Clinical Presentation, Treatment Outcomes, and Resistance-related Factors in South American Women with Low-risk Postmolar Gestational Trophoblastic Neoplasia / Apresentação clínica, resultados do tratamento e fatores relacionados à resistência em mulheres sul-americanas com neoplasia trofoblástica gestacional pós-molar de baixo risco

Abstract Objective There are few multinational studies on gestational trophoblastic neoplasia (GTN) treatment outcomes in South America. The purpose of this study was to assess the clinical presentation, treatment outcomes, and factors associated with chemoresistance in low-risk postmolar GTN treated with first-line single-agent chemotherapy in three South American centers. Methods Multicentric, historical cohort study including women with International Federation of Gynecology and Obstetrics (FIGO)-staged low-risk postmolar GTN attending centers in Argentina, Brazil, and Colombia between 1990 and 2014. Data were obtained on patient characteristics, disease presentation, and treatment response. Logistic regression was used to assess the relationship between clinical factors and resistance to first-line single-agent treatment. A multivariate analysis of the clinical factors significant in univariate analysis was performed. Results A total of 163 women with low-risk GTN were included in the analysis. The overall rate of complete response to first-line chemotherapy was 80% (130/163). The rates of complete response to methotrexate or actinomycin-D as first-line treatment, and actinomycin-D as second-line treatment postmethotrexate failure were 79% (125/157), 83% (⅚), and 70% (23/33), respectively. Switching to second-line treatment due to chemoresistance occurred in 20.2% of cases (33/163). The multivariate analysis demonstrated that patients with a 5 to 6 FIGO risk score were 4.2-fold more likely to develop resistance to first-line single-agent treatment (p= 0.019). Conclusion 1) At presentation, most women showed clinical characteristics favorable to a good outcome, 2) the overall rate of sustained complete remission after first-line single-agent treatment was comparable to that observed in developed countries, 3) a FIGO risk score of 5 or 6 is associated with development of resistance to first-line single-agent chemotherapy.

Resumo Objetivo Existem poucos estudos multinacionais sobre os resultados do tratamento da neoplasia trofoblástica gestacional (NTG) na América do Sul. O objetivo deste estudo foi avaliar a apresentação clínica, os resultados do tratamento e os fatores associados a casos de quimiorresistência em NTG pós-molar de baixo risco tratados com quimioterapia de agente único de primeira linha em três centros sul-americanos. Métodos Estudo multicêntrico de coorte histórica incluindo mulheres com NTG pós-molar de baixo risco com estadiamento International Federation of Gynecology and Obstetrics (FIGO) em centros de atendimento na Argentina, Brasil e Colômbia entre 1990 e 2014. Foram obtidos dados sobre as características do paciente, apresentação da doença e resposta ao tratamento. A regressão logística foi usada para avaliar a relação entre fatores clínicos e resistência ao tratamento de primeira linha com agente único. Foi realizada uma análise multivariada dos fatores clínicos significativos na análise univariada. Resultados Cento e sessenta e três mulheres com NTG de baixo risco foram incluídas na análise. A taxa global de resposta completa à quimioterapia de primeira linha foi de 80% (130/163). As taxas de resposta completa ao metotrexato ou actinomicina-D como tratamento de primeira linha e actinomicina-D como tratamento de segunda linha após falha do metotrexato foram 79% (125/157), 83% (⅚) e 70% (23/33), respectivamente. A mudança para o tratamento de segunda linha por quimiorresistência ocorreu em 20,2% dos casos (33/163). A análise multivariada demonstrou que pacientes com pontuação de risco FIGO de 5 a 6 foram 4,2 vezes mais propensos a desenvolver resistência ao tratamento com agente único de primeira linha (p= 0,019). Conclusão 1) Na apresentação, a maioria das mulheres demonstrou características clínicas favoráveis a um bom resultado, 2) a taxa geral de remissão completa sustentada após o tratamento de primeira linha com agente único foi comparável à de países desenvolvidos, 3) um escore de risco FIGO de 5 ou 6 está associado ao desenvolvimento de resistência à quimioterapia de agente único de primeira linha.

Clinical Presentation, Treatment Outcomes, and Resistance-related Factors in South American Women with Low-risk Postmolar Gestational Trophoblastic Neoplasia.

OBJECTIVE: There are few multinational studies on gestational trophoblastic neoplasia (GTN) treatment outcomes in South America. The purpose of this study was to assess the clinical presentation, treatment outcomes, and factors associated with chemoresistance in low-risk postmolar GTN treated with first-line single-agent chemotherapy in three South American centers. METHODS: Multicentric, historical cohort study including women with International Federation of Gynecology and Obstetrics (FIGO)-staged low-risk postmolar GTN attending centers in Argentina, Brazil, and Colombia between 1990 and 2014. Data were obtained on patient characteristics, disease presentation, and treatment response. Logistic regression was used to assess the relationship between clinical factors and resistance to first-line single-agent treatment. A multivariate analysis of the clinical factors significant in univariate analysis was performed. RESULTS: A total of 163 women with low-risk GTN were included in the analysis. The overall rate of complete response to first-line chemotherapy was 80% (130/163). The rates of complete response to methotrexate or actinomycin-D as first-line treatment, and actinomycin-D as second-line treatment postmethotrexate failure were 79% (125/157), 83% (⅚), and 70% (23/33), respectively. Switching to second-line treatment due to chemoresistance occurred in 20.2% of cases (33/163). The multivariate analysis demonstrated that patients with a 5 to 6 FIGO risk score were 4.2-fold more likely to develop resistance to first-line single-agent treatment (p = 0.019). CONCLUSION: 1) At presentation, most women showed clinical characteristics favorable to a good outcome, 2) the overall rate of sustained complete remission after first-line single-agent treatment was comparable to that observed in developed countries, 3) a FIGO risk score of 5 or 6 is associated with development of resistance to first-line single-agent chemotherapy.

OBJETIVO: Existem poucos estudos multinacionais sobre os resultados do tratamento da neoplasia trofoblástica gestacional (NTG) na América do Sul. O objetivo deste estudo foi avaliar a apresentação clínica, os resultados do tratamento e os fatores associados a casos de quimiorresistência em NTG pós-molar de baixo risco tratados com quimioterapia de agente único de primeira linha em três centros sul-americanos. MéTODOS: Estudo multicêntrico de coorte histórica incluindo mulheres com NTG pós-molar de baixo risco com estadiamento International Federation of Gynecology and Obstetrics (FIGO) em centros de atendimento na Argentina, Brasil e Colômbia entre 1990 e 2014. Foram obtidos dados sobre as características do paciente, apresentação da doença e resposta ao tratamento. A regressão logística foi usada para avaliar a relação entre fatores clínicos e resistência ao tratamento de primeira linha com agente único. Foi realizada uma análise multivariada dos fatores clínicos significativos na análise univariada. RESULTADOS: Cento e sessenta e três mulheres com NTG de baixo risco foram incluídas na análise. A taxa global de resposta completa à quimioterapia de primeira linha foi de 80% (130/163). As taxas de resposta completa ao metotrexato ou actinomicina-D como tratamento de primeira linha e actinomicina-D como tratamento de segunda linha após falha do metotrexato foram 79% (125/157), 83% (⅚) e 70% (23/33), respectivamente. A mudança para o tratamento de segunda linha por quimiorresistência ocorreu em 20,2% dos casos (33/163). A análise multivariada demonstrou que pacientes com pontuação de risco FIGO de 5 a 6 foram 4,2 vezes mais propensos a desenvolver resistência ao tratamento com agente único de primeira linha (p = 0,019). CONCLUSãO: 1) Na apresentação, a maioria das mulheres demonstrou características clínicas favoráveis a um bom resultado, 2) a taxa geral de remissão completa sustentada após o tratamento de primeira linha com agente único foi comparável à de países desenvolvidos, 3) um escore de risco FIGO de 5 ou 6 está associado ao desenvolvimento de resistência à quimioterapia de agente único de primeira linha.

Outcomes in the management of high-risk gestational trophoblastic neoplasia in trophoblastic disease centers in South America.

BACKGROUND: South America has a higher incidence of gestational trophoblastic disease than North America or Europe, but whether this impacts chemotherapy outcomes is unclear. The purpose of this study was to evaluate outcomes among women with high-risk gestational trophoblastic neoplasia (GTN) treated at trophoblastic disease centers in developing South American countries. METHODS: This retrospective cohort study included patients with high-risk GTN treated in three trophoblastic disease centers in South America (Botucatu and Rio de Janeiro, Brazil, and Buenos Aires, Argentina) from January 1990 to December 2014. Data evaluated included demographics, clinical presentation, FIGO stage, WHO prognostic risk score, and treatment-related information. The primary treatment outcome was complete sustained remission by 18 months following completion of therapy or death. RESULTS: Among 1264 patients with GTN, 191 (15.1%) patients had high-risk GTN and 147 were eligible for the study. Complete sustained remission was ultimately achieved in 87.1% of cases overall, including 68.4% of ultra high-risk GTN (score ≥12). Early death (within 4 weeks of initiating therapy) was significantly associated with ultra high-risk GTN, occurring in 13.8% of these patients (p=0.003). By Cox's proportional hazards regression, factors most strongly related to death were non-molar antecedent pregnancy (RR 4.35, 95% CI 1.71 to 11.05), presence of liver, brain, or kidney metastases (RR 4.99, 95% CI 1.96 to 12.71), FIGO stage (RR 3.14, 95% CI 1.52 to 6.53), and an ultra-high-risk prognostic risk score (RR 7.86, 95% CI 2.99 to 20.71). Median follow-up after completion of chemotherapy was 4 years. Among patients followed to that timepoint, the probability of survival was 90% for patients with high-risk GTN (score 7-11) and 60% for patients with ultra-high-risk GTN (score ≥12). CONCLUSION: Trophoblastic disease centers in developing South American countries have achieved high remission rates in high-risk GTN, but early deaths remain an important problem, particularly in ultra-high-risk GTN.

Role of Capecitabine in the Management of Gestational Trophoblastic Neoplasia: A Drug for Two Settings.

OBJECTIVE: To evaluate the role of capecitabine in the management of gestational trophoblastic neoplasia (GTN). STUDY DESIGN: The medical records of 155 patients with GTN were reviewed. All patients were treated and followed at our center. RESULTS: All patients were scored and stratified with the FIGO 2000 staging and risk factor scoring system for gestational trophoblastic disease. In the low-risk group (118 patients), 4 selected patients received capecitabine as second line of treatment, with a 75% response rate and long-term disease-free survival, and 1 of those patients needed EMA/CO to achieve cure. The cure rate was 100%. In the high-risk group 37 patients were reviewed. Capecitabine was indicated after EMA/CO or EMA/PE failure in the second, third, or sixth line. Six patients received capecitabine, with a 50% response rate, and remain as long-term survivors. Two patients who progressed with capecitabine were cured with TP/TE and EMA/PE regimens. One patient was refractory to all lines of chemotherapy. CONCLUSION: The use of capecitabine avoids multi-ple drug schemes and further toxicity for patients with curative disease, where long-term effects of therapy should be considered a second target. Its convenient oral route of administration and efficacy make capecitabine a drug to be taken into account in future studies of patients with GTN showing progression to standard regimens. Its use as new regimen in these patients must be evaluated. A greater number of cases and ideally a randomized study is needed to confirm our observation.

Variabilidad de Receptores Hormonales y her2 post neoadyuvancia en cáncer de mama / Variability in Hormone Receptor and HER2 status after neoadjuvant chemotheraphy in breast cancer

La quimioterapia neoadyuvante es un pilar fundamental en el tratamiento del cáncer de mama localmente avanzado, y la medida en que modifica la expresión de los receptores hormonales y her2 es motivo de controversia. esta variabilidad tiene importantes consecuencias pronósticas y terapéuticas. Objetivo: Evaluar la variabilidad de los Receptores Hormonales y del her2/neu pre y post neoadyuvancia en pacientes tratadas en el Hospital General de Agudos Carlos G. Durand. Material y método: Estudio retrospectivo de las historias clínicas de las pacientes sometidas a quimioterapia neoadyuvante entre septiembre de 2010 y septiembre de 2014. Se obtuvieron datos de 32 pacientes (34 tumores, 2 de las pacientes presentaron cáncer de mama bilateral). Se evaluaron Receptores Hormonales y her2 en la punción biopsia Core y en la pieza quirúrgica, y se analizó su concordancia. Resultados: La concordancia observada entre la biopsia pre neoadyuvancia y el tumor residual fue para re del 14,8% (k=0,60), para rp del 25,9% (k=0,33), para rh tomados en conjunto del 18,5% (k=0,35) y para her2 del 7,4% (k=0,70). Conclusiones: En nuestra serie encontramos una concordancia buena para her2, moderada para re y débil para rp y rh entre las muestras pre y post neoadyuvancia. La variabilidad encontrada justifica el retesteo de los biomarcadores en la pieza quirúrgica...

Gestational trophoblastic disease: a 21-year review of the clinical experience at an Argentinean public hospital.

OBJECTIVE: To analyze the clinical trends of gestational trophoblastic disease (GTD) in a public hospital of Buenos Aires, Argentina. STUDY DESIGN: A review of the clinical records of 358 patients with a diagnosis of GTD admitted to Durand Trophoblastic Disease Center between 1990 and February 2011 was performed. Features of diagnosis, treatment and follow-up were analyzed. RESULTS: A total of 358 cases of GTD were reviewed. Hydatidiform mole was diagnosed in 340 patients; of those 223 (66%) experienced spontaneous remission after evacuation. Of the 135 patients with persistent gestational trophoblastic neoplasia (GTN), 99 (73%) had low-risk GTN, 32 (26%) had high-risk GTN and 4 had either placental site trophoblastic disease or epithelioid trophoblastic tumor. In the low-risk group the first-line treatment was methotrexate and the second-line treatment was actinomycin D, etoposide, cytoxan, and oncovin (EMA/CO), with a complete response rate of 100%. High-risk patients whose WHO prognostic scores were 7-13 were treated initially with EMA/CO. Patients whose scores were >13 were treated with EMA/PE, where platinum and etoposide replaced oncovin and cytoxan. Salvage therapy in patients with relapse or resistant disease were treated with a wide variety of chemotherapy regimens. The complete response rate was 98.2%. Compliance was 100%. Three patients died. In all cases the outcome was related with inadequate initial treatment. CONCLUSION: This protocol is in agreement with international consensus. It was useful, safe and feasible in our population. The compliance with international guidelines allows reach a successful treatment and follow-up in one Latin-American population.