Resection of pulmonary metastatic choriocarcinoma in 43 drug-resistant patients

The role of pulmonary resection in the management of metastatic gestational trophoblastic neoplasia: Two cases of durable remission following surgery for chemo-resistant disease

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GTN is typically a chemo-responsive and highly curative gynecologic malignancy.

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Surgery may be beneficial in as many as 2/3 of patients with high-risk GTN.

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In select patients, resection of drug-resistant pulmonary metastases is effective.

Pulmonary Resection in the Management of High-Risk Gestational Trophoblastic Neoplasia

Objective

The aim of this study was to evaluate the role of pulmonary resection in the management of high-risk gestational trophoblastic neoplasia (GTN).

Methods

Patients who underwent pulmonary resection as part of their treatment for chemotherapy-resistant high-risk GTN from 1986 and 2014 were retrospectively analyzed. All patients had received 1 or more multiagent chemotherapy regimens preoperatively. Patient and disease characteristics were evaluated with respect to outcome.

Results

Fifteen (26%) of 58 patients treated for high-risk GTN underwent pulmonary resection with curative intent. Mean age of patients was 29 years (range, 19–37 years). International Federation of Gynecology and Obstetrics stage was III in 12 and IV in 3. International Federation of Gynecology and Obstetrics scores ranged from 5 to 20 (mean, 10). Antecedent pregnancy was nonmolar in 11 patients (73%). Adjuvant surgical procedures other than pulmonary resection were performed in 8 patients (53%). Preoperative chemotherapy regimens ranged from 1 to 10 (median, 4) and courses numbered from 2 to 32 (median, 14). Preoperative human chorionic gonadotropin (hCG) levels ranged from 2 to 2786 mIU/mL (median, 177 mIU/mL). Pulmonary wedge resections or lobectomies were performed via video-assisted thoracoscopic surgery (11) or thoracotomy (4). Two patients underwent pulmonary resections on 2 separate occasions. No patient had complications as a result of these procedures. Eleven patients (73%) were cured. In these 11 patients, hCG levels decreased to less than 2 mIU/mL within 6 to 52 days (mean, 22 days) postoperatively.

Conclusions

Pulmonary resection of chemotherapy-resistant GTN was an important component of treatment in 26% of high-risk patients, 73% of whom were cured. Ideal candidates have disease isolated to the lungs and low hCG levels.

Role of surgical therapy in the management of gestational trophoblastic neoplasia

Objective

To evaluate the role of adjuvant surgical procedures in the management of gestational trophoblastic neoplasia (GTN).

Methods

In a retrospective review of medical records at the Severance Hospital, we identified 174 patients diagnosed with GTN between 1986 and 2006. Of the 174 patients, 129 (74%) were assigned to the nonmetastatic group, and 45 (26%) to the metastatic group; of the metastatic group patients, 6 were in the low-risk group and 39 were in the high-risk group. Thirty-two patients underwent 35 surgical procedures as part of the GTN treatment. The procedures included hysterectomy, lung resection, craniotomy, uterine wedge resection, uterine suturing for bleeding, salpingo-oophorectomy, pretherapy dilatation and curettage, adrenalectomy, nephrectomy, and uterine artery embolization.

Results

Of the 32 patients who underwent surgical procedures, 28 (87%) survived. Eleven patients underwent surgery for chemoresistant disease after receiving one or more chemotherapy regimens. Twelve patients underwent procedures to control tumor hemorrhage. Nine (81%) of 11 patients with chemoresistant disease survived, and 8 patients who underwent salvage surgery for chemoresistant disease received further chemotherapy. Of 21 patients who underwent hysterectomy, 19 (90%) achieved remission. All of three patients who had resistant foci of choriocarcinoma in the lung achieved remission through pulmonary resection.

Conclusion

Adjuvant surgical procedures, especially hysterectomy and pulmonary resection for chemoresistant disease, as well as procedures to control hemorrhage, are pivotal in the management of GTN.

Gestational trophoblastic disease II: classification and management of gestational trophoblastic neoplasia

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

Residual lung lesions after completion of chemotherapy for gestational trophoblastic neoplasia: should we operate?

The significance of residual lung metastasis from malignant gestational trophoblastic neoplasm (GTN) after the completion of chemotherapy is unknown. We currently do not advocate resection of these masses. Here, we investigate the outcome of these patients. Patients with residual lung abnormalities after the completion of treatment for GTN were compared to those who had a complete radiological resolution of the disease. None of the residual masses post-treatment were surgically removed. In all, 76 patients were identified. Overall 53 (70%) patients had no radiological abnormality on CXR or CT after completion of treatment. Eight (11%) patients had residual disease on CXR alone 15 patients had residual disease on CT (19%). During follow-up, two patients (2.6%) relapsed. One of these had had a complete radiological response post-treatment whereas the other had residual disease on CT. Patients with residual lung lesions after completing treatment for GTN do not appear to have an increased chance of relapse compared to those with no residual abnormality. We continue to recommend that these patients do not require pulmonary surgery for these lesions.

Role of surgery and radiation therapy in the management of gestational trophoblastic disease

Although sensitive human chorionic gonadotrophin (hCG) assays and advances in chemotherapy have assumed primary importance in the management of gestational trophoblastic disease (GTD), surgery and radiation therapy remain important in the overall management of patients. Management of molar pregnancies consists of surgical evacuation and subsequent monitoring. Hysterectomy may decrease the risk of post-molar trophoblastic disease. When incorporated into the primary management of malignant GTD, hysterectomy decreases chemotherapy requirements for patients with low-risk disease. Surgical intervention is frequently required to control complications of disease or as therapy to stabilize patients during chemotherapy. Salvage hysterectomy or other extirpative procedures may be integrated into the management of patients with chemorefractory disease. Interventional radiographical techniques are useful adjuncts to control haemorrhage from vaginal or pelvic metastases. Radiation therapy may also be combined with chemotherapy for the management of patients with brain metastases or, rarely, isolated metastases at other sites.

Secondary pulmonary malignancy

Patients with pulmonary metastases were previously relegated to palliative medical management. Since the first metastasectomies in the nineteenth century, general acceptance of this technique has occurred. Although, initially, indications for resection of pulmonary metastases were limited to patients with solitary nodules, over time, indications have broadened to include multiple lesions, recurrent disease, and nearly all histologies. With appropriate patient selection and the absence of extrathoracic disease, survival may be improved. For patients with disseminated and symptomatic disease, surgical therapy may also provide some relief.

Metastatic gestational choriocarcinoma. Unusual pathologic variant following therapy

Two cases of metastatic gestational choriocarcinoma to the lungs have been encountered that presented unusual histologic patterns. Both lesions were solitary metastases that followed multiple courses of chemotherapy, and the patients had low serum beta-human chorionic gonadotropin (hCG) levels. Surgical excision appeared to be curative in both cases. Both neoplasms were characterized by a predominance of uniform but highly atypical mononucleate trophoblastic cells. These cells infiltrated pulmonary parenchyma, forming nests of tumor with central dense necrotic debris. Syncytiotrophoblastic cells (STB) were present but showed scant cytoplasm and little vacuolization. Hemorrhage was only focal. Immunohistochemistry revealed that some of the multinucleate STB and occasional mononucleate cells produced hCG, while human placental lactogen was focally produced in the tumors. By electron microscopy the STB were identified but lacked open lacunae lined by microvilli. Most mononucleate cells showed greater maturation evidenced by a more complex cytoplasm than is seen in typical cytotrophoblastic cells (CTB). The results suggest that these tumors are a distinctive subtype of choriocarcinoma composed largely of a form of trophoblastic cell with features intermediate between CTB and STB, yet different from the intermediate trophoblast of the placental site tumor. Identification of this morphologic variant of choriocarcinoma may have clinical utility as additional cases are studied.