Clinical characteristics and prognosis of ultra high-risk gestational trophoblastic neoplasia patients: A retrospective cohort study
Introduction
Gestational trophoblastic neoplasia (GTN) refers to a group of uncommon malignant gynecological tumors caused by abnormal proliferation of trophoblastic tissues. GTN consists of invasive mole, choriocarcinoma, placental site trophoblastic tumor (PSTT) and epitheliloid trophoblastic tumor (ETT). The International Federation of Gynecology and Obstetrics (FIGO) scoring system is used to predict prognosis of GTN patients. Low-risk GTN patients (FIGO score < 7) should be treated with single-agent. High-risk GTN patients (FIGO score ≥ 7) require multiagent chemotherapy [1]. The EMA/CO regimen (etoposide, methotrexate, actinomycin-D, cyclophosphamide, vincristine) is commonly used worldwide [2]. The overall survival (OS) rate almost approaches 100% in low-risk patients (FIGO score < 7), whereas high-risk patients (FIGO score ≥ 7) can achieve a survival rate of 80–90% [3]. However, the survival rate of high-risk patients is misleading because the prognosis of these patients is definitely different. Bolze showed that the patients with FIGO score ≥ 13 had an obviously higher 5-year death rate than the patients with FIGO score < 13 (38.4% and 4.9%, P < 0.001) [4]. Other literatures also suggested that FIGO score ≥ 12 is an independent risk factor for poor prognosis [5], [6], [7], [8]. Therefore, FIGO Cancer Report 2015 divided the GTN patients with FIGO score ≥ 7 into high-risk subgroup (7 ≤ FIGO score < 12) and ultra high-risk subgroup (FIGO score ≥ 12) [9]. However, limited information is available about ultra high-risk subgroup so far because of its rarity [10], [11].
Herein we conducted the retrospective study to analyze the clinical characteristics, the treatment efficiency and the prognosis of the ultra high-risk GTN patients treated at Peking Union Medical College Hospital (PUMCH). To the best of our knowledge, this study contained the largest sample size to date, and we revealed the prognostic risk factors of ultra high-risk GTN patients for the first time.
Section snippets
Patients
Between January 2002 and December 2015, a total of 1776 patients were diagnosed with GTN at Peking Union Medical College Hospital (PUMCH). Among these patients, 143 (8.1%) patients were defined as ultra high-risk patients with FIGO score ≥ 12, of whom 41 patients received initial chemotherapy in our hospital while the other 102 patients were transferred from other hospitals with a history of failed chemotherapy. The database and medical records were reviewed to extract the basic information,
Clinical characteristics
All of the 143 ultra high-risk GTN patients in this study were diagnosed with choriocarcinoma. The majority of the patients were diagnosed with choriocarcinoma based on clinical findings, including detailed medical history, physical examination, serum β-hCG levels, transvaginal or transabdominal sonography, chest X-ray or computed tomography (CT). Pathological evidence was not necessary for the diagnosis of choriocarcinoma. Only a minority of these patients had pathological evidences before the
Discussion
In our study, the ultra high-risk GTN accounted for 8.1% of the entire GTN cohort. Of the 143 ultra high-risk GTN patients, only 4 (2.8%) patients were at stage I, 3 (2.1%) patients were at stage II, and the other 136 (95.1%) patients were all at stage III or IV. Although the 7 cases were just at Stage I or II, six patients of them had previous chemotherapy failures and all of them had uterine lesions. Therefore, FAEV chemotherapy was given to them and six of them underwent hysterectomy or
Conflict of interest statement
We declare that we have no financial interest, commercial interest and/or other relationships with other people or organizations that can inappropriately influence our work.
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2022, European Journal of CancerCitation Excerpt :Low-risk patients are treated with single-agent chemotherapy, whereas high-risk patients receive multi-agent chemotherapy to prevent resistance. With the development of effective chemotherapy regimens, GTN has become highly curable, with remission rates of up to 100% for low-risk GTNs [4], 94–95% for high-risk GTNs including ultra-high-risk cases, and 65% for ultra-high-risk GTNs [5,6]. In the current FIGO 2000 prognostic scoring system, prognostic factors of GTN include antecedent pregnancy, pre-treatment β-human chorionic gonadotropin (β-hCG), the interval from the index pregnancy, tumour size, site of metastases, number of metastases identified, and history of chemotherapy failure [2,7].
Camrelizumab plus apatinib in patients with high-risk chemorefractory or relapsed gestational trophoblastic neoplasia (CAP 01): a single-arm, open-label, phase 2 trial
2021, The Lancet OncologyCitation Excerpt :Patients with low-risk gestational trophoblastic neoplasia are usually treated with a single-drug chemotherapy regimen; multidrug chemotherapy regimens are used for high-risk gestational trophoblastic neoplasia.1,3 Although complete response is reported in more than 90% of patients with high-risk disease after primary chemotherapy (eg, etoposide, methotrexate, and dactinomycin [EMA] plus cyclophosphamide and vincristine [CO], EMA plus etoposide and cisplatin [EP], and floxuridine, dactinomycin, etoposide, and vincristine [FAEV] regimens),1,3,4 about 5% of patients with high-risk disease patients develop chemorefractory disease, or have multiple relapses and die of disease progression.4–6 Brain and liver metastases,7,8 multidrug chemotherapy-resistant tumours,9 and infrequent pathological types (placental site trophoblastic tumour and epithelioid trophoblastic tumour)10 are adverse features that predict poorer outcomes.
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2021, Best Practice and Research: Clinical Obstetrics and GynaecologyCitation Excerpt :The score is associated with the risk of developing chemoresistance to single-agent chemotherapy, and thus guides the choice of first-line chemotherapy [9,10]. Although patients with high-risk GTN can achieve a survival rate of 80–90%, it is observed that patients with a FIGO score ≥12 have a higher 5-year death rate, being an independent risk factor for poor prognosis and therefore classified as “ultra” high-risk GTN [16–18]. Of note, the WHO Prognostic Scoring System is not applicable to patients with PSTT or ETT [9,10].