High-risk Gestational Trophoblastic Neoplasia Research Articles

797P Impact of consolidation cycles in predicting recurrence in patients treated with EMA-CO for high-risk gestational trophoblastic neoplasia

797P Impact of consolidation cycles in predicting recurrence in patients treated with EMA-CO for high-risk gestational trophoblastic neoplasia

High-intensity focused ultrasound as a pretreatment combined with hysteroscopic resection for gestational trophoblastic neoplasia with chemotherapy intolerance: a case report

Background Due to resistance and intolerance to chemotherapy, localized lesion resection may be required in some patients with Gestational trophoblastic neoplasia (GTN), which may lead to massive bleeding. In this case report, we describe the successful use of high-intensity focused ultrasound (HIFU) as an effective pretreatment method for surgical procedure in a patient with GTN to reduce the perioperative risk and the impact on fertility. Case presentation A 26-year-old woman was diagnosed with high-risk GTN (FIGO Stage III: 12 prognostic scores) after a hydatidiform mole. The fifth chemotherapy cycle was interrupted due to severe chemotherapy toxicity. However, the uterine lesion was still present and the beta-human chorionic gonadotropin (β-hCG) level was not restored to normal. Therefore, ultrasound-guided HIFU was performed as a pretreatment method to shrink the lesion and prevent massive bleeding during localized lesion resection. The effectiveness of ablation was evaluated immediately using contrast-enhanced ultrasound and Color Flow Doppler ultrasonography. One month after HIFU treatment, the uterine lesion was completely resected under hysteroscopic surgery. During the surgery, HIFU was found to have shrunk the lesion and there was minimal bleeding (5 mL). The uterine cavity morphology and menstruation returned to normal after surgery. The patient has showed no signs of recurrence as of one-year follow-up. Conclusion Ultrasound-guided HIFU ablation may be a new choice for high-risk GTN patients with chemoresistance or chemo-intolerance. As a noninvasive pretreatment method, HIFU can shrink the uterine lesion, and reduce the risk of bleeding with no obvious effect on fertility.

Gestational Trophoblastic Neoplasia—A Retrospective Analysis of Patients Treated at a Tertiary Care Oncology Center in North India

Objectives The aim of this study was to do a retrospective analysis of patients of gestational trophoblastic neoplasia (GTN) treated at our center concerning their clinical features and treatment outcomes. Materials and Methods Patients diagnosed and treated from May 2018 to December 2021 were included. All relevant information pertaining to eligible patients was retrieved from the electronic medical records. Patients were risk-stratified based on the World Health Organization (WHO) risk scoring system with a score of seven and above being classified into the high-risk category. Patients were monitored for response by measuring β-human chorionic gonadotrophin (β-HCG) levels before each consecutive cycle. Statistical Analysis Appropriate statistical analysis was performed using SPSS version 26. Results Records of 39 eligible patients were analyzed for clinical features out of which 38 were eligible for response assessment. The median age of presentation was 28 years with the majority of patients (79.4%) diagnosed based on β-HCG levels and clinical history alone. The most common symptom was bleeding per vagina (64%), while the majority of antecedent pregnancies were abortions (59%).Of the 14 low-risk category patients, 12 received single-agent methotrexate/actinomycin D, while 2 received etoposide, methotrexate actinomycin D (EMACO) regimen. Overall response rates were 85.7% with the others responding to the second-line EMACO regimen. Five patients in this group had a WHO score of 5 or 6 and all of them responded to single-agent treatment. Among the 25 high-risk category patients, all received the EMACO regimen with high-dose methotrexate added to those with brain metastasis. The response rate was 87.5% with all the nonresponders having features of ultra-high risk of liver/brain metastasis and/or a WHO score of more than 12. While one nonresponder had expired despite treatment, the other two responded to the etoposide methotrexate and actinomycin D/ etoposide and cisplatin regimen. Conclusion Our results are in consonance with other reported studies. The subcategories of low-risk GTN with a WHO score of 5 and 6 and high-risk GTN with ultra-high-risk features deserve further research in the form of multicenter prospective studies.

Treatments and outcomes in high-risk gestational trophoblastic neoplasia: A systematic review and meta-analysis.

High-risk gestational trophoblastic neoplasia (GTN) is rare and treated with diverse approaches. Limited published institutional data has yet to be systematically reviewed. To compile global high-risk GTN (prognostic score ≥7) cohorts to summarise treatments and outcomes by disease characteristics and primary chemotherapy. MEDLINE, Embase, Scopus, ClinicalTrials.gov and Cochrane were searched through March 2021. Full-text manuscripts reporting mortality among ≥10 high-risk GTN patients. Binomial proportions were summed, and random-effects meta-analyses performed. From 1137 records, we included 35 studies, representing 20 countries. Among 2276 unique high-risk GTN patients, 99.7% received chemotherapy, 35.8% surgery and 4.9% radiation. Mortality was 10.9% (243/2236; meta-analysis: 10%, 95% confidence interval [CI] 7-12%) and likelihood of complete response to primary chemotherapy was 79.7% (1506/1890; meta-analysis: 78%, 95% CI: 74-83%). Across 24 reporting studies, modern preferred chemotherapy (EMA/CO or EMA/EP) was associated with lower mortality (overall: 8.8 versus 9.5%; comparative meta-analysis: 8.1 versus 12.4%, OR 0.42, 95% CI: 0.20-0.90%, 14 studies) and higher likelihood of complete response (overall: 76.6 versus 72.8%; comparative meta-analysis: 75.9 versus 60.7%, OR 2.98, 95% CI: 1.06-8.35%, 14 studies), though studies focused on non-preferred regimens reported comparable outcomes. Mortality was increased for ultra-high-risk disease (30 versus 7.5% high-risk; meta-analysis OR7.44, 95% CI: 4.29-12.9%) and disease following term delivery (20.8 versus 7.3% following molar pregnancy; meta-analysis OR2.64, 95% CI: 1.10-6.31%). Relapse rate estimates ranged from 3 to 6%. High-risk GTN is responsive to several chemotherapy regimens, with EMA/CO or EMA/EP associated with improved outcomes. Mortality is increased in patients with ultra-high-risk, relapsed and post-term pregnancy disease.

Discovery of the prognostic marker in the whole blood sample of gestational trophoblastic neoplasia beyond immunohistochemical tissue markers: mdm2

Gestational trophoblastic disease (GTD) is an abnormal trophoblastic proliferation disease that may show malignant progression. Despite reports on the clinical and laboratory parameters for the projection of GTD, there is still a lack of histopathologic or genetic prognostic markers for patients with higher risks of malignant progression and high-risk gestational trophoblastic neoplasia. The primary aim of this study was to identify a marker other than tissue markers for evaluating the progression potential of GTD to gestational trophoblastic neoplasia (GTN). The secondary aim was to determine the tissue marker capacity to detect the progression to neoplasia. The study design was a case-control. The data of 81 patients diagnosed with GTD and 23 control were assessed. Their detailed obstetric and gynecological history were recorded, and their whole blood sample was obtained for genetic evaluation of the mouse double minute 2 (mdm2) gene expression. We also evaluated the curettage specimens for p53, c-erythroblastic oncogene B-2 (c-erbB-2), and ki67 protein expression. The expression of p53 expression was significantly increased in GTD patients and significantly higher in the GTN progressing group than in the spontaneous remission group. Although blood mdm2 gene was significantly different between the low and high-risk GTN subgroups, its expression was not different between the GTD or GTN groups. Additionally, a significant increase in c-erbB-2 was observed in the GTN group. Mdm2 might be a promising blood prognostic factor throughout the course of GTD. p53 and c-erbB-2 might be used as predictive indicators for the early diagnosis of GTN progression. Altogether, these markers may help identify patients with high risks of malignant progression, guide earlier aggressive treatment and increase treatment outcomes.

Predicting Chemotherapy Resistance in Gestational Trophoblastic Neoplasia: Ratio of Neutrophils, Lymphocytes, Monocytes, and Platelets.

BACKGROUND Neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) have recently been used as inflammatory biomarkers for cancer patients. This study aims to determine the role of pretreatment NLR, LMR, and PLR in predicting chemoresistance in gestational trophoblastic neoplasia (GTN) patients. MATERIAL AND METHODS A total of 129 low-risk and high-risk GTN patients who had received first-line chemotherapy were enrolled in this historical cohort study. The pretreatment NLR, LMR, and PLR values were analyzed to predict the resistance to first-line chemotherapy in low-risk and high-risk GTN patients. RESULTS Chemoresistant patients had significantly higher NLR than chemosensitive patients in low-risk and high-risk GTN patients (P<0.05). In high-risk GTN, patients with lower LMR and higher PLR tended to have chemoresistance to first-line chemotherapy (P=0.008, P=0.001). Univariate analysis revealed that the NLR, LMR, and PLR cut-off points of 2.654, 3.8, and 192.174, respectively, were associated with chemoresistance in high-risk GTN (P=0.0001, P=0.011, P=0.0001). The combination of NLR, PLR, and FIGO score in high-risk GTN was the best combination among other combinations with cut-off value >17 (P=0.001). CONCLUSIONS Higher NLR, lower LMR, and higher PLR were associated with chemoresistance for high-risk GTN patients. Furthermore, NLR, LMR, and PLR can improve the accuracy of predicting resistance to first-line chemotherapy in high-risk GTN.

Risk Factors That Correlate with Resistance to First-Line Chemotherapy on High-risk Gestational Trophoblastic Neoplasia

BACKGROUND: Gestational trophoblastic neoplasia (GTN) is a condition arising from abnormal proliferation of the trophoblastic cells. GTN incidence in Indonesia, precisely in Hasan Sadikin General Hospital, as many as 730 cases are reported per year. GTN is generally highly sensitive to chemotherapy, and multiagent chemotherapy regimens are recommended for high-risk GTN. Multiagent chemotherapy regimens for GTN treatment at Hasan Sadikin General Hospital are EMCO, with no other literature study describing chemotherapy resistance with EMCO today. AIM: This study aimed to identify risk factors associated with first-line chemotherapy resistance at Hasan Sadikin General Hospital. METHODS: In this cross-sectional study, medical records of 81 patients with high-risk GTN presented in the period from January 2018 to June 2021 who received EMCO chemotherapy at Hasan Sadikin General Hospital were retrieved from the archives, and medical data were reviewed and analyzed. Bivariate analysis was performed using the Chi-square test with Fisher’s exact alternative, and multivariate analysis using the binary logistic regression test. p &lt; 0.05 was considered statistically significant. RESULTS: From 81 samples that received EMCO chemotherapy, 15 (18.5%) cases were resistant to EMCO, and 66 (81.5%) cases were responsive to EMCO. The risk factors associated with EMCO resistance were histopathological features and appropriate with EMCO chemotherapy interval (p &lt; 0.05). Variables of age, previous pregnancy, GTN stage, FIGO prognostic score, stage, beta-hCG level, and side effects of EMCO did not significantly correlate with resistance to EMCO (p &gt; 0.05). CONCLUSION: Histopathological features and appropriate chemotherapy intervals were associated with the incidence of resistance to EMCO in Hasan Sadikin General Hospital.

Prognostic Factors Associated with hCG Remission and Chemotherapy Resistance in Patients with High-Risk Gestational Trophoblastic Neoplasia

Prognostic Factors Associated with hCG Remission and Chemotherapy Resistance in Patients with High-Risk Gestational Trophoblastic Neoplasia

Role of Salvage Surgery in Gestational Trophoblastic Neoplasia: a Regional Cancer Centre Experience.

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 in7/19 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.

611P Clinical characteristics and outcomes in ultra high-risk gestational trophoblastic neoplasia: Experience from an Indian cancer center

Gestational trophoblastic neoplasia (GTN) patients with WHO risk score ≥13, as well as those with brain, liver, or extensive metastasis fall in the ultra high-risk group. Available data on these patients is limited. This study aims to assess the clinical characteristics and prognosis of this group.

Serum human chorionic gonadotropin ratios for the detection of etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine resistance in high-risk gestational trophoblastic neoplasia.

AimsThis 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.MethodsSeventy‐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.ResultsAmong 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.ConclusionsA 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.

Current Evidence on Immunotherapy for Gestational Trophoblastic Neoplasia (GTN).

Simple SummaryGestational trophoblastic neoplasia (GTN) is a rare tumor group that arises from the malignant transformation of placental tissue. Based on the evaluation of International Federation of Gynecology and Obstetrics (FIGO) anatomic staging and FIGO prognostic score, GTN is divided into low-, high-, and ultra-high-risk groups if the score obtained is less than or equal to 6, greater than 6 or greater than 12, respectively. The standard treatment is chemotherapy, using a single agent in low-risk disease and multiagent chemotherapy in high- and ultra-high-risk GTN. In chemoresistant forms of GTN, the use of immune checkpoint inhibitors, such as anti-PD-1 or anti-PD-L1/2, could represent a new therapeutic strategy. In this study, we evaluate the available evidence on immune checkpoint inhibitors for GTN treatment.Background: Gestational trophoblastic disease includes a rare group of benign and malignant tumors derived from abnormal trophoblastic proliferation. Malignant forms are called gestational trophoblastic neoplasia (GTN) and include invasive mole, choriocarcinoma, placental site trophoblastic tumor and epithelioid trophoblastic tumor. Standard treatment of GTN is chemotherapy. The regimen of choice mainly depends on the FIGO prognostic score. Low-risk and high-risk GTN is treated with single-agent or multiagent chemotherapy, respectively. In the case of chemoresistance, immunotherapy may represent a new therapeutic strategy. Methods: Literature obtained from searches on PubMed concerning GTN and immunotherapy was reviewed. Results: Programmed cell death 1 (PD-1) and its ligands (PD-L1/2) are expressed in GTN. Published data on PD-1/PD-L1 inhibitors alone in GTN were available for 51 patients. Pembrolizumab is an anti-PD-1 inhibitor used in chemoresistant forms of GTN. In the TROPHIMMUN trial, Avelumab, a monoclonal antibody inhibiting PD-L1, showed promising results only in patients with GTN resistant to monochemotherapy. Conversely, in patients with resistance to multiagent chemotherapy, treatment with Avelumab was discontinued due to severe toxicity and disease progression. The association of Camrelizumab and Apatinib could represent a different treatment for forms of GTN refractory to polychemotherapy or for relapses. Conclusions: Anti-PD-1 or anti-PD-L1 might represent an important new treatment strategy for the management of chemoresistant/refractory GTN.

Efficacies of FAEV and EMA/CO regimens as primary treatment for gestational trophoblastic neoplasia.

Guidelines recommend etoposide, methotrexate, actinomycin D (EMA)/cyclophosphamide, vincristine (CO) as first-line treatment for high-risk gestational trophoblastic neoplasia (GTN). However, the floxuridine, actinomycin D, etoposide and vincristine (FAEV) regimen is commonly used to treat these patients in China. We conducted a randomised controlled trial to compare the efficacies and toxicities of FAEV and EMA/CO. Ninety-four patients with GTN were enrolled between May 2015 and April 2019 and randomly assigned to the FAEV or EMA/CO regimen. The rates of complete remission and relapse and the toxicities were compared in August 2021. Five patients were excluded from the analysis. There were 46 patients in the FAEV group and 43 patients in the EMA/CO group. The complete remission rates following primary treatment were 89.1% and 79.1% (P = 0.193), respectively. The relapse rates were 8.7% and 9.3% (P = 0.604). The apparent incidences of grade 4 myelosuppression were 60.9% and 32.6% (P = 0.008), respectively; however, they became both 32.6% (P = 0.996) after granulocyte colony-stimulating factor support. Other adverse reactions were similar in the two groups. No patient died of disease. FAEV has comparable efficacy and toxicity to EMA/CO as the primary treatment for high-risk GTN, and may thus be another first-line choice of chemotherapy. chictr.org.cn: ChiCTR1800017423.

Role of Emergency Surgery for Fatal Complications of Gestational Trophoblastic Neoplasia: A Single-Center Experience.

PurposeHigh-risk gestational trophoblastic neoplasia (GTN) can lead to fatal complications; however, few reports have assessed emergency surgery as a treatment option for such complications. Thus, this study aimed to analyze the clinical features and prognosis of patients with GTN who underwent emergency surgery.Patients and MethodsThirteen patients with high-risk or ultra-high-risk GTN who underwent emergency surgery for fatal complications in the First Affiliated Hospital of Zhejiang University, School of Medicine from 2013 to 2020 were analyzed, and their medical records were reviewed. The patients’ characteristics and treatment were evaluated with respect to outcomes.ResultsThirteen patients with GTN who underwent 15 emergency surgical procedures were identified in our center. The mean International Federation of Gynecology and Obstetrics score of these patients was 14.8 (range, 11–19). Of the 13 patients, six underwent brain surgeries, such as tumor resection (n = 5) and conservative surgery (n = 1). All the patients received multi-agent chemotherapy after emergency surgery, and the mean time from emergency surgery to subsequent chemotherapy was 12.7 days. Of the 13 patients, 10 (77%) were cured and disease-free, with a follow-up period ranging from 3 months to 8 years. All the patients (n = 6) who underwent emergency brain surgery survived and achieved complete remission.ConclusionFor patients with high-risk GTN with fatal complications, especially brain lesions, emergency surgery combined with subsequent chemotherapy may provide a favorable prognosis.

A Review of Current Management of Placental Site Trophoblastic Tumor and Epithelioid Trophoblastic Tumor.

Placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT) are rare forms of gestational trophoblastic neoplasia (GTN). These tumors differ from choriocarcinoma as they are monophasic, have slower growth rates, have lower β-hCG concentrations, and are more chemoresistant. Placental site trophoblastic tumor and ETT can be misdiagnosed, leading to inappropriate management.. The aim of this study was to review the pathogenesis, presentation, pathologic findings, and treatment for PSTT and ETT. A comprehensive literature review was performed identifying relevant research and review articles. Relevant textbook chapters and guidelines were also reviewed. Placental site trophoblastic tumor and ETT can present months to years after any antecedent pregnancy event with abnormal uterine bleeding and an elevated β-hCG. Tumors are typically confined to the uterus and secrete lower levels of β-hCG compared with other GTNs. The International Federation of Gynecology and Obstetrics prognostic scoring system does not correlate well with prognosis. These lesions can be misdiagnosed as smooth muscle tumors, metastatic melanoma, and cervical squamous cell carcinoma. However, they can be distinguished by their unique histologic and immunophenotypic features. Surgery is the mainstay of treatment for early-stage PSTT and ETT. For patients with advanced disease or for those with poor prognostic indicators, such as an antecedent pregnancy interval of greater than 48 months, a multimodal treatment paradigm of surgery and chemotherapy using a high-risk GTN platinum-etoposide containing regimen is recommended. Placental site trophoblastic tumor and ETT should be considered in the differential diagnosis in a reproductive age patient presenting with abnormal uterine bleeding and an elevated β-hCG after any antecedent pregnancy event.

Epidemiologic study on gestational trophoblastic diseases in Japan.

This study aims to estimate the population-based incidence of gestational trophoblastic diseases (GTDs) and to identify the characteristics of gestational trophoblastic neoplasia (GTN) in Japan. The annual number of GTD and live births from 1974 to 2018 were used to estimate the incidence of GTD. The data of 1,574 GTN cases from 1999 to 2018 were analyzed to identify the characteristics of low-risk GTN, high-risk GTN, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT). The incidence of hydatidiform mole was 2.02 per 1,000 live births on average which decreased from 1974 to 2008 and increased from 2009 to 2018. The incidence of low-risk GTN, high-risk GTN, PSTT, and ETT was 15.3, 3.5, 0.3, and 0.07 per 100,000 live births, respectively. The estimated incidence of post-molar GTN was 9.8% of molar patients. High-risk GTN was diagnosed more pathologically, had more various kinds of antecedent pregnancies, and had longer intervals after the antecedent pregnancy compared to low-risk GTN. Furthermore, 8.2% of high-risk GTN occurred after the subsequent non-molar pregnancy of hydatidiform mole. The cumulative percentage of developing high-risk GTN after hydatidiform mole reached 89.3% at the 60th month. The incidence of hydatidiform mole, low-risk GTN, high-risk GTN was 2.02 per 1,000 live births, 15.3 per 100,000 live births, and 3.5 per 100,000 live births, respectively. High-risk GTN was diagnosed more pathologically and later after the antecedent pregnancy than low-risk GTN. Following molar patients for five years is needed to improve the mortality of malignant GTN.

Evaluation of Incidence, Risk Factors, Diagnosis and Management of Gestational Trophoblastic Neoplasia: A Retrospective Study

Introduction: Detection of any definite established pattern in aetiological factors can help identify high risk groups among vesicular mole patients, so that the development of Gestational Trophoblastic Neoplasia (GTN) can be anticipated to avoid delay in management of this disease with almost 100% cure rate. Aim: To determine the incidence of GTN, various factors associated with the condition, and any difference in risk factors between low risk and high risk disease and to evaluate the efficacy of the different treatment protocols used. Materials and Methods: A retrospective descriptive study done in the Department of Obstetrics and Gynaecology in a tertiary level hospital in South India which included 100 cases of GTN who were registered in the Gestational Trophoblastic Disease (GTD) clinic for a period of ten years from January 2002 to December 2011. Data analysis was done from January 2020 to August 2020 The hospital incidence of GTN and proportion of GTN among vesicular mole was calculated. The different sociodemographic factors, clinical features and hormonal profile of all cases of GTN were studied in detail. Results: The incidence of GTN was 0.76 per 1000 deliveries. The proportion of GTN among molar pregnancy was 10.7%. Uterine size greater than period of amenorrhoea, bilateral theca leutin cysts especially with size &gt;6 cm and pre-evacuation Human Chorionic Gonadotropin (hCG) &gt;100,000 mIU/mL was associated with development of GTN. GTN was found more in those with complete mole and that was around 71%. Around 81% had low risk GTN and 19% had high risk GTN. Major indication for starting chemotherapy was rising βhCG (72%). Presence of theca lutein cysts and uterine size greater than period of amenorrhoea were statistically significant risk factors for high risk GTN (p=0.022 and p&lt;0.001, respectively). Conclusion: Identification of risk factors helps in early recognition of GTN and improves the overall outcome. The choice of chemotherapy depends on risk categorisation based on International Federation of Gynaecology and Obstetrics (FIGO) scoring system. Single agent for low risk and combination chemotherapy for high risk group is often sufficient.

Two cases of uneventful pregnancies following the treatment of choriocarcinoma

Introduction. Gestational trophoblastic disease represents a distinguished group of disorders that are derived from placental trophoblastic tissue aroused from abnormal fertilization. Choriocarcinoma is a malignant human chorionic gonadotropin-producing epithelial tumor arising from villous trophoblast. The choice of the chemotherapy regime is based on the International Federation of Gynecology and Obstetrics stage and World Health Organization score of the disease. The objective of this article is to show that successful pregnancy is possible even after treatment of highrisk gestational trophoblastic neoplasia. Outlines of cases. We present two successfully treated patients who achieved pregnancy and delivered healthy babies in term. Conclusion. Gestational trophoblastic neoplasia has become the most curable malignant disease since the introduction of chemotherapy, which is effective and well-tolerated, and allows fertility preservation in high-proportion of women.

A novel alternative to cytotoxic chemotherapy for gestational trophoblastic disease.

Gestational trophoblastic neoplasia refers to malignancies derived from placental trophoblasts. The principal treatment is chemotherapy. The WHO and International Federation of Obstetrics and Gynecology (FIGO) prognostic scoring system is used to triage patients as low risk (appropriate for using single drug-regimens) or high risk (requiring multidrug-regimens) based on a-priori risk chemotherapy resistance. 1 Ngan HYS Seckl MJ Berkowitz RS et al. Update on the diagnosis and management of gestational trophoblastic disease. Int J Gynaecol Obstet. 2018; 143: 79-85 Crossref PubMed Scopus (160) Google Scholar For patients with persistent or progressive disease, salvage therapies remain quite effective, such that 99% of patients with low-risk disease and 70% of those with high-risk disease are reported to eventually develop durable complete remission. 2 Freitas F Braga A Viggiano M et al. Gestational trophoblastic neoplasia lethality among Brazilian women: a retrospective national cohort study. Gynecol Oncol. 2020; 158: 452-459 Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar Nonetheless, there remains a fraction of patients who still either die due to disease or have significant morbidity from receiving multiple lines of chemotherapy. Camrelizumab plus apatinib in patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia (CAP 01): a single-arm, open-label, phase 2 trialCamrelizumab 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. Full-Text PDF

Diagnosis and management of gestational trophoblastic disease: 2021 update.

Gestational trophoblastic disease (GTD) arises from abnormal placenta and is composed of a spectrum of premalignant to malignant disorders. Changes in epidemiology of GTD have been noted in various countries. In addition to histology, molecular genetic studies can help in the diagnostic pathway. Earlier detection of molar pregnancy by ultrasound has resulted in changes in clinical presentation and decreased morbidity from uterine evacuation. Follow‐up with human chorionic gonadotropin (hCG) is essential for early diagnosis of gestational trophoblastic neoplasia (GTN). The duration of hCG monitoring varies depending on histological type and regression rate. Low‐risk GTN (FIGO Stages I–III: score <7) is treated with single‐agent chemotherapy but may require additional agents; although scores 5–6 are associated with more drug resistance, overall survival approaches 100%. High‐risk GTN (FIGO Stages II–III: score ≥7 and Stage IV) is treated with multiagent chemotherapy, with or without adjuvant surgery for excision of resistant foci of disease or radiotherapy for brain metastases, achieving a survival rate of approximately 90%. Gentle induction chemotherapy helps reduce early deaths in patients with extensive tumor burden, but late mortality still occurs from recurrent treatment‐resistant tumors.