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Frijstein MM, Lok CAR, Short D, Singh K, Fisher RA, Hancock BW, Tidy JA, Sarwar N, Kanfer E, Winter MC, Savage PM, Seckl MJ. The results of treatment with high-dose chemotherapy and peripheral blood stem cell support for gestational trophoblastic neoplasia. Eur J Cancer 2019; 109:162-171. [PMID: 30731277 DOI: 10.1016/j.ejca.2018.12.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/13/2018] [Accepted: 12/23/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the effect of high-dose chemotherapy (HDC) with peripheral blood stem cell support (PBSCS) on survival of patients with gestational trophoblastic neoplasia (GTN) with either refractory choriocarcinomas or a poor-prognosis placental site/epithelioid trophoblastic tumours (PSTT/ETTs). METHODS Databases of two referral centres for gestational trophoblastic disease were searched, and 32 patients treated with HDC between 1994 and 2015 were identified. Tissue samples were retrieved for genetic evaluation. Cox regression analyses were performed to identify possible predictors of overall survival (OS). RESULTS HDC induced a sustained complete response in 7 patients. Overall, 41% (13/32) of the patients remained disease free after HDC with or without additional treatment. Patients who survived had much lower human chorionic gonadotropin (hCG) values (all ≤12 IU/L) before and after HDC than those who died of disease. Univariable Cox regression analysis demonstrated that hCG >12 IU/L before or after HDC, International Federation of Gynaecology and Obstetrics (FIGO) stage II-IV and presence of metastases at the time of diagnosis were significantly associated with adverse OS. However, only hCG values before HDC remained significant in a multivariable model (p < 0.001). Five of 11 (45%) patients with PSTT/ETT presenting ≥48 months after antecedent pregnancy and 6 of 14 (43%) patients with refractory choriocarcinoma were in remission. Three treatment-related deaths occurred. CONCLUSIONS Despite 3 treatment-induced deaths, HDC with PBSCS appears to be active in salvaging selected patients with poor-prognosis PSTT/ETTs and refractory choriocarcinomas. Low hCG values before HDC seems a beneficial predictor of OS and may suggest that HDC acts more like a consolidation therapy.
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Affiliation(s)
- M M Frijstein
- Department of Gynaecology, Center of Gynaecologic Oncology Amsterdam, the Netherlands
| | - C A R Lok
- Department of Gynaecology, Center of Gynaecologic Oncology Amsterdam, the Netherlands
| | - D Short
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, London, UK
| | - K Singh
- Sheffield Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - R A Fisher
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, London, UK
| | - B W Hancock
- Sheffield Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - J A Tidy
- Sheffield Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - N Sarwar
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, London, UK
| | - E Kanfer
- Dept of Haematology, Hammersmith Hospital Campus of Imperial College, London, UK
| | - M C Winter
- Sheffield Trophoblastic Disease Centre, Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - P M Savage
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, London, UK
| | - M J Seckl
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, London, UK.
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Yamamoto E, Niimi K, Fujikake K, Nishida T, Murata M, Mitsuma A, Ando Y, Kikkawa F. High-dose chemotherapy with autologous peripheral blood stem cell transplantation for choriocarcinoma: A case report and literature review. Mol Clin Oncol 2016; 5:660-664. [PMID: 27900108 DOI: 10.3892/mco.2016.1011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 05/30/2016] [Indexed: 11/06/2022] Open
Abstract
Choriocarcinoma is a malignant gestational trophoblastic neoplasia (GTN) and one of the curable types of gynecological cancer. However, 10% of choriocarcinoma patients have a poor prognosis, particularly when they have metastasis, apart from pulmonary metastasis, or do not go into remission by the second chemotherapeutic regimen. We herein present the case of a 36-year-old patient who had choriocarcinoma with metastases to the lungs, liver and kidneys. The 5th and 6th regimens with cisplatin for choriocarcinoma failed and the patient developed brain metastases. She was then treated with four cycles of high-dose ifosfamide, carboplatin and etoposide (ICE) with blood progenitor cell support after confirming the effectiveness of ICE at normal doses. The serum human chorionic gonadotropin (hCG) level was 140,009 mIU/ml at the start of high-dose ICE and the patient tolerated this regimen well. However, the beneficial effect was decreasing with each successive course of treatment, with the lowest level of hCG at 103 mIU/ml after the fourth course. The patient did not achieve complete remission and succumbed to the disease 4 months after the last chemotherapy. The findings of the present case and a review of the related literature suggest that high-dose ICE with stem cell rescue may be considered as a viable treatment option for a multi-drug resistant choriocarcinoma or GTN.
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Affiliation(s)
- 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
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Kayo Fujikake
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Tetsuya Nishida
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Makoto Murata
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Aichi 466-8550, Japan
| | - Ayako Mitsuma
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya, Aichi 466-8550, Japan
| | - Yuichi Ando
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, 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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Hyman DM, Bakios L, Gualtiere G, Carr C, Grisham RN, Makker V, Sonoda Y, Aghajanian C, Jewell EL. Placental site trophoblastic tumor: Analysis of presentation, treatment, and outcome. Gynecol Oncol 2013; 129:58-62. [DOI: 10.1016/j.ygyno.2012.12.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 12/10/2012] [Accepted: 12/15/2012] [Indexed: 11/16/2022]
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Nagai Y, Kamoi S, Matsuoka T, Hata A, Jobo T, Ogasawara T, Aoki Y, Ohira S, Okamoto T, Nakamoto T, Kanda K, Matsui H. Impact of p53 immunostaining in predicting advanced or recurrent placental site trophoblastic tumors: a study of 12 cases. Gynecol Oncol 2007; 106:446-52. [PMID: 17544490 DOI: 10.1016/j.ygyno.2007.04.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Revised: 03/01/2007] [Accepted: 04/16/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To identify an indicator that can predict tumor cell spread beyond the uterine corpus. METHODS We studied clinicopathology and immunohistochemistry of 12 cases of PSTT. Two cases of epithelioid trophoblastic tumor (ETT) were included as reference cases. For immunohistochemistry, antibodies against Ki-67, p53, human chorionic gonadotropin (hCG), human placental lactogen (hPL), carcinoembryonic antigen (CEA, polyclonal antibodies; pCEA), carcinoembryonic antigen-related cellular adhesion molecule 1 (CEACAM1), and bcl-2 were used. PSTT cases were divided as confined and non-confined groups (CG and NCG, respectively). CG consisted of stage I cases with no evidence of recurrence during the follow-up, while NCG consisted of either advanced (stage II or higher) or recurrent stage I lesions. RESULTS Age, the interval from the latest pregnancy, serum hCG/hPL levels, tumor size, mitotic figures, Ki-67 labeling indices, and bcl-2 did not discriminate NCG from CG. CEACAM1 and CEA-related antigens as determined by polyclonal anti-CEA antibodies were specifically stained in PSTT cells, but they could not discriminate groups. p53 was positive in PSTT cells in NCG (6/6, 100%), while it was positive in only one case of CG (1/6, 16.7%), indicating a possible usefulness of p53 immunostaining in predicting an invasive or recurrent propensity of PSTT cells (p=0.015). CONCLUSIONS This finding also suggests the importance of p53 function in the biology of PSTT cells.
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Affiliation(s)
- Yuichiro Nagai
- Department of Molecular Pathology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, and Department of Obstetrics and Gynecology, Chiba Hokuso Hospital, Chiba 260-8670, Japan.
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El-Helw LM, Seckl MJ, Haynes R, Evans LS, Lorigan PC, Long J, Kanfer EJ, Newlands ES, Hancock BW. High-dose chemotherapy and peripheral blood stem cell support in refractory gestational trophoblastic neoplasia. Br J Cancer 2005; 93:620-1. [PMID: 16222307 PMCID: PMC2361618 DOI: 10.1038/sj.bjc.6602771] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We present retrospectively our experience in the use of high-dose chemotherapy and haematopoietic stem cell support (HSCS) for refractory gestational trophoblastic neoplasia (GTN) in the largest series so far reported. In all, 11 patients have been treated at three Trophoblast Centres between 1993 and 2004. The conditioning regimens comprised either Carbop-EC-T (carboplatin, etoposide, cyclophosphamide, paclitaxel and prednisolone) or CEM (carboplatin, etoposide and melphalan) or ICE (ifosfamide, carboplatin, etoposide). Two patients had complete human chorionic gonadotrophin responses, one for 4 and the other for 12 months. Three patients had partial tumour marker responses for 1–2 months. High-dose chemotherapy and HSCS for GTN is still unproven. Further studies are needed, perhaps in high-risk patients who fail their first salvage treatment.
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Affiliation(s)
- L M El-Helw
- YCR Academic Unit of Clinical Oncology, Weston Park Hospital, Whitham road, Sheffield S10 2SJ, UK
| | - M J Seckl
- Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - R Haynes
- Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - L S Evans
- YCR Academic Unit of Clinical Oncology, Weston Park Hospital, Whitham road, Sheffield S10 2SJ, UK
| | - P C Lorigan
- YCR Academic Unit of Clinical Oncology, Weston Park Hospital, Whitham road, Sheffield S10 2SJ, UK
| | - J Long
- Waikato Hospital, Selwyn Street, PO Box 934, Hamilton, New Zealand
| | - E J Kanfer
- Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - E S Newlands
- Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - B W Hancock
- YCR Academic Unit of Clinical Oncology, Weston Park Hospital, Whitham road, Sheffield S10 2SJ, UK
- YCR Academic Unit of Clinical Oncology, Weston Park Hospital, Whitham road, Sheffield S10 2SJ, UK. E-mail:
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Baergen RN, Rutgers JL, Young RH, Osann K, Scully RE. Placental site trophoblastic tumor: A study of 55 cases and review of the literature emphasizing factors of prognostic significance. Gynecol Oncol 2005; 100:511-20. [PMID: 16246400 DOI: 10.1016/j.ygyno.2005.08.058] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Accepted: 08/29/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The placental site trophoblastic tumor is a rare form of gestational trophoblastic disease. Fifteen percent of reported cases have been fatal, but predicting behavior in individual patients has been challenging. METHODS The clinical, gross and histopathological features of 55 cases and 180 cases in the literature were analyzed for their effect on survival and in relation to tumor stage. RESULTS The 55 patients in our series were 20 to 62 (average 32) years of age. The tumors occurred on an average of 34 months after the last known gestation. 84% were stage I, 2% stage II, 5% stage III, and 9% stage IV. Serum levels of human chorionic gonadotropin (hCG) were elevated (average 691 mIU/ml) in 77% of the cases. The tumors were on average 5 cm in greatest dimension and were composed microscopically of infiltrative sheets of intermediate (extravillous) trophoblastic cells. The mitotic rate ranged from 0 to 20 (average 5.0) per 10 high power fields. The follow-up interval averaged 4.6 years. Eight patients (15%) died from metastatic tumor, and nine additional patients had metastases or a recurrence but were alive at last contact. The most common metastatic sites were the lungs, liver, and vagina. CONCLUSIONS Significant factors associated with adverse survival in the present series were age over 35 years (P = 0.025), interval since the last pregnancy of over 2 years (P = 0.014), deep myometrial invasion (P = 0.006), stage III or IV (P < 0.0005), maximum hCG level > 1000 mIU/ml (P = 0.034), extensive coagulative necrosis (P = 0.024), high mitotic rate (P = 0.005), and the presence of cells with clear cytoplasm (P < 0.0005). Only stage and clear cytoplasm were independent predictors of overall survival, while stage and age were the only independent predictors of time to recurrence or disease-free survival. In the literature, factors associated with survival were stage (P < 0.005), interval from preceding pregnancy of over 2 years (P = 0.029), previous term pregnancy (P = 0.046), high mitotic rate (P < 0.0005), and high hCG level (P = 0.037).
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Affiliation(s)
- Rebecca N Baergen
- New York Presbyterian Hospital-Weill Cornell Medical Center, 520 East 70th Street, Starr 1002, New York, NY 10021, USA.
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Aoki Y, Kase H, Kashima K, Yahata T, Tanaka K. Placental site trophoblastic tumor presenting as subaponeurotic metastasis. Int J Gynecol Cancer 2005; 15:385-8. [PMID: 15823131 DOI: 10.1111/j.1525-1438.2005.15235.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Cases of metastatic placental site trophoblastic tumor (PSTT) have a very poor prognosis because these tumors tend to be less sensitive to chemotherapy than other types of gestational trophoblastic disease. We describe the case of a 25-year-old woman who presented with occipital tumor and abnormal vaginal bleeding. Hysterectomy, bilateral salpingo-oophorectomy, and occipital tumor removal revealed a primary PSTT in the uterus, with ovarian and occipital subaponeurotic metastases. She received etoposide, methotrexate, actinomycin-D/cyclophosphamide, vincristine chemotherapy and had a complete clinical remission. Fifteen months later, she had a recurrent subaponeurotic occipital tumor invading the cranium and underwent tumor removal along with cranial bone followed by local irradiation. She was then treated with etoposide, cis-platinum/etoposide, methotrexate, actinomycin-D chemotherapy and again had a remission for 5 months. The patient, however, had a left parietal subaponeurotic tumor, invading the dura mater, and received local irradiation. Soon after, she developed left orbital bone metastasis, treated by local irradiation. These bone metastases responded to the radiation completely. However, multiple organ metastases were found, and she died of the disease. This represents the first case of PSTT with initial subaponeurotic metastasis in a living patient. New modalities of treatment for high-risk or metastatic PSTT need to be developed.
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Affiliation(s)
- Y Aoki
- Division of Molecular Genetics, Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
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