National Health Services Foundation Trust; and The University of Manchester, Manchester, United Kingdom
| | - Michael Cullen
- From the University of Southampton, Medical Research Council (MRC) Clinical Trials Unit, London; Weston Park Hospital, Sheffield; Queen Elizabeth Hospital, Birmingham; The Christie National Health Services Foundation Trust; and The University of Manchester, Manchester, United Kingdom
| | - John A. Radford
- From the University of Southampton, Medical Research Council (MRC) Clinical Trials Unit, London; Weston Park Hospital, Sheffield; Queen Elizabeth Hospital, Birmingham; The Christie National Health Services Foundation Trust; and The University of Manchester, Manchester, United Kingdom
| | - Sally P. Stenning
- From the University of Southampton, Medical Research Council (MRC) Clinical Trials Unit, London; Weston Park Hospital, Sheffield; Queen Elizabeth Hospital, Birmingham; The Christie National Health Services Foundation Trust; and The University of Manchester, Manchester, United Kingdom
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Price JM, Hancock BW, Tidy J, Everard J, Coleman RE. Screening for central nervous system disease in metastatic gestational trophoblastic neoplasia. J Reprod Med 2010; 55:301-304. [PMID: 20795342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To evaluate the Sheffield Trophoblastic Tumour Centre protocol for central nervous system (CNS) involvement in high-risk patients with gestational trophoblastic neoplasia (GTN) and determine the impact of brain imaging and lumbar puncture (LP) results on subsequent clinical care. STUDY DESIGN The trophoblastic tumor database was searched for patients fitting any of the following criteria registered between January 1, 1988, and December 31, 2008: hCG levels > 50,000 IU/L, high risk, > or = 2 for metastases. Placental site trophoblastic tumors (PSTTs) were excluded, and all patients with signs or symptoms suggestive of CNS involvement were investigated. Patients were to have computed tomography (CT) scan of the head and, if not contraindicated, LP to determine the ratio of cerebrospinal fluid to blood hCG level. RESULTS A total of 154 patients met > or = 1 of the defined criteria for CNS investigation. In 7 patients there was evidence of CNS involvement on CT. Only 2 cases had no clinical evidence of CNS disease-both had very-high-risk choriocarcinoma. No diagnosis of CNS disease was made on LP alone. CONCLUSION We propose that in the absence of neurologic symptoms or signs, only patients with choriocarcinoma need be screened. Magnetic resonance imaging head scan is preferred as the most sensitive and safe technology available.
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Affiliation(s)
- James Michael Price
- Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, United Kingdom
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Macdonald MC, Ram R, Tidy JA, Hancock BW. Choriocarcinoma after a nonterm pregnancy. J Reprod Med 2010; 55:213-218. [PMID: 20626177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To evaluate the characteristics and outcomes of patients with choriocarcinoma following a nonterm pregnancy and compare them to the results from the same unit of patients with choriocarcinoma following a term delivery. STUDY DESIGN A retrospective case review of all patients with choriocarcinoma after a nonterm pregnancy referred to the Trophoblastic Screening and Treatment Centre, Sheffield, between 1976 and 2008. RESULTS Sixty-four patients were referred after a nonterm pregnancy. Time to diagnosis was longer in the nonterm pregnancy patients compared to patients referred following a term pregnancy. Mean human chorionic gonadotrophin (hCG) level, however, was lower in the nonterm pregnancy group: 91,329 IU/L vs. 192,121 IU/L for the term pregnancy group. The number of patients with metastases at presentation was similar in both groups (57% following term pregnancy, 51% following nonterm pregnancy), although more of the nonterm pregnancy patients received methotrexate therapy only: 36% vs. 23%. Survival in both groups was > 90%. CONCLUSION The presence of metastases, excluding pulmonary, had an adverse effect on outcome in both groups and, in accord with published data, that site and number of metastases have more impact on outcome than type of antecedent pregnancy.
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Affiliation(s)
- Madeleine C Macdonald
- Department of Gynaecological Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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Greenfield DM, Walters SJ, Coleman RE, Hancock BW, Snowden JA, Shalet SM, DeRogatis LR, Ross RJM. Quality of life, self-esteem, fatigue, and sexual function in young men after cancer: a controlled cross-sectional study. Cancer 2010; 116:1592-601. [PMID: 20186765 DOI: 10.1002/cncr.24898] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Androgen deficiency is increasingly recognized in young male cancer survivors; however, its impact on quality of life (QOL) is not established. The authors investigated the relationship between androgen levels, QOL, self-esteem, fatigue, and sexual function in young male cancer survivors compared with control subjects. METHODS A cross-sectional, observational study of 176 male cancer survivors and 213 male controls aged 25 to 45 years was performed. Subjects completed 3 QOL scales (Medical Outcomes Study 36-Item Short-Form Health Survey version 2, the 12-item General Health Questionnaire [GHQ-12], and Aging Male Scale), and measures of self-esteem (Rosenberg Self-Esteem Scale), fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue), and sexual function (Derogatis Interview for Sexual Functioning-II Self-Report-Male). RESULTS Cancer survivors had lower scores for all components of the Short-Form Health Survey, Aging Male Scale, and Functional Assessment of Chronic Illness Therapy-Fatigue, and for 4 of 5 subsections of the Derogatis Interview for Sexual Functioning than controls. The majority of these differences remained after adjusting by linear regression analysis. Levels of psychiatric disorder or self-esteem did not differ between the 2 groups. In cancer survivors, those with androgen deficiency (serum testosterone < or = 10 nmol/L) had lower scores than those without for all components of the Short-Form Health Survey, the General Health Questionnaire, Functional Assessment of Chronic Illness Therapy-Fatigue, and the Derogatis Interview for Sexual Functioning. Serum testosterone only weakly correlated with health measures. CONCLUSIONS Young male cancer survivors self-report a marked impairment in QOL, energy levels, and quality of sexual functioning, and this was exacerbated in those with androgen deficiency. However, psychological distress was not elevated, self-esteem was normal, and sexual relationships were not impaired. The relationship with testosterone is complex, and appears dependent on a threshold level rather than direct correlation. Interventional trials are needed to determine whether testosterone replacement would improve QOL in young male cancer survivors.
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Affiliation(s)
- Diana M Greenfield
- Academic Unit of Clinical Oncology, University of Sheffield, Sheffield, United Kingdom
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Alazzam M', Tidy J, Hancock BW, Powers HJ. Gestational Trophoblastic Neoplasia, an Ancient Disease: New Light and Potential Therapeutic Targets. Anticancer Agents Med Chem 2010; 10:176-85. [DOI: 10.2174/187152010790909317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2009] [Accepted: 12/02/2009] [Indexed: 11/22/2022]
Abstract
Gestational trophoblastic neoplasia is a rare malignancy, which can occur after any type of pregnancy. The incidence varies according to the geographical location and ethnic origin. Although most patients with gestational trophoblastic neoplasia are cured by conventional chemotherapy and surgery, some suffer resistant disease and may die. New therapeutic agents are needed to reduce the toxicity associated with conventional chemotherapy and treat those with resistant or refractory disease. Molecular targeted treatment provides an exciting avenue; however, the biology of gestational trophoblastic neoplasia is not well understood. This review briefly summarises recent advances in the understanding of the pathogenesis and molecular biology of this group of diseases and sheds light on molecules that could provide potential therapeutic targets.
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Affiliation(s)
| | | | | | - Hilary J. Powers
- Department of Gynaecologic Oncology, G18, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
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35
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Lim SY, Horsman JM, Hancock BW. The Mantle Cell Lymphoma International Prognostic Index: Does it work in routine practice? Oncol Lett 2010; 1:187-188. [PMID: 22966280 DOI: 10.3892/ol_00000034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 09/28/2009] [Indexed: 12/12/2022] Open
Abstract
The Mantle Cell Lymphoma International Prognostic Index (MIPI) combines four factors to differentiate low-, intermediate- and high-risk prognostic groups in advanced mantle cell lymphoma using data from patients treated in clinical trials. To evaluate its use in routine practice, we applied the simplified index retrospectively to 50 consecutive new patients attending our lymphoma service. In the log-rank and multiple comparison statistical tests there was favorable differentiation between survival curves, and particularly between the high- and low-risk groups. We concluded that the MIPI is of value in routine lymphoma practice.
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Affiliation(s)
- S Y Lim
- Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield S10 2SJ, UK
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Hoskin PJ, Lowry L, Horwich A, Jack A, Mead B, Hancock BW, Smith P, Qian W, Patrick P, Popova B, Pettitt A, Cunningham D, Pettengell R, Sweetenham J, Linch D, Johnson PW. Randomized Comparison of the Stanford V Regimen and ABVD in the Treatment of Advanced Hodgkin's Lymphoma: United Kingdom National Cancer Research Institute Lymphoma Group Study ISRCTN 64141244. J Clin Oncol 2009; 27:5390-6. [DOI: 10.1200/jco.2009.23.3239] [Citation(s) in RCA: 142] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose This multicenter, prospective, randomized controlled trial compared the efficacy and toxicity of two chemotherapy regimens in advanced Hodgkin's lymphoma (HL): the weekly alternating Stanford V and the standard, twice-weekly regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD). Patients and Methods Patients had stage IIB, III, or IV disease or had stages I to IIA disease with bulky disease or other adverse features. Radiotherapy was administered in both arms to sites of previous bulk (> 5 cm) and to splenic deposits, although this was omitted in the latter part of the trial for patients achieving complete remission (CR) in the ABVD arm. A total of 520 patients were randomly assigned and were assessed for the primary outcome measure of progression-free survival (PFS). Five hundred patients received protocol treatment, and radiotherapy was administered to 73% in the Stanford V arm and to 53% in the ABVD arm. Results The overall response rates after completion of all treatment were 91% for Stanford V and 92% for ABVD. During a median follow-up of 4.3 years, there was no evidence of a difference in projected 5-year PFS and overall survival (OS) rates (76% and 90%, respectively, for ABVD; 74% and 92%, respectively, for Stanford V). More pulmonary toxicity was reported for ABVD, whereas other toxicities were more frequent with Stanford V. Conclusion In a large, randomized trial, the efficacies of Stanford V and ABVD were comparable when given in combination with appropriate radiotherapy.
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Affiliation(s)
- Peter J. Hoskin
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Lisa Lowry
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Alan Horwich
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Andrew Jack
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Ben Mead
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Barry W. Hancock
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Paul Smith
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Wendi Qian
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Philippa Patrick
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Bilyana Popova
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Andrew Pettitt
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - David Cunningham
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Ruth Pettengell
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - John Sweetenham
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - David Linch
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
| | - Peter W.M. Johnson
- From the Mount Vernon Cancer Centre, Department of Clinical Oncology; Lymphoma Trials Office, Cancer Research United Kingdom and University College London Cancer Trials Centre; Department of Radiotherapy, Institute of Cancer Research and Royal Marsden Hospital; Medical Research Council Cancer Trials Unit; St George's Hospital Medical School; Royal Marsden Hospital; and University College London Cancer Institute, London; St James' Institute of Oncology, Haematological Malignancy Diagnostic Service, Leeds
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Yung L, Smith P, Hancock BW, Hoskin P, Gilson D, Vernon C, Linch DC. Long Term Outcome in Adolescents with Hodgkin's Lymphoma: Poor Results using Regimens Designed for Adults. Leuk Lymphoma 2009; 45:1579-85. [PMID: 15370209 DOI: 10.1080/1042819042000209404] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
It is unclear whether the outcome in adolescents with Hodgkin's lymphoma is as good as that in children and there are no prospective randomized trials comparing regimes used in children and adults in this setting. We have therefore performed an analysis of 210 adolescent patients diagnosed with Hodgkin's lymphoma between 1970-1997 and registered on the database held by the British National Lymphoma Investigation. Patients were treated according to adult regimens current at the time of their diagnosis. The complete response rate recorded in 209 patients was 76%. This was highly dependent on disease stage being 95% in patients with localized disease but 63% in those with advanced disease. The 5 year event free survival for the whole cohort was 50% falling to 41% at 20 years with overall survival of 81% falling to 68% at 5 and 20 years respectively. There is no significant difference in the 3 decades pertaining to this analysis. Of the 62 deaths in this cohort, 70% were due to Hodgkin's lymphoma but of the 13 deaths occurring beyond 10 years, only 3 were due to Hodgkin's lymphoma, the reminder being attributable to the late effects of therapy. Results from paediatric groups have been much more encouraging than those presented from this cohort. It seems the use of risk-adjusted combined modality therapy with minimization of radiation fields and doses and reduction of anthracycline and alkylator exposure has been successful in children and should be used in adolescents.
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Affiliation(s)
- L Yung
- Royal Free and University College Medical School, London WC1E 6HX
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Owadally WS, Sydes MR, Radford JA, Hancock BW, Cullen MH, Stenning SP, Johnson PWM. Initial dose intensity has limited impact on the outcome of ABVD chemotherapy for advanced Hodgkin lymphoma (HL): data from UKLG LY09 (ISRCTN97144519). Ann Oncol 2009; 21:568-573. [PMID: 19684105 DOI: 10.1093/annonc/mdp331] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This analysis was undertaken to assess the relationship between the dose intensity (DI) of initial chemotherapy and outcome in a large cohort of patients with advanced Hodgkin lymphoma treated in a randomised controlled trial, in which detailed dose data were collected prospectively. PATIENTS AND METHODS Three-hundred and eighty patients randomly assigned to receive standard doxorubicin, bleomycin, vinblastine and dacarbazine who underwent at least two cycles of treatment were studied. With a median follow-up of 6.9 years, progression-free survival (PFS) from the end of cycle 2 was analysed according to DI during those cycles. RESULTS During the first two cycles, 25% of patients received >97% of planned DI, 37% received between 86% and 97% and 38% received <86%. DI during the first two cycles was correlated with DI during the remainder of the course, but there was no evidence that early DI influenced PFS (hazard ratio 0.87, 95% confidence interval 0.67-1.11; P = 0.265). Multivariate analysis also failed to confirm the influence of early DI on PFS or overall survival. CONCLUSIONS At the range of DI delivered in a multicentre trial using conventional therapy, there is no clear evidence that early DI influences outcome. This should be tested in a prospective study.
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Affiliation(s)
- W S Owadally
- Cancer Sciences Division, Cancer Research UK Clinical Centre, Southampton
| | - M R Sydes
- Cancer Division, Medical Research Council Clinical Trials Unit, London
| | - J A Radford
- Department of Medical Oncology, Christie Hospital, Manchester
| | - B W Hancock
- Department of Medical Oncology, Weston Park Hospital, Sheffield
| | - M H Cullen
- Cancer Centre, Birmingham University Hospitals, Birmingham, UK
| | - S P Stenning
- Cancer Division, Medical Research Council Clinical Trials Unit, London
| | - P W M Johnson
- Cancer Sciences Division, Cancer Research UK Clinical Centre, Southampton.
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Absolom K, Eiser C, Michel G, Walters SJ, Hancock BW, Coleman RE, Snowden JA, Greenfield DM. Follow-up care for cancer survivors: views of the younger adult. Br J Cancer 2009; 101:561-7. [PMID: 19638979 PMCID: PMC2736810 DOI: 10.1038/sj.bjc.6605213] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Since the launch of the National Cancer Survivorship Initiative, there has been a surge of interest surrounding the value and organisation of long-term follow-up care after cancer treatment. We report the views of 309 adult cancer survivors (aged 18–45 years) on provision of follow-up and preferences for care. Methods: A total of 207 survivors completed questionnaires before and after routine consultant-led follow-up appointments and 102 were recruited by post. Measures of health status (including late effects, perceived vulnerability to late effects and quality of life), reasons for attending follow-up (clinical and supportive), issues to be discussed at follow-up and preferences for different models of care were assessed. Results: In all, 59% of the survivors reported experiencing one or more cancer-related health problems. Survivors rated clinical reasons for attending follow-up more highly than supportive reasons (P<0.001), although nutritional advice and counselling were considered useful (60 and 47%, respectively). Those still receiving scheduled follow-up appointments did not discuss the range of issues intended with ‘late effects’ and ‘fertility’, which were particularly under-discussed. Hospital rather than GP follow-up was more highly rated. Conclusion: Survivors value the clinical reassurance currently provided by consultant-led care. However, supportive needs are not systematically addressed. Multi-disciplinary services are recommended to meet supportive needs in addition to clinical care.
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Affiliation(s)
- K Absolom
- Department of Psychology, University of Sheffield, Sheffield S10 2SJ, UK
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Abstract
BACKGROUND Rituximab, a chimeric mouse/human monoclonal antibody targeting the pan-B-cell antigenic marker CD20, was the first monoclonal antibody licensed for use in the treatment of cancer. OBJECTIVE This review focuses on the impact of rituximab in the treatment of patients with B-cell non-Hodgkin lymphoma (NHL). METHODS Three key areas related to the use of rituximab in B-cell NHL are discussed: mechanism of action, clinical efficacy in both indolent and aggressive disease, and safety of its use as both monotherapy and in combination with chemotherapy. RESULTS/CONCLUSIONS Rituximab has demonstrated significant clinical efficacy in the treatment of NHL, particularly in combination with chemotherapy, and its use has revolutionized the treatment of both indolent and aggressive B-cell NHL over the past decade. Furthermore, consistent toxicity data have been obtained with a safe and tolerable profile in most patients.
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Affiliation(s)
- Matthew C Winter
- Academic Unit of Clinical Oncology, Cancer Research Centre, Weston Park Hospital, University of Sheffield, UK.
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Boafo-Yirenki M, Everard J, Tidy J, Hancock BW. A conservative approach in persistent low-level elevation of serum beta-human chorionic gonadotropin following chemotherapy for gestational trophoblastic neoplasia. J Reprod Med 2009; 54:288-290. [PMID: 19517692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To question whether patients with persistent low-level elevation of beta-human chorionic gonadotropin (beta-hCG) following chemotherapy for gestational trophoblastic neoplasia can be managed conservatively. STUDY DESIGN A retrospective study of all patients requiring chemotherapy for gestational trophoblastic neoplasia (GTN), treated in Sheffield from 1994 to 2007, evaluating those for whom a clinical decision was made to stop chemotherapy when the serum beta-hCG level remained elevated. RESULTS Of the 350 patients requiring chemotherapy, 17 had persistently elevated beta-hCG at the time chemotherapy was stopped. The range of elevation was 4-43 IU/L (mean, 7.5) and duration 3-32 weeks (mean, 10.7). In 16 patients, beta-hCG became undetectable and further treatment was not required; in only 1 patient did the level suddenly become elevated (from 12 to 77 IU/L after 3 months), requiring further and curative chemotherapy. CONCLUSION These results suggest that a conservative but watchful approach can be taken for persistent low-level elevation (up to 40 IU/L) of serum beta-hCG following chemotherapy.
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Affiliation(s)
- Melanie Boafo-Yirenki
- Sheffield Trophoblast Centre, Weston Park Hospital, Whitham Road, Sheffield, United Kingdom
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Abstract
Pixantrone (BBR2778) is a novel anthracycline derivative, manufactured by Cell Therapeutics Incorporated, WA, USA. In both preclinical and clinical studies pixantrone exhibited a significantly lower cardiac toxicity and better activity than that observed with alternative anthracyclines, as it is devoid of the putative cardiac toxicity generating 5,8-dihydroxy groups. With single-agent pixantrone, neutropenia was the dose-limiting toxicity. In relapsed aggressive non-Hodgkin lymphomas, weekly single-agent pixantrone 85 mg/m2 for 3 weeks every 4 weeks was associated with a 27% overall response rate and a 15% complete response rate. When used in combination with chemotherapy regimens overall response rates of 58–74% and complete response rates of 37–57% were achieved.
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Affiliation(s)
- Loaie M El-Helw
- Staff Grade in Medical Oncology, Cancer Research Centre, Weston Park Hospital, Sheffield S10 2SJ, UK
| | - Barry W Hancock
- Professor of Medical Oncology, YCR Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield S10 2SJ, UK
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Abstract
BACKGROUND Gestational trophoblastic neoplasia (GTN) is a rare but curable disease. The incidence in Europe and North America is nearly 1.5 per 1000 live births but much higher rates are reported from Africa and Asia. The majority of the patients respond to evacuation of the uterus plus or minus chemotherapy, however, occasional patients will die. Patients are categorised into low or high risk groups using a variety of scoring systems. A large number of regimens are used worldwide in the management of low risk GTN; there are reports of 14 different regimens in the English literature. The choice of the regimen is usually dependent on geographic location, prior training and current experience with the specific regimen. Regimens have significant differences in the route of administration, hospitalisation and side effects and so have a bearing on healthcare cost. Patients are therefore exposed to different regimens with the potential for different response rates and different side effect profiles. OBJECTIVES To determine the efficacy and safety of first line chemotherapy in the treatment of low risk GTN. SEARCH STRATEGY We electronically searched Cochrane Gynaecological Cancer Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3 2008), MEDLINE and EMBASE in September 2008. We performed additional searching of online trial registers and conference proceedings. We cross examined article references to identify relevant papers not detected by the electronic search. SELECTION CRITERIA The review included randomised controlled trials (RCTs) , quasi-RCTs and non-RCTs (cohort and case control studies (CCS)) for the treatment of low risk GTN. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion in the review using a data extraction form. Meta-analysis was performed by pooling the relative risk (RR) of individual trials. MAIN RESULTS Eight studies met the review entry criteria (n = 769). There were four RCTs and four CCS. Six different treatment regimens were identified; weekly methotrexate, 5-day methotrexate, 8-day methotrexate-folinic acid, "pulsed" dactinomycin, 5-day dactinomycin and the combination of methotrexate and dactinomycin. "Pulsed" dactinomycin was superior to weekly methotrexate in achieving primary cure without significantly increasing toxicity (three studies, RR 3.00, 95% CI 1.10 to 8.17, n = 392) . Eight-day methotrexate-folinic acid did not show significant advantage over 5-day methotrexate both in reducing toxicity or primary cure rate (two studies, RR 1.07, 95% CI 0.91 to 1.25, n = 169). The combination of methotrexate-dactinomycin resulted in significantly increased toxicity without significantly improving primary cure rate. AUTHORS' CONCLUSIONS Based on the available evidence from the included RCTs, the authors conclude that "pulsed" dactinomycin is superior to weekly parenteral methotrexate at the reported dosages. However, the authors believe that rigorously designed, multicentred, randomised double-blind trials are required to evaluate other combinations of chemotherapy regimens, most importantly "pulsed" dactinomycin with the widely used 8-day methotrexate-folinic acid.
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Affiliation(s)
- Mo'iad Alazzam
- Obstetrics & Gynaecology, Sheffield Teaching Hospitals Foundation NHS Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK, S10 2JF.
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Darby S, Jolley I, Pennington S, Hancock BW. Does chest CT matter in the staging of GTN? Gynecol Oncol 2009; 112:155-60. [DOI: 10.1016/j.ygyno.2008.10.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 10/02/2008] [Accepted: 10/07/2008] [Indexed: 01/28/2023]
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Hancock BW, Qian W, Linch D, Delchier JC, Smith P, Jakupovic I, Burton C, Souhami R, Wotherspoon A, Copie-Bergman C, Capella C, Traulle C, Levy M, Cortelazzo S, Ferreri AJM, Ambrosetti A, Pinotti G, Martinelli G, Vitolo U, Cavalli F, Gisselbrecht C, Zucca E. Chlorambucil versus observation after anti-Helicobacter therapy in gastric MALT lymphomas: results of the international randomised LY03 trial. Br J Haematol 2008; 144:367-75. [PMID: 19036078 PMCID: PMC2659366 DOI: 10.1111/j.1365-2141.2008.07486.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Gastric mucosa-associated lymphoid tissue (MALT) lymphomas are uncommon tumours characterised by a tendency to remain localised for long periods. The aetiological association between MALT lymphomas and Helicobacter pylori is well established. The role of additional chemotherapy after H. pylori eradication in localised MALT lymphomas is unclear. The LY03 trial was designed to establish whether chlorambucil after treatment for H. pylori would help prevent recurrence. Patients were treated with antibiotics for H. pylori infection. Those with successful eradication of H. pylori and no evidence of progression of lymphoma were eligible for randomisation to chlorambucil or observation. Two hundred and thirty-one patients were registered. Ninety-seven percent patients had H. pylori eradicated after antibiotics and 59% achieved macroscopically normal gastric mucosa. One hundred and ten patients were randomised. With a median follow-up of 58 months, six patients were dead and 17 had recurrent/progressive disease. The recurrence/progression rates at 5 years were 11% for chlorambucil, and 21% for observation with a difference of 10%, 95% confidence interval (CI) = −9% to 29%, P = 0·15. No difference was detected in recurrence/progression-free survival [Hazard Ratio (HR) = 0·96, 95% CI = 0·41–2·2, P = 0·91] or overall survival (HR = 1·93, 95% CI = 0·39–9·58, P = 0·42). This is the first randomised trial to show there is no good evidence to support that additional single agent chemotherapy to anti-H. pylori treatment contributes to prevent recurrence in localised gastric MALT lymphomas.
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Affiliation(s)
- Barry W Hancock
- Department of Oncology, Weston Park Hospital, Sheffield (UKLG), UK
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Morley NJ, Evans LS, Goepel J, Hancock BW. Transformed follicular lymphoma: the 25-year experience of a UK provincial lymphoma treatment centre. Oncol Rep 2008; 20:953-6. [PMID: 18813839 DOI: 10.3892/or_00000095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Follicular lymphoma can transform into diffuse large B cell lymphoma, which is usually associated with rapid disease progression, refractoriness to treatment and a poor outcome. We report the 25-year unselected experience of a UK provincial lymphoma treatment centre. This comprises of one of the largest series ever studied. Sixty-three patients were identified (56 initially presented as follicular lymphoma, 5 with 'transformed' lymphoma and 2 with follicular and transformed lymphoma from different biopsy sites). The median age at presentation was 54 years (range 32-76). The median time to transformation was 43 months (range 0-172). For all patients, the median overall survival was 76 months (range 8-254) and from transformation 10 months (range 1-166); 46 of 63 patients have died. For those whose transformation was initially treated with CHOP chemotherapy 10 were in complete remission (CR) and 14 were deceased (median survival 24, range 2-114 months). Five patients had high-dose chemotherapy and 3 were alive (at 25, 36 and 137 months). We conclude that CHOP chemotherapy (probably with rituximab) is a reasonable first treatment in fit patients and high dose chemotherapy with autologous stem cell support deserves further study.
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Affiliation(s)
- N J Morley
- YCR Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK
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Affiliation(s)
- B W Hancock
- Cancer Research Centre, Weston Park Hospital, Whitham Road, Sheffield S10 2SJ, UK.
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Okines AFC, Morris R, Hancock BW. An evaluation of FIGO 2000: the first 5 years. J Reprod Med 2008; 53:615-622. [PMID: 18773627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To evaluate the International Federation of Gynecology and Obstetrics 2000 Gestational Trophoblastic Neoplasia (GTN) staging and classification system and to identify any factors predictive of failure of first-line chemotherapy. STUDY DESIGN Patients registered at 1 center between January 2000 and December 2004 (n = 2,209) were identified from a dedicated database. Data were collected on all patients who received treatment for GTN at the center (n = 132). Survival analysis (Kaplan Meier method) and chi2 tests were performed. RESULTS One hundred twenty-two eligible patients were identified. Of those, 38 of 107 (35.5%) of patients who scored as low risk and 2 of 15 (13.3%) of patients who scored as high risk required salvage chemotherapy. Three of 107 (2.8%) of low-risk patients and 3 of 15 (20%) of high-risk patients had salvage surgery. No statistically significant predictive factors for treatment failure were identified. There was a trend toward association with increased age at diagnosis: 48.8% of patients aged > or = 30 required second-line therapy compared to 33.3% aged < 30 (p = 0.098). CONCLUSION Approximately one third of women treated on the low-risk regimen will require salvage chemotherapy, but this does not affect their survival. Women aged > or = 30 may be at particular risk of treatment failure so could be offered high-risk chemotherapy from the outset.
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Affiliation(s)
- Alicia F C Okines
- Department of Medicine, The Royal Marsden Hospital, Sutton, Surrey, UK
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Palmer JE, Hancock BW, Tidy JA. Influence of age as a factor in the outcome of gestational trophoblastic neoplasia. J Reprod Med 2008; 53:565-574. [PMID: 18773619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To question whether older patients have a worse prognosis or poorer outcomes with chemotherapeutic regimens. STUDY DESIGN All gestational trophoblastic disease (GTD) cases registered between January 1986 and September 2006 (n = 8,536) were reviewed and stratified for age. Chi2 analysis was used to ascertain whether significant differences existed with regard to patient age and histologic diagnosis or treatment requirement. Logistic regression analysis was used to predict chemotherapeutic outcomes in patients > 40 years age (n = 50). RESULTS An increased relative risk of high-risk pathology and need for treatment in the > 40 years age-group was found. Modification of the World Health Organization risk by removing the age score or altering the age score was significant on univariate analysis but did not actually improve the predictive ability with regard to patient treatment outcomes either with first-line or overall therapy. CONCLUSION Patient age may not be a risk factor for gestational trophoblastic neoplasia. With birth rates in women > 40 years and maternal age at first pregnancy significantly increasing in the United Kingdom, it is important to improve our understanding of the relationship between GTN and maternal age.
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Affiliation(s)
- Julia E Palmer
- Department of Gynecological Oncology, Sheffield Teaching Hospitals NHS Trust, and Sheffield Trophoblastic Disease Centre, Sheffield, UK.
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Palmer JE, Macdonald M, Wells M, Hancock BW, Tidy JA. Epithelioid trophoblastic tumor: a review of the literature. J Reprod Med 2008; 53:465-475. [PMID: 18720920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To identify common characteristics and provide suggestions for future reporting and management of epithelioid trophoblastic tumors (ETTs). STUDY DESIGN Definitions and treatment strategies are unclear because of low incidence and paucity of reported data. Literature search revealed 52 cases of ETT; 67% presented with abnormal vaginal bleeding, 36% had prior evidence of molar pregnancy and 35% presented with metastases. Mean age at diagnosis was 38 years. Mean pregnancy interval was 76 months. Human chorionic gonadotropin levels were 12-148,460 IU/L. RESULTS Histologic and immunohistochemical reporting varied markedly between centers, as did treatment regimens. A total of 13% were reported as dead from disease, though duration of follow-up was variable (range, 1-39 months). Differentiation of prognostic factors in ETT is problematic. Most reported cases lack long-term follow-up, and disease recurrence in ETT can be late and complex. Distinguishing ETT from other diagnoses may lead to underreporting, with an adverse prognosis associated with diagnostic delay. CONCLUSION Case reporting should contain detailed information on clinicopathologic, histologic and immunohistochemical characteristics and treatment. Data centralization in these rare tumors may be beneficial in identifying relevant prognostic parameters.
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Affiliation(s)
- Julia E Palmer
- Department of Gynecological Oncology, Sheffield Teaching Hospitals NHS Trust, and Sheffield Trophoblastic Disease Centre, Sheffield, UK.
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