Chemotherapy for resistant or recurrent gestational trophoblastic neoplasia

Challenges in treatment of gestational trophoblastic neoplasia in patients with MTHFR mutation: A case report

•We present a case of a patient with post molar pregnancy who has a MTHFR C677T mutation.•The mutation led to an alteration of recommended chemotherapy regimen.•No studies have reported treatment recommendations pertaining to gyn malignancies in patients with MTHFR allele.•We present a novel instance where MTHFR mutation altered a patient's treatment for gestational trophoblastic neoplasia.

Risk Factors That Correlate with Resistance to First-Line Chemotherapy on High-risk Gestational Trophoblastic Neoplasia

BACKGROUND: Gestational trophoblastic neoplasia (GTN) is a condition arising from abnormal proliferation of the trophoblastic cells. GTN incidence in Indonesia, precisely in Hasan Sadikin General Hospital, as many as 730 cases are reported per year. GTN is generally highly sensitive to chemotherapy, and multiagent chemotherapy regimens are recommended for high-risk GTN. Multiagent chemotherapy regimens for GTN treatment at Hasan Sadikin General Hospital are EMCO, with no other literature study describing chemotherapy resistance with EMCO today. AIM: This study aimed to identify risk factors associated with first-line chemotherapy resistance at Hasan Sadikin General Hospital. METHODS: In this cross-sectional study, medical records of 81 patients with high-risk GTN presented in the period from January 2018 to June 2021 who received EMCO chemotherapy at Hasan Sadikin General Hospital were retrieved from the archives, and medical data were reviewed and analyzed. Bivariate analysis was performed using the Chi-square test with Fisher’s exact alternative, and multivariate analysis using the binary logistic regression test. p < 0.05 was considered statistically significant. RESULTS: From 81 samples that received EMCO chemotherapy, 15 (18.5%) cases were resistant to EMCO, and 66 (81.5%) cases were responsive to EMCO. The risk factors associated with EMCO resistance were histopathological features and appropriate with EMCO chemotherapy interval (p < 0.05). Variables of age, previous pregnancy, GTN stage, FIGO prognostic score, stage, beta-hCG level, and side effects of EMCO did not significantly correlate with resistance to EMCO (p > 0.05). CONCLUSION: Histopathological features and appropriate chemotherapy intervals were associated with the incidence of resistance to EMCO in Hasan Sadikin General Hospital.

Forskolin promotes vasculogenic mimicry and invasion via Notch‑1‑activated epithelial‑to‑mesenchymal transition in syncytiolization of trophoblast cells in choriocarcinoma

Choriocarcinoma (CC) is characterized by earlier blood metastasis compared with other female genital tumors and a high incidence of massive hemorrhage. Vasculogenic mimicry (VM) is highly associated with metastasis, and syncytiotrophoblast is involved in the formation of VM in CC. Forskolin is a typical activator of the cAMP pathway, which is involved in the syncytiolization of trophoblastic cells. In the present study, to determine the effects and mechanism of forskolin on cell invasion and VM during syncytiolization in vitro and in vivo, JEG-3 and JAR cell lines were treated with 100 µM forskolin for 48 h, and wound healing and invasion assays were used to verify cell migratory and invasive capacities. A 3D culture and tube formation assays were established to detect VM. Variation of morphology and markers of the epithelial-to-mesenchymal transition (EMT) were assessed, and the role of the Notch signaling pathway was investigated in CC cells treated with forskolin. The results of the present study demonstrated that 100 µM forskolin induced syncytiolization of trophoblastic cells and enhanced the migratory and invasive abilities of JEG-3 and JAR cell lines. In addition, the capacity of VM was significantly increased, whereas tube formation ability was decreased by forskolin in vitro and in vivo compared with the respective control groups. The cellular morphology exhibited EMT during the syncytiolization process, which was further supported by the changes in EMT marker expression, including downregulation of E-cadherin and cytokeratin and upregulation of N-cadherin, vimentin and zinc finger E-box-binding homeobox 1. The Notch-1 signaling pathway was activated to induce EMT in forskolin-induced VM process in CC cells, and VM and EMT could be reversed by using the γ-secretase inhibitor DAPT to block the Notch-1 pathway. Overall, the results of the present study demonstrated that forskolin enhanced the capacity of VM formation and metastasis through Notch-1-activated EMT in the syncytiolization of trophoblastic cells.

Low-risk gestational trophoblastic neoplasia: A single-center experience from Saudi Arabia

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.

Quantitative Chemotherapeutic Profiling of Gynecologic Cancer Cell Lines Using Approved Drugs and Bioactive Compounds

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.

Second Curettage for Low-Risk Nonmetastatic Gestational Trophoblastic Neoplasia

OBJECTIVE

To evaluate the efficacy and safety of second uterine curettage in lieu of chemotherapy for patients with low-risk, nonmetastatic gestational trophoblastic neoplasia (GTN) and to evaluate whether response to second curettage is independent of patient age, World Health Organization (WHO) risk score, registration human chorionic gonadotropin (hCG) level, lesion size, and depth of myometrial invasion measured on ultrasound examination.

METHODS

This was a cooperative group multicenter prospective phase II study. Prestudy testing included quantitative hCG level, pelvic ultrasonography, and chest radiography. Patients were categorized according to WHO risk scoring criteria (low risk with a score of 0-6).

RESULTS

Sixty-four women with newly diagnosed low-risk, nonmetastatic GTN were enrolled. Four patients were excluded. Twenty-four patients (40%) (lower 95% confidence limit 27.6%) were cured after second curettage. An additional two patients (3%) achieved a complete response but did not complete follow-up. Overall, 26 of 60 patients were able to avoid chemotherapy. Surgical failure was observed in 34 women (59%) and was more common in women 19 years old or younger or 40 years old or older. One case of grade 1 uterine perforation was successfully managed by observation. Four grade 1 and one grade 3 uterine hemorrhages were reported. New metastatic disease (lung) was identified in one of these women after second curettage. In three patients (surgical failures), the second curettage pathology was placental site trophoblastic tumor, and it was placental nodule in one additional patient.

CONCLUSION

Second uterine curettage as initial treatment for low-risk, nonmetastatic GTN cures 40% of patients without significant morbidity.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov/, NCT00521118.

BRD4 inhibitor inhibits colorectal cancer growth and metastasis

Post-translational modifications have been identified to be of great importance in cancers and lysine acetylation, which can attract the multifunctional transcription factor BRD4, has been identified as a potential therapeutic target. In this paper, we identify that BRD4 has an important role in colorectal cancer; and that its inhibition substantially wipes out tumor cells. Treatment with inhibitor MS417 potently affects cancer cells, although such effects were not always outright necrosis or apoptosis. We report that BRD4 inhibition also limits distal metastasis by regulating several key proteins in the progression of epithelial-to-mesenchymal transition (EMT). This effect of BRD4 inhibitor is demonstrated via liver metastasis in animal model as well as migration and invasion experiments in vitro. Together, our results demonstrate a new application of BRD4 inhibitor that may be of clinical use by virtue of its ability to limit metastasis while also being tumorcidal.

Incidence of gestational trophoblastic disease in Tokat province, Turkey

OBJECTIVE

This study investigated the incidence of gestational trophoblastic disease (GTD) in Tokat province, Turkey.

MATERIAL AND METHODS

The medical records of patients who had been diagnosed and treated at one university hospital, six government hospitals, and one specialist hospital in Tokat province between January 2005 and December 2012 were evaluated retrospectively.

RESULTS

During the study period, there were 59,754 births and GTD was diagnosed in 73 cases. The calculated GTD incidence was 1.22/1000. The mean age of the patients diagnosed with GTD was 28.6±7.3 (range 17-51) years. In GTD, complete moles occurred in 26%, partial moles in 74%, and no invasive moles, choriocarcinomas, or placental site trophoblastic tumours were found. Only two patients received chemotherapy (methotrexate). There was no mortality associated with the disease during follow-up.

CONCLUSION

The incidence of GTD in Tokat province was 1.2 per 1000 births. Early diagnosis, treatment, and follow-up play a critical role in preventing the morbidity and mortality associated with disease. The incidence of GTD, which has a high recovery rate with adequate treatment and follow-up, can be determined from regional and community-based research.

Management of Chemoresistant and Quiescent Gestational Trophoblastic Disease

Gestational trophoblastic neoplasia (GTN) is highly chemosensitive and has a high cure rate. Since the introduction of chemotherapy, reliable measurement of human chorionic gonadotropin (hCG) levels, and individualised risk-based therapy into the management of GTN, almost all low-risk and more than 80 % of high-risk GTN cases are curable. However, approximately 25 % of high-risk GTN developed resistance to chemotherapy or relapsed after completion of initial therapy, which often necessitate salvage combination chemotherapy. On the other end of the spectrum, a proportion of patients with gestational trophoblastic disease (GTD) have persistently low levels of hCG, without clinical or radiological evidence of disease, a condition called quiescent GTD. Recently, measurement of hyperglycosylated hCG has been proposed for the management of patients with quiescent GTD. Although representing a small proportion of GTD cases, the management of patients with chemoresistant and quiescent GTD often poses challenges to medical practitioners.

Endometrial carcinoma with yolk sac tumor-like differentiation and elevated serum β-hCG: a case report and literature review

Endometrial carcinoma with a germ cell tumor component is a rare event. Here we report a uterine neoplasm with a unique combination of endometrioid adenocarcinoma and mixed germ cell malignant elements. A 28-year-old woman with abnormal vaginal bleeding, an abdominal mass, and elevated alfa-fetoprotein and beta-human chorionic gonadotropin (β-hCG) levels had a history of biopsy of an omental mass and chemotherapy in another hospital one month before her referral to our department. Histologic examination of the mass removed from the omentum revealed an endometrioid adenocarcinoma with yolk sac tumor-like differentiation. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, and removal of metastatic disease were then undertaken at our hospital. Postoperative chemotherapy was given. Eight months postoperatively, serum alfa-fetoprotein and β-hCG rose again. Cases with primary yolk sac tumors of the endometrium or endometrial carcinoma with trophoblastic differentiation in the literature were reviewed.

'There and back again': revisiting the pathophysiological roles of human endogenous retroviruses in the post-genomic era

Almost 8% of the human genome comprises endogenous retroviruses (ERVs). While they have been shown to cause specific pathologies in animals, such as cancer, their association with disease in humans remains controversial. The limited evidence is partly due to the physical and bioethical restrictions surrounding the study of transposons in humans, coupled with the major experimental and bioinformatics challenges surrounding the association of ERVs with disease in general. Two biotechnological landmarks of the past decade provide us with unprecedented research artillery: (i) the ultra-fine sequencing of the human genome and (ii) the emergence of high-throughput sequencing technologies. Here, we critically assemble research about potential pathologies of ERVs in humans. We argue that the time is right to revisit the long-standing questions of human ERV pathogenesis within a robust and carefully structured framework that makes full use of genomic sequence data. We also pose two thought-provoking research questions on potential pathophysiological roles of ERVs with respect to immune escape and regulation.

Combination chemotherapy for primary treatment of high-risk gestational trophoblastic tumour

BACKGROUND

This is an update of the original review that was published in The Cochrane Database of Systematic Reviews, 2009, Issue 2. Gestational trophoblastic neoplasia (GTN) are malignant disorders of the placenta that include invasive hydatidiform mole, choriocarcinoma, placental-site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). Choriocarcinoma and invasive hydatidiform mole respond well to chemotherapy: low-risk tumours are treated with single-agent chemotherapy (e.g. methotrexate or actinomycin D), whereas high-risk tumours are treated with combination chemotherapy (e.g. EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine)). Various drug combinations may be used for high-risk tumours; however, the comparative efficacy and safety of these regimens is not clear.

OBJECTIVES

To determine the efficacy and safety of combination chemotherapy in treating high-risk GTN.

SEARCH METHODS

For the original review, we searched the Cochrane Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL; Issue 2, 2008), MEDLINE, EMBASE and CBM in May 2008. For the updated review, we searched Cochrane Group Specialised Register, CENTRAL, MEDLINE and EMBASE to September 2012. In addition, we searched online clinical trial registries for ongoing trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing first-line combination chemotherapy interventions in women with high-risk GTN.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected data using a data extraction form. Meta-analysis could not be performed as we included only one study.

MAIN RESULTS

We included one RCT of 42 women with high-risk GTN who were randomised to MAC (methotrexate, actinomycin D and chlorambucil) or the modified CHAMOCA regimen (cyclophosphamide, hydroxyurea, actinomycin D, methotrexate, doxorubicin, melphalan and vincristine). There were no statistically significant differences in efficacy of the two regimens; however women in the MAC group experienced statistically significantly less toxicity overall and less haematological toxicity than women in the CHAMOCA group. During the study period, six women in the CHAMOCA group died compared with one in the MAC group. This study was stopped early due to unacceptable levels of toxicity in the CHAMOCA group. We identified no RCTs comparing EMA/CO with MAC or other chemotherapy regimens.

AUTHORS' CONCLUSIONS

CHAMOCA is not recommended for GTN treatment as it is more toxic and not more effective than MAC. EMA/CO is currently the most widely used first-line combination chemotherapy for high-risk GTN, although this regimen has not been rigorously compared to other combinations such as MAC or FAV in RCTs. Other regimens may be associated with less acute toxicity than EMA/CO; however, proper evaluation of these combinations in high-quality RCTs that include long-term surveillance for secondary cancers is required. We acknowledge that, given the low incidence of GTN, RCTs in this field are difficult to conduct, hence multicentre collaboration is necessary.