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Sato A, Usui H, Nakamura N, Katayama E, Shozu M, Koga K. Removal of an Intrauterine Polypoid Lesion Resolved Chemotherapy-resistant Gestational Trophoblastic Neoplasia: A Case Report. CANCER DIAGNOSIS & PROGNOSIS 2024; 4:193-197. [PMID: 38434909 PMCID: PMC10905286 DOI: 10.21873/cdp.10307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 01/12/2024] [Indexed: 03/05/2024]
Abstract
Background/Aim Single-agent chemotherapy typically has curative outcomes in patients with low-risk gestational trophoblastic neoplasia (GTN). Although surgical intervention is a potential alternative, its efficacy in these patients remains unclear. This report describes a case in which surgical excision of a uterine polypoid lesion resolved chemotherapy-resistant low-risk GTN. Case Report A 43-year-old patient received pulse actinomycin D treatment for post-molar low-risk GTN without extrauterine metastasis. However, the patient showed resistance to the chemotherapy regimen. There was no initial evidence of protrusion of GTN into the uterine cavity; however, a polypoid lesion grew into the uterine cavity during therapy. This growth was successfully excised via a transvaginal approach using forceps with minimal blood loss. There was a postoperative decrease in human chorionic gonadotropin levels, which ultimately reached the predetermined threshold without the need for changing the therapeutic protocol. Conclusion Surgical resection should be considered a viable therapeutic strategy for uterine polypoid growth in chemotherapy-resistant low-risk GTN.
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Affiliation(s)
- Asuka Sato
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Hirokazu Usui
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Natsuko Nakamura
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Eri Katayama
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
| | - Makio Shozu
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Evolution and Reproductive Medicine, Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, Chiba University Hospital, Chiba University, Chiba, Japan
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
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Zhou F, Kemin L. First-line monodrug chemotherapy in low-risk gestational trophoblastic neoplasia: a network meta-analysis. Front Oncol 2024; 13:1276771. [PMID: 38250546 PMCID: PMC10796812 DOI: 10.3389/fonc.2023.1276771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Objective The efficacy of the first-line monodrug chemotherapy has been generally established for low-risk GTN. Most patients can achieve a complete response after the first-line monodrug chemotherapy. However, which monodrug chemotherapy regimen is better for individual patients with GTN is not yet certain. This study aimed to assess the efficacy of first-line monodrug chemotherapy in low-risk gestational trophoblastic neoplasia (GTN). Method Databases, including PubMed, Embase, Web of Science, and Cochrane Library, were searched from inception to November 1, 2022, for case-control studies on first-line monodrug chemotherapy in GTN. Network meta-analysis was performed to compare the efficacy outcome of six monodrug chemotherapy regimens in GTN, with a complete response rate as the endpoint. Result Twenty-four studies were considered eligible, including 9 randomized controlled trials (RCTs) and 15 non-RCTs. A total of 3344 patients with low-risk GTN were involved. Six monodrug chemotherapy regimens were included and analyzed. In descending order of efficacy, these six regimens were VP-16 (5 days), ACT-D (5 days), MTX (5 days), ACT-D (1.25 mg/m2), MTX (8 days), and MTX (30-50 mg/m2) in all study, and five regimens were ACT-D (5 days), MTX (5 days), ACT-D (1.25 mg/m2), MTX (8 days), and MTX (30-50 mg/m2) in RCT. Conclusion Among the six first-line monodrug chemotherapy regimens for low-risk GTN in all study, VP-16 (5 days) was the best in terms of efficacy. And five regimens in RCT, ACT-D was the best. However, the finding needs to be validated through more high-quality clinical studies.
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Affiliation(s)
- Fang Zhou
- West China University Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Li Kemin
- The Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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Piątek S, Szczęsny N, Szymusik I, Karoń K, Piątkowski K, Bornio E, Bidziński M, Gujski M. Fertility-Sparing Treatment in Gestational Choriocarcinoma: Evaluating Oncological and Obstetrical Outcomes in Young Patients. Med Sci Monit 2023; 29:e942078. [PMID: 37957930 PMCID: PMC10656781 DOI: 10.12659/msm.942078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/05/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Gestational choriocarcinoma (GC) is an uncommon neoplasia that occurs in women who may not have completed a procreation plan. The aim of this study was to evaluate oncological and obstetrical outcomes in young patients with GC after fertility-sparing treatment. MATERIAL AND METHODS The eligibility criteria for the study were histopathological diagnosis of GC, age ≤40 years, and treatment with systemic chemotherapy. Patients who underwent upfront hysterectomy were excluded. The response to treatment was assessed according to beta-human chorionic gonadotropin (beta-hCG) serum measurement. Complete response and progression were considered if the beta-hCG dropped to a normal range and increased (or reached a plateau), respectively. The birth rate was calculated as the number of women who gave birth after treatment divided by the total number of patients. RESULTS A total of 18 patients fulfilled the study's eligibility criteria. A complete response and progression to first-line chemotherapy were found in 13 (72.22%) and 5 (27.78%) patients, respectively. Salvage treatment was administered to patients with progression. Overall, 16 (88.88%) patients achieved complete response after treatment and 2 (11.12%) died. GC relapse was diagnosed in 1 patient 62 months after treatment. The birth rate was 22.22%, and a total of 6 children were born. All pregnancies ended in term delivery. No congenital abnormalities were detected in the newborns. CONCLUSIONS GC is a life-threatening form of gestational trophoblastic neoplasia, mainly due to its rapid course and resistance to chemotherapy. Most patients with GC will not be able to bear children after treatment.
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Affiliation(s)
- Szymon Piątek
- Department of Gynecologic Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Natalia Szczęsny
- Faculty of Medical Sciences and Health Sciences, Kazimierz Pułaski University of Technology and Humanities, Radom, Poland
| | - Iwona Szymusik
- Department of Obstetrics, Perinatology and Neonatology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Karolina Karoń
- Faculty of Medical Sciences and Health Sciences, Kazimierz Pułaski University of Technology and Humanities, Radom, Poland
| | - Krzysztof Piątkowski
- Faculty of Medical Sciences and Health Sciences, Kazimierz Pułaski University of Technology and Humanities, Radom, Poland
| | - Ewelina Bornio
- Faculty of Medical Sciences and Health Sciences, Kazimierz Pułaski University of Technology and Humanities, Radom, Poland
| | - Mariusz Bidziński
- Department of Gynecologic Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Mariusz Gujski
- Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
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Mitric C, Yang K, Bhat G, Lheureux S, Laframboise S, Li X, Bouchard-Fortier G. Gestational trophoblastic neoplasia: does centralization of care impact clinical management? Int J Gynecol Cancer 2023; 33:1724-1732. [PMID: 37723102 DOI: 10.1136/ijgc-2023-004526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
OBJECTIVE International societies advocate for gestational trophoblastic neoplasia referral to designated expert centers. This study assessed the impact of centralization of trophoblastic care on clinical outcomes. METHODS A centralized program was implemented in 2018 at two affiliated academic hospitals, Princess Margaret Cancer Center and Mount Sinai Hospital. A retrospective analysis of patients treated between 2000 and 2022 was performed and the clinical outcomes were compared before (2000-2017) and after (2018-2022) centralization. Statistical analyses were performed with significance set as p<0.05. RESULTS A total of 94 patients with trophoblastic neoplasia were included: 60 pre-centralization and 34 post-centralization, 79.8% low-risk and 18.1% high-risk. Centralization led to significant improvement for: (1) accurate score documentation (from 37.9% to 89.3%,); (2) contraception counseling (from 67.2% to 96.7%); (3) median time from diagnosis to chemotherapy (from 9 days to 1 day); and (4) incomplete follow-up (from 20.7% to 3.3%) (all p<0.05). First-line chemotherapy for low-risk neoplasia was dactinomycin in 47.9% and 87.0% pre- and post-centralization, respectively (p=0.005). The median number of chemotherapy cycles decreased from seven to four (p=0.01), and the median number of consolidation cycles increased from two to three (p<0.001). Serum human chorionic gonadotropin (hCG) levels of 10 000-100 000 IU/L were significantly associated with longer time to hCG normalization and higher risk of resistance to first-line chemotherapy compared with hCG levels <1000 IU/L. CONCLUSION Centralization of trophoblastic neoplasia care leads to greater guideline compliance, faster chemotherapy initiation, fewer chemotherapy cycles with optimized consolidation, and enhanced surveillance completion. This supports the establishment of trophoblastic neoplasia expert centers.
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Affiliation(s)
- Cristina Mitric
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Kelsey Yang
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Gita Bhat
- Medical Oncology, Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Stephanie Lheureux
- Medical Oncology, Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Stephane Laframboise
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Xuan Li
- Department of Biostatistics, Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
| | - Geneviève Bouchard-Fortier
- Sinai Health, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre/ University Health Network, Toronto, Ontario, Canada
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Wang L, Wang Q, Xu Z, Yang L, Wang W. The efficacy and safety of 5-fluorouracil/cisplatin/vincristine as a multi-agent chemotherapy regimen in gestational trophoblastic neoplasia. Front Oncol 2023; 13:1240972. [PMID: 38023226 PMCID: PMC10644366 DOI: 10.3389/fonc.2023.1240972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To determine the efficacy and safety of the 5-fluorouracil (5-FU), cisplatin, and vincristine (FPV) chemotherapy regimen in patients with gestational trophoblastic neoplasia (GTN). Methods We performed a retrospective study of 96 GTN patients with International Federation of Gynecology and Obstetrics (FIGO) scores of 5 or greater in the Second Affiliated Hospital of Zhengzhou University from October 2013 to October 2019, including 54 patients who received FPV chemotherapy and 42 who received 5-FU/actinomycin D/vincristine (FAV) chemotherapy. A pulsed intravenous device was used to administer 5-FU. The clinical characteristics, adverse events, and response rates were compared between the groups. Results The patients in the FPV and FAV groups received a total of 228 and 190 courses of chemotherapy, respectively. Complete response (CR) was found in 88.89% (48/54) and 90.48% (38/42) of patients in the FPV group and FAV group, respectively (p = 0.801). Both chemotherapy regimens yielded CR in all low-risk patients (100% vs. 100%), whereas 86.67% and 88.24% of high-risk patients achieved CR (FPV vs. FAV, p = 0.836), respectively. The most common adverse events (AEs) were myelosuppression and gastrointestinal reactions including neutropenia (83.97%), anemia (60.05%), and nausea (46.41%). In comparison to those in the FAV group, patients in the FPV group reported higher rates of grade 1/2 nausea (53.51% vs. 37.89%, p = 0.001), hepatotoxicity (28.95% vs. 17.89%, p = 0.008), oral mucositis (23.25% vs. 10.53%, p = 0.001), and grade 3/4 neutropenia (47.37% vs. 27.37%, p < 0.001), while grade 1/2 diarrhea (7.46% vs. 13.68%, p = 0.037) and grade 3/4 oral mucositis (0 vs. 6.32%, p < 0.001) were much more common in the FAV group. The rate of overall survival at 5 years was 96.8% in the FPV group and 97.3% in the FAV group (p = 0.760), whereas the 5-year disease-free survival rates were 95.9% and 93.9% (p = 0.754), respectively. Conclusion The FPV and FAV regimens with pulsed intravenous 5-FU yielded comparable CR rates and tolerability in patients with GTN with FIGO scores of >5. Further randomized controlled trials are warranted to validate their efficacy.
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Affiliation(s)
- Lu Wang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Clinical Research Center for Gynecological and Obstetrical Disease (Gynecological Oncology), Zhengzhou, China
| | - Qian Wang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Clinical Research Center for Gynecological and Obstetrical Disease (Gynecological Oncology), Zhengzhou, China
| | - Zhen Xu
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Clinical Research Center for Gynecological and Obstetrical Disease (Gynecological Oncology), Zhengzhou, China
| | - Linli Yang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Clinical Research Center for Gynecological and Obstetrical Disease (Gynecological Oncology), Zhengzhou, China
| | - Wuliang Wang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Provincial Clinical Research Center for Gynecological and Obstetrical Disease (Gynecological Oncology), Zhengzhou, China
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Bogani G, Ray-Coquard I, Mutch D, Vergote I, Ramirez PT, Prat J, Concin N, Ngoi NYL, Coleman RL, Enomoto T, Takehara K, Denys H, Lorusso D, Takano M, Sagae S, Wimberger P, Segev Y, Kim SI, Kim JW, Herrera F, Mariani A, Brooks RA, Tan D, Paolini B, Chiappa V, Longo M, Raspagliesi F, Benedetti Panici P, Di Donato V, Caruso G, Colombo N, Pignata S, Zannoni G, Scambia G, Monk BJ. Gestational choriocarcinoma. Int J Gynecol Cancer 2023; 33:1504-1514. [PMID: 37758451 DOI: 10.1136/ijgc-2023-004704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Gestational choriocarcinoma accounts for 5% of gestational trophoblastic neoplasms. Approximately 50%, 25%, and 25% of gestational choriocarcinoma occur after molar pregnancies, term pregnancies, and other gestational events, respectively. The FIGO scoring system categorizes patients into low (score 0 to 6) and high risk (score 7 or more) choriocarcinoma. Single-agent and multi-agent chemotherapy are used in low- and high-risk patients, respectively. Chemotherapy for localized disease has a goal of eradication of disease without surgery and is associated with favorable prognosis and fertility preservation. Most patients with gestational choriocarcinoma are cured with chemotherapy; however, some (<5.0%) will die as a result of multi-drug resistance, underscoring the need for novel approaches in this group of patients. Although there are limited data due to its rarity, the treatment response with immunotherapy is high, ranging between 50-70%. Novel combinations of immune checkpoint inhibitors with targeted therapies (including VEGFR-2 inhibitors) are under evaluation. PD-L1 inhibitors are considered a potential important opportunity for chemo-resistant patients, and to replace or de-escalate chemotherapy to avoid or minimize chemotherapy toxicity. In this review, the Rare Tumor Working Group and the European Organization for Research and Treatment of Cancer evaluated the current landscape and further perspective in the management of patients diagnosed with gestational choriocarcinoma.
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Affiliation(s)
- Giorgio Bogani
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Isabelle Ray-Coquard
- Centre Leon Berard, LYON CEDEX 08, France
- Hesper lab, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - David Mutch
- Washington University in Saint Louis, St Louis, Missouri, USA
| | - Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium
| | - Pedro T Ramirez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas, USA
| | - Jaime Prat
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Nicole Concin
- Department of Gynecology and Obstetrics; Innsbruck Medical Univeristy, Innsbruck, Austria
| | | | | | - Takayuki Enomoto
- Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Belgium
| | - Kazuhiro Takehara
- Department of Gynecologic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | | | | | - Masashi Takano
- Department of Obstetrics and Gynecology, National Defense Medical College, Tokorozawa, Japan
| | - Satoru Sagae
- Gynecologic Oncology, Tokeidai Kinen Byoin, Sapporo, Japan
| | - Pauline Wimberger
- Gyncology and Obstetrics, Technische Universitat Dresden Medizinische Fakultat Carl Gustav Carus, Dresden, Germany
| | - Yakir Segev
- Obstetrics and Gynecology, Carmel Hospital, Haifa, Israel
| | - Se Ik Kim
- Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Jae-Weon Kim
- Obstetrics and gynecology, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Fernanda Herrera
- Centre Hospitalier Universitaire Vaudois Departement doncologie CHUV-UNIL, Lausanne, Switzerland
| | - Andrea Mariani
- Gynecologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Rebecca A Brooks
- Section of Gynecologic Oncology, University of Chicago Medicine, Chicago, Illinois, USA
| | - David Tan
- National University Cancer Institute, Singapore
| | - Biagio Paolini
- Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italy
| | - Valentina Chiappa
- Department of Gynecologic Oncology, IRCCS National Cancer Institute, Milan, Italy
| | | | | | | | | | | | - Nicoletta Colombo
- Medical Gynecologic Oncology Unit; University of Milan Bicocca; Milan; Italy, European Institute of Oncology, Milano, Italy
| | - Sandro Pignata
- Gynaecological Oncology, National Cancer Institute Napels, Naples, Italy
| | - Gianfranco Zannoni
- Dipartimento Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Bradley J Monk
- Virginia G Piper Cancer Center - Biltmore Cancer Center, Phoenix, Arizona, USA
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Jiang F, Mao MY, Xiang Y, Lu X, Guan CL, Jiao LZ, Wan XR, Feng FZ, Ren T, Yang JJ, Zhao J. Comparing biweekly single-dose actinomycin D with multiday methotrexate therapy for low-risk gestational trophoblastic neoplasia (FIGO Score 0-4): study protocol for a prospective, multicentre, randomized trial. BMC Cancer 2023; 23:784. [PMID: 37612621 PMCID: PMC10464396 DOI: 10.1186/s12885-023-11225-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 07/25/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Single-agent chemotherapy using methotrexate or actinomycin D is the first-line treatment for patients with low-risk gestational trophoblastic neoplasia. Various methotrexate-based and actinomycin D-based single-agent regimens can be used. However, there is insufficient evidence to determine the superior regimen. To guide doctors in selecting a single-agent chemotherapy regimen for patients with low-risk gestational trophoblastic neoplasia, we will compare two regimens. METHODS We will conduct a multicentre, randomized, prospective clinical trial. Selected low-risk gestational trophoblastic neoplasia patients (FIGO score 0-4) will be randomized 1:1 to a biweekly single-dose actinomycin D group or a multiday methotrexate therapy group. The actinomycin D group will receive IV pulse actinomycin D (1.25 mg/m2) every 14 days, and the methotrexate group will receive methotrexate (50 mg) intramuscularly on days 1, 3, 5, and 7 (4 doses per cycle) and leucovorin (15 mg) intramuscularly on days 2, 4, 6, and 8. This process will be repeated every 14 days. The primary endpoints will include the complete remission rate by single-agent therapy and the overall complete remission rate. The secondary endpoints will include the duration needed to achieve complete remission after single-agent chemotherapy, number of courses needed to achieve complete remission after single-agent chemotherapy, incidence and severity of adverse effects, effects on menstrual conditions and ovarian function based on the anti-Mullerian hormone level, and patient-reported quality of life. DISCUSSION Previous clinical trials comparing biweekly single-dose actinomycin D with multiday methotrexate therapy for treating low-risk gestational trophoblastic neoplasia patients failed to meet the expected case number. Through this multicentre study, the complete remission ratio and efficacy difference between biweekly single-dose actinomycin D and multiday methotrexate therapy will be obtained. This study will also provide the basis for formulating a preferred regimen for treating patients with low-risk gestational trophoblastic neoplasia. TRIAL REGISTRATION ClinicalTrials.gov: NCT04562558, Registered on 13 September 2020 (Protocol version 2020-9-24, version 1.0).
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Affiliation(s)
- Fang Jiang
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Ming-Yi Mao
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Yang Xiang
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
| | - Xin Lu
- Department of Gynecology Oncology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Chong-Li Guan
- Department of Gynecology Oncology, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, Gansu Province, China
| | - Lan-Zhou Jiao
- Department of Gynecology Oncology, Dalian Women's and Children's Medical Center (Group), No.1 Dunhuang Road Shahekou, Dalian, Liaoning, China
| | - Xi-Run Wan
- Department of Gynecology Oncology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Feng-Zhi Feng
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Tong Ren
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Jun-Jun Yang
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Jun Zhao
- Department of Obstetrics & Gynaecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynaecologic Diseases, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
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8
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Xue W, Cang W, Zhao J, Feng F, Wan X, Ren T, Qiu L, Yang J, Xiang Y. Effect of actinomycin D on ovarian reserve in low-risk gestational trophoblastic neoplasia. Int J Gynecol Cancer 2023; 33:1222-1226. [PMID: 37290904 PMCID: PMC10423527 DOI: 10.1136/ijgc-2023-004292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/01/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE This study aimed to explore the single-agent chemotherapy actinomycin D on ovarian reserve by measuring the anti-Mullerian hormone (AMH) levels before, during, and after chemotherapy. METHODS This study recruited premenopausal women aged 15 to 45 with a newly diagnosed low-risk gestational trophoblastic neoplasia needing actinomycin D. AMH was measured at baseline, during chemotherapy, and 1, 3, and 6 months after the last chemotherapy. The reproductive outcomes were also documented. RESULTS Of the 42 women recruited, we analyzed 37 (median: 29 years; range 19-45) with a complete dataset. The follow-up was 36 months (range 34-39). Actinomycin D significantly decreased AMH concentrations during treatment, from 2.38±0.92 ng/mL to 1.02±0.96 ng/mL (p<0.05). Partial recovery was seen at 1 month and 3 months after treatment. Full recovery was reached 6 months after treatment among patients younger than 35 years. The only factor correlated with the extent of AMH reduction at 3 months was age (r=0.447, p<0.05). Notably, the number of courses of actinomycin D was not associated with the extent of AMH reduction. A total of 18 (90%) of 20 patients who had a desire to conceive had live births with no adverse pregnancy outcomes. CONCLUSION Actinomycin D has a transient and minor effect on ovarian function. Age is the only factor that impacts the patient's rate of recovery. Patients will achieve favorable reproductive outcomes after actinomycin D treatment.
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Affiliation(s)
- Wei Xue
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Wei Cang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jun Zhao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Tong Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Ling Qiu
- Department of Clinical Laboratory, Peking Union Medical College, Beijing, Beijing, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
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9
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Braga A, Paiva G, Cattai CJ, Elias KM, Horowitz NS, Berkowitz RS. Current chemotherapeutic options for the treatment of gestational trophoblastic disease. Expert Opin Pharmacother 2023; 24:245-258. [PMID: 36399723 DOI: 10.1080/14656566.2022.2150075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Gestational trophoblastic neoplasia (GTN) is a rare tumor that arises from trophoblastic tissues with high remission rates after chemotherapy treatment. GTN can develop from any gestational events, such as miscarriage, ectopic pregnancy, and preterm/term pregnancy, but is more frequent after hydatidiform mole. The sensitivity of this tumor to chemotherapy and the presence of an exceptional tumor marker allow high remission rates, especially when patients are treated in referral centers. AREAS COVERED Observational, retrospective, prospective, systematic reviews, and meta-analysis studies focusing on GTN treatment. We searched PubMed, Medline, and the Library of Congress from January 1965 to May 2022. EXPERT OPINION Early GTN diagnosis allows low-toxic and highly effective treatment. Even multimetastatic disease has high rates of remission with multiagent regimen chemotherapy. Surgery is reserved for uterine disease in patients who have completed childbearing, in cases of chemoresistance to multiagent regimens or in the rare cases of placental site trophoblastic tumor or epithelioid trophoblastic tumor. While resistance is managed by salvage chemotherapy, cases with limited clinical response to sequential regimens have been successfully treated with immunotherapy.
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Affiliation(s)
- Antonio Braga
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil.,Department of Medicine, Vassouras Medical School, Postgraduate Program in Applied Health Sciences, Vassouras University, Vassouras, RJ, Brazil.,National Academy of Medicine, Young Leadership Physician Program, Rio de Janeiro, RJ, Brazil
| | - Gabriela Paiva
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil
| | - Cassia Juliana Cattai
- , Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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10
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Mousavi Seresht L, Farazestanian M, Yousefi Z. Single-agent chemotherapy in low-risk gestational trophoblastic neoplasia. CASPIAN JOURNAL OF INTERNAL MEDICINE 2023; 14:108-111. [PMID: 36741498 PMCID: PMC9878903 DOI: 10.22088/cjim.14.1.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 04/29/2022] [Accepted: 07/03/2022] [Indexed: 02/07/2023]
Abstract
Background Low-risk gestational trophoblastic neoplasia could be cured in the case of appropriate management with single-agent chemotherapy. This study was carried out to compare the efficacy of single-dose methotrexate versus Actinomycin-D in low-risk gestational trophoblastic neoplasia to analyze the most effective agent. Methods This retrospective cohort study was conducted on the medical record of 170 cases with the diagnosis of low-risk gestational trophoblastic neoplasia from 2012 to 2019 to evaluate the response rate of single-dose weekly-methotrexate versus biweekly-Actinomycin-D. Results Single agent chemotherapy was required in 170 patients with final risk score of less than 7. Among the 100 cases under weekly-methotrexate therapy, 29 patients were required second-line chemotherapy with Actinomycin-D and combination therapy which means complete remission of 71% with methotrexate, in comparison with 78.5% in the other group. Resistance was mostly seen in patients with documented choriocarcinoma in histology who had not received timely diagnosis and treatment. Conclusion Individualized decision in the management of low-risk gestational trophoblastic neoplasia cases, based on histology, HCG, and history is the corn stone in successful treatment.
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Affiliation(s)
- Leila Mousavi Seresht
- Department of Gynecology and Oncology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marjaneh Farazestanian
- Department of Gynecology and Oncology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zohreh Yousefi
- Department of Gynecology and Oncology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran,Correspondence: Zohreh Yousefi, Department of Gynecology and Oncology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. E-mail: , Tel: +98 3132367002
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11
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Sheikhhasani S, Abdolrazaghnejad A, Mousavi AS, Akhavan S, Zamani N, Feizabad E. Resistance to single-agent chemotherapy in low-risk gestational trophoblastic neoplasia. CASPIAN JOURNAL OF INTERNAL MEDICINE 2023; 14:47-52. [PMID: 36741497 PMCID: PMC9878912 DOI: 10.22088/cjim.14.1.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/31/2022] [Accepted: 02/13/2022] [Indexed: 02/07/2023]
Abstract
Background Methotrexate (MTX) and actinomycin D (ActD) have been used as first-line chemotherapy agents in the treatment of low-risk gestational trophoblastic neoplasia (GTN). Although low-risk GTN is considered a curable disease, its reported primary remission rates of 49 to 93% reflect the difficulties of treatment and different factors influencing it. Hence, this study aimed to determine the remission rates and related factors of single-agent chemotherapy resistance in low-risk GTN patients. Methods This retrospective study included patients with diagnosed low-risk GTN who received either MTX once a week (IM, 30mg/m2) or ActD once every two weeks (pulsed IV, 1.25mg/m2). Then, the patients were followed-up until complete remission or single-agent treatment failure to assess resistance rate and related factors. Results Eighty-four patients were included in the study (18 patients were receiving MTX and 66 patients were receiving ActD). 85.7% of all participants achieved complete remission after first-line chemotherapy (72.2% in MTX vs 89.4% in ActD). There was a significant association for higher tumor size (P=0.046), the occurrence of metastasis (P=0.019), and pretreatment β-HCG levels (P=0.005) with resistance to treatment. Conclusion This study demonstrated higher tumor size, the occurrence of metastasis, and pretreatment β-HCG levels have been associated with increased resistance to first-line chemotherapy agents.
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Affiliation(s)
- Shahrzad Sheikhhasani
- Department of Oncologic Gynecology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Aghdas Abdolrazaghnejad
- Department of Oncologic Gynecology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran,Correspondence: Aghdas Abdolrazaghnejad, Department of Oncologic Gynecology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran. E-mail: , Tel: 0098 2188948217, Fax: 0098 2188948217
| | - Azam Sadat Mousavi
- Department of Oncologic Gynecology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Setareh Akhavan
- Department of Oncologic Gynecology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Narges Zamani
- Department of Oncologic Gynecology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Feizabad
- Department of Oncologic Gynecology, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
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12
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Fertility‐sparing, surgical interventions for low‐risk, non‐metastatic gestational trophoblastic neoplasia. Cochrane Database Syst Rev 2022; 2022:CD014755. [PMCID: PMC9559390 DOI: 10.1002/14651858.cd014755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To measure efficacy and safety of fertility‐sparing surgical interventions, with or without adjuvant chemotherapy, for the treatment of women with low‐risk, non‐metastatic gestational trophoblastic neoplasia (LR‐NMGTN).
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13
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Branco-Silva M, Maesta I, Elias K, Berkowitz RS, Abbade JF, Horowitz NS. Consolidation chemotherapy in postmolar low-risk gestational trophoblastic neoplasia: a systematic review protocol. BMJ Open 2022; 12:e059484. [PMID: 35210351 PMCID: PMC8883264 DOI: 10.1136/bmjopen-2021-059484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Current evidence remains insufficient to strongly demonstrate the benefits of consolidation chemotherapy to all women with low-risk gestational trophoblastic neoplasia (GTN). This protocol outlines a systematic review to investigate whether consolidation chemotherapy is necessary for all patients with postmolar low-risk GTN after human chorionic gonadotropin normalisation with first-line single-agent chemotherapy. METHODS AND ANALYSIS A search string will be used to search the PubMed (MEDLINE), EMBASE, Web of Sciences, Scopus, LILACS and Cochrane Central Register of Controlled Trials databases. Articles will be screened at the title and abstract level, and then at the full article level by two independent reviewers using inclusion/exclusion criteria. Randomised and non-randomised study designs will be included, while case studies, commentaries, editorials, review articles, animal studies, basic science studies and cross-sectional studies, as well as studies not reporting relapse/recurrence rates and/or whether consolidation chemotherapy was delivered will be excluded. There will be no restrictions on date of publication, geographical location, study setting, or language of publication. The primary outcome is rate of recurrence/relapse. The assessments of randomised controlled trials will be performed using the risk of bias tool from the Cochrane Collaboration. Non-randomised studies will be assessed using the Newcastle-Ottawa scale. The quality of evidence will be assessed using the Grading quality of evidence and strength of recommendations (Grades of Recommendations, Assessment, Development and Evaluation) guidelines. ETHICS AND DISSEMINATION No formal ethical approval is required as all data collected will be secondary data and analysed anonymously. Results will be disseminated through a peer-reviewed publication and at scientific events. PROSPERO REGISTRATION NUMBER CRD42020164822.
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Affiliation(s)
- Mariza Branco-Silva
- Botucatu Medical School, Postgraduation Program in Tocogynecology, Sao Paulo State University Julio de Mesquita Filho, Sao Paulo, Brazil
| | - Izildinha Maesta
- Department of Gynecology and Obstetrics, Botucatu Medical School, Sao Paulo State University Julio de Mesquita Filho, Sao Paulo, Brazil
- Botucatu Trophoblastic Disease Center, Botucatu Medical School Hospital, São Paulo State University Julio de Mesquita Filho - UNESP, Botucatu, Brazil
| | - Kevin Elias
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ross Stuart Berkowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Joelcio Francisco Abbade
- Department of Gynecology and Obstetrics, Botucatu Medical School, Sao Paulo State University Julio de Mesquita Filho, Sao Paulo, Brazil
| | - Neil S Horowitz
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
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14
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Wallin E, Niemann I, Faaborg L, Fokdal L, Joneborg U. Differences in Administration of Methotrexate and Impact on Outcome in Low-Risk Gestational Trophoblastic Neoplasia. Cancers (Basel) 2022; 14:cancers14030852. [PMID: 35159119 PMCID: PMC8834333 DOI: 10.3390/cancers14030852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary Low-risk gestational trophoblastic neoplasia is a rare but highly curable malignancy. The most common first line treatment is methotrexate, which can be administered in different forms. In order to investigate the impact of route of administration on methotrexate resistance, toxicity demanding treatment switch, complete remission and relapse, we performed an observational study including women with low-risk gestational trophoblastic neoplasia in a population-based setting in Sweden and Denmark. We found that oral compared to intra-muscular administration of methotrexate gives a higher rate of drug resistance, but does not affect rates of complete remission, recurrence or overall survival. Intra-muscular treatment was associated with more toxicity leading to switch of treatment. We conclude that, although a larger proportion of women develop drug resistance, oral methotrexate, which is easy to administer and highly tolerable, could be an option for well-informed and motivated women. Abstract Methotrexate (MTX) is frequently used as first-line treatment for low-risk gestational trophoblastic neoplasia (GTN). Intravenous and intramuscular (im) routes of administration are the most common methods, although oral administration is used by some Scandinavian centers. The primary aim of this study was to assess the impact of form of administration (im/oral) on resistance to methotrexate (MTX-R) treatment in low-risk GTN. Secondary aims were time to hCG normalization, rates of toxicity-induced treatment switch, and rates of complete remission and recurrence. In total, 170 women treated at Karolinska University Hospital in Sweden and Aarhus University Hospital in Denmark between 1994 and 2018 were included, of whom 107 were given im and 63 oral MTX. MTX-R developed in 35% and 54% in the im and oral groups, respectively (p = 0.01). There was no difference in days to hCG normalization (42 vs. 41 days, p = 0.50) for MTX-sensitive women. Toxicity-induced treatment switch was only seen in the im group. Complete remission was obtained in 99.1% and 100% (p = 0.44), and recurrence rate within one year was 2.8% and 1.6% (p = 0.29). The form of administration of MTX had a significant impact on development of MTX-R and treatment-associated toxicity, but does not affect rates of complete remission, recurrence or survival.
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Affiliation(s)
- Emelie Wallin
- Department of Women’s and Children’s Health, Karolinska Institutet, 171 21 Stockholm, Sweden;
- Department of Pelvic Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Isa Niemann
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark;
- Department of Obstetrics and Gynecology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Louise Faaborg
- Department of Oncology, Vejle Hospital, 7100 Vejle, Denmark;
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark;
| | - Ulrika Joneborg
- Department of Women’s and Children’s Health, Karolinska Institutet, 171 21 Stockholm, Sweden;
- Correspondence:
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15
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Hao J, Zhou W, Zhang M, Yu H, Zhang T, An R, Xue Y. Direct comparisons of efficacy and safety between actinomycin-D and methotrexate in women with low-risk gestational trophoblastic neoplasia: a meta-analysis of randomized and high-quality non-randomized studies. BMC Cancer 2021; 21:1122. [PMID: 34663255 PMCID: PMC8524874 DOI: 10.1186/s12885-021-08849-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 10/06/2021] [Indexed: 12/03/2022] Open
Abstract
Background Actinomycin-D (Act-D) and Methotrexate (MTX) are both effective first-line agents for low-risk gestational trophoblastic neoplasia (LRGTN) with no consensus regarding which is more effective or less toxic. The primary objective of this meta-analysis is to compare Act-D with MTX in the treatment of LRGTN. Methods We systematically searched electronic databases, conferences abstracts and trial registries for randomized controlled trials (RCTs) and high-quality non-randamized controlled trials (non-RCTs), comparing Act-D with MTX for patients with LRGTN. Studies were full-text screened for quality assessment and data extraction. Eligible studies must have reported complete remission rate. A fixed-effects meta-analysis was conducted to quantify the efficacy and safety of Act-D and MTX on odds ratios (ORs) and 95% confidence intervals (95%CIs), respectively. Results A total of 8 RCTs and 9 non-RCTs (1674 patients) were included. In terms of efficacy, Act-D is superior to MTX in complete remission (80.2% [551/687] vs 65.1% [643/987]; OR 2.15, 95%CI 1.70 to 2.73). In the stratified analysis, patients from RCTs and non-RCTs both had a better complete remission from Act-D-based regimen (RCTs: 81.2% [259/319] vs 66.1% [199/301], OR 2.17, 95%CI 1.49 to 3.16; non-RCTs: 79.3% [292/368] vs 65.0% [444/686], OR 2.14, 95%CI 1.57 to 2.92). In terms of safety, patients receiving Act-D had higher risks of suffering nausea (OR 2.35, 95%CI 1.68 to 3.27), vomiting (OR 2.40, 95%CI 1.63 to 3.54), and alopecia (OR 2.76, 95%CI 1.60 to 4.75). Notably, liver toxicity (OR 0.38, 95%CI 0.19 to 0.76) was the only one that was conformed to have a higher risk for patients receiving MTX. In addition, the pooled results showed no significant difference of anaemia, leucocytopenia, neutropenia, thrombocytopnia, constipation, diarrhea, anorexia, and fatigue between Act-D and MTX. Conclusions Our meta-analysis suggests that Act-D had better efficacy profile in general, and MTX had less toxicities in LRGTN. Future clinical trials should be better orchestrated to provide more valid data on efficacy and toxicity. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08849-7.
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Affiliation(s)
- Jiatao Hao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, China
| | - Weihua Zhou
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, China
| | - Mengzhao Zhang
- Department of Urology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hui Yu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, China
| | - Taohong Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, China
| | - Ruifang An
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, China.
| | - Yan Xue
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, China.
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16
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Revzin MV, Pellerito JS, Moshiri M, Katz DS, Nezami N, Kennedy A. Use of Methotrexate in Gynecologic and Obstetric Practice: What the Radiologist Needs to Know. Radiographics 2021; 41:1819-1838. [PMID: 34597234 DOI: 10.1148/rg.2021210038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Methotrexate (MTX) is the primary pharmaceutical agent that is used for management of disorders arising from trophoblastic tissue. Its widespread international use is mostly attributable to its noninvasive, safe, and effective characteristics as a treatment option for ectopic pregnancy (EP) and gestational trophoblastic disease (GTD), with the large added benefit of fertility preservation. Although the effects of MTX usage are well documented in the gynecologic and obstetric literature, there is a scarcity of radiologic literature on the subject. Depending on the type of EP, the route of MTX administration and dosage may vary. US plays an essential role in the diagnosis and differentiation of various types of EPs, pregnancy-related complications, and complications related to MTX therapy, as well as the assessment of eligibility criteria for MTX usage. A knowledge of expected imaging findings following MTX treatment, including variability in echogenicity and shape of the EP, size fluctuations, changes in vascularity and gestational sac content, and the extent of hemoperitoneum, is essential for appropriate patient management and avoidance of unnecessary invasive procedures. A recognition of sonographic findings associated with pregnancy progression and complications such as tubal or uterine rupture, severe hemorrhage, septic abortion, and development of arteriovenous communications ensures prompt patient surgical management. The authors discuss the use of MTX in the treatment of disorders arising from trophoblastic tissue (namely EP and GTD), its mechanism of action, its route of administration, and various treatment regimens. The authors also provide a focused discussion of the role of US in the detection and diagnosis of EP and GTD, the assessment of the eligibility criteria for MTX use, and the identification of the sonographic findings seen following MTX treatment, with specific emphasis on imaging findings associated with MTX treatment success and failure. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Margarita V Revzin
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - John S Pellerito
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Mariam Moshiri
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Douglas S Katz
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Nariman Nezami
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Anne Kennedy
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
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17
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Chen L, Xi L, Jiang J, Yin R, Qu P, Li X, Wan X, Chen Y, Hu D, Mao Y, Pan Z, Cheng X, Wang X, Li Q, Weng D, Zhang X, Zhang H, Ping Q, Liu X, Xie X, Kong B, Ma D, Lu W. Chemotherapy initiation with single-course methotrexate alone or combined with dactinomycin versus multi-course methotrexate for low-risk gestational trophoblastic neoplasia: a multi-centric randomized clinical trial. Front Med 2021; 16:276-284. [PMID: 34181195 DOI: 10.1007/s11684-021-0855-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/15/2021] [Indexed: 11/29/2022]
Abstract
We aimed to evaluate the effectiveness and safety of single-course initial regimens in patients with low-risk gestational trophoblastic neoplasia (GTN). In this trial (NCT01823315), 276 patients were analyzed. Patients were allocated to three initiated regimens: single-course methotrexate (MTX), single-course MTX + dactinomycin (ACTD), and multi-course MTX (control arm). The primary endpoint was the complete remission (CR) rate by initial drug(s). The primary CR rate was 64.4% with multi-course MTX in the control arm. For the single-course MTX arm, the CR rate was 35.8% by one course; it increased to 59.3% after subsequent multi-course MTX, with non-inferiority to the control (difference -5.1%,95% confidence interval (CI) -19.4% to 9.2%, P = 0.014). After further treatment with multi-course ACTD, the CR rate (93.3%) was similar to that of the control (95.2%, P = 0.577). For the single-course MTX + ACTD arm, the CR rate was 46.7% by one course, which increased to 89.1% after subsequent multi-course, with non-inferiority (difference 24.7%, 95% CI 12.8%-36.6%, P < 0.001) to the control. It was similar to the CR rate by MTX and further ACTD in the control arm (89.1% vs. 95.2%, P =0.135). Four patients experienced recurrence, with no death, during the 2-year follow-up. We demonstrated that chemotherapy initiation with single-course MTX may be an alternative regimen for patients with low-risk GTN.
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Affiliation(s)
- Lili Chen
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Ling Xi
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jie Jiang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Rutie Yin
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, China
| | - Pengpeng Qu
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, 300052, China
| | - Xiuqin Li
- Shengjing Hospital of China Medical University, Shenyang, 110021, China
| | - Xiaoyun Wan
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Yaxia Chen
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Dongxiao Hu
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Yuyan Mao
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Zimin Pan
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Xiaodong Cheng
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Xinyu Wang
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Qingli Li
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, China
| | - Danhui Weng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xi Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Hong Zhang
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, 300052, China
| | - Quanhong Ping
- Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, 300052, China
| | - Xiaomei Liu
- Shengjing Hospital of China Medical University, Shenyang, 110021, China
| | - Xing Xie
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China
| | - Beihua Kong
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, 250012, China.
| | - Ding Ma
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Weiguo Lu
- Department of Gynecological Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006 s, China.
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18
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Qin J, Zhang S, Poon L, Pan Z, Luo J, Yu N, Wang L, Wu X, Cheng X, Xie X, Lu Y, LU W. Doppler-based predictive model for methotrexate resistance in low-risk gestational trophoblastic neoplasia with myometrial invasion: prospective study of 147 patients. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:829-839. [PMID: 32385928 PMCID: PMC8251727 DOI: 10.1002/uog.22069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/30/2020] [Accepted: 04/22/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES This prospective clinical study aimed to evaluate the vascularization characteristics of low-risk gestational trophoblastic neoplasia (GTN) using Doppler imaging and to develop a predictive model for resistance to methotrexate (MTX). METHODS Patients with low-risk GTN receiving primary MTX treatment were enrolled from the Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China, from September 2012 to August 2018. The primary endpoint was to develop and internally validate a predictive model for resistance to MTX therapy in these patients. In the training set, clinical features and Doppler hemodynamic parameters before MTX therapy were analyzed using logistic regression to identify independent predictors of MTX resistance, which were integrated into the model. The predictive performance of the model was evaluated by leave-one-out cross-validation in the training dataset and internal validation in an independent-sample test dataset. RESULTS The entire imaging protocol was completed by 147 eligible patients, of which 110 comprised the training set and 37 the test set. In the training set, cases with myometrial invasion (81.8%; 90/110) showed vascular-enriched areas in the myometrium and high velocity and low impedance ratios of the uterine artery (UtA) compared to cases without myometrial invasion (18.2%; 20/110). On multivariate logistic regression analysis, time-averaged mean velocity in UtA (UtA-TAmean) and the International Federation of Gynecology and Obstetrics (FIGO) score were identified as independent predictors (P = 0.009 and P = 0.043, respectively) of MTX resistance. The Doppler-based predictive model, developed based on the 90 cases with myometrial invasion, was y = -2.95332 + 0.41696 × FIGO score + 0.03551 × UtA-TAmean. The model showed an area under the curve of 0.757 (95% CI, 0.653-0.862) and the optimal cut-off value was 0.50622, which had 45.2% sensitivity and 96.6% specificity. The model stratified patients with low-risk GTN into low (< 10%), intermediate (10-90%) and high (> 90%) probability of MTX resistance, based on the threshold values of -1.59544 and 0.10046. The model had an accuracy of 74.4% (95% CI, 64.5-82.3%) in the cross-validation and 72.7% (95% CI, 55.8-84.9%) in the internal validation. CONCLUSIONS The Doppler-based predictive model, combining a non-invasive marker of tumor vascularity with the FIGO scoring system, can differentiate cases with low from those with high probability of developing MTX resistance and therefore has the potential to guide treatment options in patients with low-risk GTN and myometrial invasion. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J. Qin
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
| | - S. Zhang
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
| | - L. Poon
- Department of Obstetrics and GynaecologyThe Chinese University of Hong KongHong Kong SAR
| | - Z. Pan
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
| | - J. Luo
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
| | - N. Yu
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
| | - L. Wang
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
| | - X. Wu
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
| | - X. Cheng
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
| | - X. Xie
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
| | - Y. Lu
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
- Institute of Translational MedicineZhejiang University School of MedicineHangzhouChina
| | - W. LU
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
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19
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Yamamoto E, Trinh TD, Sekiya Y, Tamakoshi K, Nguyen XP, Nishino K, Niimi K, Kotani T, Kajiyama H, Shibata K, Le QT, Kikkawa F. The management of hydatidiform mole using prophylactic chemotherapy and hysterectomy for high-risk patients decreased the incidence of gestational trophoblastic neoplasia in Vietnam: a retrospective observational study. NAGOYA JOURNAL OF MEDICAL SCIENCE 2021; 82:183-191. [PMID: 32581399 PMCID: PMC7276412 DOI: 10.18999/nagjms.82.2.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The management of hydatidiform mole (HM) and the incidence of post-molar gestational trophoblastic neoplasia (GTN) in Vietnam has not been reported to date. This study aimed to study the incidence of HM and post-molar GTN and identify factors associated with post-molar GTN at a tertiary hospital in Vietnam. Five hundred and eighty-four patients who were treated for HM at Tu Du Hospital between January and December 2010 were included in this study. The mean age and gestational age at the first evacuation were 28.8 years old and 11.0 weeks, respectively. After the initial evacuation and pathological examination, 87 patients who were older than 40 or did not wish to have children underwent a hysterectomy, while the others underwent second curettage. All 472 patients who had human chorionic gonadotropin (hCG) ≥ 100,000 IU/L before treatment received one cycle of methotrexate with folinic acid as prophylactic chemotherapy. The incidence of HM was 11.1 per 1,000 deliveries; 47 patients (8.0%) developed post-molar GTN. Gestational week, hCG level at one week after the first evacuation, and pathological remnants were significantly associated with the development of post-molar GTN. The results of this study suggest that prophylactic chemotherapy and hysterectomy may be useful for high-risk HM patients to reduce post-molar GTN in settings in which the risk of post-molar GTN and loss to follow-up after HM are greater and hCG measurements and appropriate GTN treatments are unavailable. However, future studies on the long-term outcomes and side effects of prophylactic therapies on HM are required.
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Affiliation(s)
- Eiko Yamamoto
- Department of Healthcare Administrationy, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tien Dat Trinh
- Department of Obstetrics and Gynecology, Tu Du Hospital, Ho Chi Minh, Vietnam
| | - Yoko Sekiya
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Koji Tamakoshi
- Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Xuan Phuoc Nguyen
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Nishino
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomomi Kotani
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kiyosumi Shibata
- Department of Obstetrics and Gynecology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Quang Thanh Le
- Department of Obstetrics and Gynecology, Tu Du Hospital, Ho Chi Minh, Vietnam
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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20
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Joneborg U, Coopmans L, van Trommel N, Seckl M, Lok CAR. Fertility and pregnancy outcome in gestational trophoblastic disease. Int J Gynecol Cancer 2021; 31:399-411. [PMID: 33649007 DOI: 10.1136/ijgc-2020-001784] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/01/2020] [Indexed: 12/28/2022] Open
Abstract
The aim of this review is to provide an overview of existing literature and current knowledge on fertility rates and reproductive outcomes after gestational trophoblastic disease. A systematic literature search was performed to retrieve all available studies on fertility rates and reproductive outcomes after hydatidiform mole pregnancy, low-risk gestational trophoblastic neoplasia, high- and ultra-high-risk gestational trophoblastic neoplasia, and the rare placental site trophoblastic tumor and epithelioid trophoblastic tumor forms of gestational trophoblastic neoplasia. The effects of single-agent chemotherapy, multi-agent including high-dose chemotherapy, and immunotherapy on fertility, pregnancy wish, and pregnancy outcomes were evaluated and summarized. After treatment for gestational trophoblastic neoplasia, most, but not all, women want to achieve another pregnancy. Age and extent of therapy determine if there is a risk of loss of fertility. Single-agent treatment does not affect fertility and subsequent pregnancy outcome. Miscarriage occurs more often in women who conceive within 6 months of follow-up after chemotherapy. Multi-agent chemotherapy hastens the natural menopause by three years and commonly induces a temporary amenorrhea, but in young women rarely causes permanent ovarian failure or infertility. Subsequent pregnancies have a high chance of ending with live healthy babies. In contrast, high-dose chemotherapy typically induces permanent amenorrhea, and no pregnancies have been reported after high-dose chemotherapy for gestational trophoblastic neoplasia. Immunotherapy is promising and may give better outcomes than multiple schedules of chemotherapy or even high-dose chemotherapy. The first pregnancy after immunotherapy has recently been described. Data on fertility-sparing treatment in placental site trophoblastic tumor and epithelioid trophoblastic tumor are still scarce, and this option should be offered with caution. In general, patients with gestational trophoblastic neoplasia may be reassured about their future fertility and pregnancy outcome. Detailed registration of high-risk gestational trophoblastic neoplasia is still indispensable to obtain more complete data to better inform patients in the future.
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Affiliation(s)
- Ulrika Joneborg
- Department of Pelvic Cancer, Karolinska University Hospital, Karolinska Institute Department of Women's and Children's Health, Stockholm, Sweden
| | - Leonoor Coopmans
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
| | - Nienke van Trommel
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
| | - Michael Seckl
- Department of Medical Oncology, Hammersmith Hospitals; Imperial College London, London, Pennsylvania, UK
| | - Christianne A R Lok
- Department of Gynecologic Oncology, Netherlands Cancer Institute, Amsterdam, Noord-Holland, The Netherlands
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21
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Mok ZW, Merchant K, Yip SL. Management of a complete hydatidiform mole with a coexisting live fetus followed by successful treatment of maternal metastatic gestational trophoblastic disease: learning points. BMJ Case Rep 2021; 14:14/1/e235028. [PMID: 33461990 PMCID: PMC7813335 DOI: 10.1136/bcr-2020-235028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
A 34-year-old patient had her first trimester Down syndrome scan followed by serial ultrasound scans which showed a single intrauterine pregnancy with multiple cystic areas in the anterior placenta. She presented in preterm labour with a breech presentation at 32 weeks and underwent an emergency caesarean section. She delivered a male infant weighing 1750 g. The placental histopathology showed a complete hyatidiform mole. At 4 weeks postpartum, beta-human chorionic gonadotrophin (Bhcg) levels rose from 460 to 836 mIU/mL over 1 week. Metastatic workup revealed prominent pelvic nodes and pulmonary nodules in both lungs. This was discussed at the Multi-Disciplinary Tumour Board and single-agent intramuscular methotrexate was recommended. After chemotherapy, she achieved Bhcg normalisation after three cycles. This case highlights the importance of clinical vigilance even in low-risk patients. Unexpected findings on ultrasound should involve multidisciplinary input with radiology colleagues. A high index of suspicion for gestational trophoblastic disease and close follow-up is imperative.
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Affiliation(s)
- Zhun Wei Mok
- Division of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | - Khurshid Merchant
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore
| | - Swee Lin Yip
- Division of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
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22
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Schink JC, Filiaci V, Huang HQ, Tidy J, Winter M, Carter J, Anderson N, Moxley K, Yabuno A, Taylor SE, Kushnir C, Horowitz N, Miller DS. An international randomized phase III trial of pulse actinomycin-D versus multi-day methotrexate for the treatment of low risk gestational trophoblastic neoplasia; NRG/GOG 275. Gynecol Oncol 2020; 158:354-360. [PMID: 32460997 PMCID: PMC7432963 DOI: 10.1016/j.ygyno.2020.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/11/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Methotrexate and actinomycin-D are both effective first-line drugs for low-risk (WHO score 0-6) Gestational Trophoblastic Neoplasia (GTN) with considerable debate about which is more effective, less toxic, and better tolerated. The primary trial objective was to test if treatment with multi-day methotrexate (MTX) was inferior to pulse actinomycin-D (ACT-D). Secondary objectives included evaluation of severity and frequency of adverse events, and impact on quality of life (QOL). METHODS This was a prospective international cooperative group randomized phase III two arm non-inferiority study (Clinical Trials Identifier: (NCT01535053). The control arm was ACT-D; the experimental arm was multi-day MTX regimen (institutional preference of 5 or 8 day). Outcome measures included complete response rate, recurrence rate, toxicity, and QOL as measured by FACT-G and FACIT supplemental items. RESULTS The complete response rates for multi-day methotrexate and pulse actinomycin-D were 88% (23/26 patients) and 79% (22/28 patients) (p = NS) respectively, there were two recurrences in each arm, and 100% of patients survived. Significant toxicity was minimal, but mouth sores (mucositis), and eye pain were significantly more common in the MTX arm (p = 0.001 and 0.01 respectively). Quality of life showed no significant difference in overall quality of life, body image, sexual function, or treatment related side effects. The study was closed for low accrual rate (target 384, actual accrual 57), precluding statistical analysis of the primary objective. CONCLUSIONS The complete response rate for multi-day methotrexate was higher than actinomycin-D, but did not reach statistical significance. The multi-day MTX regimens were associated with significantly more mucositis and were significantly less convenient.
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Affiliation(s)
- Julian C Schink
- Cancer Treatment Centers of America, Comprehensive Care and Research Center, Chicago, IL, USA.
| | - Virginia Filiaci
- NRG Oncology Statistics and Data Management Center, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
| | - Helen Q Huang
- NRG Oncology Statistics and Data Management Center, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
| | - John Tidy
- Sheffield Teaching Hospitals, NHS Trust, Royal Hallamshire Hospital, Glossop Rd, Sheffield S10 2JF, UK.
| | - Matthew Winter
- Sheffield Teaching Hospitals, NHS Trust, Royal Hallamshire Hospital, Glossop Rd, Sheffield S10 2JF, UK.
| | - Jeanne Carter
- Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, New York, NY, USA.
| | | | - Katherine Moxley
- Oklahoma University Health Science Center, Oklahoma City, OK, USA.
| | - Akira Yabuno
- Saitama Medical University International Medical Center, Saitama, Japan.
| | - Sarah E Taylor
- Gynecologic Oncology, Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Christina Kushnir
- Gynecologic Oncology, Women's Cancer Center of Nevada, Las Vegas, NV, USA.
| | - Neil Horowitz
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
| | - David S Miller
- University of Texas Southwestern Medical Center, Dallas, TX, USA.
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23
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You B, Bolze PA, Lotz JP, Massardier J, Gladieff L, Joly F, Hajri T, Maucort-Boulch D, Bin S, Rousset P, Devouassoux-Shisheboran M, Roux A, Alves-Ferreira M, Grazziotin-Soares D, Langlois-Jacques C, Mercier C, Villeneuve L, Freyer G, Golfier F. Avelumab in Patients With Gestational Trophoblastic Tumors With Resistance to Single-Agent Chemotherapy: Cohort A of the TROPHIMMUN Phase II Trial. J Clin Oncol 2020; 38:3129-3137. [PMID: 32716740 PMCID: PMC7499607 DOI: 10.1200/jco.20.00803] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Women with gestational trophoblastic tumors (GTT) resistant to single-agent chemotherapy receive alternative chemotherapy regimens, which, although effective, cause considerable toxicity. All GTT subtypes express programmed death-ligand 1 (PD-L1), and natural killer (NK) cells are involved in trophoblast immunosurveillance. Avelumab (anti-PD-L1) induces NK cell-mediated cytotoxicity. The TROPHIMMUN trial assessed avelumab in women with chemotherapy-resistant GTT. METHODS In this phase II multicenter trial (ClinicalTrials.gov identifier: NCT03135769), women with GTT who experienced disease progression after single-agent chemotherapy received avelumab 10 mg/kg intravenously every 2 weeks until human chorionic gonadotropin (hCG) normalization, followed by 3 consolidation cycles. Rate of hCG normalization was the primary endpoint (2-step Simon design). RESULTS Between December 2016 and September 2018, 15 patients were treated. Median age was 34 years; disease stage was I or III in 53.3% and 46.7% of women, respectively; and International Federation of Gynecology and Obstetrics (FIGO) score was 0-4 in 33.3%, 5-6 in 46.7%, and ≥ 7 in 20% of patients. Prior treatment included methotrexate (100%) and actinomycin D (7%). Median follow-up was 25 months, and median number of avelumab cycles was 8 (range, 2-11). Grade 1-2 treatment-related adverse events occurred in 93% of patients, most commonly (≥ 25%) fatigue (33.3%), nausea/vomiting (33.3%), and infusion-related reaction (26.7%). One patient had grade 3 uterine bleeding (treatment unrelated). Eight patients (53.3%) had hCG normalization after a median of 9 avelumab cycles; none subsequently relapsed. Probability of normalization was not associated with disease stage, FIGO score, or baseline hCG. One patient subsequently had a healthy pregnancy. In avelumab-resistant patients (46.7%), hCG was normalized with actinomycin D (42.3%) or combination chemotherapy/surgery (57.1%). CONCLUSION In patients with single-agent chemotherapy-resistant GTT, avelumab had a favorable safety profile and cured approximately 50% of patients. Avelumab could be a new therapeutic option, particularly in patients who would otherwise receive combination chemotherapy.
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Affiliation(s)
- Benoit You
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Medical Oncology, Institut de Cancérologie des Hospices Civils de Lyon, Centre d'Investigation de Thérapeutiques en Oncologie et Hématologie de Lyon, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France
| | - Pierre-Adrien Bolze
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Jean-Pierre Lotz
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Hôpital Tenon, Pôle Onco-Hématologie Hôpitaux Universitaires de l'Est Parisien, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Jérome Massardier
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Service de Gynécologie Obstétrique, Unité de Diagnostic Anténatal, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Laurence Gladieff
- Département d'Oncologie Médicale, Institut Claudius Regaud, IUCT-ONCOPOLE, Toulouse, France
| | - Florence Joly
- Clinical Research Department, Centre François Baclesse, Caen Cedex, France
| | - Touria Hajri
- Centre de Référence des Maladies Trophoblastiques, Lyon, France
| | - Delphine Maucort-Boulch
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Service de Biostatistique, Hospices Civils de Lyon, Lyon; and CNRS UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Sylvie Bin
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Pascal Rousset
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Radiologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | | | - Adeline Roux
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Marine Alves-Ferreira
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Daniele Grazziotin-Soares
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Hôpital Tenon, Pôle Onco-Hématologie Hôpitaux Universitaires de l'Est Parisien, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Carole Langlois-Jacques
- Service de Biostatistique, Hospices Civils de Lyon, Lyon; and CNRS UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Catherine Mercier
- Service de Biostatistique, Hospices Civils de Lyon, Lyon; and CNRS UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Laurent Villeneuve
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Gilles Freyer
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Medical Oncology, Institut de Cancérologie des Hospices Civils de Lyon, Centre d'Investigation de Thérapeutiques en Oncologie et Hématologie de Lyon, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France
| | - Francois Golfier
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
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Batman S, Skeith A, Allen A, Munro E, Caughey A, Bruegl A. Cost-effectiveness of second curettage for treatment of low-risk non-metastatic gestational trophoblastic neoplasia. Gynecol Oncol 2020; 157:711-715. [PMID: 32276791 PMCID: PMC7293571 DOI: 10.1016/j.ygyno.2020.03.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 03/29/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Low-risk non-metastatic gestational trophoblastic neoplasia (GTN) has been treated with single agent chemotherapy, but second curettage is emerging as an alternative strategy with reported cure rates of 40%. We sought to estimate the cost-effectiveness of second curettage as the first line treatment of low-risk GTN. METHODS A decision-analytic model was created using TreeAge software to compare costs and outcomes for women with WHO staged low-risk GTN undergoing treatment with 5-day methotrexate (MTX), biweekly pulsed actinomycin-D, or second curettage. Probabilities were derived from the literature. Outcomes of interest included side effects from chemotherapy, need for additional agents, hemorrhage, uterine perforation, and cure rates. Utilities were applied to discounted life expectancy at a rate of 3% to generate quality adjusted life years (QALYs). Sensitivity analyses were then performed in order to assess the robustness of our assumptions. RESULTS Of the three treatment arms, MTX was associated with the lowest cost and had similar QALYs to the other studied modalities. Second curettage was associated with 49 additional cures when applied to a theoretic cohort of 1000 women, as well as an additional 83 hemorrhages and 17 uterine perforations. Sensitivity analysis on the cure rate of second curettage revealed that second curettage was not cost-effective over MTX unless its probability of cure was 98%. CONCLUSION Our study found 5-day MTX was the cost-effective strategy for treatment of women with low-risk, non-metastatic GTN when compared to second curettage and actinomycin-D. In a carefully selected patient population, second curettage may be an additional treatment strategy.
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Affiliation(s)
- Samantha Batman
- Oregon Health & Sciences University, Portland, OR, United States
| | - Ashley Skeith
- University of Michigan, Ann Arbor, MI, United States
| | - Allison Allen
- Oregon Health & Sciences University, Portland, OR, United States
| | - Elizabeth Munro
- Oregon Health & Sciences University, Portland, OR, United States
| | - Aaron Caughey
- Oregon Health & Sciences University, Portland, OR, United States
| | - Amanda Bruegl
- Oregon Health & Sciences University, Portland, OR, United States.
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Koźmiński P, Halik PK, Chesori R, Gniazdowska E. Overview of Dual-Acting Drug Methotrexate in Different Neurological Diseases, Autoimmune Pathologies and Cancers. Int J Mol Sci 2020; 21:ijms21103483. [PMID: 32423175 PMCID: PMC7279024 DOI: 10.3390/ijms21103483] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 02/07/2023] Open
Abstract
Methotrexate, a structural analogue of folic acid, is one of the most effective and extensively used drugs for treating many kinds of cancer or severe and resistant forms of autoimmune diseases. In this paper, we take an overview of the present state of knowledge with regards to complex mechanisms of methotrexate action and its applications as immunosuppressive drug or chemotherapeutic agent in oncological combination therapy. In addition, the issue of the potential benefits of methotrexate in the development of neurological disorders in Alzheimer’s disease or myasthenia gravis will be discussed.
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Alobaid A, Ahmeed S, Abuzaid M, Aldakhil L, Abu-Zaid A. Low-risk gestational trophoblastic neoplasia: A single-center experience from Saudi Arabia. Avicenna J Med 2019; 9:89-93. [PMID: 31404135 PMCID: PMC6647918 DOI: 10.4103/ajm.ajm_188_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective To report our single-center experience in terms of patient clinical characteristics, treatment outcomes, and chemotherapy-related toxicities in patients with low-risk gestational trophoblastic neoplasia (GTN). Materials and Methods A retrospective cross-sectional study (2008-2013) was conducted at a tertiary health-care hospital in Saudi Arabia. Forty-four (n = 44) patients met the inclusion criteria for low-risk GTN. Methotrexate (MTX) was administered in a 5-day regimen: 0.3-0.5mg/kg intravenously (IV) daily for 5 days every 2 weeks (maximum 25mg per dose). Actinomycin D (ActD) was administered 1.25mg/m2 pulsed IV every 2 weeks. Results The majority of patients had molar pregnancy as the antecedent event (86%), developed GTN within the first 4 months after the initial evacuation (93.2%), had human chorionic gonadotropin levels between 1,000 and 10,000 mIU/dL (36.3%), and had the World Health Organization prognostic scores from 0 to 2 (48.7%). Only 38 patients accepted treatment with chemotherapy. A total of 37 patients received first-line MTX; 34 patients of them achieved complete remission (CR, 92%). The three patients who developed MTX resistance were salvaged with sequential ActD and all achieved CR of 100%. Only one patient received first-line ActD and achieved CR. The overall survival as well as cure rate for all patients with low-risk GTN was 100%. No patient developed MTX-related hepatic toxicity or ActD-related blister formation. No severe adverse effects occurred. Conclusion Our 5-day IV MTX regimen was highly effective in treating patients with low-risk GTN, with CR rate of 92% and no severe toxicity. Primary and sequential ActD therapy appears to be very effective.
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Affiliation(s)
- Abdulaziz Alobaid
- Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Samer Ahmeed
- Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed Abuzaid
- Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Latifa Aldakhil
- Department of Obstetrics and Gynecology, King Khaled University Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Ahmed Abu-Zaid
- College of Medicine, Alfaisal University, Riyadh, Kingdom of Saudi Arabia.,College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Verri D, Pasciuto T, Epstein E, Fruscio R, Mascilini F, Moro F, Scambia G, Valentin L, Testa AC. GestaTIonal TrophoblAstic NeoplasIa Ultrasound assessMent: TITANIUM study. Int J Gynecol Cancer 2019; 29:1216-1220. [DOI: 10.1136/ijgc-2019-000434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2019] [Indexed: 11/03/2022] Open
Abstract
BackgroundThere are limited data on ultrasound morphologic features of gestational trophoblastic neoplasia. A predictive model to determine predictors of response to therapy would be ideal in the management of patients with this rare disease.Primary Objectives and Study HypothesisTITANIUM is a prospective, multicenter, observational study aiming to describe ultrasound features of gestational trophoblastic neoplasia and to investigate the role of ultrasound in identifying patients at high risk of resistance to single-drug therapy. The study hypothesis is that ultrasound could improve the International Federation of Gynecology and Obstetrics (FIGO) scoring system for early identification of patients predisposed to single-drug resistance.Trial Design and Major Inclusion/Exclusion CriteriaPatients eligible have a diagnosis of gestational trophoblastic neoplasia according to FIGO or the criteria set by Charing Cross Hospital, London, UK. At diagnosis, patients are classified as low-risk (score 0–6) or high-risk (score >6) according to the FIGO risk scoring system, and a baseline ultrasound scan is performed. Patients receive treatment according to local protocol at each institution. Follow-up ultrasound examinations are performed at 1, 4, 10, 16, and 22 months after start of chemotherapy, and at each scan, serum human chorionic gonadotropin (hCG) level, and chemotherapy treatment, if any, are recorded.Primary EndpointsOur aims are to define ultrasound features of gestational trophoblastic neoplasia and to develop a predictive model of resistance to single-drug therapy in low-risk patients.Sample SizeThe sample size was calculated assuming that 70% of patients with gestational trophoblastic neoplasia are at low risk, and estimating the rate of resistance to single-drug therapy in this group to be 40%. Assuming a dropout rate of 10%, we should recruit at least 120 patients. With this sample size, we can attempt to create a mathematical model with three variables (either two ultrasound parameters in addition to the risk score or three ultrasound variables statistically significant at univariate analysis) to predict resistance to single-drug therapy in low-risk patients.Estimated Dates for Completing Accrual and Presenting ResultsThe accrual started in February 2019. Additional referral centers for gestational trophoblastic disease, with similar ultrasound expertise, are welcome to participate in the study. Enrollment should be completed by December 2021, and analysis will be conducted in December 2023.Trial RegistrationThe study received the Ethical Committee approval of the Coordinator Center (Rome) in January 2019 (Protocol No. 0004668/19).
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Kang HL, Zhao Q, Yang SL, Duan W. Efficacy of Combination Therapy with Actinomycin D and Methotrexate in the Treatment of Low-Risk Gestational Trophoblastic Neoplasia. Chemotherapy 2019; 64:42-47. [PMID: 31163446 DOI: 10.1159/000500165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/27/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We aimed to identify an optimal regimen for low-risk gestational trophoblastic neoplasia (LR-GTN) providing reduction in dosage and toxicity/side effects, enhancement of therapeutic efficacy, and a shorter treatment duration. METHODS A total of 149 LR-GTN patients were enrolled in the affiliated Beijing Maternity Hospital of Capital Medical University from January 2014 to January 2017 and randomly divided into 3 groups with 50 cases in the methotrexate (MTX) group, 49 in actinomycin D (ACT-D) group, and 50 in ACT-D+MTX group. Follow-up recorded symptoms, physical and bimanual gynecological examinations, routine blood test, serum β-HCG level, liver and renal functions, electrolytes, electrocardiogram before each treatment course, and pelvic and abdominal B-mode ultrasound or pelvic/abdominal/chest computed tomography. RESULTS Serum complete remission (SCR) was 96.0, 87.8, and 83.7% for the ACT-D+MTX, ACT-D, and MTX groups, respectively, with SCR being highest in the ACT-D+MTX group, statistically higher than in the MTX group. Vomiting was the only side effect differing significantly by chemotherapy regimen, with a distinctly higher incidence in the ACT-D+MTX group compared with the MTX group (p = 0.028). The reduction rate of serum β-HCG in the ACT-D+MTX group was significantly greater than in the other 2 groups. CONCLUSION Combined ACT-D+MTX chemotherapy achieved overall better efficacy and showed less toxicity than ACT-D or MTX alone, and thus can be prioritized for the treatment of LR-GTN.
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Affiliation(s)
- Hai-Li Kang
- Gynecologic Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Qun Zhao
- Gynecologic Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Shu-Li Yang
- Gynecologic Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Wei Duan
- Gynecologic Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China,
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Gorshkov K, Sima N, Sun W, Lu B, Huang W, Travers J, Klumpp-Thomas C, Michael SG, Xu T, Huang R, Lee EM, Cheng X, Zheng W. Quantitative Chemotherapeutic Profiling of Gynecologic Cancer Cell Lines Using Approved Drugs and Bioactive Compounds. Transl Oncol 2019; 12:441-452. [PMID: 30576957 PMCID: PMC6302136 DOI: 10.1016/j.tranon.2018.11.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/27/2018] [Accepted: 11/27/2018] [Indexed: 12/29/2022] Open
Abstract
Heterogeneous response to chemotherapy is a major issue for the treatment of cancer. For most gynecologic cancers including ovarian, cervical, and placental, the list of available small molecule therapies is relatively small compared to options for other cancers. While overall cancer mortality rates have decreased in the United States as early diagnoses and cancer therapies have become more effective, ovarian cancer still has low survival rates due to the lack of effective treatment options, drug resistance, and late diagnosis. To understand chemotherapeutic diversity in gynecologic cancers, we have screened 7914 approved drugs and bioactive compounds in 11 gynecologic cancer cell lines to profile their chemotherapeutic sensitivity. We identified two HDAC inhibitors, mocetinostat and entinostat, as pan-gynecologic cancer suppressors with IC50 values within an order of magnitude of their human plasma concentrations. In addition, many active compounds identified, including the non-anticancer drugs and other compounds, diversely inhibited the growth of three gynecologic cancer cell groups and individual cancer cell lines. These newly identified compounds are valuable for further studies of new therapeutics development, synergistic drug combinations, and new target identification for gynecologic cancers. The results also provide a rationale for the personalized chemotherapeutic testing of anticancer drugs in treatment of gynecologic cancer.
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Affiliation(s)
- Kirill Gorshkov
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA
| | - Ni Sima
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA; Department of Gynecologic Oncology, Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, 866 Yuhangtang Rd, Hangzhou 310058, PR China
| | - Wei Sun
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA
| | - Billy Lu
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA
| | - Wei Huang
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA; Department of Gynecologic Oncology, Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, 866 Yuhangtang Rd, Hangzhou 310058, PR China
| | - Jameson Travers
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA
| | - Carleen Klumpp-Thomas
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA
| | - Samuel G Michael
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA
| | - Tuan Xu
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA
| | - Ruili Huang
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA
| | - Emily M Lee
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA
| | - Xiaodong Cheng
- Department of Gynecologic Oncology, Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, 866 Yuhangtang Rd, Hangzhou 310058, PR China
| | - Wei Zheng
- National Center for Advancing Translational Sciences, National Institutes of Health, 9800 Medical Center Drive, Bethesda, MD 20892, USA.
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Braga A, Mora P, de Melo AC, Nogueira-Rodrigues A, Amim-Junior J, Rezende-Filho J, Seckl MJ. Challenges in the diagnosis and treatment of gestational trophoblastic neoplasia worldwide. World J Clin Oncol 2019; 10:28-37. [PMID: 30815369 PMCID: PMC6390119 DOI: 10.5306/wjco.v10.i2.28] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/12/2018] [Accepted: 01/01/2019] [Indexed: 02/06/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) is a rare tumor that originates from pregnancy that includes invasive mole, choriocarcinoma (CCA), placental site trophoblastic tumor and epithelioid trophoblastic tumor (PSTT/ETT). GTN presents different degrees of proliferation, invasion and dissemination, but, if treated in reference centers, has high cure rates, even in multi-metastatic cases. The diagnosis of GTN following a hydatidiform molar pregnancy is made according to the International Federation of Gynecology and Obstetrics (FIGO) 2000 criteria: four or more plateaued human chorionic gonadotropin (hCG) concentrations over three weeks; rise in hCG for three consecutive weekly measurements over at least a period of 2 weeks or more; and an elevated but falling hCG concentrations six or more months after molar evacuation. However, the latter reason for treatment is no longer used by many centers. In addition, GTN is diagnosed with a pathological diagnosis of CCA or PSTT/ETT. For staging after a molar pregnancy, FIGO recommends pelvic-transvaginal Doppler ultrasound and chest X-ray. In cases of pulmonary metastases with more than 1 cm, the screening should be complemented with chest computed tomography and brain magnetic resonance image. Single agent chemotherapy, usually Methotrexate (MTX) or Actinomycin-D (Act-D), can cure about 70% of patients with FIGO/World Health Organization (WHO) prognosis risk score ≤ 6 (low risk), reserving multiple agent chemotherapy, such as EMA/CO (Etoposide, MTX, Act-D, Cyclophosphamide and Oncovin) for cases with FIGO/WHO prognosis risk score ≥ 7 (high risk) that is often metastatic. Best overall cure rates for low and high risk disease is close to 100% and > 95%, respectively. The management of PSTT/ETT differs and cure rates tend to be a bit lower. The early diagnosis of this disease and the appropriate treatment avoid maternal death, allow the healing and maintenance of the reproductive potential of these women.
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Affiliation(s)
- Antonio Braga
- Postgraduate Program of Medical Sciences, Fluminense Federal University, Niterói 24033-900, Brazil
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Paulo Mora
- Postgraduate Program of Medical Sciences, Fluminense Federal University, Niterói 24033-900, Brazil
- Brazilian National Cancer, Hospital do Câncer 2, Rio de Janeiro 20220-410, Brazil
| | | | - Angélica Nogueira-Rodrigues
- Department of Internal Medicine, Faculty of Medicine, Minas Gerais Federal University, Belo Horizonte 30130-100, Brazil
| | - Joffre Amim-Junior
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Jorge Rezende-Filho
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, United Kingdom
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Aznab M, Nankali A, Daeichin S. Determination of Clinical Process and Response Rate to Treatment in Patients with Gestational Trophoblastic Neoplasia (GTN) with Low and High Risk and Evaluation of Their First Pregnancy Outcome. Int J Hematol Oncol Stem Cell Res 2018; 12:291-297. [PMID: 30774829 PMCID: PMC6375376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background: The present study was conducted to determine the response to treatment in patients with GTN, the survival rate and to investigate the outcomes of first pregnancy after chemotherapy. Materials and Methods: The treatment protocol was based on the FIGO Staging of GTN and the Modified WHO Prognostic Scoring. Results: Complete remission was achieved with MTX in 100% of the low-risk patients and with combination therapy in 91% of the high-risk cases. Out of 27 low-risk patients, 21 had no metastasis 6 had lung metastasis, 18 preserved their fertility and conceived in the first year following the chemotherapy. Out of 3 patients who had developed invasive moles, 1 got pregnant after chemotherapy. Four of the patients with choriocarcinoma conceived in the first year following the chemotherapy. In the patient with placental site trophoblastic tumors, there was no pregnancy due to hysterectomy. Conclusion: GTN was found to be a chemosensitive condition, but more effective therapeutic protocols are therefore required.
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Affiliation(s)
- Mozaffar Aznab
- Department of Internal Medicine, Taleghani Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Anisodowleh Nankali
- Department of Obstetrics and Gynecology, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Sara Daeichin
- Department of Obstetrics and Gynecology, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Li J, Li S, Yu H, Wang X, Lu X. A comprehensive analysis of gestational trophoblastic neoplasia trials posted at online clinical trial registries. Eur J Obstet Gynecol Reprod Biol 2018; 230:136-140. [PMID: 30278377 DOI: 10.1016/j.ejogrb.2018.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/08/2018] [Accepted: 09/24/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We conducted a comprehensive analysis of gestational trophoblastic neoplasia (GTN) trials posted at online registries and aimed to provide useful information for future GTN trial designs. STUDY DESIGN We searched ClinicalTrials.gov, EU Clinical Trials Register, WHO International Clinical Trials Registry Portal (ICTRP) Search Portal, Australian New Zealand Clinical Trial Registry, ISRCTN Register, and Chinese Clinical Trial Register for all the clinical trials reporting GTN treatments. The general information of each trial was extracted. RESULTS Twenty trials meeting the inclusion criteria were included in the final analysis. In total, 6 trials were phase II trials, 2 were phase II/III trials, 7 were phase III trials, and 1 was a phase IV trial; and the phase type of 4 trials were not reported. The conditions included low-risk GTN (n = 15), high-risk GTN (n = 2), and mixed GTN (n = 3). Randomization was performed in 15 trials, and the remaining 5 trials were single-arm trials. The median enrollment size for randomized clinical trials (RCTs) and single-arm trials was 80 and 38, respectively. Among the RCTs, parallel assignment was used in 12 trials, crossover assignment was used in 1, and the intervention models of 2 were not reported. For masking, 15 trials were open-label, 2 were single-blinded, 2 were double-blinded, and the masking status of 1 was not reported. Ovarian functions and pregnancy outcome after chemotherapy were evaluated in only 2 trials. Regarding sponsorship, 2 trials had industry sponsorship. CONCLUSION Conducting RCTs for GTN is challenging, and international collaboration and smarter clinical trial designs are required for future GTN trials.
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Affiliation(s)
- Jun Li
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Shufen Li
- State Key Laboratory of Medical Genomics and Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Rd, Shanghai, 200025, China
| | - Hailin Yu
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Xingran Wang
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Xin Lu
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China.
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Li L, Wan X, Feng F, Ren T, Yang J, Zhao J, Jiang F, Xiang Y. Pulse actinomycin D as first-line treatment of low-risk post-molar non-choriocarcinoma gestational trophoblastic neoplasia. BMC Cancer 2018; 18:585. [PMID: 29792175 PMCID: PMC5966914 DOI: 10.1186/s12885-018-4512-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 05/16/2018] [Indexed: 11/25/2022] Open
Abstract
Background Little data exists predicting the resistance to actinomycin D (Act-D) single-agent for gestational trophoblastic neoplasia (GTN). The objective was to determine the overall success of pulse Act-D and the factors predictive of resistance to pulse Act-D in the treatment of low-risk, non-choriocarcinoma post-molar GTN. Methods From January 2013 to October 2016, according to the FIGO criteria for the diagnosis of post-molar disease and the FIGO risk-factor scoring system for GTN, a total of 135 patients with post-molar non-choriocarcinoma GTN who were chemotherapy-naive with a FIGO score < 7 were treated with single-agent pulse Act-D as a first-line regimen, in Peking Union Medical College Hospital. The pulse Act-D regimen is defined as 1.25 mg/m2 (max 2 mg) IV push every other week. All patients were followed until May 2017. Epidemiological and clinical data were compared between patients with remission and resistance to Act-D to determine predictive factors by univariate and multivariate analysis. Results Ninety-six of 135 patients (71.1%) achieved complete remission after first-line chemotherapy of pulse Act-D. In multivariate analysis, existing invasive uterine lesions observed by pre-chemotherapy transvaginal ultrasound (odds ratio [OR] 7.5, 95% confidence intervals [CI] 2.7–20.8), FIGO score ≥ 5 (OR 15.2, 95% CI 1.5–156.1) and pre-chemotherapy levels of β-hCG ≥ 4000 IU/L (OR 3.1, 95% CI 1.2–8.3) were independent high-risk factors predicting resistance to pulse Act-D as single-agent chemotherapy. During follow-up, no relapse, treatment-associated serious adverse events, or death occurred. Conclusions As first-line chemotherapy, pulse Act-D was effective and tolerable for patients with low-risk post-molar non-choriocarcinoma. Existing invasive uterine lesions observed by pre-chemotherapy transvaginal ultrasound, a FIGO score ≥ 5, and pre-chemotherapy levels of β-hCG ≥ 4000 IU/L were independent factors for resistance to pulse Act-D. Electronic supplementary material The online version of this article (10.1186/s12885-018-4512-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lei Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Tong Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Jun Zhao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Fang Jiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China.
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Bi X, Zhang J, Cao D, Sun H, Feng F, Wan X, Xiang Y, Qiu L, Cheng X, Yang J, Shen K. Anti-Müllerian hormone levels in patients with gestational trophoblastic neoplasia treated with different chemotherapy regimens: a prospective cohort study. Oncotarget 2017; 8:113920-113927. [PMID: 29371957 PMCID: PMC5768374 DOI: 10.18632/oncotarget.23027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/13/2017] [Indexed: 11/25/2022] Open
Abstract
Purpose To assess the ovarian reserve of patients with gestational trophoblastic neoplasia (GTN) treated with chemotherapy by evaluating serum anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) levels before, during, and after chemotherapy. Results The basal AMH level (mean: 3.98 ± 3.20 ng/mL) negatively correlated with age, while the basal FSH level (mean: 5.71 ± 9.69 mIU/mL) had no correlation with age. After 3 chemotherapy cycles, serum AMH levels decreased and FSH levels increased. The magnitude of the AMH level decline was significantly greater for combination chemotherapy than for single-agent dactinomycin D therapy (61.80% vs. 27.57%) (p = 0.0004) and was higher in patients whose regimens included etoposide (73.69% vs 40.51%) (p = 0.0359). After chemotherapy completion, AMH levels showed a further decline, and cumulative AMH concentration change was associated with doses of vincristine (p = 0.009) and etoposide (p = 0.032). At the 3-month follow-up, AMH levels significantly increased in the dactinomycin D group (p = 0.0067). Materials and Methods This prospective study included 34 patients with GTN. Serum AMH and FSH levels were measured before chemotherapy, after the 3rd cycle, and at 2 weeks and 3 months after chemotherapy. Cumulative changes of serum AMH levels in patients who received different chemotherapy regimens were analyzed. Conclusions Chemotherapy for GTN affects the ovarian reserve, with substantial differences between chemotherapy protocols. The results improve our understanding of ovarian toxicity and support the use of fertility preservation strategies.
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Affiliation(s)
- Xiaoning Bi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jingjing Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Hengzi Sun
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ling Qiu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xinqi Cheng
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jiaxin Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
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Andresen V, Gjertsen BT. Drug Repurposing for the Treatment of Acute Myeloid Leukemia. Front Med (Lausanne) 2017; 4:211. [PMID: 29238707 PMCID: PMC5712546 DOI: 10.3389/fmed.2017.00211] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 11/09/2017] [Indexed: 01/07/2023] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous disease characterized by the accumulation of immature myeloid progenitor cells in the bone marrow, compromising of normal blood cell production and ultimately resulting in bone marrow failure. With a 20% overall survival rate at 5 years and 50% in the 18- to 65-year-old age group, new medicines are needed. It is proposed that development of repurposed drugs may be a part of the new therapy needed. AML is subdivided into recurrent molecular entities based on molecular genetics increasingly accessible for precision medicine. Novel therapy developments form a basis for novel multimodality therapy and include liposomal daunorubicin/cytarabine, broad or FLT3-specific tyrosine kinase inhibitors, Bcl-2 family inhibitors, selective inhibitors of nuclear export, metabolic inhibitors, and demethylating agents. The use of non-transplant immunotherapy is in early development in AML with the exceptional re-approval of a toxin-conjugated anti-CD33. However, the full potential of small molecule inhibitors and modalities like immunological checkpoint inhibitors, immunostimulatory small molecules, and CAR-T cell therapy is unknown. Some novel therapeutics will certainly benefit AML patient subgroups; however, due to high cost, more affordable alternatives are needed globally. Also the heterogeneity of AML will likely demand a broader repertoire of therapeutic molecules. Drug repurposing or repositioning represent a source for potential therapeutics with well-known toxicity profiles and reasonable prices. This implies that biomarkers of response need to accompany the development of antileukemic therapies for sharply defined patient subgroups. We will illustrate repurposing in AML with selected examples and discuss some experimental and regulatory limitations that may obstruct this development.
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Affiliation(s)
- Vibeke Andresen
- Center for Cancer Biomarkers (CCBIO), Department of Clinical Science, Precision Oncology Research Group, University of Bergen, Bergen, Norway
| | - Bjørn T. Gjertsen
- Center for Cancer Biomarkers (CCBIO), Department of Clinical Science, Precision Oncology Research Group, University of Bergen, Bergen, Norway
- Department of Internal Medicine, Hematology Section, Haukeland University Hospital, Bergen, Norway
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SEOM clinical guidelines in gestational trophoblastic disease (2017). Clin Transl Oncol 2017; 20:38-46. [PMID: 29149431 PMCID: PMC5785593 DOI: 10.1007/s12094-017-1793-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/02/2017] [Indexed: 11/20/2022]
Abstract
Gestational trophoblastic disease (GTD) is a rare but curable disease. Recent improvements in diagnosis and molecular biology have resulted in changes in staging and treatment. These guidelines provide evidence-based recommendation on how to manage GTD.
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Wang Q, Fu J, Hu L, Fang F, Xie L, Chen H, He F, Wu T, Lawrie TA. Prophylactic chemotherapy for hydatidiform mole to prevent gestational trophoblastic neoplasia. Cochrane Database Syst Rev 2017; 9:CD007289. [PMID: 28892119 PMCID: PMC6483742 DOI: 10.1002/14651858.cd007289.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND This is an update of the original Cochrane Review published in Cochrane Library, Issue 10, 2012.Hydatidiform mole (HM), also called a molar pregnancy, is characterised by an overgrowth of foetal chorionic tissue within the uterus. HMs may be partial (PM) or complete (CM) depending on their gross appearance, histopathology and karyotype. PMs usually have a triploid karyotype, derived from maternal and paternal origins, whereas CMs are diploid and have paternal origins only. Most women with HM can be cured by evacuation of retained products of conception (ERPC) and their fertility preserved. However, in some women the growth persists and develops into gestational trophoblastic neoplasia (GTN), a malignant form of the disease that requires treatment with chemotherapy. CMs have a higher rate of malignant transformation than PMs. It may be possible to reduce the risk of GTN in women with HM by administering prophylactic chemotherapy (P-Chem). However, P-Chem given before or after evacuation of HM to prevent malignant sequelae remains controversial, as the risks and benefits of this practice are unclear. OBJECTIVES To evaluate the effectiveness and safety of P-Chem to prevent GTN in women with a molar pregnancy. To investigate whether any subgroup of women with HM may benefit more from P-Chem than others. SEARCH METHODS For the original review we performed electronic searches in the Cochrane Gynaecological Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2012), MEDLINE (1946 to February week 4, 2012) and Embase (1980 to 2012, week 9). We developed the search strategy using free text and MeSH. For this update we searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 5, 2017), MEDLINE (February 2012 to June week 1, 2017) and Embase (February 2012 to 2017, week 23). We also handsearched reference lists of relevant literature to identify additional studies and searched trial registries. SELECTION CRITERIA We included randomised controlled trials (RCTs) of P-Chem for HM. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion in the review and extracted data using a specifically designed data collection form. Meta-analyses were performed by pooling data from individual trials using Review Manager 5 (RevMan 5) software in line with standard methodological procedures expected by Cochrane methodology. MAIN RESULTS The searches identified 161 records; after de-duplication and title and abstract screening 90 full-text articles were retrieved. From these we included three RCTs with a combined total of 613 participants. One study compared prophylactic dactinomycin to no prophylaxis (60 participants); the other two studies compared prophylactic methotrexate to no prophylaxis (420 and 133 participants). All participants were diagnosed with CMs. We considered the latter two studies to be of poor methodological quality.P-Chem reduced the risk of GTN occurring in women following a CM (3 studies, 550 participants; risk ratio (RR) 0.37, 95% confidence interval (CI) 0.24 to 0.57; I² = 0%; P < 0.00001; low-quality evidence). However, owing to the poor quality (high risk of bias) of two of the included studies, we performed sensitivity analyses excluding these two studies. This left only one small study of high-risk women to contribute data for this primary outcome (59 participants; RR 0.28, 95% CI 0.10 to 0.73; P = 0.01); therefore we consider this evidence to be of low quality.The time to diagnosis was longer in the P-Chem group than the control group (2 studies, 33 participants; mean difference (MD) 28.72, 95% CI 13.19 to 44.24; P = 0.0003; low-quality evidence); and the P-Chem group required more courses to cure subsequent GTN (1 poor-quality study, 14 participants; MD 1.10, 95% CI 0.52 to 1.68; P = 0.0002; very low quality evidence).There were insufficient data to perform meta-analyses for toxicity, overall survival, drug resistance and reproductive outcomes. AUTHORS' CONCLUSIONS P-Chem may reduce the risk of progression to GTN in women with CMs who are at a high risk of malignant transformation; however, current evidence in favour of P-Chem is limited by the poor methodological quality and small size of the included studies. As P-Chem may increase drug resistance, delays treatment of GTN and may expose women toxic side effects, this practice cannot currently be recommended.
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Affiliation(s)
- Qiuyi Wang
- West China Second University Hospital, West China Women's and Children's HospitalDepartment of Obstetrics and Gynecology2 JiangtianluChengduSichuanChina610041
| | - Jing Fu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyChengduSichuanChina
- Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan UniversityChengduChina
| | - Lina Hu
- The Second Affiliated Hospital of Chongqing Medical UniversityThe Obstetrics and Gynecology Department76 Linjiang RdChongqingChina400010
| | - Fang Fang
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyChengduSichuanChina
| | - Lingxia Xie
- West China Second University Hospital, West China Women's and Children's HospitalDepartment of Obstetrics and Gynecology2 JiangtianluChengduSichuanChina610041
| | - Hengxi Chen
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyChengduSichuanChina
| | - Fan He
- The Second Affiliated Hospital of Chongqing Medical UniversityCenter for Reproductive Medicine, Department of Obstetrics and Gynecology74 Linjiang RoadChongqingChongqingChina400010
| | - Taixiang Wu
- West China Hospital, Sichuan UniversityChinese Clinical Trial Registry, Chinese Ethics Committee of Registering Clinical TrialsNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Theresa A Lawrie
- The Evidence‐Based Medicine Consultancy Ltd3rd Floor Northgate HouseUpper Borough WallsBathUKBA1 1RG
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Miller CR, Chappell NP, Sledge C, Leath CA, Phippen NT, Havrilesky LJ, Barnett JC. Are different methotrexate regimens as first line therapy for low risk gestational trophoblastic neoplasia more cost effective than the dactinomycin regimen used in GOG 0174? Gynecol Oncol 2016; 144:125-129. [PMID: 27816248 DOI: 10.1016/j.ygyno.2016.10.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 10/21/2016] [Accepted: 10/23/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Gynecologic Oncology Group (GOG) 0174 compared weekly intramuscular methotrexate (MTX) with biweekly pulsed intravenous dactinomycin (Act-D) as single-agent chemotherapy for low-risk gestational trophoblastic neoplasia (GTN). Act-D had a higher rate of initial complete response (CR) (70% vs. 53%, p=0.01), but multi-day regimens of MTX have higher historic success rates. We assessed the cost-effectiveness of Act-D vs. MTX per GOG 0174 and explored multi-day MTX regimens. METHODS A cost effectiveness decision model was constructed with data from GOG 0174. Outcome was cost per first-line treatment success expressed in terms of incremental cost-effectiveness ratio (ICER). Front-line failures were assumed to receive cross-over single agent therapy, second line failures; multi-agent chemotherapy. GOG 0174 had no quality of life (QOL) evaluation, so equal QOL (utility 1.0) was assumed but varied in sensitivity analysis. A second exploratory model included 5-day and 8-day MTX regimens. RESULTS Act-D ($18,505) was more expensive compared to weekly MTX ($8950) with an ICER of $56,215 per first-line treatment success compared to weekly MTX. Small decreases in QOL dramatically increased the ICER during sensitivity analysis. Models with multi-day MTX regimens were also more cost-effective than Act-D. If effectiveness was redefined as avoidance of multi-agent chemotherapy, weekly MTX was more effective. CONCLUSIONS With a complete cure rate for low-risk GTN regardless of initial agent, our model supports provider hesitation toward first line Act-D for low risk GTN. While Act-D is more effective for first line treatment success, it is more costly, and does not decrease rate of multi-agent chemotherapy use.
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Affiliation(s)
- Caela R Miller
- San Antonio Military Medical Center, Ft Sam Houston, TX, United States.
| | - Nicole P Chappell
- San Antonio Military Medical Center, Ft Sam Houston, TX, United States
| | - Caitlin Sledge
- San Antonio Military Medical Center, Ft Sam Houston, TX, United States
| | - Charles A Leath
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Neil T Phippen
- Walter Reed National Military Medical Center, Bethesda, MD, United States
| | | | - Jason C Barnett
- San Antonio Military Medical Center, Ft Sam Houston, TX, United States
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Lee YJ, Park JY, Kim DY, Suh DS, Kim JH, Kim YM, Kim YT, Nam JH. Comparing and evaluating the efficacy of methotrexate and actinomycin D as first-line single chemotherapy agents in low risk gestational trophoblastic disease. J Gynecol Oncol 2016; 28:e8. [PMID: 27819410 PMCID: PMC5323289 DOI: 10.3802/jgo.2017.28.e8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 09/19/2016] [Accepted: 09/28/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare responses to single-agent chemotherapies and evaluate the predictive factors of resistance in low risk (LR) gestational trophoblastic disease (GTD). The chemotherapy agents included methotrexate (MTX) and actinomycin D (ACT-D). METHODS We conducted a retrospective study of 126 patients with GTD who were treated between 2000 and 2013. A total of 71 patients with LR GTD were treated with MTX (8-day regimen or weekly regimen, n=53) or ACT-D (bi-weekly pulsed regimen or 5-day regimen, n=18). The successful treatment group and the failed treatment group were compared and analyzed to identify prognostic factors. RESULTS The complete response rates were 83.3% for ACT-D and 62.2% for MTX, with no statistically significant difference. There was no severe adverse effect reported for either group. Longer interval durations from the index pregnancy (>2 months, p=0.040) and larger tumor size (>3 cm, p=0.020) were more common in non-responders than in responders; these results were statistically significant. CONCLUSION Based on our results, ACT-D may be a better option than MTX as a first-line single chemotherapy agent for LR GTD. The bi-weekly pulsed ACT-D regimen had minimal, or at least the same, toxicities compared with MTX. However, due to the lack of strong supporting evidence, it cannot be conclusively stated that this is the best single agent for first-line chemotherapy in LR GTD patients. Further larger controlled trials will be necessary to establish the best guidelines for GTD treatment.
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Affiliation(s)
- Young Jae Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeong Yeol Park
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Dae Yeon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dae Shik Suh
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jong Hyeok Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yong Man Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young Tak Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Joo Hyun Nam
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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