Gestational trophoblastic neoplasia management: an update

Gestational trophoblastic neoplasia: an update

Gestational trophoblastic neoplasia (GTN) includes invasive mole, choriocarcinoma, and placental site trophoblastic tumors. The overall cure rate in treating these tumors currently exceeds 90%. Thorough evaluation and staging allow selection of appropriate therapy that maximizes chances for cure while minimizing toxicity. Nonmetastatic (stage I) and low-risk metastatic (stages II and III, World Health Organization score < 7) GTN can be treated with single-agent chemotherapy, resulting in a survival rate approaching 100%. High-risk metastatic GTN (stage IV, WHO score > or = 7) requires initial multiagent chemotherapy with or without adjuvant radiation and surgery to achieve a survival rate of 80% to 90%.

Major clinical research advances in gynecologic cancer 2008

In this review, we summarized 14 major clinical advances in gynecology which occurred in 2008. For cervical cancer, clinical impact of HPV vaccine, prognostic value of imaging during radiotherapy, and oncologic/obstetric outcomes of fertility-sparing surgery were chosen. For uterine cancer, optimal method of adjuvant radiotherapy in intermediate-risk patients, extent of lymph node dissection, outcome of robot-assisted staging surgery, new standard chemotherapy regimen for leiomyosarcoma were selected. For ovarian cancer, recent changes in adjuvant therapy, feasibility of neoadjuvant chemotherapy, prediction of optimal secondary cytoreduction, studies on new biomarkers, advances in screening and treatment of women with BRCA mutations were included. For other cancers, the safety of sentinel lymph node dissection in vulvar cancer and chemotherapy regimens for low-risk gestational trophoblastic tumors were reviewed.

Why does cytotoxic chemotherapy cure only some cancers?

Despite frequent responses to chemotherapy, curative treatment remains elusive for the majority of patients with metastatic solid tumors. By contrast, in testicular cancer, gestational choriocarcinoma, Hodgkin disease and high-grade lymphomas, chemotherapy is routinely curative, even for patients who present with widely disseminated disease. In the common advanced cancers, however, over 40 years of cytotoxic drug development has brought no significant change in cure rates. One interpretation is that the intrinsic properties of the malignancies themselves, rather than the qualities of individual drugs or combination therapies, are primarily responsible for their curability with chemotherapy. We suggest that the curability of these malignancies results from an intrinsic 'locked-in' state of sensitivity to proapoptotic stresses in these cells. A common property of such curable malignancies is that they arise from cells that undergo major genetic rearrangements or recombination as part of their normal physiology. The absence of further genetic and epigenetic changes in genes that regulate apoptosis, DNA repair and senescence allows these cells to maintain their intrinsic sensitivity to chemotherapy. This process allows the cells, when challenged with chemotherapy, to undergo the natural apoptotic pathways that contribute to their intrinsic qualities of chemosensitivity and high curability.