Gestational trophoblastic diseases: new standards for therapy

Spontaneous uterine perforation of choriocarcinoma with negative beta-human chorionic gonadotropin after chemotherapy

OBJECTIVE

To report an extremely rare case of spontaneous uterine perforation of choriocarcinoma with negative beta-human chorionic gonadotropin (β-hCG) post-chemotherapy.

CLINICAL PRESENTATION AND INTERVENTION

We present a 35-year-old choriocarcinoma patient whose serial serum β-hCG levels following a fifth course of chemotherapy had been within the normal range, but who developed spontaneous uterine perforation with intra-abdominal hemorrhage after eight courses of combined chemotherapy. The patient then underwent an emergency hysterectomy and survived.

CONCLUSION

Patients with persistent focus of disease in the uterus might experience uterine perforation even after adequate chemotherapy, and therefore, the follow-up for patients after chemotherapy is very important.

Usefulness of low-dose CT in the detection of pulmonary metastasis of gestational trophoblastic tumours

AIM

To determine whether a low-dose spiral chest computed tomography (CT) examination could replace standard-dose chest CT in detecting pulmonary metastases in patients with gestational trophoblastic tumour (GTT).

MATERIALS AND METHODS

In a prospective investigation, 67 chest CT examinations of 39 GTT patients were undertaken. All the patients underwent CT examinations using standard-dose (150 mAs, pitch 1, standard reconstruction algorithm) and low-dose (40 mAs, pitch 2, bone reconstruction algorithm) protocols. Two radiologists interpreted images independently. A metastasis was defined as a nodule within lung parenchyma that could not be attributed to a pulmonary vessel. The number of metastases detected with each protocol was recorded. The size of each lesion was measured and categorized as <5, 5-9.9, and > or = 10 mm. Wilcoxon's signed rank test was used to assess the difference between the numbers of lesion detected by the two protocols.

RESULTS

The CT dose index (CTDI) for the standard-dose and low-dose CT protocols was 10.4 mGy and 1.4 mGy, respectively. One thousand, six hundred, and eighty-two metastases were detected by standard-dose CT, and 1460 lesions by the low-dose protocol. The numbers detected by low-dose CT were significantly less than those detected by standard-dose CT (Z=-3.776, p<0.001), especially for nodules smaller than 5mm (Z=-4.167, p<0.001). However, the disease staging and risk score of the patients were not affected by use of the low-dose protocol.

CONCLUSION

Low-dose chest CT can be used as a staging and follow-up procedure for patients with GTT.

Treatment of metastatic gestational trophoblastic neoplasia

Treatment of persistent gestational trophoblastic neoplasia (GTN) has been one of the success stories of modern day chemotherapy; however, occasional patients with metastatic disease still die. A potential difficulty in assessing published studies is that patient groups can be selected for treatment differently according to how risk categories are defined. The involvement of a specialist team from the outset is essential. Patients with low-risk metastatic GTN are treated successfully with single-agent chemotherapy using methotrexate or dactinomycin. Patients with high-risk metastatic disease receive combination chemotherapy regimens from the start. Worldwide experience has been accrued by use of regimens devised and tested by large centres. The high response rate and good long-term survival, as well as the tolerable acute and cumulative toxic effects, associated with use of etoposide, methotrexate and dactinomycin, alternating with cyclophosphamide and vincristine, make this protocol, or one of its variants, the current initial treatment of choice for patients. In view of the success of these regimens difficulty would be encountered in mounting a worthwhile randomised controlled trial; however, further well-designed studies are needed of novel approaches in very-high-risk and multiresistant disease.

Présentation inhabituelle d'un choriocarcinome gestationnel

Gestational choriocarcinoma is a rare malignant tumour with a strong metastatic potential. We report a case of a 31-year-old patient with a gestational trophoblastic tumor revealed by renal and pulmonary metastases, one year after a normal pregnancy. The diagnosis was established by the pathologist on the radical nephrectomy specimen. The evolution was quickly favorable after adequate treatment using multiagent chemotherapy. This case highlights the polymorphic aspects of the gestational choriocarcinoma and stresses the importance of a betaHCG assessment anytime abnormal symptoms occur in the outcome of a pregnancy.

Choriocarcinome utérin en péri-ménopause

We report a case of a primary uterine choriocarcinoma associated with adenocarcinoma occurring during peri-menopausal age, and review the literature. The clinical course and the histopathology of the case were reviewed and a Medline literature search for other cases was performed. BHCG and analysis of uterine curettage provided the diagnosis of choriocarcinoma. Polychemotherapy, started immediately after the patient's clinical condition deteriorated, was successful. Colpohysterectomy and pelvic lymphadenectomy were performed 5 months later. Treatment was completed by vaginal curietherapy. Histopathologic examination of the surgical specimen revealed only adenocarcinoma. The patient was followed for 18 months without evidence of recurrence. The literature search revealed that primary forms are exceptional; the etiology is unknown. Treatment is based on polychemotherapy. Primary choriocarcinomas are rare tumours, associated with other histopathological forms. We document a case occurring during the peri-menopausal period and review the literature on this pathology. The very poor prognosis in the past has changed with early polychemotherapy.

Prospective strategies to enforce selectively cell death in cancer cells

Although induction of apoptosis (cell death mediated by caspases) determines response to cancer therapy, this approach is limited by lack of selectivity in available apoptosis-inducing agents. Furthermore, most cancers, almost by definition, are resistant to apoptosis, growth arrest and cell senescence. Then, how can anticancer agents kill cancer cell without unacceptable toxicity to a patient? The potential therapeutic approaches range from selective inhibition of antiapoptotic pathways, antiangiogenic therapy, tissue-selective therapy (including immunotherapy) to exploitation of, for example, drug resistance, oncoprotein addiction, unrestricted cell cycles, hypermitogenic and hypoxic features of cancer cells. These overlapping and complementary approaches rely on rational drug combinations (at mechanism-based doses and sequences) aimed at matching targets. To ensure killing of cancer cells selectively, we may combine apoptosis- and senescence-inducing agents with inhibitors of apoptosis (to protect normal cells), inhibitors of signal transduction with cell cycle-dependent chemotherapy, antiangiogenic agents with hypoxia-inducible factor-1 inhibitors, tissue-selective therapy with differentiating agents and activators of death receptors with chemotherapy. In theory, consecutive use of these drug combinations may control cancer.

Epidemiology and aetiology of gestational trophoblastic diseases

Gestational trophoblastic diseases (GTD) consist of a group of neoplastic disorders arising from placental trophoblastic tissue after normal or abnormal fertilisation. The WHO classification of GTD includes hydatidiform mole, invasive mole, choriocarcinoma, placental site trophoblastic tumour, and miscellaneous and unclassified trophoblastic lesions. GTD have a varying potential for local invasion and metastases and they generally respond to chemotherapy. Broad variations in the distribution of GTD exist worldwide, with higher frequencies in some parts of Asia, the Middle East and Africa, but the extent to which they can be attributed to methodological difficulties in obtaining accurate rates is unclear. Maternal age and a history of GTD have been established as strong risk factors for hydatidiform mole and choriocarcinoma. We review published data on the worldwide distribution of GTD, original data from cancer- registry-based statistics on choriocarcinoma, and major aetiological hypotheses, including parental age, AB0 blood groups, history of GTD, reproductive factors, oral contraceptive use, and other environmental factors.

Cytokeratin 20 as a biomarker of gestational trophoblastic disease: diagnostic and prognostic significance

OBJECTIVES

This study was designed to examine whether cytokeratin 20 (CK20) is expressed in molar pregnancies and may therefore be used in the diagnosis of gestational trophoblastic disease (GTD). The potential of CK20 expression in predicting the evolution and the prognosis of the different subtypes of GTD was also assessed.

METHODS

A total of 48 samples were studied for CK20 expression by RT-PCR methodology. Among these, 24 samples were obtained by curettage of the uterine cavity of patients diagnosed with hydatidiform mole (14 complete moles and 10 partial moles), 4 samples were obtained from choriocarcinoma cell lines (2 JAR and 2 JEG), and 20 samples were of normal trophoblast (control group) obtained from patients that underwent elective termination of pregnancy.

RESULTS

Expression of CK20 was identified in all the samples of complete mole (CM), all choriocarcinoma cell lines, and 50% of the patients with partial mole (PM). None of the preparations of normal trophoblastic tissue from the control group expressed the CK20. A significant difference (P < 0.00001) was found in CK20 expression between samples of patients with GTD and control samples. Comparison between CK20 expression in CMs and PMs revealed a significantly more frequent expression of CK20 in CMs (P = 0.006). More than 50% of the patients with PMs that were positive for CK20 had an invasive evolution.

CONCLUSIONS

In our opinion, CK20 may assist in distinguishing between molar and normal trophoblastic tissue and may be considered a marker of GTD. In cases in which pathological classification of different subtypes of GTD is in doubt, CK20-positive expression is suggestive for a CM whereas CK20-negative is more indicative for PM.