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Coopmans L, Larsson A, Joneborg U, Lok C, van Trommel N. Surgical Management of Gestational Trophoblastic Disease. Gynecol Obstet Invest 2023; 89:214-229. [PMID: 37788661 DOI: 10.1159/000534065] [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: 01/10/2023] [Accepted: 09/04/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Gestational trophoblastic disease (GTD) is a rare pregnancy-related condition consisting of premalignant and malignant forms arising from proliferation of trophoblastic cells. The malignant forms are collectively referred to as gestational trophoblastic neoplasia (GTN) and are highly sensitive to chemotherapy. However, surgical procedures remain indispensable in the diagnosis and treatment of GTD. OBJECTIVES The aim of this review was to summarize surgical interventions in the treatment of GTD and GTN. We reviewed indications, efficacy, possible complications, and oncological outcomes of surgery. METHODS Three searches were performed in the databases of PubMed, Embase, and the Cochrane Library to create an up-to-date overview of existing literature on the following subjects: (1) the role of primary hysterectomy in GTD and GTN; (2) the role of second curettage in GTD and GTN; (3) fertility sparing surgery in GTN; (4) surgical management of metastases. Included articles originated from the time period 1952-2022. Articles written in English, Spanish, and French were included. OUTCOMES Thirty-eight articles were found and selected. Surgical evacuation through suction curettage is most used and advised in the treatment of GTD. A second curettage could be beneficial in patients with low hCG levels and low FIGO scores. In women who have completed their families, primary hysterectomy might be considered as the risk of subsequent GTN is lower than after suction curettage. In case of the rare forms of GTN (epithelioid trophoblastic tumor or placental site trophoblastic tumor) surgical tumor resection remains the most important step in treatment. Data on fertility sparing surgery in GTN are scarce and this treatment should be considered experimental. CONCLUSION AND OUTLOOK Surgery remains an important part of treatment of GTD and is sometimes indispensable to achieve curation. Further collection of evidence is needed to determine treatment steps.
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Affiliation(s)
- Leonoor Coopmans
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands,
| | - Agnes Larsson
- Department of Gynecologic Cancer Surgery, Karolinska University Hospital and Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Ulrika Joneborg
- Department of Gynecologic Cancer Surgery, Karolinska University Hospital and Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Christianne Lok
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nienke van Trommel
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Tejas SV, Pallavi VR, Shobha K, Rajshekhar SK. Role of Salvage Surgery in Gestational Trophoblastic Neoplasia: a Regional Cancer Centre Experience. Indian J Surg Oncol 2022; 13:702-706. [PMID: 36687227 PMCID: PMC9845464 DOI: 10.1007/s13193-022-01644-1] [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: 06/07/2022] [Accepted: 09/02/2022] [Indexed: 01/25/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) is a curable cancer with chemotherapy. However, some develop chemoresistance to standard chemotherapy and surgery can be a useful option in them. Our study aimed to assess the role of salvage surgery in GTN with chemoresistance. It is a retrospective hospital-based study from 2000 to 2021. Case sheets of women who underwent salvage surgery for chemoresistance were reviewed and clinical parameters like preoperative hCG, antecedent pregnancy, WHO risk score, multiple chemotherapy regimens prior surgery, presence of > 1 disease site, and presence of residual choriocarcinoma that predicted the effect of surgery on serological response were assessed using Fisher's exact test. A total of 19 patients with high-risk GTN developed chemoresistance and underwent salvage surgery. Eight underwent hysterectomy, 3 underwent hysterectomy plus adnexal tumour resection, six received fertility-sparing surgery, and two underwent segmental resection of the lung. Histopathological examination revealed viable tumour in 7/19 patients, but significant fall in median hCG level from 161.5 mIU/ml (preoperatively) to 15.5 mIU/ml (postoperatively) was noted. Preoperative hCG < 100 mIU/ml (p = 0.019) was the most important determinant of complete response to surgery. All the patients who had disease confined to the uterus and/or lungs at the time of surgery achieved remission after completion of treatment. Our study concludes that in the case of chemoresistant high-risk GTN, carefully selected cases with low hCG levels and disease confined to the uterus and/or lungs get the most benefit of surgery. The use of postoperative chemotherapy after complete response is essential to maintain remission and prevent relapse.
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Affiliation(s)
| | - V. R. Pallavi
- Department of Gynaecological Oncology, Kidwai Memorial Institute of Oncology, Bangalore, India
| | - K. Shobha
- Department of Gynaecological Oncology, Kidwai Memorial Institute of Oncology, Bangalore, India
| | - S. K. Rajshekhar
- Department of Gynaecological Oncology, Kidwai Memorial Institute of Oncology, Bangalore, India
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Zhao L, Qin Y, Ma D, Liu H. Surgical treatment of lung metastasis in patients with refractory gestational trophoblastic neoplasia: A retrospective study. Gynecol Oncol 2022; 167:37-41. [PMID: 35931469 DOI: 10.1016/j.ygyno.2022.07.030] [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: 06/14/2022] [Revised: 07/23/2022] [Accepted: 07/29/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE The lungs are the most common site of metastasis in patients with gestational trophoblastic neoplasia. We investigated surgical management and prognostic factors of patients with refractory gestational trophoblastic neoplasia to assess the value of lung metastasis resection. PATIENTS AND METHODS The clinical data of patients with refractory gestational trophoblastic neoplasia and lung metastasis treated at Peking Union Medical College Hospital from January 2005 to December 2020 were retrospectively analyzed. Surgical characteristics and survival outcomes were analyzed. RESULTS In total, 213 patients with refractory gestational trophoblastic neoplasia and lung metastasis were screened, and 148 patients who underwent unilateral lung resection were analyzed. Patients' median age was 32 years. Lobectomy was performed in 65.5% of patients, while wedge resection was performed in 34.5%. The rate of postoperative complications was 12.2%. The pathological rate was 66.2%. Video-assisted thoracoscopic surgery showed better surgical characteristics than thoracotomy did. Compared with lobectomy, wedge resection had a shorter operative time, shorter duration of chest tube placement, shorter postoperative hospital stay, and fewer postoperative complications. The median follow-up period was 36 months. During follow-up, 90.5% of patients achieved complete remission. The 5-year disease-free and overall survival rates were 80.4% and 92.6%, respectively. More previous chemotherapy courses and failure to achieve normal β-human chorionic gonadotropin levels postoperatively were predictors of poor prognosis. CONCLUSIONS Surgical treatment of lung metastasis is valuable and safe for patients with refractory gestational trophoblastic neoplasia. The minimally invasive video-assisted thoracoscopic approach and wedge resection are recommended.
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Affiliation(s)
- Luo Zhao
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, China
| | - Yingzhi Qin
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, China
| | - Dongjie Ma
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, China
| | - Hongsheng Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, CAMS & PUMC, Beijing 100730, China.
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Qin J, Zhang S, Poon L, Pan Z, Luo J, Yu N, Wang L, Wu X, Cheng X, Xie X, Lu Y, LU W. Doppler-based predictive model for methotrexate resistance in low-risk gestational trophoblastic neoplasia with myometrial invasion: prospective study of 147 patients. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:829-839. [PMID: 32385928 PMCID: PMC8251727 DOI: 10.1002/uog.22069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/30/2020] [Accepted: 04/22/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES This prospective clinical study aimed to evaluate the vascularization characteristics of low-risk gestational trophoblastic neoplasia (GTN) using Doppler imaging and to develop a predictive model for resistance to methotrexate (MTX). METHODS Patients with low-risk GTN receiving primary MTX treatment were enrolled from the Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China, from September 2012 to August 2018. The primary endpoint was to develop and internally validate a predictive model for resistance to MTX therapy in these patients. In the training set, clinical features and Doppler hemodynamic parameters before MTX therapy were analyzed using logistic regression to identify independent predictors of MTX resistance, which were integrated into the model. The predictive performance of the model was evaluated by leave-one-out cross-validation in the training dataset and internal validation in an independent-sample test dataset. RESULTS The entire imaging protocol was completed by 147 eligible patients, of which 110 comprised the training set and 37 the test set. In the training set, cases with myometrial invasion (81.8%; 90/110) showed vascular-enriched areas in the myometrium and high velocity and low impedance ratios of the uterine artery (UtA) compared to cases without myometrial invasion (18.2%; 20/110). On multivariate logistic regression analysis, time-averaged mean velocity in UtA (UtA-TAmean) and the International Federation of Gynecology and Obstetrics (FIGO) score were identified as independent predictors (P = 0.009 and P = 0.043, respectively) of MTX resistance. The Doppler-based predictive model, developed based on the 90 cases with myometrial invasion, was y = -2.95332 + 0.41696 × FIGO score + 0.03551 × UtA-TAmean. The model showed an area under the curve of 0.757 (95% CI, 0.653-0.862) and the optimal cut-off value was 0.50622, which had 45.2% sensitivity and 96.6% specificity. The model stratified patients with low-risk GTN into low (< 10%), intermediate (10-90%) and high (> 90%) probability of MTX resistance, based on the threshold values of -1.59544 and 0.10046. The model had an accuracy of 74.4% (95% CI, 64.5-82.3%) in the cross-validation and 72.7% (95% CI, 55.8-84.9%) in the internal validation. CONCLUSIONS The Doppler-based predictive model, combining a non-invasive marker of tumor vascularity with the FIGO scoring system, can differentiate cases with low from those with high probability of developing MTX resistance and therefore has the potential to guide treatment options in patients with low-risk GTN and myometrial invasion. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J. Qin
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
| | - S. Zhang
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
| | - L. Poon
- Department of Obstetrics and GynaecologyThe Chinese University of Hong KongHong Kong SAR
| | - Z. Pan
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
| | - J. Luo
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
| | - N. Yu
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
| | - L. Wang
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
| | - X. Wu
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
| | - X. Cheng
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
| | - X. Xie
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
| | - Y. Lu
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
- Institute of Translational MedicineZhejiang University School of MedicineHangzhouChina
| | - W. LU
- Women's Reproductive Health Key Laboratory of Zhejiang Province, Women's HospitalZhejiang University School of MedicineHangzhouZhejiangChina
- Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang ProvinceHangzhouZhejiangChina
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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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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: 16] [Impact Index Per Article: 3.2] [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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Kong Y, Tao G, Zong L, Yang J, Wan X, Wang W, Xiang Y. Diagnosis and Management of Mixed Gestational Trophoblastic Neoplasia: A Study of 16 Cases and a Review of the Literature. Front Oncol 2019; 9:1262. [PMID: 31803628 PMCID: PMC6873612 DOI: 10.3389/fonc.2019.01262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 10/31/2019] [Indexed: 11/23/2022] Open
Abstract
Objective: Mixed gestational trophoblastic neoplasia (GTN) is a rare occurrence that refers to the coexistence of choriocarcinoma and/or placental site trophoblastic tumor and/or epithelioid trophoblastic tumor. The diagnosis and management of mixed GTN are challenging. We investigated the clinicopathological characteristics, diagnoses, treatments, and outcomes of patients with mixed GTN. Materials and Methods: The medical records and pathological sections of 16 patients with mixed GTN who were treated at Peking Union Medical College Hospital and The Second Xiangya Hospital of Central South University between January 2012 and December 2018 were reviewed. Results: Pretreatment serum human chorionic gonadotropin (hCG) levels ranged from 180 to 625,024 IU/L, and were >10,000 IU/L in 14 of the 16 patients, none of whom were diagnosed correctly at initial presentation. Two patients were diagnosed with choriocarcinoma coexisting with intermediate trophoblastic tumor (ITT) through dilation and curettage (D&C) before treatment. Another 5 patients were histologically confirmed to have placental site trophoblastic tumor (PSTT) by D&C but final pathological findings showed mixed PSTT and choriocarcinoma at subsequent hysterectomy. Seven post-chemotherapy patients with an initial clinical diagnosis of choriocarcinoma underwent surgery because of chemoresistance and their pathological findings revealed coexisting ITT. The remaining 2 patients were found to have choriocarcinoma coexisting with ITT following cervical biopsy and pulmonary lobectomy. All patients received chemotherapy: 14 underwent surgery combined with chemotherapy and 2 received chemotherapy alone to preserve fertility. Other than 1 patient who died of disease progression, 15 patients (93.8%) achieved complete remission (CR) after treatment, although 5 (33.3%) relapsed. Of these 5 patients with relapse, 3 achieved CR after additional treatment, 1 was receiving an immune checkpoint inhibitor, and 1 was lost to follow-up after refusing further therapy. Conclusion: Mixed GTN is difficult to diagnose on initial presentation. Overlap of the ITT component should be considered in refractory chemoresistant choriocarcinoma. Coexistence of choriocarcinoma should be suspected in ITT patients with high hCG levels. Surgery combined with chemotherapy is optimal treatment for choriocarcinoma mixed with ITT.
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Affiliation(s)
- Yujia Kong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Guangshi Tao
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Liju Zong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Junjun Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wenze Wang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Abstract
OBJECTIVE Choriocarcinoma is rare in postmenopausal women, and an early diagnosis contributes to a potential cure. METHODS We report a rare case of a postmenopausal woman with choriocarcinoma. The 61-year-old patient presented with irregular vaginal bleeding, 11 years after menopause and 30 years after the birth of the last child. RESULTS Radiological investigation found a 3-cm mass on the lower left part of the vaginal wall, and also bilateral lung nodules. Gynecological examination found 3-4 cm blue and purple nodules in the lower left part of the vaginal wall. Her serum CA125 and serum β-hCG levels were 10.2 and 9273.9 mIU/mL, respectively. The early diagnosis was a choriocarcinoma, and combination chemotherapy (etoposide, kengshengmycin, methotrexate, leucovorin, vincristine, and cyclophosphamide [EMACO]) was administered. After the sixth chemotherapy session, her serum β-hCG level was <2 mIU/mL, and two additional consolidation chemotherapy sessions were performed. She achieved serological remission, but 4 months after completion of the chemotherapy, a rise in serum β-hCG level was observed. Therefore, she was subjected to a second treatment with EMACO and fluorouracil (5-Fu) local injection chemotherapy. After nine chemotherapy sessions and three local 5-Fu injections, she showed a normal β-hCG level, with negative radiological results, and negative pigmentation in the lower left part of the vaginal wall. After a 4-year follow-up period, no local recurrence or distant metastases was found. CONCLUSIONS This patient has shown a mild response to chemotherapy when compared with patients in reproductive age, and the combination of standard chemotherapy with local injection chemotherapy may be helpful for treating similar clinical cases.
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Lima LDELA, Padron L, Câmara R, Sun SY, Rezende J, Braga A. The role of surgery in the management of women with gestational trophoblastic disease. Rev Col Bras Cir 2018; 44:94-101. [PMID: 28489216 DOI: 10.1590/0100-69912017001009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 12/09/2016] [Indexed: 02/07/2023] Open
Abstract
The Gestational Trophoblastic Disease includes an interrelated group of diseases originating from placental tissue, with distinct behaviors concerning local invasion and metastasis. The high sensitivity of the serial dosages of human chorionic gonadotrophin, combined with advances in chemotherapy treatment, have made gestational trophoblastic neoplasia curable, most often through chemotherapy. However, surgery remains of major importance in the management of patients with gestational trophoblastic disease, improving their prognosis. Surgery is necessary in the control of the disease's complications, such as hemorrhage, and in cases of resistant/relapsed neoplasia. This review discusses the indications and the role of surgical interventions in the management of women with molar pregnancy and gestational trophoblastic neoplasia. RESUMO Doença trofoblástica gestacional inclui um grupo interrelacionado de doenças originadas do tecido placentário, com tendências distintas de invasão local e metástase. A alta sensibilidade das dosagens seriadas de gonadotrofina coriônica humana aliada aos avanços do tratamento quimioterápico tornou a neoplasia trofoblástica gestacional, curável, na maioria das vezes, através da quimioterapia. No entanto, a cirurgia permanece ainda, da maior importância na condução de pacientes com doença trofoblástica gestacional, melhorando seu prognóstico. A cirurgia é necessária no controle de complicações da doença, tais como hemorragia, e em casos de neoplasia resistente/recidivada. Esta revisão discute as indicações e o papel das intervenções cirúrgicas durante o manejo de mulheres com gravidez molar e neoplasia trofoblástica gestacional.
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Affiliation(s)
- Lana DE Lourdes Aguiar Lima
- - Federal University of Rio de Janeiro, Center for Trofoblastic Disease of the Maternity School, Rio de Janeiro, Rio de Janeiro State, Brazil.,- Federal University of Rio de Janeiro, Post-Graduate Program in Perinatal Health of the Maternity School, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Lílian Padron
- - Federal University of Rio de Janeiro, Center for Trofoblastic Disease of the Maternity School, Rio de Janeiro, Rio de Janeiro State, Brazil.,- Fluminense Federal University, Post-Graduate Program in Medical Sciences, Niterói, Rio de Janeiro State, Brazil
| | - Raphael Câmara
- - Federal University of Rio de Janeiro, Center for Trofoblastic Disease of the Maternity School, Rio de Janeiro, Rio de Janeiro State, Brazil.,- Federal University of Rio de Janeiro, Institute of Gynecology, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Sue Yazaki Sun
- - Paulista School of Medicine, Federal University of São Paulo, Center for Trophoblastic Diseases of the São Paulo Hospital, Sao Paulo, Sao Paulo State, Brazil
| | - Jorge Rezende
- - Federal University of Rio de Janeiro, Center for Trofoblastic Disease of the Maternity School, Rio de Janeiro, Rio de Janeiro State, Brazil.,- Federal University of Rio de Janeiro, Post-Graduate Program in Perinatal Health of the Maternity School, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Antônio Braga
- - Federal University of Rio de Janeiro, Center for Trofoblastic Disease of the Maternity School, Rio de Janeiro, Rio de Janeiro State, Brazil.,- Federal University of Rio de Janeiro, Post-Graduate Program in Perinatal Health of the Maternity School, Rio de Janeiro, Rio de Janeiro State, Brazil.,- Fluminense Federal University, Post-Graduate Program in Medical Sciences, Niterói, Rio de Janeiro State, Brazil
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Patni R. Gestational Trophoblastic Neoplasia: The Role of Surgery Cannot be Undermined! INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2017. [DOI: 10.1007/s40944-017-0157-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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FERTILITY-SPARING HYSTEROTOMY IN MALIGNANT TROPHOBLASTIC TUMOURS TREATMENT. EUREKA: HEALTH SCIENCES 2017. [DOI: 10.21303/2504-5679.2017.00341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim is to improve treatment efficacy and life quality of patients with malignant trophoblastic tumours.
Fertility-sparing hysterotomy with uterine reconstruction was carried in 16 patients aged of 17 to 32 years: 2 cases due to urgent and 13 – due to planned indications.
On the basis of research, the indications for the urgent and planned fertility-sparing hysterotomy with uterine reconstruction in patients with malignant trophoblastic tumours were formulated. No postoperative complications. Steady remission in all cases. Follow up from 1 to 17 years (averaged 9.2 years).
1. Localized uterine resection with uterine reconstruction – the method of choice in malignant trophoblastic tumours surgical treatment;
2. Fertility-sparing hysterotomy with uterine reconstruction is only possible in centers which are experienced in the complex multimodality treatment of gestational trophoblastic neoplasms;
3. Basic requirement of fertility-sparing surgery is beginning adjuvant chemotherapy as soon as possible.
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Yousefi Z, Mottaghi M, Rezaei A, Ghasemian S. Abnormal Presentation of Choriocarcinoma and Literature Review. IRANIAN JOURNAL OF CANCER PREVENTION 2016; 9:e4389. [PMID: 27482332 PMCID: PMC4951767 DOI: 10.17795/ijcp-4389] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 03/15/2016] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Gestational trophoblastic neoplasms have highly been malignant potential, which usually occurred in child-bearing age women. Unusual feature of this malignancy would be rare, it was important to take in mind the possibility of GTN in different manifestation. Based on the above mentioned, the aim of this presentation would be the management and outcome of a case series of choriocarcinoma patients with abnormal manifestation. CASE PRESENTATION We have presented four patients, first who initially manifestation with signs of septic shock, the second case with severe gastrointestinal hemorrhage, the third case with postpartum infection and the forth case was a postmenopausal bleeding patient. CONCLUSIONS In case of metastatic choriocarcinoma with precise history, accurate diagnosis and appropriate treatment have led us to curable results.
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Affiliation(s)
- Zohreh Yousefi
- Department of Obstetrics and Gynecology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Mansorhe Mottaghi
- Department of Obstetrics and Gynecology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | | | - Sedighe Ghasemian
- Department of Obstetrics and Gynecology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, IR Iran
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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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Feng F, Hu H, Wu L, Ren T, Wan X, Xiang Y. Thoracotomy in refractory gestational trophoblastic neoplasia with lung metastasis after normalization of serum beta human chorionic gonadotropin (β-hCG) with salvage chemotherapy. Onco Targets Ther 2014; 7:171-6. [PMID: 24511240 PMCID: PMC3913543 DOI: 10.2147/ott.s56361] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To assess the need for pulmonary surgery in the treatment of refractory gestational trophoblastic neoplasia with lung metastasis after normalization of serum beta human chorionic gonadotropin (β-hCG) level with salvage chemotherapy. Materials and methods A review of medical records of patients with refractory gestational trophoblastic neoplasia who underwent pulmonary surgery and received combined chemotherapy between January 1995 and December 2008 at the Peking Union Medical College Hospital was retrospectively performed. The positive pathologic findings in surgical specimens were defined as trophoblastic cells documented in the specimen. Pathologic findings were reported. Results There were 21 patients with preoperative normal β-hCG. Of 21 patients, six (28.6%) had positive pathologic findings. The positive pathologic findings remained at 27.3% in 11 patients who had received no less than two cycles of consolidation chemotherapy before pulmonary surgery. Univariate analysis found that no variables in patient characteristics were associated with pathologic findings. At the median follow-up of 78 months (9–186 months), 85.7% (18 of 21) patients were alive, and no statistical difference was observed in the disease-free survival between the patients with positive and negative pathologic findings. The 5-year overall survival was 72.2%. Conclusion Pulmonary surgery is valuable in the treatment of refractory patients with lung metastasis after normalization of serum β-hCG level following salvage chemotherapy, irrespective of viable trophoblasts in surgical specimens. Further study will be necessary to clarify the importance of this observation.
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Affiliation(s)
- Fengzhi Feng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Huiying Hu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Lei Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Tong Ren
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xirun Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Zhao J, Xiang Y, Zhao D, Ren T, Feng F, Wan X. Isolated epithelioid trophoblastic tumor of the vagina: a case report and review of the literature. Onco Targets Ther 2013; 6:1523-6. [PMID: 24194644 PMCID: PMC3814932 DOI: 10.2147/ott.s50553] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
An epithelioid trophoblastic tumor (ETT) is a rare trophoblastic tumor originating from chorionic-type intermediate trophoblasts. Vaginal involvement in ETT in the form of isolated lesions has not been previously reported. A 43-year-old woman presented with vaginal wall cysts and was diagnosed with ETT by pathological examination after cystectomy. No clinical evidence of uterine involvement was found at diagnosis or during follow-up. The patient was treated with chemotherapy and surgery after the first recurrence and underwent follow-up for 8 months. The serum human chorionic gonadotropin titer remained at undetectable levels.
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Affiliation(s)
- Jing Zhao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Ryu JH, Choi CH, Kim TJ, Lee JW, Kim BG, Bae DS. Chemo-resistant choriocarcinoma metastatic to colon cured by low-anterior resection. J Gynecol Oncol 2011; 22:203-6. [PMID: 21998764 PMCID: PMC3188720 DOI: 10.3802/jgo.2011.22.3.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 06/18/2010] [Accepted: 06/30/2010] [Indexed: 11/30/2022] Open
Abstract
The role of surgery in the treatment of patients with metastatic choriocarcinoma has diminished. We present a case of chemo-resistant metastatic choriocarcinoma salvaged by surgery. A 48-year-old patient presented with uterine perforation and severe intractable hemorrhage, and histological examination revealed a choriocarcinoma. After 6 years of disease-free state, recurrence occurred in the rectosigmoid colon. Seven cycles of EMACO chemotherapy was administered, and the human chorionic gonadotropin level was normalized. Three months after the chemotherapy, the rectosigmoid colon metastasis progressed. Low anterior resection with lymphadenectomy up to the level of the inferior mesenteric artery was conducted. After the operation, the human chorionic gonadotropin level decreased to within the normal range. There has been no evidence of disease for 13 months since the operation. Local resection of metastases seems to play a significant role in curing the disease in a small subset of patients.
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Affiliation(s)
- Ju Hyun Ryu
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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