The results of treatment with high-dose chemotherapy and peripheral blood stem cell support for gestational trophoblastic neoplasia

Case report: Multidrug resistant gestational trophoblastic neoplasia: focus on failure of immunotherapy and success of high-dose chemotherapy

Gestational trophoblastic neoplasia (GTN) is extremely rare, but has a very good prognosis, with a cure rate close to 100%, for low-risk diseases. This article describes the case of a healthy 28-year-old nulliparous patient with GTN resistant to multiple lines of treatment. The era of immunotherapy is revolutionizing oncology, having already proved its worth in the treatment of many cancers. This article will have a specific focus on the emerging role of immunotherapy in the treatment of GTN. Unfortunately, the use of an immune checkpoint inhibitor (ICI) failed in our case, emphasizing on the necessity to clearly define the future role of immune therapy in GTN. Finally, given the rapid progression of the disease after hysterectomy, induction with Paclitaxel- Ifosfamide and then intensification with high-dose Carboplatin and Etoposide with peripheral blood stem cell support was given as a rescue therapy with still curative intent.

A Phase II Basket Trial of Dual Anti-CTLA-4 and Anti-PD-1 Blockade in Rare Tumors (DART SWOG 1609 Cohort 47) in Patients with Gestational Trophoblastic Neoplasia

PURPOSE

The efficacy of immune checkpoint blockade in gestational trophoblastic neoplasia (GTN) remains uncertain. We report the results of the GTN cohort of SWOG S1609 dual anti-CTLA-4 and anti-PD-1 blockade in rare tumors (DART).

PATIENTS AND METHODS

This prospective, open-label phase II trial evaluated ipilimumab plus nivolumab across multiple rare tumor cohorts, including GTN. Eligible patients received nivolumab 240 mg, i.v. every 2 weeks and ipilimumab 1 mg/kg i.v. every 6 weeks. The primary endpoint was overall response rate [ORR; complete response (CR) + partial response (PR)] by quantitative serum beta human chorionic gonadotropin (β-hCG); secondary endpoints included progression-free survival (PFS), overall survival (OS), and toxicity.

RESULTS

Four patients with refractory GTN enrolled and received therapy. At 11 months of ongoing follow-up, 3 of 4 patients responded [ORR = 75% (CR, 25%, n = 1, tumor mutation burden = 1 mutation/megabase; PD-L1 tumor proportion score = 50%); PR, 50%, n = 2)]. Responders included malignant gestational trophoblastic neoplasm (n = 1, CR, PFS 11+ months) and choriocarcinoma (n = 2, both PRs, PFS 10+ and 6+ months). One patient with epithelioid trophoblastic tumor experienced disease progression. The 6-month PFS was 75% [95% confidence interval (CI), 43%-100%], and the median PFS was not reached (range, 35-339+ days); all 4 patients were alive at last follow-up. Two patients experienced grade 3 immune-related toxicity (arthralgia and colitis); there were no grade ≥4 events.

CONCLUSIONS

Ipilimumab plus nivolumab demonstrated efficacy in chemotherapy-refractory GTN, an ultra-rare cancer affecting young women. Three of 4 patients achieved ongoing objective responses with a reasonable safety profile at 6-11+ months.

Progress of immunotherapies in gestational trophoblastic neoplasms

BACKGROUND

Different from other malignant gynecologic tumors, gestational trophoblastic neoplasms (GTNs) exhibit an exceptionally high cure rate primarily through chemotherapeutic interventions. However, there exists a small subset of refractory GTNs that do not respond to conventional chemotherapies. In such cases, the emergence of immunotherapies has demonstrated significant benefits in managing various challenging GTNs.

PURPOSE

This article aims to provide a comprehensive and systematic review of the immune microenvironment and immunotherapeutic approaches for GTNs. The purpose is to identify potential biomarkers that could enhance disease management and summarize the available immunotherapies for ease of reference.

METHODS

We reviewed the relevant literatures toward immunotherapies of GTNs from PubMed.

CONCLUSION

Current immunotherapeutic strategies for GTNs mainly revolve around immune checkpoint inhibitors (ICIs) targeting programmed death receptor 1 (PD-1) and programmed cell death ligand 1 (PD-L1). Prominent examples include avelumab, pembrolizumab, and camrelizumab. However, existing researches into the underlying mechanisms are still limited.

Management of trophoblastic tumors : review of evidence, current practice, and future directions

INTRODUCTION

Gestational trophoblastic neoplasia (GTN) is a group of rare tumors characterized by abnormal trophoblastic proliferation following pregnancy including invasive moles, choriocarcinomas, and intermediate trophoblastic tumors (ITT). Although the treatment and follow-up of GTN has been heterogeneous, globally the emergence of expert networks has helped to harmonize its management.

AREAS COVERED

We provide an overview of the current knowledge, diagnosis, and management strategies in GTN and discuss innovative therapeutic options under investigation. While chemotherapy has been the historical backbone of GTN treatment, promising drugs such as immune checkpoint inhibitors targeting the PD-1/PD-L1 pathway and anti-angiogenic tyrosine kinase inhibitors are currently being investigated remodeling the therapeutical landscape of trophoblastic tumors.

EXPERT OPINION

Chemotherapy regimens for GTN have potential long-term effects on fertility and quality of life, making innovative and less toxic therapeutic approaches necessary. Immune checkpoint inhibitors have shown promise in reversing immune tolerance in GTN and have been evaluated in several trials. However, immunotherapy is associated with rare but life-threatening adverse events and evidence of immune-related infertility in mice, highlighting the need for further research and careful consideration of its use. Innovative biomarkers could help personalize GTN treatments and reduce chemotherapy burden in some patients.

Current chemotherapeutic options for the treatment of gestational trophoblastic disease

INTRODUCTION

Gestational trophoblastic neoplasia (GTN) is a rare tumor that arises from trophoblastic tissues with high remission rates after chemotherapy treatment. GTN can develop from any gestational events, such as miscarriage, ectopic pregnancy, and preterm/term pregnancy, but is more frequent after hydatidiform mole. The sensitivity of this tumor to chemotherapy and the presence of an exceptional tumor marker allow high remission rates, especially when patients are treated in referral centers.

AREAS COVERED

Observational, retrospective, prospective, systematic reviews, and meta-analysis studies focusing on GTN treatment. We searched PubMed, Medline, and the Library of Congress from January 1965 to May 2022.

EXPERT OPINION

Early GTN diagnosis allows low-toxic and highly effective treatment. Even multimetastatic disease has high rates of remission with multiagent regimen chemotherapy. Surgery is reserved for uterine disease in patients who have completed childbearing, in cases of chemoresistance to multiagent regimens or in the rare cases of placental site trophoblastic tumor or epithelioid trophoblastic tumor. While resistance is managed by salvage chemotherapy, cases with limited clinical response to sequential regimens have been successfully treated with immunotherapy.

Gestational Choriocarcinoma Manifesting as Spontaneous Hemothorax in Third Trimester of Pregnancy: A Case Report

Gestational trophoblastic neoplasia (GTN) is an aggressive malignancy arising from the trophoblastic tissue. It is rarely seen in association with advanced intrauterine pregnancy. Most common manifestations are due to bleeding caused by the rich vascularity of trophoblastic tissue. We describe here a case of a 28-year-old female patient who presented to us at 32 weeks of pregnancy with sudden onset dyspnea and hemodynamic instability. On evaluation, imaging techniques revealed a gross left hemothorax requiring intercostal tube insertion for stabilization. Emergency thoracotomy and hemothorax drainage were performed wherein a tumor mass in the lower lobe of left lung was identified and resected. Histopathological examination confirmed the diagnosis of choriocarcinoma. Beta HCG levels were found to be elevated. Final diagnosis of a FIGO stage IV high-risk gestational choriocarcinoma was made. Following this, six cycles of multi-agent EMA-CO chemotherapy was administered to the patient. Patient had an excellent response to treatment with documented serial fall in β HCG levels and she continues to be in remission after 6 months of follow-up. In conclusion, in the circumstance of any pregnant women presenting with abnormal bleeding symptoms such as hemothorax, choriocarcinoma as a cause should be considered for early diagnosis and effective management.

Ten-Year Review of Gestational Trophoblastic Disease at Lady Reading Hospital, Peshawar

Objective: To determine the frequency and management outcome of gestational trophoblastic disease (GTD) in Lady Reading Hospital.

Methods: This was a retrospective observational study at Lady Reading Hospital, Peshawar, from January 2011 to December 2021. Hospital records of all patients with GTD were reviewed and all were included in this study except those with an incomplete record or unconfirmed histology. Treatment was analysed in terms of surgical, chemotherapy or no treatment, and outcomes were noted in terms of complete remission, disease persistence or death.

Results: In 10 years 353 patients were admitted with GTD, and the frequency of the disease was 3.72 cases per 1000 pregnancies. The most frequent lesions were complete mole 65.2% (n=230) followed by invasive mole 20.4% (n=72). Mortality rate was 0.56% (n=2).

Maternal blood group analysis revealed that B positive 28.3% (n=100) was more frequent. O positive blood group was found more in the malignant form of the disease at 3.96% (n=14). GTD was most prevalent in 21 to 30 years of age (41.4%, n=146). Regarding treatment, in 69.97% (n=247) of cases, suction and evacuation were performed, in 4.2% (n=15) of cases hysterectomy was performed as primary therapy, and 4.8% (17) needed hysterectomy for chemoresistance.

In this study 42.49% (n=150) were given single-agent chemotherapy and 4.8% (n=17) were given multi-agent therapy. We had 21.33% (32) patients with a risk score of 7-9. In the group with a risk score of 7-9, 15.62% (n=5) patients were directly started on multi-agent therapy because of evidence of metastasis or choriocarcinoma; the remaining 84.37% (n=27) of patients who had no evidence of metastasis, no prior chemotherapy, no choriocarcinoma and International Federation of Obstetrics and Gynecology (FIGO) stage 1 were given single-agent methotrexate with folinic acid (eight days) after informed consent. In 18.75% of patients (n=6) hysterectomy was performed as the primary treatment either for haemorrhage or with age > 40, family completed, or reluctance to undergo chemotherapy. They all had a complete cure. In 3.1% (n=1) of cases, resistance to single-agent therapy was found and multi-agent treatment was started. Overall, in 96.29% of patients, complete remission was achieved with single-agent therapy in patients with risk scores of 7-9.

Conclusion: The frequency of GTD was 3.4/1000 pregnancies. Complete mole was the most frequent lesion, and single-agent chemotherapy had a good outcome in low- and high-risk patients with a risk score of 7-9 (with no evidence of metastasis, prior chemotherapy, or choriocarcinoma and FIGO stage 1).

Current Evidence on Immunotherapy for Gestational Trophoblastic Neoplasia (GTN)

Simple Summary

Gestational trophoblastic neoplasia (GTN) is a rare tumor group that arises from the malignant transformation of placental tissue. Based on the evaluation of International Federation of Gynecology and Obstetrics (FIGO) anatomic staging and FIGO prognostic score, GTN is divided into low-, high-, and ultra-high-risk groups if the score obtained is less than or equal to 6, greater than 6 or greater than 12, respectively. The standard treatment is chemotherapy, using a single agent in low-risk disease and multiagent chemotherapy in high- and ultra-high-risk GTN. In chemoresistant forms of GTN, the use of immune checkpoint inhibitors, such as anti-PD-1 or anti-PD-L1/2, could represent a new therapeutic strategy. In this study, we evaluate the available evidence on immune checkpoint inhibitors for GTN treatment.

Abstract

Background: Gestational trophoblastic disease includes a rare group of benign and malignant tumors derived from abnormal trophoblastic proliferation. Malignant forms are called gestational trophoblastic neoplasia (GTN) and include invasive mole, choriocarcinoma, placental site trophoblastic tumor and epithelioid trophoblastic tumor. Standard treatment of GTN is chemotherapy. The regimen of choice mainly depends on the FIGO prognostic score. Low-risk and high-risk GTN is treated with single-agent or multiagent chemotherapy, respectively. In the case of chemoresistance, immunotherapy may represent a new therapeutic strategy. Methods: Literature obtained from searches on PubMed concerning GTN and immunotherapy was reviewed. Results: Programmed cell death 1 (PD-1) and its ligands (PD-L1/2) are expressed in GTN. Published data on PD-1/PD-L1 inhibitors alone in GTN were available for 51 patients. Pembrolizumab is an anti-PD-1 inhibitor used in chemoresistant forms of GTN. In the TROPHIMMUN trial, Avelumab, a monoclonal antibody inhibiting PD-L1, showed promising results only in patients with GTN resistant to monochemotherapy. Conversely, in patients with resistance to multiagent chemotherapy, treatment with Avelumab was discontinued due to severe toxicity and disease progression. The association of Camrelizumab and Apatinib could represent a different treatment for forms of GTN refractory to polychemotherapy or for relapses. Conclusions: Anti-PD-1 or anti-PD-L1 might represent an important new treatment strategy for the management of chemoresistant/refractory GTN.

CBR3-AS1 Accelerates the Malignant Proliferation of Gestational Choriocarcinoma Cells by Stabilizing SETD4

Background

Gestational choriocarcinoma (GC) is a rare malignant gestational trophoblastic tumor. Long noncoding RNA (lncRNA) CBR3 antisense RNA 1 (CBR3-AS1) has been reported to serve as a critical oncogene and facilitate tumor progression. Besides, we found that CBR3-AS1 is implicated in GC progression.

Materials and Methods

Gene and protein expression was detected via quantitative reverse transcription PCR (RT-qPCR) and western blot analyses, respectively. CCK-8 assay and colony formation assay were performed to assess cell proliferative abilities while flow cytometry analysis was applied for cell cycle and apoptosis. To analyze the specific mechanism among CBR3-AS1, SET domain containing 4 (SETD4), and polypyrimidine tract binding protein 1 (PTBP1), RNA binding protein immunoprecipitation (RIP), RNA pulldown, and mRNA stability assays were conducted.

Results

CBR3-AS1 was markedly upregulated in GC cells, and its downregulation suppressed cell proliferation, induced cell cycle arrest, but promoted cell apoptosis in GC. SETD4 was determined as the downstream mRNA of CBR3-AS1 and positively regulated by CBR3-AS1 in GC cells. Furthermore, CBR3-AS1 could interact with its RNA binding protein (RBP) PTBP1, thereby stabilizing SETD4 mRNA. Rescue assays verified that CBR3-AS1 facilitates GC cell malignant proliferation via SETD4.

Conclusion

CBR3-AS1 accelerates the malignant proliferation of GC cells via stabilizing SETD4.

Immune Checkpoint Inhibitors for the Treatment of Gestational Trophoblastic Neoplasia: Rationale, Effectiveness, and Future Fertility

OPINION STATEMENT

Most individuals with gestational trophoblastic neoplasia (GTN) are cured with chemotherapy; however, about 5% of them will develop chemotherapy-resistant disease and will die of disease progression. Most GTN tissues express programmed death ligand-1 (PDL-1), making immune checkpoint inhibitors (ICIs) targeting this pathway an attractive treatment option for individuals with GTN. There is increasing evidence to support the use of ICIs for individuals with recurrent or resistant GTN, but available data are derived from case reports and small single arm trials. As promising as it seems, not all individuals with GTN respond to ICIs, and there is lack of evidence toward which factors mediate the effect of ICIs on GTN. In addition, treatment-related adverse events and impact on future fertility are not negligible and should be considered before initiating this treatment. Therefore, additional research is needed to evaluate treatment outcome of ICIs in GTN compared to standard treatment, and to identify molecular and clinical predictors for treatment response, before this treatment is incorporated into the standard of care.

Choriocarcinoma After Full-Term Pregnancy: A Case Report and Review of the Literature

Choriocarcinoma is a disease associated with uncontrollable proliferation and malignant change of cells of the placenta and belongs to the malignant end of the spectrum in gestational trophoblastic disease. These tumours are usually developed after molar pregnancies, and their incidence after full-term pregnancies is extremely rare.

We present a very rare case of a 30-year-old lady, admitted with a five-month history of vaginal bleeding after a normal pregnancy. The human chorionic gonadotropin (hCG) was at a level of 209,566. A pelvic ultrasound scan revealed an endometrial thickness of 6 cm and the presence of an intra-uterine mass measuring 56 × 50 × 45 mm. After discussion with the regional gestational trophoblastic disease centre, we proceeded to a surgical evacuation of the uterus, which confirmed a post-partum choriocarcinoma (International Federation of Gynaecology and Obstetrics (FIGO) score 9). Care was continued in the specialised centre with multi-agent chemotherapy. The response was excellent, and the patient was subsequently discharged after 10 cycles of chemotherapy, and a 10-year follow-up was arranged.

Choriocarcinomas after full-term pregnancies are a rare entity. Even when they happen, they are usually associated with pregnancy complications in the ante-natal period. The prognosis is usually very good, provided that prompt diagnosis and referral to a specialised centre are made. Low-risk patients are usually treated with methotrexate monotherapy, whereas high-risk women would normally require multi-agent chemotherapy. The diagnosis of choriocarcinoma might be proven challenging even for experienced clinicians. Women should be informed that the prognosis is usually excellent, provided that they receive the right treatment.

Diagnosis and management of gestational trophoblastic disease: 2021 update

Gestational trophoblastic disease (GTD) arises from abnormal placenta and is composed of a spectrum of premalignant to malignant disorders. Changes in epidemiology of GTD have been noted in various countries. In addition to histology, molecular genetic studies can help in the diagnostic pathway. Earlier detection of molar pregnancy by ultrasound has resulted in changes in clinical presentation and decreased morbidity from uterine evacuation. Follow-up with human chorionic gonadotropin (hCG) is essential for early diagnosis of gestational trophoblastic neoplasia (GTN). The duration of hCG monitoring varies depending on histological type and regression rate. Low-risk GTN (FIGO Stages I-III: score <7) is treated with single-agent chemotherapy but may require additional agents; although scores 5-6 are associated with more drug resistance, overall survival approaches 100%. High-risk GTN (FIGO Stages II-III: score ≥7 and Stage IV) is treated with multiagent chemotherapy, with or without adjuvant surgery for excision of resistant foci of disease or radiotherapy for brain metastases, achieving a survival rate of approximately 90%. Gentle induction chemotherapy helps reduce early deaths in patients with extensive tumor burden, but late mortality still occurs from recurrent treatment-resistant tumors.

Progress to international harmonisation of care and future developments

Considerable differences exist in the management of gestational trophoblastic disease (GTD) both nationally and internationally despite numerous efforts to harmonise patient care. This partly reflects differences in healthcare systems and availability of resources. However, even in first world equivalent economies with similar healthcare systems differences remain, which appear to impact survival. Recently, new international guidelines have been established in Europe through a series of consensus meetings. Improvement of outcomes will depend on the establishment of dedicated centres with appropriate patient pathways according to these guidelines. This review will highlight some of the differences and efforts to unify the management of GTD across the globe and discuss areas for future development.

Fertility and pregnancy outcome in gestational trophoblastic disease

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.

Treatment of high-risk gestational trophoblastic neoplasia and chemoresistance/relapsed disease

High-risk gestational trophoblastic neoplasia (GTN) has an increased risk of developing chemoresistance to single-agent chemotherapy; therefore, the primary treatment should be a multiagent etoposide-based regimen, preferably EMA/CO. After remission (normalization of human chorionic gonadotropin - hCG), at least three consolidation courses of EMA-CO are needed to reduce the risk of relapse. Chemoresistance is diagnosed during treatment if hCG levels plateau/increase, in two consecutive values over a two-week period. When this occurs after remission, in the absence of a new pregnancy, there is a relapse. In both cases, after re-assessment of the extent of disease, EMA-EP is the most common chemotherapy choice. Even in these cases, remission rates are high. After remission is achieved, hCG should be measured monthly for a year. Pregnancy can be allowed after 12 months from remission. The follow-up of these patients in referral centers minimizes the chance of death from this disease and should be encouraged.

Treatment of gestational trophoblastic disease in the 2020s

PURPOSE OF REVIEW

This review demonstrates the evidence for new systemic anticancer treatments and how they integrate within conventional management for gestational trophoblastic neoplasia (GTN). We present the evidence on atypical placental site nodules, and how they incorporate within the GTN spectrum, as well as updates regarding GTN staging and follow-up.

RECENT FINDINGS

First-line treatment for GTN still lies in conventional chemotherapy, although the introduction of anti-PD1/PD-L1 immune checkpoint inhibitors has shown significant promise in management of relapsed disease, with responses reported in multiple relapsed choriocarcinomas as well as epithelioid trophoblastic tumours and placental site trophoblastic tumours (ETT/PSTT). Following completion of treatment, ETT/PSTT still require life-long surveillance but for other GTN, no recurrences have been detected after 7 years.

SUMMARY

Checkpoint inhibitors are likely to play an increasing role in the future management of GTN management. Further refinement of prognostic factors to identify those most at risk of GTN recurrence is warranted so that surveillance can be focussed on those most at risk, whilst minimizing unnecessary intervention for those at lower risk.

Placental site trophoblastic tumour and epithelioid trophoblastic tumour

Placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT) are the rarest subtypes of gestational trophoblastic disease (GTD). Their diagnosis is complicated and lacks specific and sensitive tumour markers. They are slow-growing tumours and can occur months to years after any type of antecedent pregnancy. The primary treatment for localised disease is hysterectomy. However, extra-uterine invasion and/or metastasis occur in about one-third of cases and still cause death in a small number. Most patients are young; hence, fertility preservation is a consideration. The major obstacle for prognosis is chemotherapy resistance. The current understanding of these tumours remains elusive and no randomized controlled trials have been done. Even those centres treating a large number of patients with GTD will infrequently manage PSTT/ETT. In this review, we assess progress in the understanding of the disease and discuss four main clinical challenges - establishing conformity of practice, devising a risk-adapted approach to clinical management, establishing long-term follow-up data and evaluating therapies for poor prognosis and multi drug-resistant patients.

Cordycepin Inhibits Human Gestational Choriocarcinoma Cell Growth by Disrupting Centrosome Homeostasis

Introduction

Human gestational choriocarcinoma, a type of gestational trophoblastic disease, occurs after miscarriage, abortion, ectopic pregnancy, or molar pregnancy. Despite recent advances in the mechanism of anticancer drugs that induce human gestational choriocarcinoma apoptosis or block its growth, new therapeutic approaches are needed to be established. Cordycepin is an active anti-cancer component extracted from Cordyceps sinensis. It prevents cell proliferation both in vitro and in vivo.

Materials and Methods

Here, we examined cell growth by counting cell numbers, and performing a flow cytometry assay and EdU incorporation assay. Centrosome and cytoskeleton-related structures were observed by immunofluorescence assay. The DNA damage-related signaling was examined by Western blot assay.

Results

Here, we showed that cordycepin inhibited human gestational choriocarcinoma cell proliferation and induced cell death. In addition, treatment with cordycepin activated DNA-PK and ERK, thus inducing centrosome amplification and aberrant mitosis. These amplified centrosomes also disrupted microtubule arrays and actin networks, thus leading to defective cell adhesion. Furthermore, cordycepin induced autophagy for triggering cell death.

Conclusion

Thus, our study demonstrates that cordycepin inhibits cell proliferation and disrupts the cytoskeleton by triggering centrosome amplification.

Practical clinical guidelines of the EOTTD for treatment and referral of gestational trophoblastic disease

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.

A review on management of gestational trophoblastic neoplasia

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.

A Review on the Pathogenesis and Clinical Management of Placental Site Trophoblastic Tumors

Placental site trophoblastic tumor (PSTT) is a rare type of gestational trophoblastic disease originating from the intermediate trophoblast. Compared with hydatidiform mole, invasive hydatidiform mole and choriocarcinoma, the diagnosis of PSTT is more complicated and lacks specific and sensitive tumor markers. Most PSTT patients demonstrate malignant potential, and the primary treatment of PSTT is hysterectomy. However, metastasis occasionally occurs and even causes death in a small number of PSTT patients. Most PSTT patients are young women hence fertility preservation is an important consideration. The major obstacle for PSTT patient prognosis is chemotherapy resistance. However, the current understanding of the pathogenesis of PSTT and clinical treatment remains elusive. In this review, we summarized the research progress of PSTT in recent years from three aspects: mechanism, clinical presentation, and treatment and prognosis. Well-conducted multi-center studies with sufficient sample sizes are of great importance to better examine the pathological progress and evaluate the prognosis of PSTT patients, so as to develop prevention and early detection programs, as well as novel treatment strategies, and finally improve prognosis for PSTT patients.

Gestational Trophoblastic Neoplasia, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

Gestational trophoblastic neoplasia (GTN), a subset of gestational trophoblastic disease (GTD), occurs when tumors develop in the cells that would normally form the placenta during pregnancy. The NCCN Guidelines for Gestational Trophoblastic Neoplasia provides treatment recommendations for various types of GTD including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor.