1
|
Hamid M, Joyce CM, Carroll HK, Kenneally C, Mulcahy S, O'Neill MK, Coulter J, O'Reilly S. Challenging gestational trophoblastic disease cases and mimics: An exemplar for the management of rare tumours. Eur J Obstet Gynecol Reprod Biol 2023; 286:76-84. [PMID: 37224702 DOI: 10.1016/j.ejogrb.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Rare tumour management is challenging for clinicians as evidence bases are limited and clinical trials are difficult to conduct. It is even more difficult for patients where self-reliance alone is insufficient to overcome the challenges of navigating care which is often poorly evidence based. In Ireland, a national Gestational Trophoblastic Disease (GTD) service was established as one of 3 initiatives for rare tumours by the National Cancer Control Programme. The service has a national clinical lead, a dedicated supportive nursing service and a clinical biochemistry liaison team. This study sought to assess the impact of a GTD centre using national clinical guidelines and integrating and networking with European and International GTD groups on the clinical management of challenging GTD cases and to consider the application of this model of care to other rare tumour management. STUDY DESIGN In this article, we analyse the impact of a national GTD service on five challenging cases, and review how the service affects patient management in this rare tumour type. These cases were selected from a cohort of patients who were voluntarily registered in the service based on the diagnostic management dilemma they posed. RESULTS Case management was impacted by the identification of GTD mimics, the provision of lifesaving treatment of metastatic choriocarcinoma with brain metastasis, networking with international colleagues, the identification of early relapse, the use of genetics to differentiate treatment pathways and prognosis, and supportive supervision of treatment courses of up to 2 years of therapy in a cohort of patients starting or completing families. CONCLUSION The National GTD service could be an exemplar for the management of rare tumours (such as cholangiocarcinoma) in our jurisdiction which could benefit from a similar constellation of supports. Our study demonstrates the importance of a nominated national clinical lead, dedicated nurse navigator support, registration of cases and networking. The impact of our service would be greater if registration was mandatory rather than voluntary. Such a measure would also ensure equity of access for patients to the service, assist in quantifying the need for resourcing and facilitate research to improve outcomes.
Collapse
Affiliation(s)
- M Hamid
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland
| | - C M Joyce
- Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology, University College Cork, Cork, Ireland; Department of Biochemistry and Cell Biology, University College Cork, Cork, Ireland; Department of Clinical Biochemistry, Cork University Hospital, Cork, Ireland.
| | - H K Carroll
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland
| | - C Kenneally
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - S Mulcahy
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Mary-Kate O'Neill
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - J Coulter
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - S O'Reilly
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland; Cancer Research @UCC, University College Cork, Cork, Ireland
| |
Collapse
|
2
|
You B, Bolze PA, Lotz JP, Massardier J, Gladieff L, Floquet A, Hajri T, Descargues P, Langlois-Jacques C, Bin S, Villeneuve L, Roux A, Alves-Ferreira M, Grazziotin-Soares D, Dherret G, Gerentet C, Rousset P, Freyer G, Golfier F. Avelumab in patients with gestational trophoblastic tumors with resistance to polychemotherapy: Cohort B of the TROPHIMMUN phase 2 trial. Gynecol Oncol 2023; 168:62-67. [PMID: 36401942 DOI: 10.1016/j.ygyno.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE There is a need for innovative treatments in women with gestational trophoblastic tumors (GTT) resistant to chemotherapy. The TROPHIMMUN trial assessed the efficacy of avelumab in patients with resistance to single-agent chemotherapy (cohort A), or to polychemotherapy (cohort B). Cohort B outcomes are reported here. METHODS In the cohort B of this phase 2 multicenter trial (NCT03135769), women with GTT progressing after polychemotherapy received avelumab 10 mg/kg intravenously every 2 weeks until human chorionic gonadotropin (hCG) normalization, followed by 3 consolidation cycles. The primary endpoint was the rate of hCG normalization enabling treatment discontinuation (2-stage Simon design). RESULTS Between February 2017 and August 2020, 7 patients were enrolled. Median age was 37 years (range: 29-47); disease stage was I or III in 42.9% and 57.1%; FIGO score was 9-10 in 28.6%, 11 in 28.6%, and 16 in 14.3%, respectively. Median follow-up was 18.2 months. One patient (14.3%) experienced hCG normalization enabling treatment discontinuation. However, resistance to avelumab was observed in the remaining 6 patients (85.7%). The cohort B was stopped for futility. Grade 1-2 treatment-related adverse events occurred in 57.1%, most commonly fatigue (42.9%), nausea, diarrhea, infusion-related reaction, muscle pains, dry eyes (each 14.3%). The median resistance-free survival was 1.4 months (95% CI 0.7-5.3). CONCLUSIONS Although avelumab is active in patients with single-agent chemotherapy-resistant GTT (cohort A), it was associated with limited efficacy in patients with resistance to polychemotherapy (cohort B). The prognosis of patients with polychemotherapy resistance remains poor, and innovative immunotherapy-based therapeutic combinations are needed.
Collapse
Affiliation(s)
- Benoit You
- Centre de Référence des Maladies Trophoblastiques, Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Sud, EA 3738 CICLY, Lyon, France; Medical Oncology, Institut de Cancérologie des Hospices Civils de Lyon (IC-HCL), CITOHL, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France.
| | - Pierre-Adrien Bolze
- Centre de Référence des Maladies Trophoblastiques, Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Sud, EA 3738 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, APHP, 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
| | | | - Touria Hajri
- Centre de Référence des Maladies Trophoblastiques, Lyon, France
| | - Pierre Descargues
- Centre de Référence des Maladies Trophoblastiques, Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Sud, EA 3738 CICLY, Lyon, France; Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Carole Langlois-Jacques
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; 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
| | - Laurent Villeneuve
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, 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, APHP, Université Pierre et Marie Curie, Paris, France
| | - Guillemine Dherret
- Medical Oncology, Institut de Cancérologie des Hospices Civils de Lyon (IC-HCL), CITOHL, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France
| | - Christine Gerentet
- Medical Oncology, Institut de Cancérologie des Hospices Civils de Lyon (IC-HCL), CITOHL, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France
| | - Pascal Rousset
- Univ Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Sud, EA 3738 CICLY, Lyon, France; Radiologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Gilles Freyer
- Univ Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Sud, EA 3738 CICLY, Lyon, France; Medical Oncology, Institut de Cancérologie des Hospices Civils de Lyon (IC-HCL), CITOHL, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France
| | - Francois Golfier
- Centre de Référence des Maladies Trophoblastiques, Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Sud, EA 3738 CICLY, Lyon, France; Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France
| |
Collapse
|
3
|
Liang L, Chen Y, Wu C, Cao Z, Xia L, Meng J, He L, Yang C, Wang Z. MicroRNAs: key regulators of the trophoblast function in pregnancy disorders. J Assist Reprod Genet 2023; 40:3-17. [PMID: 36508034 PMCID: PMC9742672 DOI: 10.1007/s10815-022-02677-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022] Open
Abstract
The placenta is essential for a successful pregnancy and healthy intrauterine development in mammals. During human pregnancy, the growth and development of the placenta are inseparable from the rapid proliferation, invasion, and migration of trophoblast cells. Previous reports have shown that the occurrence of many pregnancy disorders may be closely related to the dysfunction of trophoblasts. However, the function regulation of human trophoblast cells in the placenta is poorly understood. Therefore, studying the factors that regulate the function of trophoblast cells is necessary. MicroRNAs (miRNAs) are small, non-coding, single-stranded RNA molecules. Increasing evidence suggests that miRNAs play a crucial role in regulating trophoblast functions. This review outlines the role of miRNAs in regulating the function of trophoblast cells and several common signaling pathways related to miRNA regulation in pregnancy disorders.
Collapse
Affiliation(s)
- Lingli Liang
- grid.412017.10000 0001 0266 8918Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hunan International Scientific and Technological Cooperation Base of Arteriosclerotic Disease, Hengyang Medical College, University of South China, Hengyang, 421001 China
| | - Yanjun Chen
- grid.412017.10000 0001 0266 8918Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hunan International Scientific and Technological Cooperation Base of Arteriosclerotic Disease, Hengyang Medical College, University of South China, Hengyang, 421001 China
| | - Chunyan Wu
- grid.412017.10000 0001 0266 8918Department of Cardiovascular, The Third Affiliated Hospital of University of South China, Hengyang, 421001 China
| | - Zitong Cao
- grid.412017.10000 0001 0266 8918Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hunan International Scientific and Technological Cooperation Base of Arteriosclerotic Disease, Hengyang Medical College, University of South China, Hengyang, 421001 China
| | - Linzhen Xia
- grid.412017.10000 0001 0266 8918Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hunan International Scientific and Technological Cooperation Base of Arteriosclerotic Disease, Hengyang Medical College, University of South China, Hengyang, 421001 China
| | - Jun Meng
- grid.461579.8Department of Function, The First Affiliated Hospital of University of South China, Hengyang, 421001 China
| | - Lu He
- grid.461579.8Department of Gynecology, The First Affiliated Hospital of University of South China, Hengyang, 421001 China
| | - Chunfen Yang
- grid.461579.8Department of Gynecology, The First Affiliated Hospital of University of South China, Hengyang, 421001 China
| | - Zuo Wang
- grid.412017.10000 0001 0266 8918Institute of Cardiovascular Disease, Key Laboratory for Arteriosclerology of Hunan Province, Hunan International Scientific and Technological Cooperation Base of Arteriosclerotic Disease, Hengyang Medical College, University of South China, Hengyang, 421001 China
| |
Collapse
|
4
|
Liu W, Zhao W, Huang X. Outcomes and prognostic factors of placental-site trophoblastic tumor: a retrospective study of 58 cases. Arch Gynecol Obstet 2022; 306:1633-1641. [DOI: 10.1007/s00404-022-06502-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/28/2022] [Indexed: 11/02/2022]
|
5
|
Tsai J, Vellayappan B, Venur V, McGranahan T, Gray H, Urban RR, Tseng YD, Palmer J, Foote M, Mayr NA, Combs SE, Sahgal A, Chang EL, Lo SS. The optimal management of brain metastases from gestational trophoblastic neoplasia. Expert Rev Anticancer Ther 2022; 22:307-315. [PMID: 35114862 DOI: 10.1080/14737140.2022.2038566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Gestational trophoblastic diseases and neoplasias (GTDs and GTNs) comprise a spectrum of diseases arising from abnormally proliferating placental/trophoblastic tissue following an antecedent molar or non-molar pregnancy. These can spread to the brain hematogenously in about 10% of patients, mostly in high-risk disease. The optimal management of patients with brain metastases from GTN is unclear, with multiple systemic regimens under use and an uncertain role for radiotherapy. AREAS COVERED Here, we review the epidemiology, workup, and treatment of GTN with central nervous system (CNS) involvement. Literature searches in PubMed and Google Scholar were conducted using combinations of keywords such as "gestational trophoblastic disease," "gestational trophoblastic neoplasia," "choriocarcinoma," and "brain metastases." EXPERT OPINION Systemic therapy is the frontline treatment for GTN with brain metastases, and radiotherapy should only be considered in the context of a clinical trial or for resistant/recurrent disease. Surgery has a limited role in palliating symptoms or relieving intracranial pressure/bleeding. Given the highly specialized care these patients require, treatment at a high-volume referral center with multidisciplinary collaboration likely leads to better outcomes. Randomized trials should be conducted to determine the best systemic therapy option for GTN.
Collapse
Affiliation(s)
- Joseph Tsai
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
| | | | - Vyshak Venur
- Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Tresa McGranahan
- Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Heidi Gray
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | - Renata R Urban
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
| | - Joshua Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital, The Ohio State University, Columbus, OH, USA
| | - Matthew Foote
- Princess Alexandra Hospital, University of Queensland, ICON Cancer Care, Brisbane 4072, Australia
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA 98195, USA
| |
Collapse
|
6
|
Albright BB, Myers ER, Moss HA, Ko EM, Sonalkar S, Havrilesky LJ. Surveillance for gestational trophoblastic neoplasia following molar pregnancy: a cost-effectiveness analysis. Am J Obstet Gynecol 2021; 225:513.e1-513.e19. [PMID: 34058170 PMCID: PMC9941751 DOI: 10.1016/j.ajog.2021.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Historically, published guidelines for care after molar pregnancy recommended monitoring human chorionic gonadotropin levels for the development of gestational trophoblastic neoplasia until normal and then for 6 months after the first normal human chorionic gonadotropin. However, there are little data underlying such recommendations, and recent evidence has demonstrated that gestational trophoblastic neoplasia diagnosis after human chorionic gonadotropin normalization is rare. OBJECTIVE We sought to estimate the cost-effectiveness of alternative strategies for surveillance for gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after complete and partial molar pregnancy. STUDY DESIGN A Markov-based cost-effectiveness model, using monthly cycles and terminating after 36 months/cycles, was constructed to compare alternative strategies for asymptomatic human chorionic gonadotropin surveillance after the first normal (none; monthly testing for 1, 3, 6, and 12 months; or every 3-month testing for 3, 6, and 12 months) for both complete and partial molar pregnancy. The risk of reduced surveillance was modeled by increasing the probability of high-risk disease at diagnosis. Probabilities, costs, and utilities were estimated from peer-reviewed literature, with all cost data applicable to the United States and adjusted to 2020 US dollars. The primary outcome was cost per quality-adjusted life year ($/quality-adjusted life year) with a $100,000/quality-adjusted life year willingness-to-pay threshold. RESULTS Under base-case assumptions, we found no further surveillance after the first normal human chorionic gonadotropin to be the dominant strategy from both the healthcare system and societal perspectives, for both complete and partial molar pregnancy. After complete mole, this strategy had the lowest average cost (healthcare system, $144 vs maximum $283; societal, $152 vs maximum $443) and highest effectiveness (2.711 vs minimum 2.682 quality-adjusted life years). This strategy led to a slightly higher rate of death from gestational trophoblastic neoplasia (0.013% vs minimum 0.009%), although with high costs per gestational trophoblastic neoplasia death avoided (range, $214,000 to >$4 million). Societal perspective costs of lost wages had a greater impact on frequent surveillance costs than rare gestational trophoblastic neoplasia treatment costs, and no further surveillance was more favorable from this perspective in otherwise identical analyses. No further surveillance remained dominant or preferred with incremental cost-effectiveness ratio of <$100,000 in all analyses for partial mole, and most sensitivity analyses for complete mole. Under the assumption of no disutility from surveillance, surveillance strategies were more effective (by quality-adjusted life year) than no further surveillance, and a single human chorionic gonadotropin test at 3 months was found to be cost-effective after complete mole with incremental cost-effectiveness ratio of $53,261 from the healthcare perspective, but not from the societal perspective (incremental cost-effectiveness ratio, $288,783). CONCLUSION Largely owing to the rare incidence of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after molar pregnancy, prolonged surveillance is not cost-effective under most assumptions. It would be reasonable to reduce, and potentially eliminate, current recommendations for surveillance after human chorionic gonadotropin normalization after molar pregnancy, particularly among partial moles. With any reduction in surveillance, patients should be counseled on symptoms of gestational trophoblastic neoplasia and established in routine gynecologic care.
Collapse
Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emily M Ko
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| |
Collapse
|
7
|
Collet C, Lopez J, Battail C, Allias F, Devouassoux-Shisheboran M, Patrier S, Lemaitre N, Hajri T, Massardier J, You B, Mallet F, Golfier F, Alfaidy N, Bolze PA. Transcriptomic Characterization of Postmolar Gestational Choriocarcinoma. Biomedicines 2021; 9:biomedicines9101474. [PMID: 34680590 PMCID: PMC8533618 DOI: 10.3390/biomedicines9101474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/01/2021] [Accepted: 10/08/2021] [Indexed: 01/13/2023] Open
Abstract
The human placenta shares properties with solid tumors, such as rapid growth, tissue invasion, cell migration, angiogenesis, and immune evasion. However, the mechanisms that drive the evolution from premalignant proliferative placental diseases—called hydatidiform moles—to their malignant counterparts, gestational choriocarcinoma, as well as the factors underlying the increased aggressiveness of choriocarcinoma arising after term delivery compared to those developing from hydatidiform moles, are unknown. Using a 730-gene panel covering 13 cancer-associated canonical pathways, we compared the transcriptomic profiles of complete moles to those of postmolar choriocarcinoma samples and those of postmolar to post-term delivery choriocarcinoma. We identified 33 genes differentially expressed between complete moles and postmolar choriocarcinoma, which revealed TGF-β pathway dysregulation. We found the strong expression of SALL4, an upstream regulator of TGF-β, in postmolar choriocarcinoma, compared to moles, in which its expression was almost null. Finally, there were no differentially expressed genes between postmolar and post-term delivery choriocarcinoma samples. To conclude, the TGF-β pathway appears to be a crucial step in the progression of placental malignancies. Further studies should investigate the value of TGF- β family members as biomarkers and new therapeutic targets.
Collapse
Affiliation(s)
- Constance Collet
- Institut National de la Santé et de la Recherche Médicale U1292, Biologie et Biotechnologie pour la Santé, 38043 Grenoble, France; (C.C.); (C.B.); (N.L.); (N.A.)
- Commissariat à l’Energie Atomique et aux Energies Alternatives (CEA), Interdisciplinary Research Institute of Grenoble, CEDEX, 38054 Grenoble, France
- Service Obstétrique, Centre Hospitalo-Universitaire Grenoble Alpes, University Grenoble-Alpes, CS 10217, CEDEX 9, 38043 Grenoble, France
| | - Jonathan Lopez
- Department of Biochemistry and Molecular Biology, Plateforme de Recherche de Transfert en Oncologie, University of Lyon 1, Hospices Civils de Lyon, University Hospital Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France;
- Centre de Recherche en Cancérologie de Lyon, INSERM U1052, CNRS UMR5286, Faculté de Médecine Lyon Est, 69008 Lyon, France
| | - Christophe Battail
- Institut National de la Santé et de la Recherche Médicale U1292, Biologie et Biotechnologie pour la Santé, 38043 Grenoble, France; (C.C.); (C.B.); (N.L.); (N.A.)
- Commissariat à l’Energie Atomique et aux Energies Alternatives (CEA), Interdisciplinary Research Institute of Grenoble, CEDEX, 38054 Grenoble, France
- Service Obstétrique, Centre Hospitalo-Universitaire Grenoble Alpes, University Grenoble-Alpes, CS 10217, CEDEX 9, 38043 Grenoble, France
| | - Fabienne Allias
- Department of Pathology, University Hospital Lyon, Sud University of Lyon 1, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France; (F.A.); (M.D.-S.)
- French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France; (S.P.); (T.H.); (J.M.); (B.Y.); (F.G.)
| | - Mojgan Devouassoux-Shisheboran
- Department of Pathology, University Hospital Lyon, Sud University of Lyon 1, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France; (F.A.); (M.D.-S.)
- French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France; (S.P.); (T.H.); (J.M.); (B.Y.); (F.G.)
| | - Sophie Patrier
- French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France; (S.P.); (T.H.); (J.M.); (B.Y.); (F.G.)
- Department of Pathology, University Hospital of Rouen, CEDEX, 76031 Rouen, France
| | - Nicolas Lemaitre
- Institut National de la Santé et de la Recherche Médicale U1292, Biologie et Biotechnologie pour la Santé, 38043 Grenoble, France; (C.C.); (C.B.); (N.L.); (N.A.)
- Commissariat à l’Energie Atomique et aux Energies Alternatives (CEA), Interdisciplinary Research Institute of Grenoble, CEDEX, 38054 Grenoble, France
- Service Obstétrique, Centre Hospitalo-Universitaire Grenoble Alpes, University Grenoble-Alpes, CS 10217, CEDEX 9, 38043 Grenoble, France
| | - Touria Hajri
- French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France; (S.P.); (T.H.); (J.M.); (B.Y.); (F.G.)
| | - Jérôme Massardier
- French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France; (S.P.); (T.H.); (J.M.); (B.Y.); (F.G.)
- Department of Obstetrics and Gynecology, University Hospital Femme Mere Enfant, University of Lyon 1, 51, Boulevard Pinel, 69500 Bron, France
| | - Benoit You
- French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France; (S.P.); (T.H.); (J.M.); (B.Y.); (F.G.)
- Investigational Center for Treatments in Oncology and Hematology of Lyon (CITOHL), Medical Oncology Department, University of Lyon 1, Hospices Civils de Lyon, University Hospital Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France
| | - François Mallet
- Joint Research Unit Hospices Civils de Lyon-bioMérieux, Hospices Civils de Lyon, Lyon Sud Hospital, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France;
- Medical Diagnostic Discovery Department (MD3), bioMérieux S.A., 69280 Marcy l’Etoile, France
- Joint Research Unit Hospices Civils de Lyon-bioMérieux, EA 7426 Patho-Physiology of Injury-Induced Immunosuppression, PI3, Claude Bernard Lyon 1 University, Edouard Herriot Hospital, 69437 Lyon, France
| | - François Golfier
- French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France; (S.P.); (T.H.); (J.M.); (B.Y.); (F.G.)
- Department of Gynecological Surgery and Oncology, Hospices Civils de Lyon, University Hospital Lyon Sud, University of Lyon 1, Obstetrics, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France
| | - Nadia Alfaidy
- Institut National de la Santé et de la Recherche Médicale U1292, Biologie et Biotechnologie pour la Santé, 38043 Grenoble, France; (C.C.); (C.B.); (N.L.); (N.A.)
- Commissariat à l’Energie Atomique et aux Energies Alternatives (CEA), Interdisciplinary Research Institute of Grenoble, CEDEX, 38054 Grenoble, France
- Service Obstétrique, Centre Hospitalo-Universitaire Grenoble Alpes, University Grenoble-Alpes, CS 10217, CEDEX 9, 38043 Grenoble, France
| | - Pierre-Adrien Bolze
- French Center for Trophoblastic Diseases, University Hospital Lyon Sud, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France; (S.P.); (T.H.); (J.M.); (B.Y.); (F.G.)
- Department of Gynecological Surgery and Oncology, Hospices Civils de Lyon, University Hospital Lyon Sud, University of Lyon 1, Obstetrics, 165 Chemin du Grand Revoyet, 69495 Pierre Bénite, France
- Correspondence: ; Tel.: +33-(0)4-78-86-66-78
| |
Collapse
|
8
|
Contribution of Ezrin on the Cell Surface Plasma Membrane Localization of Programmed Cell Death Ligand-1 in Human Choriocarcinoma JEG-3 Cells. Pharmaceuticals (Basel) 2021; 14:ph14100963. [PMID: 34681187 PMCID: PMC8540387 DOI: 10.3390/ph14100963] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/01/2021] [Accepted: 09/22/2021] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint blockade (ICB) antibodies targeting programmed cell death ligand-1 (PD-L1) and programmed cell death-1 (PD-1) have improved survival in patients with conventional single agent chemotherapy-resistant gestational trophoblastic neoplasia (GTN). However, many patients are resistant to ICB therapy, the mechanisms of which are poorly understood. Unraveling the regulatory mechanism for PD-L1 expression may provide a new strategy to improve ICB therapy in patients with GTN. Here, we investigated whether the ezrin/radixin/moesin (ERM) family, i.e., a group of scaffold proteins that crosslink actin cytoskeletons with several plasma membrane proteins, plays a role in the regulation of PD-L1 expression using JEG-3 cells, a representative human choriocarcinoma cell line. Our results demonstrate mRNA and protein expressions of ezrin, radixin, and PD-L1, as well as their colocalization in the plasma membrane. Intriguingly, immunoprecipitation experiments revealed that PD-L1 interacted with both ezrin and radixin and the actin cytoskeleton. Moreover, gene silencing of ezrin but not radixin strongly diminished the cell surface expression of PD-L1 without altering the mRNA level. These results indicate that ezrin may contribute to the cell surface localization of PD-L1 as a scaffold protein in JEG-3 cells, highlighting a potential therapeutic target to improve the current ICB therapy in GTN.
Collapse
|
9
|
Coulter J, van Trommel N, Lok C. Ten steps to establish a national centre for gestational trophoblastic disease. Curr Opin Oncol 2021; 33:435-441. [PMID: 34172592 DOI: 10.1097/cco.0000000000000756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Gestational trophoblastic disease (GTD) is a group of heterogeneous disorders characterized by abnormal proliferation of trophoblastic tissue. GTD is a rare disease that is curable in the vast majority of patients when managed appropriately. The aim of the review is to discuss the important steps necessary to establish a center of excellence for GTD. RECENT FINDINGS Care of patients with a rare disease is complicated by lack of strong evidence, scattering of patients across the country and limited expertise of medical professionals. The establishment of a center of excellence requires awareness of its benefit, funding, a solid business case and most of all dedicated clinicians. A multidisciplinary team and formulation of national guidelines are important steps before clinical pathways can be developed and treatment can be evaluated for improvement of care and research purposes. International embedding can facilitate the process and lead to the development of a (inter) national acknowledged sustainable center of excellence. SUMMARY Centers of excellence could optimize the care of patients with GTD and promote research.
Collapse
Affiliation(s)
- John Coulter
- Department of Obstetrics and Gynecology, Cork University Maternity Hospital, Cork, Ireland
| | - Nienke van Trommel
- Department of Gynecologic Oncology, Centre of Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - Christianne Lok
- Department of Gynecologic Oncology, Centre of Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
10
|
Rheumatoid factor and falsely elevated results in commercial immunoassays: data from an early arthritis cohort. Rheumatol Int 2021; 41:1657-1665. [PMID: 33944985 PMCID: PMC8316178 DOI: 10.1007/s00296-021-04865-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/12/2021] [Indexed: 10/28/2022]
Abstract
The aim of the study was to assess RF cross-reactivity to animal antibodies used in immunoassays, and to test if selected commercial immunoassays are vulnerable to interference from RF, causing false test results. Our study included samples from patients with RF-positive rheumatoid arthritis (RA) and controls (patients with RF-negative RA and psoriatic arthritis), included in an early arthritis-cohort. Reactivity to mouse IgG1, mouse IgG2a, rabbit IgG, bovine IgG, sheep/goat IgG and human IgG was analysed using in-house interference assays. RF-positive sera with strong reactivity to mouse IgG1 were analysed in three commercial immunoassays. To reveal interference, results before and after addition of blocking aggregated murine IgG1 were compared. Samples from 124 RF-positive RA patients and 66 controls were tested. We found considerably stronger reactivity toward animal antibodies, particularly mouse IgG1 (73% vs. 12%) and rabbit IgG (81% vs. 6%), in sera from RF-positive RA-patients compared to controls (p < 0.001). After selecting samples for testing in commercial assays, interference was revealed in 6/30 sera in the Architect β-hCG assay, 7/10 sera in the 27-plex cytokine assays, and in 2/33 samples in the Elecsys Soluble Transferrin Receptor assay. Our study revealed considerable RF reactivity to animal antibodies used in immunoassays and RF was associated with falsely elevated results in immunoassays used in clinical care and research. Clinicians, laboratorians, researchers and assay manufacturers must be alert to the risk of falsely elevated test results in RF-positive RA patients.
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Vandewal A, Delbecque K, Van Rompuy AS, Noel JC, Marbaix E, Delvenne P, Nisolle M, Van Nieuwenhuysen E, Kridelka F, Vergote I, Goffin F, Han SN. Curative effect of second curettage for treatment of gestational trophoblastic disease - Results of the Belgian registry for gestational trophoblastic disease. Eur J Obstet Gynecol Reprod Biol 2020; 257:95-99. [PMID: 33383413 DOI: 10.1016/j.ejogrb.2020.12.001] [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: 07/13/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We assessed the curative effect of a second curettage in patients with persistent hCG serum levels after first curettage for a gestational trophoblastic disease (GTD). STUDY DESIGN This prospective observational study used the data of the Belgian register for GTD between July 2012 and January 2017. We analysed the data of patients who underwent a second curettage. We included 313 patients in the database. Primary endpoints were need for second curettage and chemotherapy. RESULTS Thirty-seven patients of the study population (12 %) underwent a second curettage. 20 had persistent human chorionic gonadotropin hormone (hCG) elevation before second curettage. Of them, 9 patients (45 %) needed no further treatment afterwards. Eleven patients (55 %) needed further chemotherapy. Nine (82 %) were cured with single-agent chemotherapy and 2 patients (18 %) needed multi-agent chemotherapy. Of the 37 patients, patients with hCG levels below 5000 IU/L undergoing a second curettage were cured without chemotherapy in 65 % versus 45 % of patients with hCG level more than 5000 IU/L. Of the ten patients with a hCG level below 1000 IU/L, eight were cured without chemotherapy. CONCLUSIONS Patients with post-mole gestational trophoblastic neoplasia can benefit from a second curettage to avoid chemotherapy, especially when the hCG level is lower than 5000 IU/L.
Collapse
Affiliation(s)
- A Vandewal
- Department of Obstetrics and Gynaecology, Gynecologic Oncology, Leuven Cancer Institute University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - K Delbecque
- Department of Pathologic Anatomy, University Hospital of Liège, Liège, Belgium
| | - A S Van Rompuy
- Department of Pathologic Anatomy, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - J-Ch Noel
- Department of Pathologic Anatomy, Erasmus Hospital, Brussels, Belgium
| | - E Marbaix
- Department of Pathologic Anatomy, University Hospital Saint-Luc, Brussels, Belgium
| | - P Delvenne
- Department of Pathologic Anatomy, University Hospital of Liège, Liège, Belgium
| | - M Nisolle
- Department of Obstetrics and Gynaecology, University Hospital of Liège, Liège, Belgium
| | - E Van Nieuwenhuysen
- Department of Obstetrics and Gynaecology, Gynecologic Oncology, Leuven Cancer Institute University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - F Kridelka
- Department of Obstetrics and Gynaecology, University Hospital of Liège, Liège, Belgium
| | - I Vergote
- Department of Obstetrics and Gynaecology, Gynecologic Oncology, Leuven Cancer Institute University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - F Goffin
- Department of Obstetrics and Gynaecology, University Hospital of Liège, Liège, Belgium
| | - S N Han
- Department of Obstetrics and Gynaecology, Gynecologic Oncology, Leuven Cancer Institute University Hospitals Leuven, KU Leuven, Leuven, Belgium.
| |
Collapse
|
13
|
Dudiak KM, Maturen KE, Akin EA, Bell M, Bhosale PR, Kang SK, Kilcoyne A, Lakhman Y, Nicola R, Pandharipande PV, Paspulati R, Reinhold C, Ricci S, Shinagare AB, Vargas HA, Whitcomb BP, Glanc P. ACR Appropriateness Criteria® Gestational Trophoblastic Disease. J Am Coll Radiol 2020; 16:S348-S363. [PMID: 31685103 DOI: 10.1016/j.jacr.2019.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 11/30/2022]
Abstract
Gestational trophoblastic disease (GTD), a rare complication of pregnancy, includes both benign and malignant forms, the latter collectively referred to as gestational trophoblastic neoplasia (GTN). When metastatic, the lungs are the most common site of initial spread. Beta-human chorionic gonadotropin, elaborated to some extent by all forms of GTD, is useful in facilitating disease detection, diagnosis, monitoring treatment response, and follow-up. Imaging evaluation depends on whether GTD manifests in one of its benign forms or whether it has progressed to GTN. Transabdominal and transvaginal ultrasound with duplex Doppler evaluation of the pelvis are usually appropriate diagnostic procedures in either of these circumstances, and in posttreatment surveillance. The appropriateness of more extensive imaging remains dependent on a diagnosis of GTN and on other factors. The use of imaging to assess complications, typically hemorrhagic, should be guided by the location of clinical signs and symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Collapse
Affiliation(s)
| | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | - Maria Bell
- Sanford Health, Sioux Falls, South Dakota, American College of Obstetricians and Gynecologists
| | | | - Stella K Kang
- New York University Medical Center, New York, New York
| | | | - Yulia Lakhman
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Refky Nicola
- State University of New York Upstate Medical University, Syracuse, New York
| | | | | | | | - Stephanie Ricci
- Cleveland Clinic, Cleveland, Ohio, American College of Obstetricians and Gynecologists
| | - Atul B Shinagare
- Brigham & Women's Hospital Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Bradford P Whitcomb
- University of Connecticut, Farmington, Connecticut, Society of Gynecologic Oncology
| | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Bouchard-Fortier G, Ghorani E, Short D, Aguiar X, Harvey R, Unsworth N, Kaur B, Sarwar N, Seckl MJ. Following chemotherapy for gestational trophoblastic neoplasia, do residual lung lesions increase the risk of relapse? Gynecol Oncol 2020; 158:698-701. [PMID: 32654764 DOI: 10.1016/j.ygyno.2020.06.483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There remains uncertainty about the prognostic significance of residual lung lesion on imaging after completion of treatment of low- or high-risk gestational trophoblastic neoplasia (GTN). Here, we determine if such residual lung lesions are associated with an increased risk of relapse. METHODS We retrospectively screened our electronic database to identify patients with low- or high-risk GTN and lung metastases between 2004 and 18. Recurrences among patients with or without residual lung lesions on imaging were compared. Chi square analysis and Kaplan-Meier survival curves were constructed. As the numbers of cases were low, we combined this data with our previously published and non-overlapping patient cohort (1995-2004). RESULTS Of 1304 GTN patients treated at our centre between 2004 and 18, 99 had lung metastases without other distant sites. There were 40 patients (40.4%) with residual lung lesions. Whilst an increased rate of relapse was observed among patients with residual lung lesions (4/40; 10.0%) compared to without such lesions (3/59; 5.1%), this difference was not statistically significant (p = .35). By combining the data with our previous cohort, there was an increase in relapse rate of patients with residual lung lesions (5/63; 7.9%) compared to those without such lesions (4/112; 3.6%). However, this difference was also not statistically significant (p = .21). CONCLUSION Residual lung lesions on imaging after completion of GTN treatment are common. However, this finding did not statistically increase relapse rate. Due to low number of recurrent events, a multi-centre, larger dataset would be needed to provide more definitive evidence.
Collapse
Affiliation(s)
- Genevieve Bouchard-Fortier
- Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada; Division of Gynecologic Oncology, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada; Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK.
| | - Ehsan Ghorani
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Dee Short
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Xianne Aguiar
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Richard Harvey
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Nick Unsworth
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Baljeet Kaur
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Naveed Sarwar
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College, London W6 8RF, UK
| |
Collapse
|
16
|
Pregnancy after oocyte donation in a patient with NLRP7 gene mutations and recurrent molar hydatidiform pregnancies. J Assist Reprod Genet 2020; 37:2273-2277. [PMID: 32592075 DOI: 10.1007/s10815-020-01861-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/16/2020] [Indexed: 01/26/2023] Open
Abstract
Molar pregnancies are benign trophoblastic diseases associated with a risk of malignant transformation. If aetiology remains mostly unknown, the risk of recurrent molar pregnancy is around 1.5% after one molar pregnancy and around 25% after 2 molar pregnancies. In the later situation, genetic mutations have been described, increasing hugely this risk. In case of mutations, probability to obtain a normal pregnancy is estimated around 1.8%. We report the case of a Caucasian 30-year-old woman whose previous five spontaneous pregnancies had a negative outcome: a spontaneous miscarriage and then 4 complete hydatidiform moles. Genetic testing revealed that the patient carried two heterozygous mutations in the NLRP7 gene (c.2982-2A > G and Y318CfsX7). According to this, counselling was conducted to advocate for oocyte donation in order to obtain a normal pregnancy. This technique enabled a complication-free, singleton pregnancy that resulted in a healthy term live birth of a 2900 g female. Few months after delivery, the patient presented a new complete hydatidiform mole. Women presented with mutations in the NLRP7, KHDC3L or PADI6 genes are unlikely to obtain normal pregnancies, with a major risk of reproductive failure. In such a context, oocyte donation may be the best option. Only 4 normal pregnancies and deliveries have been published in this situation through this technique to our knowledge.
Collapse
|
17
|
Freitas F, Braga A, Viggiano M, Velarde LGC, Maesta I, Uberti E, Madi JM, Yela D, Fernandes K, Silveira E, Leal E, Sun SY, Dos Santos Esteves APV, Filho JR, Junior JA, Elias KM, Horowitz NS, Berkowitz RS. Gestational trophoblastic neoplasia lethality among Brazilian women: A retrospective national cohort study. Gynecol Oncol 2020; 158:452-459. [PMID: 32402634 DOI: 10.1016/j.ygyno.2020.04.704] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/21/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate GTN lethality among Brazilian women comparing cases of death by GTN with those who survived, thereby identifying factors associated with GTN lethality. METHODS We retrospectively reviewed medical records of women with GTN treated at ten Brazilian GTN Reference Centers, from January 1960 to December 2017. We evaluated factors associated with death from GTN and used Cox proportional hazards regression models to identify independent variables with significant influence on the risk of death. RESULTS From 2186 patients with GTN included in this study, 2092 (95.7%) survived and 89 (4%) died due to GTN. When analyzing the relative risk (RR), adjusted for WHO/FIGO score, patients with low risk disease had a significantly higher risk of death if they had choriocarcinoma (RR: 12.40), metastatic disease (RR: 12.57), chemoresistance (RR: 3.18) or initial treatment outside the Reference Center (RR: 12.22). In relation to patients with high-risk GTN, these factors were significantly associated with death due to GTN: the time between the end of antecedent pregnancy and the initiation of chemotherapy (RR: 4.10), metastatic disease (RR: 14.66), especially in brain (RR: 8.73) and liver (RR: 5.76); absence of chemotherapy or initial treatment with single agent chemotherapy (RR: 10.58 and RR: 1.81, respectively), chemoresistance (RR: 3.20) and the initial treatment outside the Reference Center (RR: 28.30). CONCLUSION The risk of mortality from low and high-risk GTN can be reduced by referral of these patients to a Reference Center or, if not possible, to involve clinicians in a Reference Center with consultation regarding management.
Collapse
Affiliation(s)
- Fernanda Freitas
- Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil
| | - Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.
| | - Mauricio Viggiano
- Goiania Trophoblastic Disease Center, Clinics Hospital of Goias Federal University, Goiania, GO, Brazil
| | | | - Izildinha Maesta
- Botucatu Trophoblastic Disease Center, Clinical Hospital of Botucatu Medical School, Department of Gynecology and Obstetrics, São Paulo State University-UNESP, Botucatu, SP, Brazil
| | - Elza Uberti
- Porto Alegre Trophoblastic Disease Center, Mario Totta Maternity Ward, Irmandade da Santa Casa de Misericórdia Hospital, Porto Alegre, RS, Brazil
| | - Jose Mauro Madi
- Caxias do Sul Trophoblastic Disease Center, General Hospital of Caxias do Sul, School of Medicine, Center for Biological and Health Sciences, Caxias do Sul University, Caxias do Sul, RS, Brazil
| | - Daniela Yela
- Campinas Trophoblastic Disease Center, University of Campinas, Campinas, SP, Brazil
| | - Karayna Fernandes
- Jundiai Trophoblastic Disease Center, Jundiai Medical School, Jundiai, SP, Brazil
| | - Eduardo Silveira
- Santos Trophoblastic Disease Center, Guilherme Álvaro Hospital, Santos, SP, Brazil
| | - Elaine Leal
- Rio Branco Trophoblastic Disease Center, Clinics Hospital of Acre, Rio Branco, AC, Brazil
| | - Sue Yazaki Sun
- São Paulo Hospital Trophoblastic Disease Center, Paulista School of Medicine, São Paulo Federal University, São Paulo, SP, Brazil
| | - Ana Paula Vieira Dos Santos Esteves
- Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - Jorge Rezende Filho
- Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil
| | - Joffre Amim Junior
- Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, 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, 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, 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, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
18
|
Lok C, van Trommel N, Massuger L, Golfier F, Seckl M. Practical clinical guidelines of the EOTTD for treatment and referral of gestational trophoblastic disease. Eur J Cancer 2020; 130:228-240. [PMID: 32247260 DOI: 10.1016/j.ejca.2020.02.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIM Gestational trophoblastic disease (GTD) is a heterogeneous group of disorders characterised by abnormal proliferation of trophoblastic tissue. Since GTD and its malignant sequel gestational trophoblastic neoplasia (GTN) are rare diseases, little evidence is available from randomised controlled trials on optimal treatment and follow-up. Treatment protocols vary within Europe, and even between different centres within countries. One of the goals of the 'European Organisation for Treatment of Trophoblastic Diseases' (EOTTD) is to harmonise treatment in Europe. To provide a basis for European standardisation of definitions, treatment and follow-up protocols in GTD, we composed a set of guidelines for minimal requirements and optimal management of GTD. METHODS Members from each EOTTD country attended multiple workshops during annual EOTTD meetings. Clinical guidelines were formulated by consensus and evidence where available. The following guidelines were discussed: diagnostics of GTD and GTN, treatment of low-risk GTN, high-risk GTN, ultra-high-risk GTN, placental site and epithelioid trophoblastic tumours and follow-up. RESULTS Between 40 and 65 EOTTD members from 17 European countries and 7 non-European countries attended the clinical workshops held on 6 occasions. Flow diagrams for patient management were composed to display minimum and best practice for most treatment situations. New agreed definitions of recurrence and chemotherapy resistance were formulated. CONCLUSIONS Despite the many differences between and within the participating countries, an important step in uniform treatment of GTD and GTN within Europe was made by the Clinical Working Party of the EOTTD. This is an example on how guidelines and harmonisation can be achieved within international networks.
Collapse
Affiliation(s)
- Christianne Lok
- Department of Gynecologic Oncology, Centre for Gynecologic Oncology Amsterdam, Location Antoni van Leeuwenhoek - The Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Nienke van Trommel
- Department of Gynecologic Oncology, Centre for Gynecologic Oncology Amsterdam, Location Antoni van Leeuwenhoek - The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Leon Massuger
- Department of Gynecologic Oncology, Radboud University Medical Hospital, Nijmegen, the Netherlands
| | - François Golfier
- Department of Gynecologic and Oncologic Surgery and Obstetrics, French Trophoblastic Disease Centre, Lyon University Hospitals, Lyon Sud Hospital, France
| | - Michael Seckl
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London, UK.
| | | |
Collapse
|
19
|
Cavoretto P, Cioffi R, Mangili G, Petrone M, Bergamini A, Rabaiotti E, Valsecchi L, Candiani M, Seckl MJ. A Pictorial Ultrasound Essay of Gestational Trophoblastic Disease. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:597-613. [PMID: 31468566 DOI: 10.1002/jum.15119] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/30/2019] [Accepted: 08/03/2019] [Indexed: 06/10/2023]
Abstract
Gestational trophoblastic disease (GTD) includes a wide variety of clinical and histopathologic entities that require prompt identification and definition by the integration of clinical, laboratory, and imaging data. Recently, the role of grayscale ultrasound and spectral and power/color Doppler techniques has become pivotal in the diagnosis, staging, and management of GTD, thanks to both technical improvements and the growing expertise of dedicated operators. The aim of this essay is to summarize the most recent data on the ultrasound and Doppler findings of GTD and to provide a pictorial overview, including useful prognostic and therapeutic implications for clinical practice.
Collapse
Affiliation(s)
- Paolo Cavoretto
- Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Raffaella Cioffi
- Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Giorgia Mangili
- Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Micaela Petrone
- Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Alice Bergamini
- Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Emanuela Rabaiotti
- Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Luca Valsecchi
- Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Massimo Candiani
- Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Center, Imperial College National Health Service Healthcare Trust and Imperial College London, London, England
| |
Collapse
|
20
|
Sharami SRY, Saffarieh E. A review on management of gestational trophoblastic neoplasia. J Family Med Prim Care 2020; 9:1287-1295. [PMID: 32509606 PMCID: PMC7266251 DOI: 10.4103/jfmpc.jfmpc_876_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The rare presence of malignant cancerous cells afar any type of pregnancy is known as gestational trophoblastic neoplasia (GTN). GTN are benign lesions which mostly happen due to the activity of extravillous trophoblast cells and the placental villous tree development. These kinds of diseases would be occurring mainly due to the following clinicopathologic conditions: (I) existence of epithelioid trophoblastic tumor (ETT), (II) rare type of choriocarcinoma cancer, (III) gestational trophoblastic tumor of mole, and (IV) the rare malignant tumor of placental site trophoblastic tumor. OBJECTIVE This comprehensive study is trying to review the most recent approaches in comprehension of pathogenesis, more precise diagnosis, and also the most effective therapeutic procedures for patients who suffer from GTN disorders. MATERIALS AND METHOD A comprehensive research was carried out on scientific databases of Science Citation Index (SCI), MEDLINE, EMBASE, HMIC, PubMed, CINAHL, Google Scholar, Cochrane Database of Systematic Reviews (CDSR), and PsycINFO over the time period of 2005 to 2019. The keywords which applied for discovering more related records were including: Gestational trophoblastic diseases (GTD), Gestational trophoblastic neoplasia (GTN), molar pregnancy, choriocarcinoma, human chorionic gonadotropin (hCG), diagnosis, management and treatment. CONCLUSION In spite of the fact that GTN patients are treated with conventional surgical therapies or/and chemotherapy, in some patients with resistant disease, these therapies may not be effective and patients may die. Some novel remedial agents are required for decreasing the level of toxicity caused through administering conventional chemotherapy and also treating the patients who suffer from refractory or resistant disease. The newest issues are related to GTN diagnosis, process of progression of hydatidiform mole (HM) to GTN, and the issue of GTN drug resistance. In this regard, we should have a comprehensive knowledge on GTN genetics for answering all the available questions about this disorder.
Collapse
Affiliation(s)
| | - Elham Saffarieh
- Abnormal Uterine Bleeding Research Center, Semnan University of Medical Science, Semnan, Iran
| |
Collapse
|
21
|
Cheng M, Lee NR, Wang PH. The use of VMP regimen as the first line chemotherapy for low-risk gestational trophoblastic neoplasia. Taiwan J Obstet Gynecol 2019; 58:717-718. [PMID: 31542101 DOI: 10.1016/j.tjog.2019.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Min Cheng
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Na-Rong Lee
- Department of Nursing, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Obstetrics and Gynecology, Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.
| |
Collapse
|
22
|
Cheng NM, Chang WH, Wang PH. The first-line therapy for low-risk gestational trophoblastic neoplasia: Does single agent or multi-agent work? Taiwan J Obstet Gynecol 2019; 58:585-586. [PMID: 31542075 DOI: 10.1016/j.tjog.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Nai-Ming Cheng
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Hsun Chang
- Department of Nursing, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Obstetrics and Gynecology, Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.
| |
Collapse
|
23
|
Clinical characteristics and outcomes of extrauterine epithelioid trophoblastic tumors. Arch Gynecol Obstet 2019; 300:725-735. [PMID: 31312959 DOI: 10.1007/s00404-019-05239-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/02/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Epithelioid trophoblastic tumor (ETT) derived from intermediate trophoblasts is one type of gestational trophoblastic neoplasia (GTN), and it accounts for less than 2% of all gestational trophoblastic diseases (GTD). Extrauterine ETT is extremely rare, and there is currently no consistent strategy for its treatment and management. Therefore, the aim of the study is to analyze and summarize the clinicopathologic features of extrauterine ETT with or without metastasis. METHOD The Web of Knowledge, Google Scholar, EMbase, congress of library, and PubMed were searched for extrauterine ETT without primary uterine lesions. All available data were extracted from published case reports or serial case reports, and then, the clinical and pathological characteristics were analyzed. RESULTS Twenty-two clinical studies consisting of 27 patients diagnosed with extrauterine ETT, according to the given inclusion and exclusion criteria, were included in the study. A total of 27 cases of extrauterine ETT were identified. Of these cases, four (14.81%) were located in the lungs, three (11.11%) in the ovaries, two (7.41%) in the vagina, and eight (29.63%) patients had other primary lesions. The patients originated from different continents, with 59% located in Asia and 26% in North America. Among 23 patients, the antecedent pregnancy prior to the diagnosis was full-term in 12 cases, abortion in 6 cases, hydatidiform mole in 3 cases, and invasive mole in 1 case. From the available antecedent information on pregnancy, the median interval from pregnancy to diagnosis of extrauterine ETT was 4 years. Additionally, the median gravidity and para of the patients was three times and two times, respectively. The median hCG titer was 14,374 mIU/mL in 5 patients, and the mean β-HCG titer was 3,724,805 mIU/mL in 14 patients. For all patients, the disease was confined to extrauterine ETT at diagnosis. From the available information, 20 cases were successfully treated by extraction of local lesions, and 12 cases received chemotherapy. Diagnosis was confirmed by histological tests. The Ki-67 staining ranged from 8.7 to 80%, and tumors were positive for hCG, PLAP, EMA, and p63. CONCLUSION In this study, we observed that abnormal levels of serum hCG titers and the local presentation of lesions with varying intervals after antecedent term pregnancy were the most common presenting features of extrauterine ETT. In addition, we found that the extraction of extrauterine lesions was needed for the treatment of extrauterine ETT. Of course, the follow-up was also important.
Collapse
|
24
|
Placental site trophoblastic tumor and epithelioid trophoblastic tumor: Clinical and pathological features, prognostic variables and treatment strategy. Gynecol Oncol 2019; 153:684-693. [PMID: 31047719 DOI: 10.1016/j.ygyno.2019.03.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/01/2019] [Accepted: 03/06/2019] [Indexed: 12/30/2022]
Abstract
Placental site trophoblastic tumor [PSTT] and epithelioid trophoblastic tumor [ETT] are the rarest gestational trophoblastic neoplasias, developing from intermediate trophoblast of the implantation site and chorion leave, respectively. PSTT and ETT share some clinical-pathological features, such as slow growth rates, early stage at presentation, relatively low βhCG levels and poor response to chemotherapy. The mortality rate ranges from 6.5% to 27% for PSTT and from 10% to 24.2% for ETT. Advanced stage, long interval between antecedent pregnancy and diagnosis, and presence of clear cells are the independent prognostic variables for PSTT, and they may be similar for ETT. Hysterectomy can represent the only therapy for early disease, whereas adjuvant chemotherapy should be reserved to patients with poor risk factors, such as an interval from the antecedent pregnancy >4 years, deep myometrial invasion or serosal involvement. Few cases of fertility-sparing treatment in young women have been reported. An individualized multidisciplinary approach, including chemotherapy and debulking surgery with abdominal and/or extra-abdominal procedures, is warranted for advanced disease. EP/EMA and TP/TE are the preferred regimens in this setting. Immunohistochemistry has sometimes shown expression of EGFR, VEGF, MAPK, PDGF-R and PD-L1, and therefore investigational studies on biological agents targeting these molecules are strongly warranted for chemotherapy resistant-disease.
Collapse
|
25
|
Li X, Xu Y, Liu Y, Cheng X, Wang X, Lu W, Xie X. The management of hydatidiform mole with lung nodule: a retrospective analysis in 53 patients. J Gynecol Oncol 2019; 30:e16. [PMID: 30740949 PMCID: PMC6393642 DOI: 10.3802/jgo.2019.30.e16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/07/2018] [Accepted: 10/23/2018] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the significance of lung nodule in hydatidiform mole, we retrospectively compared the clinical outcomes of those patients treated with different strategies. Methods The patients were divided into three groups: chemotherapy immediately once lung nodule was detected (group 1, n=17), delayed chemotherapy until human chorionic gonadotrophin (hCG) level met the diagnostic criteria for gestational trophoblastic neoplasia (GTN) (group 2, n=18), and hCG surveillance alone until hCG level was normalized spontaneously (group 3, n=18). The clinical parameters of these patients were collected and analyzed. Results Totally 53 (4.0%) patients were included from 1,323 cases with molar pregnancy during past 16 years. Among them, the diameters of lung nodules were 0.3–2.5 cm. Chemotherapy cycles for achieving hCG normalization and the failure rate of first-line chemotherapy in group 1 were significantly increased than that in group 2 (5 vs. 3 cycles, p=0.000, 58.8% vs. 11.1%, p=0.005). The hCG level of all 18 cases in group 3 was normalized spontaneously within 6 months. Of those, lung nodules of 9 patients disappeared spontaneously, accounting for 25% (9/36) of patients who initially selected observation. The proportion of single nodule in group 3 was significantly higher than that in group 2 (10/18 vs. 2/18, p=0.012). Conclusion Our results suggest that lung nodule alone is not an adequate indication of chemotherapy in molar pregnancy. hCG surveillance is safe for patients with lung nodule, especially with single nodule, as long as their hCG levels do not meet International Federation of Gynecology and Obstetrics diagnostic criteria for GTN.
Collapse
Affiliation(s)
- Xiao Li
- Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Yaping Xu
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Obstetrics and Gynecology, Hangzhou Red Cross Hospital, Hangzhou, China
| | - Yuanyuan Liu
- Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaodong Cheng
- Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xinyu Wang
- Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weiguo Lu
- Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang Province, Hangzhou, China
| | - Xing Xie
- Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
26
|
Frijstein MM, Lok CAR, Coulter J, van Trommel NE, ten Kate – Booij MJ, Golfier F, Seckl MJ, Massuger LFAG. Is there uniformity in definitions and treatment of gestational trophoblastic disease in Europe? Int J Gynecol Cancer 2019; 29:108-112. [DOI: 10.1136/ijgc-2018-000028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/29/2018] [Accepted: 09/06/2018] [Indexed: 11/04/2022] Open
Abstract
ObjectivesBecause gestational trophoblastic disease is rare, little evidence is available from randomized controlled trials on optimal treatment and follow-up. Treatment protocols vary within Europe, and even between different centers within countries. One of the goals of the European Organization for Treatment of Trophoblastic Diseases (EOTTD) is to harmonize treatment in Europe. To provide a basis for international standardization of definitions, treatment and follow-up protocols in gestational trophoblastic disease, we evaluated differences and similarities between protocols in EOTTD countries.MethodsMembers from each EOTTD country were asked to complete an online structured questionnaire comprising multiple-choice and multiple-answer questions. The following themes were discussed: incidence of gestational trophoblastic disease and gestational trophoblastic neoplasia, definitions, guidelines, classification system, treatment, recurrence, and follow-up.ResultsForty-four respondents from 17 countries participated in this study. Guidelines were present in 80% of the countries and the FIGO (Fédération Internationale de Gynécologie et d'Obstétrique) staging and risk classification was often used to estimate risks. Agreement about when to start chemotherapy for post-molar gestational trophoblastic neoplasia was present among 66% of the respondents. Preferred first-line treatments in low- and high-risk gestational trophoblastic neoplasia were methotrexate (81%) and EMA-CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine) (93%), respectively. The definition of human chorionic gonadotropin normalization after hydatidiform mole evacuation was two consecutive normal values for nine countries. The FIGO definition of post-molar gestational trophoblastic neoplasia based on human chorionic gonadotropin plateau or rise was agreed on by 69% of respondents, and only 69% and 74% defined low-risk and high-risk disease, respectively, using FIGO criteria. There were major differences in definitions of recurrence, chemotherapy resistance and follow-up protocols among countries, despite EOTTD consensus statements.ConclusionsThis questionnaire provides a good overview of current clinical practices in different countries. Based on the survey results, it is clear that there are several gestationaltrophoblastic disease-related topics that need urgent attention within the EOTTD community to create more uniformity and to aid the development of uniform guidelines in Europe.
Collapse
|
27
|
Yang J, Zong L, Wang J, Wan X, Feng F, Xiang Y. Epithelioid Trophoblastic Tumors: Treatments, Outcomes, and Potential Therapeutic Targets. J Cancer 2019; 10:11-19. [PMID: 30662520 PMCID: PMC6329873 DOI: 10.7150/jca.28134] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/03/2018] [Indexed: 12/22/2022] Open
Abstract
Background: Epithelioid trophoblastic tumors (ETTs) are the rarest type of gestational trophoblastic neoplasias. We investigated the clinical features, treatments, outcomes, and prognostic factors in patients with ETT, and explored potential therapeutic targets. Methods: We retrospectively analyzed the clinical features, treatments, survival, and prognostic factors of 21 ETT patients treated at our institution between January 2002 and December 2017. Expression levels of programmed cell death 1 (PD-1), PD-1 ligands (PD-L1and PD-L2), B7 family ligands (B7-H3, B7-H4, V-domain Ig suppressor of T cell activation [VISTA], and B7-H6), and CD105 expression were assessed by immunohistochemistry. Results: Fourteen patients with ETT (66.7%) presented with irregular vaginal bleeding. Three stage I patients (14.3%) with normal β-human chorionic gonadotropin (β- hCG) levels underwent hysterectomy alone. Of the remaining 18 patients who had elevated β-hCG levels (85.7%), 1 received chemotherapy and 17 underwent surgery and multi-agent chemotherapy. After treatment, 17 patients (81.0%) achieved complete remission (2 of whom [11.8%] later relapsed) and 4 (19.0%) with stage IV died of their disease. On univariate and multivariate analyses, stage IV disease was an independent prognostic factor for overall and disease-free survival (P < 0.001). PD-L1, B7-H3, and CD105 were detected in 100% of samples, PD-L2 and VISTA in 82%, B7-H6 in 18%, and B7-H4 was undetectable in ETT cells. Conclusions: Hysterectomy and metastatic lesion resection are essential for controlling ETT. Surgery plus chemotherapy are recommended for patients with abnormal β-hCG levels and metastatic disease. PD-L1, PD-L2, B7-H3, VISTA and CD105 are potential therapeutic targets for metastatic ETT.
Collapse
Affiliation(s)
- Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Liju Zong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Jing Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, PR China
| |
Collapse
|
28
|
Outcome of First-Line Hysterectomy for Gestational Trophoblastic Neoplasia in Patients No Longer Wishing to Conceive and Considered With Isolated Lung Metastases: A Series of 30 Patients. Int J Gynecol Cancer 2018; 28:1766-1771. [DOI: 10.1097/igc.0000000000001367] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ObjectiveThis study aimed to assess the outcome of first-line hysterectomy in patients diagnosed as having gestational trophoblastic neoplasia (GTN) whose postoperative imaging showed lung images considered as metastases.MethodsFrom 1999 to 2016, patients no longer wishing to conceive, treated by their initial physician by hysterectomy, and whose postoperative imaging workup showed lung images considered as metastasis were identified in the French Trophoblastic Disease Reference Center database. We sought to identify significant predictive factors of requiring salvage chemotherapy.ResultsThirty patients were identified with a maximum number of 2 visible lung nodules and a median largest size of 14 mm on chest x-ray. Nine of these patients had an International Federation of Gynecology and Obstetrics score of higher than 6, and there were no postterm GTN. Twenty-two patients (73.33%; 95% confidence interval, 54.11–87.72; P = 0.0053) normalized their human chorionic gonadotropin (hCG) without salvage chemotherapy, whereas 7 received 1 line of salvage monochemotherapy (8-day methotrexate) and 1 required 2 lines of monochemotherapy (5-day actinomycin D after failure of methotrexate). After a 12.45-month median follow-up (range, 3–48.4 months) since the first normalized hCG, none of these patients died. The median interval between successful hysterectomy and hCG normalization was 3.15 months (range, 1.6–8.7 months). Patients who required salvage chemotherapy had a median size of the largest lung metastasis on chest computed tomography of 4 mm larger than those cured by hysterectomy (P = 0.0455).ConclusionsFor GTN patients no longer wishing to conceive with lung metastases discovered postoperatively, treated by hysterectomy, and whose hCG is decreasing, it is reasonable to expect and to inform patients that approximately 27% will require salvage chemotherapy. However, in patients with lung metastases discovered preoperatively, evidence to recommend first-line hysterectomy is insufficient and these patients should receive first-line chemotherapy.
Collapse
|
29
|
Gestational trophoblastic neoplasia with brain metastasis at initial presentation: a retrospective study. Int J Clin Oncol 2018; 24:153-160. [PMID: 30242539 DOI: 10.1007/s10147-018-1337-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the survival and functional outcome of patients with brain metastasis due to gestational trophoblastic neoplasia (GTN). METHODS A 17-year retrospective study based on case review of women with brain metastasis from GTN identified by the electronic databases held in the French Reference Centre. PRIMARY OUTCOME MEASURE 5-year overall survival calculated with the Kaplan-Meier method. SECONDARY OUTCOME MEASURES causes of death, prognostic factors and functional outcomes. RESULTS 21 patients had GTN brain metastasis and were treated with multidrug chemotherapy without concomitant whole-brain radiation therapy. Three patients died early (< 4 weeks) of cerebral hemorrhage, 3 died ≥ 1 months after treatment initiation and 15 were alive at the date of last contact. The overall survival rate at 5 years was 69.8% (95% CI 44.3-85.3). After excluding early deaths, the survival rate at 5 years was 81.5% (95% CI 52.3-93.7). No predictive factor of survival was identified. Although 11 of the 12 (92%) surviving patients contacted still reported sequelae, nine of them (75%) had resumed a normal life. CONCLUSIONS After excluding early deaths, this study implies a high survival rate in patients with brain metastasis from GTN. These results were achieved in the total absence of whole-brain radiotherapy and almost completely without the need for intrathecal methotrexate.
Collapse
|
30
|
First-line hysterectomy for women with low-risk non-metastatic gestational trophoblastic neoplasia no longer wishing to conceive. Gynecol Oncol 2018; 150:282-287. [DOI: 10.1016/j.ygyno.2018.05.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/27/2018] [Accepted: 05/31/2018] [Indexed: 11/18/2022]
|
31
|
Costa C, Massardier J, Gamondes D, Cottin V. Pulmonary Arteriovenous Malformation After Metastatic Gestational Trophoblastic Tumor. Arch Bronconeumol 2018; 55:57-59. [PMID: 29884426 DOI: 10.1016/j.arbres.2018.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/16/2018] [Accepted: 04/09/2018] [Indexed: 10/14/2022]
Affiliation(s)
- Christine Costa
- Departamento do Tórax, Centro Hospitalar Lisboa Norte, Lisboa, Portugal.
| | | | - Delphine Gamondes
- Service de Radiologie, Hospices Civils de Lyon, Groupe Hospitalier Est, Lyon, France
| | - Vincent Cottin
- Service de Pneumologie, Hospices Civils de Lyon, Groupe Hospitalier Est, Lyon, France; Université Claude Bernard Lyon 1, France; Centre National de Référence des Maladies Pulmonaires Rares, Lyon, France
| |
Collapse
|
32
|
Abstract
OBJECTIVE Epithelioid trophoblastic tumor is a rare gestational trophoblastic neoplasm usually presenting in women of reproductive age, with a history of a prior gestational event. Its presentation in postmenopausal women is extremely rare. Immunohistochemical staining is a helpful aid to distinguish epithelioid trophoblastic tumor from other gestational trophoblastic neoplasms. Correct diagnosis is crucial for clinical management that can vary according to the type of gestational trophoblastic neoplasm. METHODS We report the case of a 63-year-old postmenopausal woman 33 years after her last full-term pregnancy and another case of a 57-year-old postmenopausal woman who had had a first-trimester abortion 30 years previously as her last gestational event, both presenting cervical epithelioid trophoblastic tumors. In both cases, immunohistochemistry played an important role in differentiating this entity from other gestational trophoblastic neoplasms. Surgery was the primary treatment in both cases. The first patient remained disease-free and died 5 years later due to a rectal adenocarcinoma, and the second patient remains disease-free at publication. RESULTS In both cases, the hysterectomy specimen confirmed the presence of two large epithelioid trophoblastic tumors arising in the endocervix and lower uterine segment with no extrauterine disease. Nuclear positivity for p63 allowed differentiation from a placental site trophoblastic tumor. The Ki67 proliferative index was 20% and 35%, respectively. CONCLUSIONS Epithelioid trophoblastic tumors may occur a long time after a prior gestational event and should even be excluded in postmenopausal women with uterine masses. Immunohistochemical staining is helpful to make the differential diagnosis with other gestational trophoblastic neoplasms.
Collapse
|
33
|
PD-L1 Expression in Premalignant and Malignant Trophoblasts From Gestational Trophoblastic Diseases Is Ubiquitous and Independent of Clinical Outcomes. Int J Gynecol Cancer 2018; 27:554-561. [PMID: 28060141 DOI: 10.1097/igc.0000000000000892] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Recently reported expression of programmed cell death 1 ligand 1 (PD-L1) in gestational trophoblastic diseases (GTDs) suggests that the immune tolerance of pregnancy might be hijacked during neoplastic process. We assessed PD-L1 protein expression in premalignant and malignant GTD lesions and analyzed associations with disease severity and chemotherapy outcomes. METHODS We included 83 GTD whole-tissue sections from 76 patients in different treatment settings. PD-L1 protein expression was assessed with immunohistochemistry in each trophoblast subtype with the Allred total score (ATS), which combines intensity and proportion expression on a 0- to 8-point scale. Peritumoral immune infiltrate was scored on hematoxylin-eosin-safran-stained slides. RESULTS PD-L1 expression was ubiquitous and strong in all GTD trophoblast subtypes. For invasive moles, ATS scores were maximal at 8 in 100%, 100%, and 75% of syncytiotrophoblast, villous cytotrophoblast, and extravillous cytotrophoblast specimens, respectively. For choriocarcinomas, ATS was 8 in 80% of specimens. Immune infiltrates were moderate to severe in 61%, 100%, and 100% of peritumoral zones of choriocarcinoma, epithelioid trophoblastic tumor, and invasive moles, respectively. Because of the homogeneous pathological findings, no significant differences in PD-L1 expression profiles or peritumoral immune infiltrates were found regarding FIGO (International Federation of Gynecology Obstetrics) prognostic score, fatal outcome, or chemosensitivity. CONCLUSIONS We confirm that PD-L1 is constitutively expressed in all GTD premalignant and malignant trophoblast subtypes, independently from FIGO score, chemoresistance, or fatal outcomes, thereby suggesting a crucial role for PD-L1 in the development and tolerance of GTD. Assessment of anti-PD-L1 drug in GTD patients has been activated.
Collapse
|
34
|
Lowered reference limits for hCG improve follow-up of patients with hCG-producing tumors. Clin Biochem 2017; 52:73-79. [PMID: 29198759 DOI: 10.1016/j.clinbiochem.2017.11.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/24/2017] [Accepted: 11/27/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Human Chorionic Gonadotropin (hCG) is produced by germ cell tumors, but can also be elevated in benign conditions such as primary hypogonadism, where hCG is produced by the pituitary gland. In our experience, the reference limits for hCG (Elecsys hCG+β-assay, Roche Diagnostics), were unnecessarily high and did not reflect levels encountered in clinical practice. We wanted to establish new reference limits to increase the clinical utility of the hCG-assay. METHODS We analysed hCG in serum samples from a healthy adult population and in a cohort of testicular cancer survivors. The gonadotropins LH and FSH were measured in the cohort and in a selection of the reference population to assess gonadal function. RESULTS We found low hCG levels for all men and women <45years (97.5 percentiles 0.1 and 0.2IU/L, respectively) from the healthy population (n=795) having normal FSH and LH. Due to assay limitations, we suggest a common reference limit of <0.3IU/L. For the age group ≥45, the 97.5 percentiles in the healthy population were 0.5IU/L for men and 6.0IU/L for women. In all subjects from both the reference population and the cohort (n=732), hCG levels exceeding the reference limit could be fully explained by reduced gonadal function indicated by elevated LH and FSH levels. CONCLUSION The Elecsys hCG+β-assay should have lower reference limits than recommended by the manufacturer, with important implications for tumor follow-up. Elevated hCG is rare with intact gonadal function, both in a normal population and among survivors of testicular cancer, and should lead to further investigations when encountered in clinical practice.
Collapse
|
35
|
Dreyfus M. [Maternal deaths due to gestational trophoblastic diseases, results from the French confidential enquiry into maternal deaths, 2010-2012]. ACTA ACUST UNITED AC 2017; 45:S58-S60. [PMID: 29113877 DOI: 10.1016/j.gofs.2017.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Indexed: 11/26/2022]
Abstract
Gestational trophoblastic diseases (GTD) correspond to several entities which all have a common pattern: hypersecretion of human chorionic gondotrophin by trophoblastic hyperplasia. Between 2010 and 2012, there were 4 maternal deaths due to GTD (choriocarcinoma). The ratio of maternal death caused by GTD was 0,16/100,000 living births which was similar to the rate from the 2007-2009 period. These deaths represented 1.6% from the whole maternal mortality and 3.3% of the direct maternal mortality. These four deaths occurred after delivery and the diagnosis of GTD was made between 60 and 180 days in the postpartum period. Two cases seemed to be potentially avoidable. The main causes of suboptimal management were linked to delay either in diagnosis of GTD or in initiating the appropriate treatment. The analysis of these maternal deaths gave the opportunity to stress some major lessons to optimize medical management of GTD. Therefore, a patient presenting with persistent bleedings more than six weeks after delivery needs some specific exams such as plasma human chorionic gondotrophin measurement and histopathologic examination to affirm GTD and start early specific treatments generally leading to complete recovery.
Collapse
Affiliation(s)
- M Dreyfus
- , Gynécologie-obstétrique et médecine de la reproduction, université Caen, CHU de Caen, UFR Médecine Caen avenue de la Côte-de-Nacre, 14003 Caen, France.
| |
Collapse
|
36
|
Zheng W, Sun R, Yang L, Zeng X, Xue Y, An R. Daidzein inhibits choriocarcinoma proliferation by arresting cell cycle at G1 phase through suppressing ERK pathway in vitro and in vivo. Oncol Rep 2017; 38:2518-2524. [DOI: 10.3892/or.2017.5928] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 08/17/2017] [Indexed: 11/05/2022] Open
|
37
|
Braga A, Torres B, Burlá M, Maestá I, Sun SY, Lin L, Madi JM, Uberti E, Viggiano M, Elias KM, Berkowitz RS. Is chemotherapy necessary for patients with molar pregnancy and human chorionic gonadotropin serum levels raised but falling at 6months after uterine evacuation? Gynecol Oncol 2017; 143:558-564. [PMID: 27640962 DOI: 10.1016/j.ygyno.2016.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 09/06/2016] [Accepted: 09/10/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the outcomes of Brazilian patients with molar pregnancy who continue human chorionic gonadotropin (hCG) surveillance with those treated with chemotherapy when hCG was still positive, but falling at 6months after uterine evacuation. METHODS Retrospective chart review of 12,526 patients with hydatidiform mole treated at one of nine Brazilian reference centers from January 1990 to May 2016. RESULTS At 6months from uterine evacuation, 96 (0.8%) patients had hCG levels raised but falling. In 15/96 (15.6%) patients, chemotherapy was initiated immediately per FIGO 2000 criteria, while 81/96 (84.4%) patients were managed expectantly. Among the latter, 65/81 (80.2%) achieved spontaneous remission and 16 (19.8%) developed postmolar gestational trophoblastic neoplasia (GTN). Patients who received chemotherapy following expectant management required more time for remission (11 versus 8months; p=0.001), had a greater interval between uterine evacuation and initiating chemotherapy (8 versus 6months; p<0.001), and presented with a median WHO/FIGO risk score higher than women treated according to FIGO 2000 criteria (4 versus 2, p=0.04), but there were no significant differences in the need for multiagent treatment regimens (1/15 versus 3/16 patients, p=0.60). None of the women relapsed, and no deaths occurred in either group. CONCLUSION In order to avoid unnecessary exposure of women to chemotherapy, we no longer follow the FIGO 2000 recommendation to treat all patients with molar pregnancy and hCG raised but falling at 6months after evacuation. Instead, we pursue close hormonal and radiological surveillance as the best strategy for these patients.
Collapse
Affiliation(s)
- Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Maternity Ward of Santa Casa da Misericórdia do Rio de Janeiro), Rio de Janeiro, Rio de Janeiro, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Brazil.
| | - Berenice Torres
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Maternity Ward of Santa Casa da Misericórdia do Rio de Janeiro), Rio de Janeiro, Rio de Janeiro, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Brazil
| | - Marcelo Burlá
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Maternity Ward of Santa Casa da Misericórdia do Rio de Janeiro), Rio de Janeiro, Rio de Janeiro, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Izildinha Maestá
- Trophoblastic Diseases Center of the Clinical Hospital of Botucatu Medical School, Department of Gynecology and Obstetrics, São Paulo State University, Botucatu, São Paulo, Brazil
| | - Sue Yazaki Sun
- São Paulo Hospital Trophoblastic Disease Center, Paulista School of Medicine, São Paulo Federal University, São Paulo, São Paulo, Brazil
| | - Lawrence Lin
- São Paulo Clinics Hospital Trophoblastic Disease Center, University of São Paulo, São Paulo, São Paulo, Brazil
| | - José Mauro Madi
- Caxias do Sul Trophoblastic Disease Center, General Hospital of Caxias do Sul, School of Medicine, Center for Biological and Health Sciences, Caxias do Sul University, Caxias do Sul, Rio Grande do Sul, Brazil
| | - Elza Uberti
- Porto Alegre Trophoblastic Disease Center, Mario Totta Maternity Ward, Irmandade da Santa Casa de Misericórdia Hospital, Porto Alegre, Rio Grande do Sul, Brazil
| | - Maurício Viggiano
- Goiás Trophoblastic Disease Center, Clinical Hospital of Goiás, Goiás Federal University, Goiânia, Goiás, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
38
|
Markwerth P, Madea B, Kristiansen G, Doberentz E. Chorionkarzinom als seltene Ursache eines plötzlichen Todes eines 33-jährigen Mannes. Rechtsmedizin (Berl) 2017. [DOI: 10.1007/s00194-017-0148-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
39
|
Contribution of Syncytins and Other Endogenous Retroviral Envelopes to Human Placenta Pathologies. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2017; 145:111-162. [DOI: 10.1016/bs.pmbts.2016.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
40
|
Wei H, Zhang T, Liu B, Xue X, Wang G. Choriocarcinoma of unknown origin with multiple organ metastasis and cerebral hemorrhage: A case report and literature review. Oncol Lett 2016; 11:3749-3752. [PMID: 27313687 DOI: 10.3892/ol.2016.4463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/18/2016] [Indexed: 12/20/2022] Open
Abstract
A 26-year-old man was admitted to Beijing Friendship Hospital, Capital Medical University (Beijing, China) with a 4-day history of headache, moderate fever and numbness in the right upper limb. Prior to this, the patient had been diagnosed with cerebral hemorrhage by computed tomography (CT) scan upon visiting a local hospital. Chest X-ray revealed multiple lesions in the lungs. Following referral, no abnormalities were found elsewhere, including in the testes, during a physical examination. Additional examination of other tumor biomarkers was unremarkable, and the initial suspicion of parasitic infection was ruled out. Tests revealed extremely high levels of β-human chorionic gonadotropin (>200,000 mIU/ml). In addition, CT scans showed multiple metastases in the head, lungs, liver and kidneys. An ultrasound-guided Tru-Cut biopsy of the liver was performed in order to form a definitive diagnosis. Although the patient was treated with mannitol to reduce intracranial pressure, and with cefoperazone sodium and sulbactam sodium to fight infection, the patient succumbed to a cerebral hernia on the fourth day of hospitalization. Following this, the ultrasound-guided Tru-Cut liver biopsy result was received, which suggested a diagnosis of choriocarcinoma.
Collapse
Affiliation(s)
- Hongtao Wei
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Tianpeng Zhang
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Bing Liu
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, P.R. China
| | - Xiaowei Xue
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, P.R. China
| | - Guoxing Wang
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, P.R. China
| |
Collapse
|
41
|
Silva JF, Serakides R. Intrauterine trophoblast migration: A comparative view of humans and rodents. Cell Adh Migr 2016; 10:88-110. [PMID: 26743330 DOI: 10.1080/19336918.2015.1120397] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Trophoblast migration and invasion through the decidua and maternal uterine spiral arteries are crucial events in placentation. During this process, invasive trophoblast replace vascular endothelial cells as the uterine arteries are remodeled to form more permissive vessels that facilitate adequate blood flow to the growing fetus. Placentation failures resulting from either extensive or shallow trophoblastic invasion can cause pregnancy complications such as preeclampsia, intrauterine growth restriction, placenta creta, gestational trophoblastic disease and even maternal or fetal death. Consequently, the use of experimental animal models such as rats and mice has led to great progress in recent years with regards to the identification of mechanisms and factors that control trophoblast migration kinetics. This review aims to perform a comparative analysis of placentation and the mechanisms and factors that coordinate intrauterine trophoblast migration in humans, rats and mice under physiological and pathological conditions.
Collapse
Affiliation(s)
- Juneo F Silva
- a Laboratório de Endocrinologia e Metabolismo, Departamento de Fisiologia e Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais , Belo Horizonte , Minas Gerais , Brazil
| | - Rogéria Serakides
- b Laboratório de Patologia, Departamento de Clínica e Cirurgia Veterinárias, Escola de Veterinária, Universidade Federal de Minas Gerais , Belo Horizonte , Minas Gerais , Brazil
| |
Collapse
|