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Ng JS, Ilancheran A. The role of surgery in gestational trophoblastic disease: an overview. Int J Gynecol Cancer 2024; 34:409-415. [PMID: 38438170 DOI: 10.1136/ijgc-2023-004584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Gestational trophoblastic disease comprises a group of rare, and potentially malignant, conditions that arise from abnormal trophoblastic proliferation. When there is invasion and evidence of metastatic disease, gestational trophoblastic neoplasia is used. While chemotherapy is the mainstay of treatment for gestational trophoblastic neoplasia, the role of surgery has come full circle in recent years. Before the introduction of highly effective systemic treatment options, surgery was the default treatment. Surgery for gestational trophoblastic neoplasia often yielded unsatisfactory results and mortality remained high. In recent years, the role of adjuvant surgery in the management of gestational trophoblastic neoplasia has been examined with great interest. We aim to provide an overview of the various surgical approaches employed in managing gestational trophoblastic neoplasia, including their indications, techniques, and outcomes. Additionally, we discuss whether there is a role to do less in surgery for gestational trophoblastic neoplasia and describe our experience with a modified surgical technique for its treatment. By summarizing the current evidence, this article highlights the significant contributions of surgery to the holistic management of patients with gestational trophoblastic neoplasia and provides a framework on which to base management and treatment programs.
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Affiliation(s)
- Joseph S Ng
- Department of Obstetrics and Gynecology, National University of Singapore, Singapore
- Gynecologic Cancer Program, National University Cancer Institute, Singapore
| | - Arunachalam Ilancheran
- Department of Obstetrics and Gynecology, National University of Singapore, Singapore
- Gynecologic Cancer Program, National University Cancer Institute, Singapore
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Liu W, Zhu Y, Wang Y, Li R, Zou D, Chen R, Yang L, Huang Y. Role of immune checkpoint inhibitors combined with chemotherapy in recurrent drug-resistant gestational trophoblastic neoplasia: Four case reports and literature review. Cancer Rep (Hoboken) 2024; 7:e2016. [PMID: 38425251 PMCID: PMC10905155 DOI: 10.1002/cnr2.2016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/02/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Multiple studies have confirmed that programmed cell death 1 (PD-1) and programmed cell death ligand 1 (PD-L1) is widely expressed in gestational trophoblastic neoplasia (GTN) tissues. Therefore, immune checkpoint inhibitors may be an option for the treatment of recurrent and drug-resistant GTN. CASE Four patients with recurrent or drug-resistant GTN who were treated with PD-1/PD-L1 checkpoint inhibitor agents combined with chemotherapy were reported. The mean age of recurrence was 45.8 years (35-56 years), including three cases of choriocarcinoma (CC) and one case of invasive mole (IM). International Federation of Gynecology and Obstetrics (FIGO) prognosis score: ≤6 (low risk) in one case, 7-12 (high risk) in one case, ≥13 (very high risk) in two cases. There were two cases of lung metastasis and one case of vulvar and inguinal lymph node metastasis. One of the four patients underwent total hysterectomy and one patient underwent resection of lung metastases. All the four patients received comprehensive treatment of immunotherapy combined with chemotherapy after relapse, among which one patient achieved complete response (CR), two patients achieved partial response (PR), and one patient developed progressive disease (PD). Three patients who achieved PR or CR were maintained by single agent immunotherapy after combination therapy, and there was no disease recurrence during follow-up. One patient with PD also achieved CR after using salvage chemotherapy after recurrence, and there was no disease recurrence during follow-up. During the treatment, four patients had different degrees of immune-related adverse reactions, all of which were grade I-II, and no severe adverse reactions were found. CONCLUSION Immune checkpoint inhibitors combined with chemotherapy has an impressive therapeutic effect on recurrent or drug-resistant GTN with mild adverse reactions, which can be used as a treatment option for such patients. However, due to the lack of large sample data support, the specific time and treatment course of its use, long-term use of adverse reactions and whether it affects fertility function remain to be solved.
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Affiliation(s)
- Weiqing Liu
- Department of Gynecologic OncologyChongqing University Cancer HospitalChongqingChina
| | - Yukai Zhu
- Department of Gynecologic OncologyChongqing University Cancer HospitalChongqingChina
| | - Ya Wang
- Department of Gynecologic OncologyChongqing University Cancer HospitalChongqingChina
| | - Rong Li
- Department of Gynecologic OncologyChongqing University Cancer HospitalChongqingChina
| | - Dongling Zou
- Department of Gynecologic OncologyChongqing University Cancer HospitalChongqingChina
| | - Rui Chen
- Department of PathologyChongqing University Cancer HospitalChongqingChina
| | - Lu Yang
- Department of Medical IconographyChongqing University Cancer HospitalChongqingChina
| | - Yu Huang
- Department of Gynecologic OncologyChongqing University Cancer HospitalChongqingChina
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Bolze P, Schoenen S, Margaillan M, Braga A, Sauthier P, Elias K, Seckl M, Winter M, Coulter J, Lok C, Joneborg U, Undurraga Malinverno M, Hajri T, Massardier J, You B, Golfier F, Goffin F. Chemotherapy is not needed when complete evacuation of gestational choriocarcinoma leads to hCG normalization. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108012. [PMID: 38350264 DOI: 10.1016/j.ejso.2024.108012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/23/2024] [Accepted: 02/07/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND The standard treatment for gestational choriocarcinoma is chemotherapy. OBJECTIVE To describe the risk of recurrence with expectant management of gestational choriocarcinoma that has reached a normal human chorionic gonadotropin level after tumor removal without adjuvant chemotherapy. METHODS A retrospective multicenter international cohort study was conducted from 1981 to 2017 involving 11 gestational trophoblastic disease reference centers with patient's follow-up extended until 2023. Clinical and biological data of included patients were extracted from each center's database. The inclusion criteria were i) histological diagnosis of gestational choriocarcinoma in any kind of placental tissue retrieved, ii) spontaneous normalization of human chorionic gonadotropin level following choriocarcinoma retrieval, iii) patient did not receive any oncological treatment for the choriocarcinoma, iv) and at least 6 months of follow-up after the first human chorionic gonadotropin level normalization. RESULTS Among 80 patients with retrieved gestational choriocarcinoma and whose human chorionic gonadotropin level normalized without any other oncological therapy, none had a recurrence of choriocarcinoma after a median follow-up of 50 months. The median interval between choriocarcinoma excision and human chorionic gonadotropin level normalization was 48 days. The International Federation of Gynecology and Obstetrics/World Health Organization risk score was ≤6 in 93.7% of the cases. CONCLUSIONS This multicenter international study reports that selected patients with gestational choriocarcinoma managed in gestational trophoblastic disease reference centers did not experience any relapse when the initial tumor evacuation is followed by human chorionic gonadotropin level normalization without any additional treatment. Expectant management may be a safe approach for highly selected patients.
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Affiliation(s)
- Pa Bolze
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France.
| | - S Schoenen
- Centre Belge de Référence des Maladies Trophoblastiques, Liège, Belgium.
| | - M Margaillan
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France
| | - A Braga
- Rio de Janeiro Trophoblastic Disease Reference Center, Rio de Janeiro, Brazil
| | - P Sauthier
- Réseau des Maladies Trophoblastiques Du Québec, Montréal, Canada
| | - K Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, USA
| | - M Seckl
- Charing Cross Gestational Trophoblastic Disease Center, London, UK
| | - M Winter
- Sheffield Center for Trophoblastic Diseases, Sheffield, UK
| | - J Coulter
- Department of Gynaecology Obstetrics, Cork University Maternity Hospital, Cork, Ireland
| | - C Lok
- Center of Gynaecologic Oncology, Amsterdam, Netherlands
| | - U Joneborg
- Department of Women's and Children's Health and Department of Pelvic Cancer, Karolinska Institutet/University Hospital, Stockholm, Sweden
| | - M Undurraga Malinverno
- Unité D'oncogynécologie, Département de Gynécologie et Obstétrique, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - T Hajri
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France
| | - J Massardier
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France
| | - B You
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France
| | - F Golfier
- Centre Français de Référence des Maladies Trophoblastiques, CHU Lyon Sud, France
| | - F Goffin
- Centre Belge de Référence des Maladies Trophoblastiques, Liège, Belgium
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Patel SP, Othus M, Chae YK, Dennis MJ, Gordon S, Mutch D, Samlowski W, Robinson WR“R, Sharon E, Ryan C, Lopez G, Plets M, Blanke C, Kurzrock R. 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. Clin Cancer Res 2024; 30:33-38. [PMID: 37882676 PMCID: PMC10842092 DOI: 10.1158/1078-0432.ccr-23-2293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/28/2023] [Accepted: 10/24/2023] [Indexed: 10/27/2023]
Abstract
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.
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Affiliation(s)
- Sandip P. Patel
- Division of Medical Oncology, University of California San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Megan Othus
- SWOG Statistical and Data Management Center/Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Young Kwang Chae
- Division of Medical Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael J. Dennis
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sarah Gordon
- Virginia Commonwealth University/Massey Cancer Center Division of Hematology, Oncology, Palliative Care, Virginia Commonwealth University, Richmond, VA, USA (during conduct of trial); Thomas Jefferson University/Sidney Kimmel Cancer Center, Philadelphia, PA, USA (current affiliation)
| | - David Mutch
- Division of Gynecologic Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Wolfram Samlowski
- Division of Medical Oncology, Nevada Cancer Institute, Las Vegas, NV, USA
| | - William R. “Rusty” Robinson
- Division of Gynecologic Oncology, University of Mississippi Medical Center Cancer Center and Research Institute, Jackson, MS, USA (during conduct of trial); Tulane Medical School, New Orleans, LA, USA (current affiliation)
| | - Elad Sharon
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD, USA
| | - Christopher Ryan
- Division of Hematology and Oncology, Oregon Health and Science University Knight Cancer Institute, Portland, OR, USA
| | - Gabby Lopez
- SWOG Statistical and Data Management Center/Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Melissa Plets
- SWOG Statistical and Data Management Center/Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Charles Blanke
- SWOG Group Chair’s Office/Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | - Razelle Kurzrock
- Division of Medical Oncology, Medical College of Wisconsin Froedtert Cancer Center, Milwaukee, WI, USA
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Mangla M, Palo S, Kanikaram P, Kaur H. Non-gestational choriocarcinoma: unraveling the similarities and distinctions from its gestational counterpart. Int J Gynecol Cancer 2023:ijgc-2023-004906. [PMID: 38123189 DOI: 10.1136/ijgc-2023-004906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Choriocarcinoma is a highly vascular and invasive tumor of anaplastic trophoblast, predominantly made up of cytotrophoblasts and syncytiotrophoblasts without villi. Based on its origin, choriocarcinoma can be either gestational or non-gestational. Non-gestational choriocarcinoma can be of germ cell origin, or can be seen in association with a somatic high-grade malignancy. It is difficult to differentiate gestational from non-gestational choriocarcinoma, especially in the reproductive age group. It is important to distinguish between the two, for accurate staging and prognostication, deciding the primary treatment modality, (ie, surgery or chemotherapy), and tailoring follow-up timeframes after diagnosis. An extensive literature search was performed regarding all cases of non-gestational choriocarcinoma, published before March 2023. A note was made of whether the origin of choriocarcinoma was ascertained and how gestational choriocarcinoma was differentiated from non-gestational choriocarcinoma. The keywords used for literature search were "non-gestational choriocarcinoma", "primary choriocarcinoma", "ovarian choriocarcinoma", "ovarian germ cell tumors", or "choriocarcinomatous differentiation". This review aims to summarize the similarities and differences in the epidemiology, pathogenesis, clinical presentation, and management guidelines between gestational and non-gestational choriocarcinoma, which can form an important educational resource for clinicians and laboratory physicians dealing with such cases.
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Affiliation(s)
- Mishu Mangla
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences - Bibinagar, Hyderabad, Telangana, India
| | - Seetu Palo
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences - Bibinagar, Hyderabad, Telangana, India
| | - Poojitha Kanikaram
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences - Bibinagar, Hyderabad, Telangana, India
| | - Harpreet Kaur
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences - Bilaspur, Bilaspur, Himachal Pradesh, India
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Piątek S, Szczęsny N, Szymusik I, Karoń K, Piątkowski K, Bornio E, Bidziński M, Gujski M. Fertility-Sparing Treatment in Gestational Choriocarcinoma: Evaluating Oncological and Obstetrical Outcomes in Young Patients. Med Sci Monit 2023; 29:e942078. [PMID: 37957930 PMCID: PMC10656781 DOI: 10.12659/msm.942078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/05/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Gestational choriocarcinoma (GC) is an uncommon neoplasia that occurs in women who may not have completed a procreation plan. The aim of this study was to evaluate oncological and obstetrical outcomes in young patients with GC after fertility-sparing treatment. MATERIAL AND METHODS The eligibility criteria for the study were histopathological diagnosis of GC, age ≤40 years, and treatment with systemic chemotherapy. Patients who underwent upfront hysterectomy were excluded. The response to treatment was assessed according to beta-human chorionic gonadotropin (beta-hCG) serum measurement. Complete response and progression were considered if the beta-hCG dropped to a normal range and increased (or reached a plateau), respectively. The birth rate was calculated as the number of women who gave birth after treatment divided by the total number of patients. RESULTS A total of 18 patients fulfilled the study's eligibility criteria. A complete response and progression to first-line chemotherapy were found in 13 (72.22%) and 5 (27.78%) patients, respectively. Salvage treatment was administered to patients with progression. Overall, 16 (88.88%) patients achieved complete response after treatment and 2 (11.12%) died. GC relapse was diagnosed in 1 patient 62 months after treatment. The birth rate was 22.22%, and a total of 6 children were born. All pregnancies ended in term delivery. No congenital abnormalities were detected in the newborns. CONCLUSIONS GC is a life-threatening form of gestational trophoblastic neoplasia, mainly due to its rapid course and resistance to chemotherapy. Most patients with GC will not be able to bear children after treatment.
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Affiliation(s)
- Szymon Piątek
- Department of Gynecologic Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Natalia Szczęsny
- Faculty of Medical Sciences and Health Sciences, Kazimierz Pułaski University of Technology and Humanities, Radom, Poland
| | - Iwona Szymusik
- Department of Obstetrics, Perinatology and Neonatology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Karolina Karoń
- Faculty of Medical Sciences and Health Sciences, Kazimierz Pułaski University of Technology and Humanities, Radom, Poland
| | - Krzysztof Piątkowski
- Faculty of Medical Sciences and Health Sciences, Kazimierz Pułaski University of Technology and Humanities, Radom, Poland
| | - Ewelina Bornio
- Faculty of Medical Sciences and Health Sciences, Kazimierz Pułaski University of Technology and Humanities, Radom, Poland
| | - Mariusz Bidziński
- Department of Gynecologic Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Mariusz Gujski
- Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
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Wang W, Shi J, Zheng L. METTL3 promotes choriocarcinoma progression by activating the miR-935/GJA1 pathway in an m6A-dependent manner. Am J Reprod Immunol 2023; 90:e13791. [PMID: 37881126 DOI: 10.1111/aji.13791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/26/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023] Open
Abstract
The emerging role of microRNA-935 (miR-935) in modulating cancer progression has been recognized. However, its role in regulating choriocarcinoma (CCA) development and progression remains unknown. The present work aims to reveal the effect of miR-935 on CCA cell tumor properties and the related mechanism. The RNA expression of methyltransferase 3, N6-adenosine-methyltransferase complex catalytic subunit (METTL3), miR-935, and gap junction protein alpha 1 (GJA1) was detected by quantitative real-time polymerase chain reaction. Protein expression of GJA1, Ki67, and METTL3 was measured by western blotting and immunohistochemistry assays. CCK-8 and colony formation were used to analyze cell proliferation. Transwell assays were performed to assess cell migration and invasion. Angiogenesis was investigated by tube formation assay. Xenograft mouse model assay was used to determine miR-935-mediated effect on tumor formation in vivo. The luciferase reporter assay and RNA pull-down assay were used to verify the relationship between miR-935 and GJA1. MeRIP assay was used to analyze the m6A methylation of pri-miR-935. MiR-935 expression was significantly upregulated in CCA tissues and cells when compared with control groups. MiR-935 overexpression promoted CCA cell proliferation, migration, invasion, and tube formation and tumor tumorigenesis in vitro and in vivo, but miR-935 knockdown showed the opposite effects. In addition, miR-935 targeted GJA1 and mediated CCA cell tumor properties by negatively regulating GJA1 expression. METTL3 promoted miR-935 maturation by inducing m6A methylation of pri-miR-935, and its overexpression contributed to CCA cell tumor properties through the regulation of miR-935. METTL3 promoted choriocarcinoma progression by m6A-dependently activating the miR-935/GJA1 pathway.
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Affiliation(s)
- Wenzhi Wang
- Department of Gynaecology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Jianyong Shi
- Department of Gynaecology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Lei Zheng
- College of Pharmacy, Xi'an Medical University, Xi'an, China
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Niimi K, Yamamoto E, Oda Y, Nishiko Y, Shibata M, Nishino K, Kajiyama H. A case of complete remission of intractable gestational choriocarcinoma with subsequent chemotherapy after pembrolizumab. Taiwan J Obstet Gynecol 2023; 62:745-748. [PMID: 37679006 DOI: 10.1016/j.tjog.2023.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 09/09/2023] Open
Abstract
OBJECTIVE Gestational choriocarcinoma is a gestational trophoblastic neoplasia (GTN) that originates from abnormal trophoblast proliferation. Although chemotherapy is effective for choriocarcinoma, personalized treatment becomes essential when patients develop chemoresistance. Here, we present the clinical course of a case of intractable choriocarcinoma that achieved complete remission with pembrolizumab following cytotoxic chemotherapy. CASE REPORT A 38-year-old woman was initially diagnosed with low-risk GTN and treated with single- and multi-agent chemotherapy. She underwent a hysterectomy and was diagnosed with pathological choriocarcinoma with high-risk GTN. She was treated with multiple courses of several chemotherapy regimens. However, she did not achieve remission. Her choriocarcinoma showed high microsatellite instability; therefore, she took ten courses of pembrolizumab, but her hCG value increased. Subsequently, she underwent eight courses of paclitaxel and carboplatin alternating with paclitaxel and etoposide and achieved remission. CONCLUSION This case suggests that pembrolizumab may improve the efficacy of subsequent chemotherapy.
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Affiliation(s)
- Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.
| | - Eiko Yamamoto
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yukari Oda
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yuki Nishiko
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Mayu Shibata
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kimihiro Nishino
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Paydas S. Immune checkpoint inhibitor using in cases with gestational trophoblastic diseases. Med Oncol 2023; 40:106. [PMID: 36823367 DOI: 10.1007/s12032-022-01941-3] [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: 11/11/2022] [Accepted: 12/24/2022] [Indexed: 02/25/2023]
Abstract
Gestational trophoblastic neoplasias (GTNs) are chemosensitive disorders with very high cure rates. However, individuals with chemoresistant diseases pass away as a result of their illness, necessitating the use of innovative medications. Immune checkpoint inhibitors (ICIs) are a critical component of the strategy for the management of drug-resistant GTD due to the high rate of PD-1 expression and the paternal genetic inheritance in GTNs. Immunotherapy is mentioned as a potential therapeutic approach for chemotherapy-resistant GTD in the most recent worldwide recommendations. However, multicenter worldwide collaborative studies are required to give additional evidence to detect and identify prognostic markers due to the rarity of GTDs and the dearth of data in the literature.
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Affiliation(s)
- Semra Paydas
- Dept of Medical Oncology, Faculty of Medicine, Cukurova University, Adana, Turkey.
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Watanabe E, Yokoi A, Yoshida K, Sugiyama M, Kitagawa M, Nishino K, Yamamoto E, Niimi K, Yamamoto Y, Kajiyama H. Drug library screening identifies histone deacetylase inhibition as a novel therapeutic strategy for choriocarcinoma. Cancer Med 2023; 12:4543-4556. [PMID: 36106577 PMCID: PMC9972027 DOI: 10.1002/cam4.5243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/20/2022] [Accepted: 08/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Choriocarcinoma is a rare and aggressive gynecological malignancy. The standard treatment is systemic chemotherapy as choriocarcinoma exhibits high chemosensitivity. However, refractory choriocarcinoma exhibits chemoresistance; thus, the prognosis remains very poor. This study aimed to identify novel therapeutic agents for choriocarcinoma by utilizing a drug repositioning strategy. METHODS Three choriocarcinoma cell lines (JAR, JEG-3, and BeWo) and a human extravillous trophoblast cell line (HTR-8/SVneo) were used for the analyses. The growth inhibitory effects of 1,271 FDA-approved compounds were evaluated in vitro screening assays and selected drugs were tested in tumor-bearing mice. Functional analyses of drug effects were performed based on RNA sequencing. RESULTS Muti-step screening identified vorinostat, camptothecin (S, +), topotecan, proscillaridin A, and digoxin as exhibiting an anti-cancer effect in choriocarcinoma cells. Vorinostat, a histone deacetylase inhibitor, was selected as a promising candidate for validation and the IC50 values for choriocarcinoma cells were approximately 1 μM. RNA sequencing and subsequent pathway analysis revealed that the ferroptosis pathway was likely implicated, and key ferroptosis-related genes (i.e., GPX4, NRF2, and SLC3A2) were downregulated following vorinostat treatment. Furthermore, vorinostat repressed tumor growth and downregulated the expression of GPX4 and NRF2 in JAR cell-bearing mice model. CONCLUSION Vorinostat, a clinically approved drug for the treatment of advanced primary cutaneous T-cell lymphoma, showed a remarkable anticancer effect both in vitro and in vivo by regulating the expression of ferroptosis-related genes. Therefore, vorinostat may be an effective therapeutic candidate for patients with choriocarcinoma.
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Affiliation(s)
- Eri Watanabe
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akira Yokoi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Institute for Advanced Research, Nagoya University, Nagoya, Japan
| | - Kosuke Yoshida
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Institute for Advanced Research, Nagoya University, Nagoya, Japan
| | - Mai Sugiyama
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masami Kitagawa
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Nishino
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eiko Yamamoto
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Yamamoto
- Laboratory of Integrative Oncology, National Cancer Center Research Institute, Tokyo, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Braga A, Paiva G, Cattai CJ, Elias KM, Horowitz NS, Berkowitz RS. Current chemotherapeutic options for the treatment of gestational trophoblastic disease. Expert Opin Pharmacother 2023; 24:245-258. [PMID: 36399723 DOI: 10.1080/14656566.2022.2150075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Gestational trophoblastic neoplasia (GTN) is a rare tumor that arises from trophoblastic tissues with high remission rates after chemotherapy treatment. GTN can develop from any gestational events, such as miscarriage, ectopic pregnancy, and preterm/term pregnancy, but is more frequent after hydatidiform mole. The sensitivity of this tumor to chemotherapy and the presence of an exceptional tumor marker allow high remission rates, especially when patients are treated in referral centers. AREAS COVERED Observational, retrospective, prospective, systematic reviews, and meta-analysis studies focusing on GTN treatment. We searched PubMed, Medline, and the Library of Congress from January 1965 to May 2022. EXPERT OPINION Early GTN diagnosis allows low-toxic and highly effective treatment. Even multimetastatic disease has high rates of remission with multiagent regimen chemotherapy. Surgery is reserved for uterine disease in patients who have completed childbearing, in cases of chemoresistance to multiagent regimens or in the rare cases of placental site trophoblastic tumor or epithelioid trophoblastic tumor. While resistance is managed by salvage chemotherapy, cases with limited clinical response to sequential regimens have been successfully treated with immunotherapy.
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Affiliation(s)
- Antonio Braga
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil.,Department of Medicine, Vassouras Medical School, Postgraduate Program in Applied Health Sciences, Vassouras University, Vassouras, RJ, Brazil.,National Academy of Medicine, Young Leadership Physician Program, Rio de Janeiro, RJ, Brazil
| | - Gabriela Paiva
- Department of Obstetrics and Gynecology, Postgraduate Program in Perinatal Health, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil.,, Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil
| | - Cassia Juliana Cattai
- , Department of Maternal Child, Postgraduate Program in Medical Sciences, Antonio Pedro University Hospital of Fluminense Federal University, Niterói, RJ, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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12
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Mousavi Seresht L, Farazestanian M, Yousefi Z. Single-agent chemotherapy in low-risk gestational trophoblastic neoplasia. CASPIAN JOURNAL OF INTERNAL MEDICINE 2023; 14:108-111. [PMID: 36741498 PMCID: PMC9878903 DOI: 10.22088/cjim.14.1.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 04/29/2022] [Accepted: 07/03/2022] [Indexed: 02/07/2023]
Abstract
Background Low-risk gestational trophoblastic neoplasia could be cured in the case of appropriate management with single-agent chemotherapy. This study was carried out to compare the efficacy of single-dose methotrexate versus Actinomycin-D in low-risk gestational trophoblastic neoplasia to analyze the most effective agent. Methods This retrospective cohort study was conducted on the medical record of 170 cases with the diagnosis of low-risk gestational trophoblastic neoplasia from 2012 to 2019 to evaluate the response rate of single-dose weekly-methotrexate versus biweekly-Actinomycin-D. Results Single agent chemotherapy was required in 170 patients with final risk score of less than 7. Among the 100 cases under weekly-methotrexate therapy, 29 patients were required second-line chemotherapy with Actinomycin-D and combination therapy which means complete remission of 71% with methotrexate, in comparison with 78.5% in the other group. Resistance was mostly seen in patients with documented choriocarcinoma in histology who had not received timely diagnosis and treatment. Conclusion Individualized decision in the management of low-risk gestational trophoblastic neoplasia cases, based on histology, HCG, and history is the corn stone in successful treatment.
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Affiliation(s)
- Leila Mousavi Seresht
- Department of Gynecology and Oncology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marjaneh Farazestanian
- Department of Gynecology and Oncology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zohreh Yousefi
- Department of Gynecology and Oncology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran,Correspondence: Zohreh Yousefi, Department of Gynecology and Oncology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. E-mail: , Tel: +98 3132367002
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13
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Kong Y, Wang W, Lin J, Wan X, Feng F, Ren T, Zhao J, Yang J, Xiang Y. Management and Predictors of Treatment Failure in Patients with Chemo-Resistant/Relapsed Gestational Trophoblastic Neoplasia with Lung Metastasis. J Clin Med 2022; 11:jcm11247270. [PMID: 36555889 PMCID: PMC9784534 DOI: 10.3390/jcm11247270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/26/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022] Open
Abstract
The aim of the study was to assess the effectiveness of a combined treatment modality of salvage chemotherapy and pulmonary resection in chemo-resistant/relapsed gestational trophoblastic neoplasia (GTN) with lung metastasis and identify predictors of treatment failure. Data of patients with chemo-resistant/relapsed GTN with lung metastasis who received salvage chemotherapy combined with pulmonary resection were retrospectively analyzed. Among 134 included patients, the number of preoperative chemotherapy regimens ranged from 2−8 (median, 3), and courses ranged from 4−37 (median, 14). Pulmonary lobectomies, segmentectomies, wedge resections, and lobectomies plus wedge resections were performed in 84, 5, 35, and 10 patients, respectively. After completion of treatment, 130 (97.0%) patients achieved complete remission. In the entire cohort, the 5-year overall survival (OS) rate was 87.6%. OS rates were similar between stage III and stage IV disease cohorts (89.4% vs. 75.0%, p = 0.137). Preoperative β-human chorionic gonadotropin (β-hCG) levels > 10 IU/L (p = 0.027) and number of preoperative chemotherapy regimens > 3 (p = 0.018) were predictors of treatment failure. The combined treatment modality of salvage chemotherapy and pulmonary resection is effective in patients with chemo-resistant/relapsed GTN with lung metastasis, improving their prognoses. Patients with preoperative serum β-hCG >10 IU/L and those with >3 chemotherapy regimens preoperatively may not benefit from this multidisciplinary treatment.
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Affiliation(s)
| | | | | | | | | | | | | | - Junjun Yang
- Correspondence: (J.Y.); (Y.X.); Tel.: +86-6915-5635 (J.Y.); +86-6915-6068 (Y.X.)
| | - Yang Xiang
- Correspondence: (J.Y.); (Y.X.); Tel.: +86-6915-5635 (J.Y.); +86-6915-6068 (Y.X.)
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14
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Sirimusika N, Boonyapipat S. Serum human chorionic gonadotropin ratios for the detection of etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine resistance in high‐risk gestational trophoblastic neoplasia. Health Sci Rep 2022; 5:e729. [PMID: 35873390 PMCID: PMC9301295 DOI: 10.1002/hsr2.729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/11/2022] Open
Abstract
Aims This study aimed to identify the optimal human chorionic gonadotropin (hCG) ratio in predicting etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine resistance in women diagnosed with high‐risk gestational trophoblastic neoplasia (GTN) and to compare the chemoresistant disease detection rate by using the optimal hCG ratio and traditional criteria. Methods Seventy‐six women with primary high‐risk GTN treated with etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine in a tertiary‐care center were included. The hCG ratio was determined by its serum pretreatment level divided by that before each cycle of chemotherapy. The traditional criteria for chemoresistance included plateau or rising of hCG or presence of new metastasis. The optimal hCG ratio was determined using receiver operating characteristics (ROC) curve analysis. Results Among the specificities of 90%, 92.5%, and 95%, the 90% specificity yielded the best ROC curve. At 90% specificity, the best area under curve value was at the fourth cycle with 75% sensitivity. The hCG ratio at the fourth cycle was 31.92. Using the ratio at the fourth cycle, chemoresistant disease was detected in six out of eight patients, compared to one in the traditional criteria. When combining the two diagnostic tools, the cumulative detection rate in the fourth cycle was 10/12 (83.3%) of total drug resistance. Among patients who developed drug resistance at the fourth cycle or thereafter, the use of the ratio at the fourth cycle could diagnose chemoresistance approximately two cycles earlier than that with the traditional criteria. Conclusions A hCG ratio of <31.9 at the fourth cycle should be considered a high‐risk for etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine resistance and may need second‐line chemotherapy. The ratio increases the detection rate of resistance to these drugs more than the traditional criteria.
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Affiliation(s)
- Nathapol Sirimusika
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology Faculty of Medicine, Prince of Songkla University, Hat Yai Songkhla Thailand
| | - Sathana Boonyapipat
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology Faculty of Medicine, Prince of Songkla University, Hat Yai Songkhla Thailand
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15
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Salman L, Bouchard-Fortier G, Covens A. Immune Checkpoint Inhibitors for the Treatment of Gestational Trophoblastic Neoplasia: Rationale, Effectiveness, and Future Fertility. Curr Treat Options Oncol 2022; 23:1035-1043. [PMID: 35511345 DOI: 10.1007/s11864-022-00988-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Lina Salman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave, Toronto, ON, M5G2M9, Canada
| | - Genevieve Bouchard-Fortier
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave, Toronto, ON, M5G2M9, Canada.,Division of Gynecologic Oncology, Princess Margaret Cancer Centre/Sinai Health Systems, Toronto, ON, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave, Toronto, ON, M5G2M9, Canada. .,Division of Gynecologic Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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16
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Wang X, Cheng Y, Li W, Mao R, Zhu T, Lu J, Yue X, Lu X. Management of relapsed gestational trophoblastic neoplasia: What can help to reduce the re-recurrence rate? J Obstet Gynaecol Res 2022; 48:1451-1457. [PMID: 35289459 DOI: 10.1111/jog.15228] [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: 09/02/2021] [Revised: 12/29/2021] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
AIM To explore the risk factors for re-recurrence in relapsed gestational trophoblastic neoplasia (GTN) and therapeutic approaches to reduce the re-recurrence rate. METHODS Data of relapsed GTN treated in the Obstetrics and Gynecology Hospital of Fudan University from January 1, 2015, to December 31, 2020, were reviewed retrospectively. Risk factors associated with re-recurrence were analyzed using Logistic regression analysis. RESULTS A total of 39 relapsed GTN patients were included in our study. At the time of the first relapse, 14 patients received single-agent chemotherapy and 25 patients received multi-agent chemotherapy. Surgery was performed in 19 patients. Complete remission was achieved in all of the patients. Re-recurrence occurred in 21 patients. Univariate analysis suggested that unifocal recurrence was the only factor significantly associated with re-recurrence (OR = 0.25, p = 0.04). Recurrence pattern-based subgroup analysis showed that the proportion of re-recurrence was lower in patients who received both surgery and chemotherapy compared to those who received only chemotherapy in the unifocal recurrence group (3/11 vs. 2/4), but not in the non-unifocal recurrence group (7/8 vs. 9/16). The results of the multivariate analysis showed that there was no significant difference in re-recurrence rates between the surgical approaches and that the non-unifocal recurrence pattern was an independent risk factor for re-recurrence. CONCLUSIONS For relapsed GTN with unifocal recurrence pattern, surgical removal of the lesion can effectively reduce the re-recurrence rate.
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Affiliation(s)
- Xingran Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yu Cheng
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Wenzhi Li
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Runye Mao
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Tingting Zhu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Jiaqi Lu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xiaoni Yue
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xin Lu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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17
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Wallin E, Niemann I, Faaborg L, Fokdal L, Joneborg U. Differences in Administration of Methotrexate and Impact on Outcome in Low-Risk Gestational Trophoblastic Neoplasia. Cancers (Basel) 2022; 14:cancers14030852. [PMID: 35159119 PMCID: PMC8834333 DOI: 10.3390/cancers14030852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary Low-risk gestational trophoblastic neoplasia is a rare but highly curable malignancy. The most common first line treatment is methotrexate, which can be administered in different forms. In order to investigate the impact of route of administration on methotrexate resistance, toxicity demanding treatment switch, complete remission and relapse, we performed an observational study including women with low-risk gestational trophoblastic neoplasia in a population-based setting in Sweden and Denmark. We found that oral compared to intra-muscular administration of methotrexate gives a higher rate of drug resistance, but does not affect rates of complete remission, recurrence or overall survival. Intra-muscular treatment was associated with more toxicity leading to switch of treatment. We conclude that, although a larger proportion of women develop drug resistance, oral methotrexate, which is easy to administer and highly tolerable, could be an option for well-informed and motivated women. Abstract Methotrexate (MTX) is frequently used as first-line treatment for low-risk gestational trophoblastic neoplasia (GTN). Intravenous and intramuscular (im) routes of administration are the most common methods, although oral administration is used by some Scandinavian centers. The primary aim of this study was to assess the impact of form of administration (im/oral) on resistance to methotrexate (MTX-R) treatment in low-risk GTN. Secondary aims were time to hCG normalization, rates of toxicity-induced treatment switch, and rates of complete remission and recurrence. In total, 170 women treated at Karolinska University Hospital in Sweden and Aarhus University Hospital in Denmark between 1994 and 2018 were included, of whom 107 were given im and 63 oral MTX. MTX-R developed in 35% and 54% in the im and oral groups, respectively (p = 0.01). There was no difference in days to hCG normalization (42 vs. 41 days, p = 0.50) for MTX-sensitive women. Toxicity-induced treatment switch was only seen in the im group. Complete remission was obtained in 99.1% and 100% (p = 0.44), and recurrence rate within one year was 2.8% and 1.6% (p = 0.29). The form of administration of MTX had a significant impact on development of MTX-R and treatment-associated toxicity, but does not affect rates of complete remission, recurrence or survival.
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Affiliation(s)
- Emelie Wallin
- Department of Women’s and Children’s Health, Karolinska Institutet, 171 21 Stockholm, Sweden;
- Department of Pelvic Cancer, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Isa Niemann
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark;
- Department of Obstetrics and Gynecology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Louise Faaborg
- Department of Oncology, Vejle Hospital, 7100 Vejle, Denmark;
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark;
| | - Ulrika Joneborg
- Department of Women’s and Children’s Health, Karolinska Institutet, 171 21 Stockholm, Sweden;
- Correspondence:
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18
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Joyce CM, Fitzgerald B, McCarthy TV, Coulter J, O'Donoghue K. Advances in the diagnosis and early management of gestational trophoblastic disease. BMJ MEDICINE 2022; 1:e000321. [PMID: 36936581 PMCID: PMC9978730 DOI: 10.1136/bmjmed-2022-000321] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/21/2022] [Indexed: 12/23/2022]
Abstract
Gestational trophoblastic disease describes a group of rare pregnancy related disorders that span a spectrum of premalignant and malignant conditions. Hydatidiform mole (also termed molar pregnancy) is the most common form of this disease. Hydatidiform mole describes an abnormal conceptus containing two copies of the paternal genome, which is classified as partial when the maternal genome is present or complete when the maternal genome is absent. Hydatidiform mole typically presents in the first trimester with irregular vaginal bleeding and can be suspected on ultrasound but confirmation requires histopathological evaluation of the products of conception. Most molar pregnancies resolve without treatment after uterine evacuation, but occasionally the disease persists and develops into gestational trophoblastic neoplasia. Close monitoring of women after molar pregnancy, with regular measurement of human chorionic gonadotrophin concentrations, allows for early detection of malignancy. Given the rarity of the disease, clinical management and treatment is best provided in specialist centres where very high cure rates are achievable. This review looks at advances in the diagnosis and early management of gestational trophoblastic disease and highlights updates to disease classification and clinical guidelines. Use of molecular genotyping for improved diagnostic accuracy and risk stratification is reviewed and future biomarkers for the earlier detection of malignancy are considered.
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Affiliation(s)
- Caroline M Joyce
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- INFANT Research Centre, 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
| | - Brendan Fitzgerald
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- Department of Pathology, Cork University Hospital, Cork, Ireland
| | - Tommie V McCarthy
- Department of Biochemistry and Cell Biology, University College Cork, Cork, Ireland
| | - John Coulter
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Keelin O'Donoghue
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
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Peng Z, Zhang Y, Shi D, Jia Y, Shi H, Liu H. miR-497-5p/SALL4 axis promotes stemness phenotype of choriocarcinoma and forms a feedback loop with DNMT-mediated epigenetic regulation. Cell Death Dis 2021; 12:1046. [PMID: 34732693 PMCID: PMC8566582 DOI: 10.1038/s41419-021-04315-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 09/17/2021] [Accepted: 10/07/2021] [Indexed: 12/13/2022]
Abstract
Choriocarcinoma stem-like cells (CSLCs) might be at the origin of choriocarcinoma development associated with drug resistance or relapse. Spalt-like transcription factor 4 (SALL4), which is considered to be a stemness-related gene, can be regulated by miRNAs. In this study, SALL4 result is associated with progression-free survival of choriocarcinoma patients and CSLC's stemness characteristics. In addition, it could be downregulated by miR-497-5p by direct binding. miR-497-5p silencing by hypermethylation promoted malignant CSLC phenotype in vitro and in vivo. Furthermore, increased DNA methyltransferases (DNMTs) by SALL4 upregulation inhibited miR-497-5p expression via hypermethylation promotion. SALL4 appeared to be a key factor in promoting stemness phenotype of choriocarcinoma. Silencing miR-497-5p and SALL4 promotes choriocarcinoma progression and forms a feedback loop with DNMT-mediated epigenetic regulation, playing a crucial role in stemness maintenance in choriocarcinoma.
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Affiliation(s)
- Zheng Peng
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
| | - Yi Zhang
- Department of Gynecology and Obstetrics, Xiangya Hospital of Central South University, Changsha, 410008, China
| | - Dazun Shi
- Department of Gynecology and Obstetrics, Xiangya Hospital of Central South University, Changsha, 410008, China
| | - Yanyan Jia
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Huirong Shi
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Huining Liu
- Department of Gynecology and Obstetrics, Xiangya Hospital of Central South University, Changsha, 410008, China
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20
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Cheng H, Zong L, Kong Y, Wang X, Gu Y, Cang W, Zhao J, Wan X, Yang J, Xiang Y. Camrelizumab plus apatinib in patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia (CAP 01): a single-arm, open-label, phase 2 trial. Lancet Oncol 2021; 22:1609-1617. [PMID: 34624252 DOI: 10.1016/s1470-2045(21)00460-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment options for patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia are scarce. The synergistic antitumour effect of immunotherapy and antiangiogenic drugs has been shown in many solid tumours. This phase 2 trial evaluated the activity and safety of camrelizumab (PD-1 inhibitor) plus apatinib (VEGF receptor inhibitor) in patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia. METHODS This was a single-arm, open-label, phase 2 trial, done at a single tertiary health-care centre in Beijing, China. Women (18-70 years) with high-risk (International Federation of Gynecology and Obstetrics score ≥7) chemorefractory or relapsed gestational trophoblastic neoplasia who had received at least two lines of previously unsuccessful multidrug chemotherapy regimens and had an Eastern Cooperative Oncology Group performance status of 0-2 were eligible for inclusion. Patients received 4-week cycles of intravenous camrelizumab 200 mg every 2 weeks plus oral apatinib 250 mg once per day until disease progression or unacceptable toxicity. The primary endpoint was objective response rate assessed according to serum human chorionic gonadotrophin concentration. Activity and safety were analysed in all patients who received at least one dose of study drug. The study is ongoing, but recruitment is complete. The study is registered with ClinicalTrials.gov, NCT04047017. FINDINGS Between Aug 7, 2019, and March 18, 2020, 20 patients enrolled; 19 (95%) were diagnosed with choriocarcinoma and one (5%) had placental site trophoblastic tumour. The median follow-up duration was 18·5 months (IQR 14·6-20·9). The objective response rate was 55% (95% CI 32-77); ten (50%; 95% CI 27-73) patients had complete response. The most common grade 3 treatment-related adverse events were hypertension (five [25%] patients), rash (four [20%] patients), neutropenia (two [10%]), leukocytopenia (two [10%]), and aspartate aminotransferase increase (two [10%]). One patient had a treatment-related serious adverse event (aspartate aminotransferase 19-times higher than the upper limit of normal). No grade 4 or 5 treatment-related adverse events were reported. INTERPRETATION Camrelizumab plus apatinib showed promising antitumour activity and acceptable toxicity and could be a salvage therapy option for the treatment of high-risk chemorefractory or relapsed gestational trophoblastic neoplasia. Immune checkpoint inhibitors combined with chemotherapy for heavily-treated patients and upfront use of camrelizumab plus apatinib for patients with high-risk gestational trophoblastic neoplasia are under investigation in phase 2 trials. FUNDING National Natural Science Foundation of China, Jiangsu Hengrui Pharmaceuticals.
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Affiliation(s)
- Hongyan Cheng
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liju Zong
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yujia Kong
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyu Wang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Gu
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Cang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhao
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, National Clinical Research Centre for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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21
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Paspalj V, Polterauer S, Poetsch N, Reinthaller A, Grimm C, Bartl T. Long-term survival in multiresistant metastatic choriocarcinoma after pembrolizumab treatment: A case report. Gynecol Oncol Rep 2021; 37:100817. [PMID: 34258357 PMCID: PMC8253948 DOI: 10.1016/j.gore.2021.100817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 12/13/2022] Open
Abstract
•Checkpoint inhibitor therapy affecting PD-L1 as treatment for advanced solid tumors.•Success in trial pembrolizumab therapy in multiresistant metastatic choriocarcinoma.•Long-term remission after pembrolizumab therapy in multiresistant choriocarcinoma.•Only six reported cases, one with comparable follow-up and outcome.
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Key Words
- CPI, checkpoint inhibitor
- CT, computed tomography
- Choriocarcinoma
- ECOG, Eastern Cooperative Oncology Group
- ETT, epithelioid trophoblastic tumor
- GTD, gestational trophoblastic disease
- GTN
- GTN, gestational trophoblastic neoplasia
- PD-1/PDL-1, programmed cell death-1/ programmed cell death ligand-1
- PSTT, placental site trophoblastic tumor
- Pembrolizumab
- WHO, Worl Health Organization
- cMRI, cerebral magnetic resonance imaging
- β-HCG
- β-HCG, beta-human chorionic gonadotropin
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Affiliation(s)
- V. Paspalj
- Division of General Gynecology and Gynecologic Oncology, Department of Obstetrics and Gynecology, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - S. Polterauer
- Division of General Gynecology and Gynecologic Oncology, Department of Obstetrics and Gynecology, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Austria
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, Austria
| | - N. Poetsch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - A. Reinthaller
- Division of General Gynecology and Gynecologic Oncology, Department of Obstetrics and Gynecology, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Austria
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, Austria
| | - C. Grimm
- Division of General Gynecology and Gynecologic Oncology, Department of Obstetrics and Gynecology, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Austria
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, Austria
| | - T. Bartl
- Division of General Gynecology and Gynecologic Oncology, Department of Obstetrics and Gynecology, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Austria
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22
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Niimi K, Yamamoto E, Morita S, Morikawa M, Hattori H, Hatakeyama M, Morita M, Nishino K, Oda Y, Watanabe E, Yamamoto T, Kajiyama H, Kikkawa F. Next-generation genome sequencing of a matched normal-tumor pair from a patient with intractable gestational choriocarcinoma: A case report. Mol Clin Oncol 2021; 15:143. [PMID: 34094541 PMCID: PMC8165691 DOI: 10.3892/mco.2021.2305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 04/16/2021] [Indexed: 12/13/2022] Open
Abstract
Gestational choriocarcinoma is a gestational trophoblastic neoplasia (GTN) originating from trophoblastic cells with abnormal proliferation. Although chemotherapy is effective for treating this cancer, when patients develop chemoresistance, personalized treatment, such as the use of drugs matching their genomes, is required. The present report describes a case of intractable gestational choriocarcinoma identified using a next-generation sequencing (NGS)-based tumor panel. A 51-year-old woman was diagnosed with gestational choriocarcinoma via pathological and short tandem repeat analyses. The patient did not achieve remission despite many regimens of chemotherapy, including high-dose therapy with autologous peripheral blood stem cell transplantation. To identify drugs tailored to this particular choriocarcinoma, NGS was performed on the tumor of the patient, and the tumor genome was compared with that of the patient's blood sample using the NCC Oncopanel System. Consequently, 245 single nucleotide variants (SNVs) with a mean SNV allele frequency of 63.1% were identified. This high frequency was because the genome of the gestational choriocarcinoma contained part of the genome of the partner. Therefore, our experience of the present intractable case of choriocarcinoma suggested that matched normal-tumor pair analysis is not appropriate for treatment decisions in GTN cases. When using an NGS-based tumor panel to assess choriocarcinoma, researchers must consider whether the genomic DNA of the patient and their partner are involved in the GTN.
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Affiliation(s)
- Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Eiko Yamamoto
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Sachi Morita
- Department of Medical Genomics Center, Nagoya University Hospital, Nagoya, Aichi 466-8550, Japan
| | - Maki Morikawa
- Department of Medical Genomics Center, Nagoya University Hospital, Nagoya, Aichi 466-8550, Japan
| | - Hikaru Hattori
- Department of Medical Technique, Nagoya University Hospital, Nagoya, Aichi 466-8550, Japan
| | - Miki Hatakeyama
- Department of Medical Genomics Center, Nagoya University Hospital, Nagoya, Aichi 466-8550, Japan
| | - Mami Morita
- Department of Medical Genomics Center, Nagoya University Hospital, Nagoya, Aichi 466-8550, Japan
| | - Kimihiro Nishino
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Yukari Oda
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Eri Watanabe
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Toshimichi Yamamoto
- Department of Legal Medicine and Bioethics, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
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23
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Nakamura K, Niimi K, Yamamoto E, Ikeda Y, Nishino K, Suzuki S, Kajiyama H, Kikkawa F. Core 2 β1,6-N-acetylglucosaminyltransferases accelerate the escape of choriocarcinoma from natural killer cell immunity. Biochem Biophys Rep 2021; 26:100951. [PMID: 33644424 PMCID: PMC7895715 DOI: 10.1016/j.bbrep.2021.100951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/23/2021] [Accepted: 02/05/2021] [Indexed: 11/27/2022] Open
Abstract
Hyperglycosylated human chorionic gonadotropin (H-hCG) is secreted from choriocarcinoma and contains a core2 O-glycan formed by core2 β1,6-N-acetylglucosaminyl transferase (C2GnT). Choriocarcinoma is considered immunogenic as it is gestational and contains paternal chromosomal components. Here we examined the function of C2GnT in the evasion of choriocarcinoma cells from natural killer (NK) cell-mediating killing. We determined that C2GnT is highly expressed in malignant gestational trophoblastic neoplasms. C2GnT KO downregulates core2 O-glycan expression in choriocarcinoma cells, which are more efficiently killed by NK cells than control cells. C2GnT KO cell containing tumor necrosis factor-related apoptosis inducing ligand have lower viability than control cells. Additionally, poly-N-acetyllactosamine in core2 branched oligosaccharides on MHC class I-related chain A (MICA) and mucin1 (MUC1) is significantly reduced in C2GnT KO cells. Meanwhile, the cumulative survival rate of nude mice inoculated with C2GnT KO tumors was higher than that of the control group. These findings suggest that choriocarcinoma cells may escape NK cell-mediated killing via glycosylation of MICA and MUC1. C2GnT knockout reduces core2 O-glycan expression in choriocarcinoma cells C2GnT KO cells are more readily killed by NK cells C2GnT KO cells containing TRAIL have lower viability than controls MHC class I-related chain A and MUC1 glycosylation is reduced in C2GnT KO cells Survival rate of nude mice inoculated with C2GnT KO tumors is higher than controls
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Key Words
- C2GnT
- C2GnT, core2 beta 1, 6-N acetylglucosaminyl transferase
- Choriocarcinoma
- DR4, death receptor 4
- EVT, extravillous trophoblast
- GTD, gestational trophoblastic disease
- GTN, gestational trophoblastic neoplasm
- H-hCG, hyperglycosylated human chorionic gonadotropin
- HLA, human leukocyte antigen
- Immunosuppression
- LEL, Lycopersicon esculentum lectin
- MICA, MHC class I-related chain A
- MUC1, mucin1
- NKG2D, natural killer group 2 member D
- Natural killer cell
- O-glycan
- PSTT, placental site trophoblastic tumor
- TRAIL, tumor necrosis factor-related apoptosis inducing ligand
- hCG, human chorionic gonadotropin
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Affiliation(s)
- Kenichi Nakamura
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eiko Yamamoto
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiki Ikeda
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Nishino
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Suzuki
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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24
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Braga A, Elias KM, Horowitz NS, Berkowitz RS. Treatment of high-risk gestational trophoblastic neoplasia and chemoresistance/relapsed disease. Best Pract Res Clin Obstet Gynaecol 2021; 74:81-96. [PMID: 33622563 DOI: 10.1016/j.bpobgyn.2021.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/05/2020] [Accepted: 01/08/2021] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center (Maternity School of Rio de Janeiro Federal University and Antonio Pedro University Hospital of Fluminense Federal University), Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil.
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, 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
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25
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Abstract
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.
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Affiliation(s)
- James Clark
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Road, London W68RF UK
| | - Susanna Slater
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Road, London W68RF UK
| | - Michael J Seckl
- Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, Fulham Palace Road, London W68RF UK
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26
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Jareemit N, Horowitz NS, Goldstein DP, Berkowitz RS, Elias KM. Outcomes for relapsed versus resistant low risk gestational trophoblastic neoplasia following single-agent chemotherapy. Gynecol Oncol 2020; 159:751-757. [PMID: 33023756 DOI: 10.1016/j.ygyno.2020.09.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/27/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare outcomes for relapsed versus resistant low risk gestational trophoblastic neoplasia (GTN) following single-agent chemotherapy. METHODS This was a single center retrospective study of low risk GTN. Cases failing to achieve a normal hCG with first-line therapy were defined as chemotherapy resistance. Cases achieving hCG remission, but recurring, were defined as relapse. Primary endpoints were remission rate with second-line therapy and time to remission. Univariate and multivariate analyses were performed to define prognostic factors. RESULTS Among 877 low risk GTN patients there were 124 (14.8%) chemotherapy resistant and 22 (2.6%) relapse cases. Complete remission rates with second-line therapy were similar between relapse (77.3%) and resistant (76.6%) cases (p = 0.95), but resistance was associated with a longer time to reach complete remission with second-line therapy (median 8.3 vs 4.9 weeks; p = 0.024). In multivariate analysis, the significant prognostic factors for second-line therapy remission and time to second-line therapy remission were use of multi-agent chemotherapy (OR of 9.45; 95%CI, 2.13-41.97; p = 0.003) and primary chemo-resistance (HR of 0.27; 95%CI, 0.12-0.59; p = 0.001), respectively. With additional therapies, sustained remission rates rose to 90% (18/20) for relapse and 99.2% (120/121) for chemo-resistance (p = 0.053). CONCLUSIONS Although second-line therapy for resistant or relapsed low risk GTN is able to achieve complete remission in most cases, time to complete remission for relapsed disease was shorter than for resistant disease. Further studies on the biologic differences between resistant and relapsed disease may clarify the optimal treatment for these clinical situations.
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Affiliation(s)
- Nida Jareemit
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States; New England Trophoblastic Disease Center, Boston, MA, United States
| | - Donald P Goldstein
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States; New England Trophoblastic Disease Center, Boston, MA, United States
| | - Ross S Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States; New England Trophoblastic Disease Center, Boston, MA, United States
| | - Kevin M Elias
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States; New England Trophoblastic Disease Center, Boston, MA, United States.
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27
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Reproductive outcomes after floxuridine-based regimens for gestational trophoblastic neoplasia: A retrospective cohort study in a national referral center in China. Gynecol Oncol 2020; 159:464-469. [PMID: 32917411 DOI: 10.1016/j.ygyno.2020.08.018] [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: 06/17/2020] [Accepted: 08/15/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To analyze the reproductive outcomes of gestational trophoblastic neoplasia (GTN) patients who were cured only by floxuridine-based regimens. METHODS This was a retrospective analysis of 464 patients who were treated with only floxuridine-based regimens at Peking Union Medical College Hospital between January 2002 and December 2013 and retained their reproductive ability. Their reproductive outcomes were analyzed. The factors affecting pregnancy intention were identified by logistic regression. RESULTS Of the 464 patients (average age, 28.0 ± 5.7 years; median follow-up = 85 months), the livebirth rate was 72.2%, while the rates of spontaneous abortion, induced abortion and ectopic pregnancy were 9.2% (n = 41), 8.7% (n = 39) and 1.8% (n = 8), respectively. The GTN recurrence rate was 2.1%. The time from chemotherapy completion to first conception in the induced abortion group was significantly shorter than those in spontaneous abortion, full-term/premature, and ectopic pregnancy groups (P ≤ 0.001, <0.001, =0.015, respectively). The logistic analysis showed that the age at onset of GTN (OR = 0.899, 95% CI 0.851-0.951, P < 0.001), parity at onset of GTN (parity = 1, OR = 0.123, 95% CI 0.068-0.225, P < 0.001; parity = 2-3, OR = 0.058, 95% CI 0.014-0.232, P < 0.001) and interval from the index pregnancy to chemotherapy were independent factors affecting pregnancy intention. Among the 36 pregnancies occurring within 12 months postchemotherapy, only one choriocarcinoma occurred, and 20 culminated in induced abortions (55.6%). CONCLUSIONS After floxuridine-based chemotherapy, the pregnancy rate of GTN patients after fertility-preserving treatment is comparable to that of the normal population. Pregnancy losses within one year after chemotherapy completion are mainly caused by induced abortion.
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28
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Clair KH, Gallegos N, Bristow RE. Successful treatment of metastatic refractory gestational choriocarcinoma with pembrolizumab: A case for immune checkpoint salvage therapy in trophoblastic tumors. Gynecol Oncol Rep 2020; 34:100625. [PMID: 32964090 PMCID: PMC7490982 DOI: 10.1016/j.gore.2020.100625] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 01/04/2023] Open
Abstract
Cure rates are high for choriocarcinoma, however chemoresistant disease often leads to death. High expression of PD-L1 suggests a role for checkpoint inhibitors in choriocarcinoma. Pembrolizumab should be considered for salvage therapy for chemoresistant choriocarcinoma.
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Affiliation(s)
- Kiran H Clair
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, United States
| | - Nicolas Gallegos
- Department of Pathology, University of California Irvine Medical Center, Orange, CA, United States
| | - Robert E Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, United States
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29
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You B, Bolze PA, Lotz JP, Massardier J, Gladieff L, Joly F, Hajri T, Maucort-Boulch D, Bin S, Rousset P, Devouassoux-Shisheboran M, Roux A, Alves-Ferreira M, Grazziotin-Soares D, Langlois-Jacques C, Mercier C, Villeneuve L, Freyer G, Golfier F. Avelumab in Patients With Gestational Trophoblastic Tumors With Resistance to Single-Agent Chemotherapy: Cohort A of the TROPHIMMUN Phase II Trial. J Clin Oncol 2020; 38:3129-3137. [PMID: 32716740 PMCID: PMC7499607 DOI: 10.1200/jco.20.00803] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Women with gestational trophoblastic tumors (GTT) resistant to single-agent chemotherapy receive alternative chemotherapy regimens, which, although effective, cause considerable toxicity. All GTT subtypes express programmed death-ligand 1 (PD-L1), and natural killer (NK) cells are involved in trophoblast immunosurveillance. Avelumab (anti-PD-L1) induces NK cell-mediated cytotoxicity. The TROPHIMMUN trial assessed avelumab in women with chemotherapy-resistant GTT. METHODS In this phase II multicenter trial (ClinicalTrials.gov identifier: NCT03135769), women with GTT who experienced disease progression after single-agent chemotherapy received avelumab 10 mg/kg intravenously every 2 weeks until human chorionic gonadotropin (hCG) normalization, followed by 3 consolidation cycles. Rate of hCG normalization was the primary endpoint (2-step Simon design). RESULTS Between December 2016 and September 2018, 15 patients were treated. Median age was 34 years; disease stage was I or III in 53.3% and 46.7% of women, respectively; and International Federation of Gynecology and Obstetrics (FIGO) score was 0-4 in 33.3%, 5-6 in 46.7%, and ≥ 7 in 20% of patients. Prior treatment included methotrexate (100%) and actinomycin D (7%). Median follow-up was 25 months, and median number of avelumab cycles was 8 (range, 2-11). Grade 1-2 treatment-related adverse events occurred in 93% of patients, most commonly (≥ 25%) fatigue (33.3%), nausea/vomiting (33.3%), and infusion-related reaction (26.7%). One patient had grade 3 uterine bleeding (treatment unrelated). Eight patients (53.3%) had hCG normalization after a median of 9 avelumab cycles; none subsequently relapsed. Probability of normalization was not associated with disease stage, FIGO score, or baseline hCG. One patient subsequently had a healthy pregnancy. In avelumab-resistant patients (46.7%), hCG was normalized with actinomycin D (42.3%) or combination chemotherapy/surgery (57.1%). CONCLUSION In patients with single-agent chemotherapy-resistant GTT, avelumab had a favorable safety profile and cured approximately 50% of patients. Avelumab could be a new therapeutic option, particularly in patients who would otherwise receive combination chemotherapy.
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Affiliation(s)
- Benoit You
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Medical Oncology, Institut de Cancérologie des Hospices Civils de Lyon, Centre d'Investigation de Thérapeutiques en Oncologie et Hématologie de Lyon, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France
| | - Pierre-Adrien Bolze
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Jean-Pierre Lotz
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Hôpital Tenon, Pôle Onco-Hématologie Hôpitaux Universitaires de l'Est Parisien, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Jérome Massardier
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Service de Gynécologie Obstétrique, Unité de Diagnostic Anténatal, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Laurence Gladieff
- Département d'Oncologie Médicale, Institut Claudius Regaud, IUCT-ONCOPOLE, Toulouse, France
| | - Florence Joly
- Clinical Research Department, Centre François Baclesse, Caen Cedex, France
| | - Touria Hajri
- Centre de Référence des Maladies Trophoblastiques, Lyon, France
| | - Delphine Maucort-Boulch
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Service de Biostatistique, Hospices Civils de Lyon, Lyon; and CNRS UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Sylvie Bin
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Pascal Rousset
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Radiologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | | | - Adeline Roux
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Marine Alves-Ferreira
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Daniele Grazziotin-Soares
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Hôpital Tenon, Pôle Onco-Hématologie Hôpitaux Universitaires de l'Est Parisien, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Carole Langlois-Jacques
- Service de Biostatistique, Hospices Civils de Lyon, Lyon; and CNRS UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Catherine Mercier
- Service de Biostatistique, Hospices Civils de Lyon, Lyon; and CNRS UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Laurent Villeneuve
- Unité Recherche et Epidémiologie Cliniques - Pôle de Santé Publique, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Gilles Freyer
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Medical Oncology, Institut de Cancérologie des Hospices Civils de Lyon, Centre d'Investigation de Thérapeutiques en Oncologie et Hématologie de Lyon, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Lyon, France
| | - Francois Golfier
- Centre de Référence des Maladies Trophoblastiques, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Sud, CICLY, Lyon, France.,Service de Chirurgie Gynécologique et Oncologique, Obstétrique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
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Zhao L, Qin Y, Ma D, Li L, Han Z, Li S, Liu H. Thoracoscopic Surgery to Treat Lung Metastases from Refractory Choriocarcinoma. Cancer Manag Res 2020; 12:3851-3858. [PMID: 32547221 PMCID: PMC7259456 DOI: 10.2147/cmar.s251249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/05/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the use of video-assisted thoracoscopic surgery to treat lung metastases from refractory choriocarcinoma. Patients and Methods We reviewed patients diagnosed with refractory choriocarcinoma who underwent lung resection by video-assisted thoracoscopic surgery combined with chemotherapy between October 2013 and August 2019 at the Peking Union Medical College Hospital. The surgical records, pathologic findings and survival rates were analyzed. Results The study included 73 patients who underwent 78 thoracoscopic surgeries. Most patients underwent lobectomy (48.7%), and 17 patients (21.8%) underwent resection of more than one lobe. The median operation time and bleeding volume were 95 minutes and 50 mL, respectively. The median duration of chest tube use and hospital stay were 3 days and 4 days, respectively. Postoperative complications were documented in 6 patients (7.7%). The thoracic lymph nodes were harvested in 51 patients (65.4%), but none of these patients had positive nodes. A total of 69.2% of the patients had positive pathologic findings. The mean follow-up time was 30 months. During follow-up, 11 patients experienced disease relapse, and 2 of them died because of brain metastasis. The overall disease-free rate was 83.6%, and the survival rate was 97.0% after excluding those lost to follow-up. Patients with decreased postoperative β-hCG showed a higher disease-free rate during follow up (P<0.05). Conclusion The minimally invasive video-assisted thoracoscopic approach is a valuable and safe treatment for refractory choriocarcinoma patients with lung metastases. Lymphadenectomy is not suggested for these patients. Patients with decreased postoperative β-hCG levels may achieve a much better prognostic result.
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Affiliation(s)
- Luo Zhao
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, People's Republic of China
| | - Yingzhi Qin
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, People's Republic of China
| | - Dongjie Ma
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, People's Republic of China
| | - Li Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, People's Republic of China
| | - Zhijun Han
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, People's Republic of China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, People's Republic of China
| | - Hongsheng Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, People's Republic of China
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Yu H, Li J, Zhu T, Xue X, Lu X. Evaluation and influence of lung metastasis on patient outcome in gestational trophoblastic neoplasia: A 10-year study at a single institution. Eur J Obstet Gynecol Reprod Biol 2020; 251:162-166. [PMID: 32505789 DOI: 10.1016/j.ejogrb.2020.05.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the outcomes and related factors of gestational trophoblastic neoplasia (GTN) with lung metastasis in comparison with GTN without metastasis. STUDY DESIGN GTN is a spectrum of diseases arising from trophoblastic cells, and treatment outcome is promising because of its high sensitivity to chemotherapy. Lung metastasis is not usually considered to be an adverse prognostic factor in the evaluation and treatment of GTN. The clinical records of 48 GTN patients with lung metastasis and 162 GTN patients without metastasis were reviewed and analysed retrospectively from 2003 to 2013. Data were compared between patients with and without metastasis. RESULTS Twenty-five percent of GTN patients with lung metastasis presented with pre-treatment serum human chorionic gonadotropin ≥105 mIU/mL, which was significantly higher compared with GTN patients without metastasis (9.3 %, p < 0.01). Regarding the International Federation of Gynecology and Obstetrics (FIGO) score, 39.6 % of patients with lung metastasis were in the high-risk group (FIGO score ≥ 7), compared with 13.6 % of patients without metastasis (p < 0.01). However, on multi-variate analysis, only a FIGO score ≥7 was associated with lung metastasis. The relapse rate of GTN patients with lung metastasis was significantly higher than that of those without metastasis (8.3 % vs 0.6 %, p < 0.05). In the patients who relapsed, non-postmolar GTN, high-risk GTN and first-line chemoresistance were observed more frequently compared with the patients who did not relapse (p < 0.05). CONCLUSION GTN patients with lung metastasis appear to have increased risk of relapse compared with GTN patients without metastasis. To overcome this, there is a need to consider adjustment of the FIGO scoring system to enable GTN patients with lung metastasis to receive more intensive chemotherapy.
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Affiliation(s)
- Hailin Yu
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Jun Li
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Tingting Zhu
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Xiaohong Xue
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China
| | - Xin Lu
- Obstetrics and Gynaecology Hospital, Fudan University, Shanghai, China.
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Savage P, Winter M, Parker V, Harding V, Sita-Lumsden A, Fisher RA, Harvey R, Unsworth N, Sarwar N, Short D, Aguiar X, Tidy J, Hancock B, Coleman R, Seckl MJ. Demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma: a UK population study. BJOG 2020; 127:1102-1107. [PMID: 32146729 DOI: 10.1111/1471-0528.16202] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma. DESIGN A retrospective national population-based study. SETTING UK 1995-2015. POPULATION A total of 234 women with a diagnosis of gestational choriocarcinoma, in the absence of a prior molar pregnancy, managed at the UKs two gestational trophoblast centres in London and Sheffield. METHODS Retrospective review of the patient's demographic and clinical data. Comparison with contemporary UK birth and pregnancy statistics. MAIN OUTCOMES Incidence statistics for non-molar choriocarcinoma across the maternal age groups. Cure rates for patients by FIGO prognostic score group. RESULTS Over the 21-year study period, there were 234 cases of non-molar gestational choriocarcinoma, giving an incidence of 1:66 775 relative to live births and 1:84 226 to viable pregnancies. For women aged under 20, the incidence relative to viable pregnancies was 1:223 494, for ages 30-34, 1:80 227, and for ages 40-45, 1:41 718. Treatment outcomes indicated an overall 94.4% cure rate. Divided by FIGO prognostic groups, the cure rates were low-risk group 100%, high-risk group 96% and ultra-high-risk group 80.5%. CONCLUSIONS Non-molar gestational choriocarcinoma is a very rare diagnosis with little prior detailed information on the demographics and natural history. The data in this study give age-related incidence data based on a large national population study. The results also demonstrated the widely varying natural history of this rare malignancy and the marked correlation of disease incidence with rising maternal age. TWEETABLE ABSTRACT National gestational choriocarcinoma database indicates a close association between increasing maternal age and incidence.
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Affiliation(s)
- P Savage
- Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial Hospitals NHS Trust, London, UK
| | - M Winter
- Sheffield Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - V Parker
- Sheffield Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - V Harding
- Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial Hospitals NHS Trust, London, UK
| | - A Sita-Lumsden
- Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial Hospitals NHS Trust, London, UK
| | - R A Fisher
- Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial Hospitals NHS Trust, London, UK
| | - R Harvey
- Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial Hospitals NHS Trust, London, UK
| | - N Unsworth
- Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial Hospitals NHS Trust, London, UK
| | - N Sarwar
- Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial Hospitals NHS Trust, London, UK
| | - D Short
- Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial Hospitals NHS Trust, London, UK
| | - X Aguiar
- Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial Hospitals NHS Trust, London, UK
| | - J Tidy
- Sheffield Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - B Hancock
- Sheffield Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - R Coleman
- Sheffield Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - M J Seckl
- Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Centre, Charing Cross Hospital, Imperial Hospitals NHS Trust, London, UK
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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.
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Affiliation(s)
| | - Elham Saffarieh
- Abnormal Uterine Bleeding Research Center, Semnan University of Medical Science, Semnan, Iran
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Kong Y, Zong L, Cheng H, Jiang F, Wan X, Feng F, Ren T, Zhao J, Yang J, Xiang Y. Management and risk factors of recurrent gestational trophoblastic neoplasia: An update from 2004 to 2017. Cancer Med 2020; 9:2590-2599. [PMID: 32022487 PMCID: PMC7131839 DOI: 10.1002/cam4.2901] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE We investigated the clinical characteristics, treatments, and survival of patients with gestational trophoblastic neoplasia (GTN) who experienced recurrence. Factors predictive of recurrence were also investigated. METHODS Patients with GTN who recurred after completing chemotherapy at Peking Union Medical College Hospital Trophoblastic Disease Center were identified between January 2004 and December 2017. Logistic regression analysis was used to identify factors predictive of GTN recurrence. RESULTS A total of 1827 patients with GTN achieved complete remission (CR) at our center, of whom 118 (6.5%) experienced recurrence during follow-up. The recurrence rates for patients initially treated at our center and those referred to us were 2.7% and 14.6%, respectively. The majority of recurrent patients received floxuridine-based multiagent chemotherapy (n = 64). Patients who underwent surgery achieved a significantly higher CR rate than those who did not (88.6% vs 61.1%, P = .001). Although 94.1% of recurrent patients reachieved CR, 33.3% of them recurred for a second time. The 5-year survival rate of the entire cohort was 80.4%. An interval between antecedent pregnancy and chemotherapy >12 months (OR: 6.600, 95% CI [3.217-13.540], P < .001), and an interval from first chemotherapy to achieving β-human chorionic gonadotropin (β-hCG) normalization >14 weeks (OR: 2.226, 95% CI [1.080-4.588], P = .030) were predictors of recurrence. CONCLUSIONS Patients with recurrent GTN are prone to recurring for a second time. Surgery plays a beneficial role in the management of recurrent GTN. An interval between antecedent pregnancy and chemotherapy >12 months, and an interval from first chemotherapy to achieving β-hCG normalization >14 weeks were predictors of recurrence.
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Affiliation(s)
- Yujia Kong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liju Zong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongyan Cheng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fang Jiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tong Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Abu-Rustum NR, Yashar CM, Bean S, Bradley K, Campos SM, Chon HS, Chu C, Cohn D, Crispens MA, Damast S, Dorigo O, Eifel PJ, Fisher CM, Frederick P, Gaffney DK, Han E, Huh WK, Lurain JR, Mariani A, Mutch D, Nagel C, Nekhlyudov L, Fader AN, Remmenga SW, Reynolds RK, Sisodia R, Tillmanns T, Ueda S, Wyse E, McMillian NR, Scavone J. Gestational Trophoblastic Neoplasia, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:1374-1391. [PMID: 31693991 DOI: 10.6004/jnccn.2019.0053] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - David Cohn
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | | | | | | | - John R Lurain
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - David Mutch
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Christa Nagel
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | - Todd Tillmanns
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Stefanie Ueda
- UCSF Helen Diller Family Comprehensive Cancer Center
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Balachandran K, Salawu A, Ghorani E, Kaur B, Sebire NJ, Short D, Harvey R, Hancock B, Tidy J, Singh K, Sarwar N, Winter MC, Seckl MJ. When to stop human chorionic gonadotrophin (hCG) surveillance after treatment with chemotherapy for gestational trophoblastic neoplasia (GTN): A national analysis on over 4,000 patients. Gynecol Oncol 2019; 155:8-12. [DOI: 10.1016/j.ygyno.2019.07.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/20/2019] [Accepted: 07/23/2019] [Indexed: 01/04/2023]
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37
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Savage P. Advances in current and emerging therapeutics for gestational trophoblast malignancies. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1559047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Philip Savage
- Department of Oncology, Brighton and Sussex University Hospitals, Brighton, UK
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38
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Yen CJ, Yen CC, Tsai HW. Postmolar metastatic choriocarcinoma mimicking primary lung cancer. JOURNAL OF CANCER RESEARCH AND PRACTICE 2019. [DOI: 10.4103/jcrp.jcrp_7_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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39
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Wu C, Yu S, Tan Q, Guo P, Liu H. Role of AhR in regulating cancer stem cell-like characteristics in choriocarcinoma. Cell Cycle 2018; 17:2309-2320. [PMID: 30311543 PMCID: PMC6226230 DOI: 10.1080/15384101.2018.1535219] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 09/06/2018] [Accepted: 10/03/2018] [Indexed: 01/01/2023] Open
Abstract
Choriocarcinoma is sensitive to chemotherapy. However, drug resistance has become one of the major problems in recent years. Previous studies have shown that many tumors contained a small fraction of cells that exhibited enhanced tumor initiating potential and stem cell-like properties. It is hypothesized that cancer stem cells (CSCs) are organized in a cellular hierarchy. They also have the qualities of self-renewal, chemoresistance, and so on. The identification of CSCs in choriocarcinoma and the mechanism contributing to their qualities remain largely unknown. This study focused on the role of AhR, a transcription factor abundantly expressed in many different types of cancer, in the regulation of the expansion of choriocarcinoma CSCs and the exact molecular mechanisms. Spheroid cells isolated from choriocarcinoma in serum-free conditions have stem cell-like characteristics. The expression and nuclear translocation of AhR were markedly elevated in spheroid cells. Activation of AhR by 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) significantly increased the spheroid-forming efficiency, chemotherapy resistance, and ability to form tumor xenografts of the cells, whereas AhR knockdown, using short hairpin RNA (shRNA), dramatically reduced stem cell properties. Mechanistically, activating the β-catenin pathway might be an essential biological function of AhR during the regulation of the CSC characteristics. This study also identified ABCG2, which plays an important role in CSCs, as a direct target of AhR. Together, these results strongly suggested the participation of AhR in choriocarcinoma carcinogenesis. Targeting AhR may provide a novel therapeutic opportunity for choriocarcinoma.
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MESH Headings
- ATP Binding Cassette Transporter, Subfamily G, Member 2/genetics
- ATP Binding Cassette Transporter, Subfamily G, Member 2/metabolism
- Animals
- Carcinogenesis
- Cell Line, Tumor
- Cell Proliferation/drug effects
- Cell Survival/drug effects
- Choriocarcinoma/metabolism
- Choriocarcinoma/pathology
- Drug Resistance, Neoplasm
- Female
- Humans
- Mice
- Mice, Inbred BALB C
- Neoplasm Proteins/genetics
- Neoplasm Proteins/metabolism
- Neoplastic Stem Cells/cytology
- Neoplastic Stem Cells/metabolism
- Polychlorinated Dibenzodioxins/pharmacology
- RNA Interference
- RNA, Small Interfering/metabolism
- Receptors, Aryl Hydrocarbon/antagonists & inhibitors
- Receptors, Aryl Hydrocarbon/genetics
- Receptors, Aryl Hydrocarbon/metabolism
- Spheroids, Cellular/cytology
- Spheroids, Cellular/metabolism
- Transcriptional Activation
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Affiliation(s)
- Chenchun Wu
- Department of Gynecology and Obstetrics, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Shuran Yu
- Department of Gynecology and Obstetrics, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Qianxia Tan
- Department of Gynecology and Obstetrics, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Peng Guo
- Department of Gynecology and Obstetrics, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Huining Liu
- Department of Gynecology and Obstetrics, Xiangya Hospital Central South University, Changsha, Hunan, China
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Nagai Y, Nakamoto T, Nakasone T, Taira Y, Aoki Y. High-risk gestational choriocarcinoma with an unusual presentation and the treatment course of refractory or quiescent/minimally invasive disease. Gynecol Oncol Rep 2018; 26:56-59. [PMID: 30302364 PMCID: PMC6175744 DOI: 10.1016/j.gore.2018.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 09/25/2018] [Accepted: 10/02/2018] [Indexed: 11/05/2022] Open
Abstract
A patient with high-risk choriocarcinoma who had refractory or quiescent/minimally invasive disease. She was treated with seven lines of chemotherapy and salvage surgeries. The patient had persistently low hCG levels without evidence of disease for 4 years. Then radiological evidence of pulmonary metastasis was finally achieved, and the patient was salvaged by surgery. It is crucial to identify the site of active disease to facilitate surgical resection and cure.
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Affiliation(s)
- Yutaka Nagai
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa 903-0215, Japan
| | - Tomoko Nakamoto
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa 903-0215, Japan
| | - Tadaharu Nakasone
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa 903-0215, Japan
| | - Yusuke Taira
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa 903-0215, Japan
| | - Yoichi Aoki
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa 903-0215, Japan
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Identification and characterisation of NANOG+/ OCT-4 high/SOX2+ doxorubicin-resistant stem-like cells from transformed trophoblastic cell lines. Oncotarget 2018; 9:7054-7065. [PMID: 29467949 PMCID: PMC5805535 DOI: 10.18632/oncotarget.24151] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 01/02/2018] [Indexed: 01/14/2023] Open
Abstract
Treatment of gestational trophoblastic diseases (GTD) involves surgery, radiotherapy and chemotherapy. Although, these therapeutic approaches are highly successful, drug resistance and toxicity remain a concern for high risk patients. This Chemoresistance has also been observed in the presence of cancer stem cells that are thought to be responsible for cases of cancer recurrence. In this study, we report the presence of previously unknown populations of trophoblastic stem-like cells (SLCs) that are resistant to the chemotherapeutic drug doxorubicin. We demonstrate that these populations express the stem cell markers NANOG and Sox2 and higher levels of OCT-4 (NANOG+/OCT-4high/SOX2+). Although chemoresistant, we show that the invasive capacity of these trophoblastic SLCs is significantly inhibited by doxorubicin treatment. To better characterise these populations, we also identified cellular pathways that are involved in SLCs-chemoresistance to doxorubicin. In summary, we provide evidence of the presence of NANOG+/OCT-4+/SOX2+ trophoblastic SLCs that are capable to contribute to the susceptibility to GTD and that may be involved in Chemoresistance associated with drug resistance and recurrence in high risk GTDs' patients. We propose that targeting these populations could be therapeutically exploited for clinical benefit.
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Maestá I, Nitecki R, Horowitz NS, Goldstein DP, de Freitas Segalla Moreira M, Elias KM, Berkowitz RS. Effectiveness and toxicity of first-line methotrexate chemotherapy in low-risk postmolar gestational trophoblastic neoplasia: The New England Trophoblastic Disease Center experience. Gynecol Oncol 2018; 148:161-167. [DOI: 10.1016/j.ygyno.2017.10.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 11/24/2022]
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Ghorani E, Kaur B, Fisher RA, Short D, Joneborg U, Carlson JW, Akarca A, Marafioti T, Quezada SA, Sarwar N, Seckl MJ. Pembrolizumab is effective for drug-resistant gestational trophoblastic neoplasia. Lancet 2017; 390:2343-2345. [PMID: 29185430 DOI: 10.1016/s0140-6736(17)32894-5] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/06/2017] [Accepted: 10/17/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Ehsan Ghorani
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, UK; Cancer Immunology Unit, University College London Cancer Institute, London, UK
| | - Baljeet Kaur
- Department of Histopathology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, UK
| | - Rosemary A Fisher
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, UK
| | - Dee Short
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, UK
| | - Ulrika Joneborg
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Joseph W Carlson
- Department of Oncology-Pathology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ayse Akarca
- Department of Cellular Pathology, University College London Hospital, London, UK
| | - Teresa Marafioti
- Department of Cellular Pathology, University College London Hospital, London, UK
| | - Sergio A Quezada
- Cancer Immunology Unit, University College London Cancer Institute, London, UK
| | - Naveed Sarwar
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, UK
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, UK.
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Ham J, Lim W, Bazer FW, Song G. Silibinin stimluates apoptosis by inducing generation of ROS and ER stress in human choriocarcinoma cells. J Cell Physiol 2017; 233:1638-1649. [PMID: 28657208 DOI: 10.1002/jcp.26069] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 06/27/2017] [Indexed: 02/06/2023]
Abstract
Silibinin is a flavonolignan extracted from seeds of milk thistles. Traditionally, it has been used as a therapeutic agent for liver disorders, and now it is well-known for its anti-cancer effects. However, studies on anti-cancer effects of silibinin on choriocarcinoma are very limited. Therefore, we performed proliferation and apoptosis assays to determine effects of silibinin on the viability of human choriocarcinoma (JAR and JEG3) cells. Our results showed that silibinin significantly inhibited proliferation and induced apoptosis in both JAR and JEG3 cells, and significantly increased reactive oxygen species (ROS) and lipid peroxidation. Moreover, silibinin disrupted mitochondrial function by inducing permeabilization of mitochondrial membrane potential and calcium ion efflux in JAR and JEG3 cells. Furthermore, silibinin-induced apoptosis in choriocarcinoma cells via AKT, mitogen-activated protein kinases (MAPK) and unfolded protein response (UPR) signal transduction. Collectively, our results suggest that silibinin is a novel therapeutic agent or dietary supplement for management of human placental choriocarcinomas.
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Affiliation(s)
- Jiyeon Ham
- Institute of Animal Molecular Biotechnology and Department of Biotechnology, College of Life Sciences and Biotechnology, Korea University, Seoul, Republic of Korea
| | - Whasun Lim
- Department of Biomedical Sciences, Catholic Kwandong University, Gangneung, Republic of Korea
| | - Fuller W Bazer
- Center for Animal Biotechnology and Genomics and Department of Animal Science, Texas A & M University, College Station, Texas
| | - Gwonhwa Song
- Institute of Animal Molecular Biotechnology and Department of Biotechnology, College of Life Sciences and Biotechnology, Korea University, Seoul, Republic of Korea
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Sun P, Wu Q, Ruan G, Zheng X, Song Y, Zhun J, Wu L, Gotlieb WH. Expression patterns of maspin and mutant p53 are associated with the development of gestational trophoblastic neoplasia. Oncol Lett 2016; 12:3135-3142. [PMID: 27899973 PMCID: PMC5103910 DOI: 10.3892/ol.2016.5074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 06/27/2016] [Indexed: 02/01/2023] Open
Abstract
Gestational trophoblastic disease (GTD) is a group of conditions that originate from the abnormal proliferation of trophoblastic cells. GTDs encompass hydatidiform moles (HMs) and gestational trophoblastic neoplasia (GTN). GTNs are a group of malignant diseases that require chemotherapy, or more aggressive treatment. There is a requirement for more tumor markers to predict the development of GTN from HMs. The current study evaluated the expression of maspin and tumor protein p53 (p53) in GTD, and their role in predicting the development of GTN. Expression of maspin and mutant p53 (m-p53) was detected by immunohistochemistry in 48 normal first trimester placentas, matched for gestational age to 49 HMs that regressed, 39 malignant HMs and 11 invasive moles or choriocarcinomas. Spearman's rank correlation analysis and logistic regression were performed on the expression patterns of maspin and m-p53, and on the clinical prognostic factors in GTD. Compared with normal placenta levels, the expression levels of maspin were decreased, whereas the expression levels of m-p53 were increased in GTDs (P<0.05). The expression levels of maspin and m-p53 in complete and partial HMs were not significantly different (P>0.05). In HMs, maspin expression was inversely correlated with serum β human chorionic gonadotropin, uterine size and diameter of theca-lutein cysts; however, m-p53 expression demonstrated a positive correlation with these factors (all P<0.05). Compared with the high-risk metastatic group (FIGO score ≥7), the low-risk group (FIGO score <7) exhibited a higher rate of positive maspin expression (P=0.041), and the frequency of positive m-p53 expression was significantly higher in patients with an advanced FIGO stages (FIGO stage ≥III) compared with patients in early stages (FIGO stage ≤II; 87.9 vs. 58.8%; P=0.019). The combination of maspin negative expression with m-p53 positive expression had an 84% specificity value, 76% positive predictive value and 70% negative predictive value for the development of GTN. In conclusion, maspin-negative and m-p53-positive expression is associated with the development of GTN in HMs.
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Affiliation(s)
- Pengming Sun
- Institute of Gynecologic Oncology, Fujian Maternity and Children Health Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Qibin Wu
- Institute of Gynecologic Oncology, Fujian Maternity and Children Health Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Guanyu Ruan
- Institute of Gynecologic Oncology, Fujian Maternity and Children Health Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Xiu Zheng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Yiyi Song
- Institute of Gynecologic Oncology, Fujian Maternity and Children Health Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Jianfan Zhun
- Department of Pathology, Fujian Maternity and Children Health Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Lixiang Wu
- Department of Pathology, Fujian Maternity and Children Health Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Walter H Gotlieb
- Department of Gynecologic Oncology and Colposcopy, Jewish General Hospital, Mcgill University, Montreal, Quebec H3T1E2, Canada
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Couder F, Massardier J, You B, Abbas F, Hajri T, Lotz JP, Schott AM, Golfier F. Predictive factors of relapse in low-risk gestational trophoblastic neoplasia patients successfully treated with methotrexate alone. Am J Obstet Gynecol 2016; 215:80.e1-7. [PMID: 26829503 DOI: 10.1016/j.ajog.2016.01.183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 01/13/2016] [Accepted: 01/22/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with 2000 FIGO low-risk gestational trophoblastic neoplasia are commonly treated with single-agent chemotherapy. Methotrexate is widely used in this indication in Europe. Analysis of relapse after treatment and identification of factors associated with relapse would help understand their potential impacts on 2000 FIGO score evolution and chemotherapy management of gestational trophoblastic neoplasia patients. OBJECTIVE This retrospective study analyzes the predictive factors of relapse in low-risk gestational trophoblastic neoplasia patients whose hormone chorionic gonadotropin (hCG) normalized with methotrexate alone. STUDY DESIGN Between 1999 and 2014, 993 patients with gestational trophoblastic neoplasia were identified in the French Trophoblastic Disease Reference Center database, of which 465 were low-risk patients whose hCG normalized with methotrexate alone. Using univariate and multivariate analysis we identified significant predictive factors for relapse after methotrexate. The Kaplan-Meier method was used to plot the outcome of patients. RESULTS The 5-year recurrence rate of low-risk gestational trophoblastic neoplasia patients whose hCG normalized with methotrexate alone was 5.7% (confidence interval [IC], 3.86-8.46). Univariate analysis identified an antecedent pregnancy resulting in a delivery (HR = 5.96; 95% CI, 1.40-25.4, P = .016), a number of methotrexate courses superior to 5 courses (5-8 courses vs 1-4: HR = 6.19; 95% CI, 1.43-26.8, P = .015; 9 courses and more vs 1-4: HR = 6.80; 95% CI, 1.32-35.1, P = .022), and hCG normalization delay centered to the mean as predictive factors of recurrence (HR = 1.27; 95% CI, 1.09-1.49, P = .003). Multivariate analysis confirmed the type of antecedent pregnancy and the number of methotrexate courses as independent predictive factors of recurrence. A low-risk gestational trophoblastic neoplasia arising after a normal delivery had an 8.66 times higher relapse risk than that of a postmole gestational trophoblastic neoplasia (95% CI, 1.98-37.9], P = .0042). A patient who received 5-8 courses of methotrexate had a 6.7 times higher relapse risk than a patient who received 1-4 courses (95% CI, 1.54-29.2, P = .011). A patient who received 9 courses or more had an 8.1 times higher relapse risk than a patient who received 1-4 courses of methotrexate (95% CI, 1.54-42.6, P = .014). CONCLUSION Low-risk gestational trophoblastic neoplasia following a delivery and patients who need more than 4 courses of methotrexate to normalization are at a higher risk of relapse than other low-risk patients. Allotting a higher score to the "antecedent pregnancy" FIGO item should be considered for postdelivery gestational trophoblastic neoplasia. Further analysis of the need for consolidation courses is warranted.
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Lim W, Yang C, Bazer FW, Song G. Chrysophanol Induces Apoptosis of Choriocarcinoma Through Regulation of ROS and the AKT and ERK1/2 Pathways. J Cell Physiol 2016; 232:331-339. [DOI: 10.1002/jcp.25423] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 05/09/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Whasun Lim
- Department of Biotechnology and Institute of Animal Molecular Biotechnology; College of Life Sciences and Biotechnology; Korea University; Seoul Republic of Korea
| | - Changwon Yang
- Department of Biotechnology and Institute of Animal Molecular Biotechnology; College of Life Sciences and Biotechnology; Korea University; Seoul Republic of Korea
| | - Fuller W. Bazer
- Center for Animal Biotechnology and Genomics and Department of Animal Science; Texas A&M University; College Station Texas
| | - Gwonhwa Song
- Department of Biotechnology and Institute of Animal Molecular Biotechnology; College of Life Sciences and Biotechnology; Korea University; Seoul Republic of Korea
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Snyman LC. Gestational trophoblastic disease: An overview. SOUTHERN AFRICAN JOURNAL OF GYNAECOLOGICAL ONCOLOGY 2015. [DOI: 10.1080/20742835.2009.11441132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- L C Snyman
- Gynaecologic Oncology Unit, Department of Obstetrics and Gynaecology, University of Pretoria
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Rattanaburi A, Boonyapipat S, Supasinth Y. Human Chorionic Gonadotropin (hCG) Regression Curve for Predicting Response to EMA/CO (Etoposide, Methotrexate, Actinomycin D, Cyclophosphamide and Vincristine) Regimen in Gestational Trophoblastic Neoplasia. Asian Pac J Cancer Prev 2015; 16:5037-41. [PMID: 26163637 DOI: 10.7314/apjcp.2015.16.12.5037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An hCG regression curve has been used to predict the natural history and response to chemotherapy in gestational trophoblastic disease. We constructed hCG regression curves in high-risk gestational trophoblastic neoplasia (GTN) treated with EMA/CO and identified an optimal hCG level to detect EMA/CO resistance in GTN. MATERIALS AND METHODS Eighty-one women with GTN treated with EMA/CO were classified as primary high-risk GTN (n=65) and single agent-resistance GTN (n=16). The hCG levels prior to each course of chemotherapy were plotted in the 10th, 50th, and 90th percentiles to construct the hCG regression curves. Diagnostic performance was evaluated for an optimal cut-off value. RESULTS The median hCG levels were 264,482 mIU/mL mIU/mL and 495.5 mIU/mL mIU/mL for primary high-risk GTN and single agent-resistance GTN, respectively. The 50th percentile of the hCG level in primary high-risk GTN and single agent-resistance turned to normal before the 4th and the 2nd course of chemotherapy, respectively. The 90th percentile of the hCG level in primary high-risk GTN and single agent-resistance turned to normal before the 9th and the 2nd course of chemotherapy, respectively. The hCG level of ≥118.6 mIU/mL mIU/mL at the 5thcourse of EMA/CO predicted the EMA/CO resistance in primary high-risk GTN patients with a sensitivity of 85.7% and a specificity of 100%. CONCLUSION EMA/CO resistance in primary high-risk GTN can be predicted by using an hCG regression curve in combination with the cut-off value of 118.6 mIU/mL at the 5thcourse of chemotherapy.
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Affiliation(s)
- Athithan Rattanaburi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand E-mail :
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Dickson EL, Mullany SA. Gestational Trophoblastic Disease. Gynecol Oncol 2015. [DOI: 10.1007/978-1-4939-1976-5_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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