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Singh K, Rollins S, Ireson J. Gestational Trophoblastic Disease: Best Practice Nursing Guidelines. Gynecol Obstet Invest 2023; 89:247-253. [PMID: 37040714 DOI: 10.1159/000530570] [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: 12/14/2022] [Accepted: 03/29/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Clinical outcomes in gestational trophoblastic disease (GTD) are generally excellent, but GTD is a rare and complex condition that requires specialist information and support to offer a gold standard of care. Across Europe, specialist nurses and/or midwives are increasingly common in the GTD multidisciplinary team to work alongside medical professionals in a holistic model of care; however, the role is sometimes non-existent or can vary significantly between GTD centres. OBJECTIVES The aim of the European Organisation for Treatment of Trophoblastic Diseases' (EOTTD) is to harmonise best practice in Europe. To provide a basis for the European standardisation of best practice nursing care in GTD, a group of European GTD nurses/midwives composed guidelines for minimal requirements and optimal nursing care of GTD patients. METHODS Members of the EOTTD member countries with nursing representation attended multiple workshops, both virtual and in person, and guidelines were created by consensus and evidence where available. OUTCOME 16 nurses and 1 midwife from 4 countries (England, Ireland, Sweden, and the Netherlands) contributed. The group created flow diagrams for treatment and screening patients, showing minimum and best practice nursing care for patients with GTD. CONCLUSION Despite the many different models of care and resources available to GTD services, this consensus working group has provided a set of guidelines to drive forward a patient focused holistic model of care for GTD patients. This is an original paper, whereby no such guidelines in GTD nursing have been developed before. The implementation of guidelines will encourage other health care professionals to improve the provision of patient care.
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Affiliation(s)
- Kam Singh
- Sheffield Trophoblastic Disease Centre, Weston Park Hospital, Sheffield, UK
| | - Sarah Rollins
- Sheffield Trophoblastic Disease Centre, Weston Park Hospital, Sheffield, UK
| | - Jane Ireson
- Sheffield Trophoblastic Disease Centre, Weston Park Hospital, Sheffield, UK
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Singh K, Gillett S, Ireson J, Hills A, Tidy JA, Coleman RE, Hancock BW, Winter MC. M-EA (methotrexate, etoposide, dactinomycin) and EMA-CO (methotrexate, etoposide, dactinomycin / cyclophosphamide, vincristine) regimens as first-line treatment of high-risk gestational trophoblastic neoplasia. Int J Cancer 2020; 148:2335-2344. [PMID: 33210289 DOI: 10.1002/ijc.33403] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/05/2020] [Accepted: 10/26/2020] [Indexed: 11/06/2022]
Abstract
High-risk gestational trophoblastic neoplasia (GTN) is highly chemosensitive with an excellent prognosis with treatment. Historically in the United Kingdom, the high-risk regimens used have been M-EA (methotrexate, etoposide, dactinomycin) (Sheffield) and EMA-CO (methotrexate, etoposide, dactinomycin / cyclophosphamide, vincristine) (Charing Cross, London) with prior published data suggesting no difference in survival between these. Our Sheffield treatment policy changed in 2014, switching from M-EA to EMA-CO, aiming to reduce time in hospital, and harmonise UK practice. We aimed to report the toxicities, response rates and survival outcomes for 79 patients with high-risk GTN treated in the first-line setting with either M-EA (n = 59) or EMA-CO (n = 20) from 1998 to 2018. Median duration of treatment was similar (M-EA, 17.3 weeks (IQR 13.9-22.6) and 17.6 weeks (IQR 13.4-20.7) with EMA-CO. For M-EA, overall human chorionic gonadotrophin (hCG) complete response (CR) rate was 84.7% (n = 50/59). Two patients died of drug-resistant disease after several lines of multiagent chemotherapy; overall survival is 96.6% (median follow-up 10.4 years). For EMA-CO, overall hCG CR rate was 70%, overall survival is 100% (median follow-up 4 years). In our experience, patients treated with EMA-CO experienced an apparent increased incidence of neutropenia, non-neutropenic Grade 3-4 infection, peripheral neuropathy and more treatment delays and nights in hospital. Granulocyte-colony stimulating factor, after both EMA and CO arms, titrated to baseline neutrophil count improved the toxicity profile. Both treatment regimens are associated with excellent prognosis; selection of regimen may be further guided by individual patients' personal, social and family circumstances. There is further rationale to explore whether these regimens can be refined, such as 2-weekly EMA, to optimise patient experience and reduce toxicity while maintaining efficacy.
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Affiliation(s)
- Kam Singh
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Sarah Gillett
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Jane Ireson
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Anne Hills
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - John A Tidy
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Robert E Coleman
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Barry W Hancock
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
| | - Matthew C Winter
- Trophoblastic Disease Centre, Weston Park Cancer Centre, Sheffield, UK
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Braga A, Mora P, de Melo AC, Nogueira-Rodrigues A, Amim-Junior J, Rezende-Filho J, Seckl MJ. Challenges in the diagnosis and treatment of gestational trophoblastic neoplasia worldwide. World J Clin Oncol 2019; 10:28-37. [PMID: 30815369 PMCID: PMC6390119 DOI: 10.5306/wjco.v10.i2.28] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/12/2018] [Accepted: 01/01/2019] [Indexed: 02/06/2023] Open
Abstract
Gestational trophoblastic neoplasia (GTN) is a rare tumor that originates from pregnancy that includes invasive mole, choriocarcinoma (CCA), placental site trophoblastic tumor and epithelioid trophoblastic tumor (PSTT/ETT). GTN presents different degrees of proliferation, invasion and dissemination, but, if treated in reference centers, has high cure rates, even in multi-metastatic cases. The diagnosis of GTN following a hydatidiform molar pregnancy is made according to the International Federation of Gynecology and Obstetrics (FIGO) 2000 criteria: four or more plateaued human chorionic gonadotropin (hCG) concentrations over three weeks; rise in hCG for three consecutive weekly measurements over at least a period of 2 weeks or more; and an elevated but falling hCG concentrations six or more months after molar evacuation. However, the latter reason for treatment is no longer used by many centers. In addition, GTN is diagnosed with a pathological diagnosis of CCA or PSTT/ETT. For staging after a molar pregnancy, FIGO recommends pelvic-transvaginal Doppler ultrasound and chest X-ray. In cases of pulmonary metastases with more than 1 cm, the screening should be complemented with chest computed tomography and brain magnetic resonance image. Single agent chemotherapy, usually Methotrexate (MTX) or Actinomycin-D (Act-D), can cure about 70% of patients with FIGO/World Health Organization (WHO) prognosis risk score ≤ 6 (low risk), reserving multiple agent chemotherapy, such as EMA/CO (Etoposide, MTX, Act-D, Cyclophosphamide and Oncovin) for cases with FIGO/WHO prognosis risk score ≥ 7 (high risk) that is often metastatic. Best overall cure rates for low and high risk disease is close to 100% and > 95%, respectively. The management of PSTT/ETT differs and cure rates tend to be a bit lower. The early diagnosis of this disease and the appropriate treatment avoid maternal death, allow the healing and maintenance of the reproductive potential of these women.
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Affiliation(s)
- Antonio Braga
- Postgraduate Program of Medical Sciences, Fluminense Federal University, Niterói 24033-900, Brazil
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Paulo Mora
- Postgraduate Program of Medical Sciences, Fluminense Federal University, Niterói 24033-900, Brazil
- Brazilian National Cancer, Hospital do Câncer 2, Rio de Janeiro 20220-410, Brazil
| | | | - Angélica Nogueira-Rodrigues
- Department of Internal Medicine, Faculty of Medicine, Minas Gerais Federal University, Belo Horizonte 30130-100, Brazil
| | - Joffre Amim-Junior
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Jorge Rezende-Filho
- Department of Gynecology and Obstetrics, Faculty of Medicine, Rio de Janeiro Federal University, Postgraduate Program of Perinatal Health, Maternity School, Rio de Janeiro 22240-000, Brazil
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College London, London W6 8RF, United Kingdom
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Zhao P, Wang S, Zhang X, Lu W. A Novel Prediction Model for Postmolar Gestational Trophoblastic Neoplasia and Comparison With Existing Models. Int J Gynecol Cancer 2017; 27:1028-1034. [PMID: 28498254 DOI: 10.1097/igc.0000000000000976] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The aim of this study was to comparatively study a novel model and existing models of predicting postmolar gestational trophoblastic neoplasia (GTN). METHODS Two hundred twenty-two patients with complete hydatidiform moles were enrolled retrospectively. A natural regression was noted in 195 patients (spontaneous regression group), whereas the remaining 27 patients entered postmolar GTN (postmolar GTN group). The upper limits of the 95% confidence interval of human chorionic gonadotropin (hCG) values and hCG regression rates were calculated aggregately from the spontaneous regression group. The 4 prediction models (weekly hCG regression curve and weekly hCG regression rate curve reported by previous studies; daily hCG regression curve and daily hCG regression rate curve pioneered by us) were then plotted. The individual hCG curve of the postmolar GTN group was plotted and compared with the prediction models, respectively. The individual hCG curve superimposing the prediction curve was considered showing an elevated risk of GTN. RESULTS All patients with postmolar GTN were preidentified by daily hCG regression rate curve. The other 3 prediction models had a considerable rate of failure in identification. Mean diagnosis time of daily hCG regression rate curve was significantly lower (P = 0.008), with an average of 15.3 days gained compared with International Federation of Gynecology and Obstetrics criteria. Cochran Q test showed that daily hCG regression rate curve produced a significantly better performance in predicting postmolar GTN than weekly hCG regression curve (P = 0.01). CONCLUSIONS Our data showed that daily hCG regression rate curve gives a better prediction of postmolar GTN and might potentially enhance the monitoring of patients with molar pregnancy, especially those who could not adhere to International Federation of Gynecology and Obstetrics protocols. However, this preliminary research should not change current clinical practice until further validation is carried out.
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Affiliation(s)
- Peng Zhao
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Singh K, Warnock C, Ireson J, Strickland S, Short D, Seckl M, Hancock B. Experiences of Women With Gestational Trophoblastic Neoplasia Treated With
High-Dose Chemotherapy and Stem Cell Transplantation: A Qualitative Study. Oncol Nurs Forum 2017. [DOI: 10.1188/17.onf.375-383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Couto S, Metello JL, Ramos S, Ferreira P, Ilgenfritz R, Sá e Melo P, Elgindy E. Gestational trophoblastic neoplasia after in vitro fertilization and embryo-transfer. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2016. [DOI: 10.1016/j.mefs.2015.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Darby S, Jolley I, Pennington S, Hancock BW. Does chest CT matter in the staging of GTN? Gynecol Oncol 2009; 112:155-60. [DOI: 10.1016/j.ygyno.2008.10.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 10/02/2008] [Accepted: 10/07/2008] [Indexed: 01/28/2023]
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Lurain JR. Gestational Trophoblastic Neoplasia. Oncology 2007. [DOI: 10.1007/0-387-31056-8_51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Allen SD, Lim AK, Seckl MJ, Blunt DM, Mitchell AW. Radiology of gestational trophoblastic neoplasia. Clin Radiol 2006; 61:301-13. [PMID: 16546459 DOI: 10.1016/j.crad.2005.12.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2005] [Revised: 10/26/2005] [Accepted: 12/05/2005] [Indexed: 12/20/2022]
Abstract
Gestational trophoblastic neoplasia (GTN) encompasses a broad spectrum of placental lesions from the pre-malignant hydatidiform mole (complete and partial) through to the malignant invasive mole, choriocarcinoma and rare placental site trophoblastic tumour (PSTT). Ultrasound remains the radiological investigation of choice for initial diagnosis, and it can also predict invasive and recurrent disease. Magnetic resonance imaging is of invaluable use in assessing extra-uterine tumour spread, tumour vascularity, and overall staging. Positron emission tomography and computed tomography undoubtedly have a role in recurrent and metastatic disease, while angiography has a place in disease and complication management. This review will describe the relevant pathophysiology and natural history of GTN, and the use of imaging techniques in the diagnosis and management of these conditions.
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Affiliation(s)
- S D Allen
- Department of Radiology, Charing Cross Hospital, Hammersmith Hospitals NHS Trust, London, UK
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Powles T, Savage P, Short D, Young A, Pappin C, Seckl MJ. Residual lung lesions after completion of chemotherapy for gestational trophoblastic neoplasia: should we operate? Br J Cancer 2006; 94:51-4. [PMID: 16404359 PMCID: PMC2361065 DOI: 10.1038/sj.bjc.6602899] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The significance of residual lung metastasis from malignant gestational trophoblastic neoplasm (GTN) after the completion of chemotherapy is unknown. We currently do not advocate resection of these masses. Here, we investigate the outcome of these patients. Patients with residual lung abnormalities after the completion of treatment for GTN were compared to those who had a complete radiological resolution of the disease. None of the residual masses post-treatment were surgically removed. In all, 76 patients were identified. Overall 53 (70%) patients had no radiological abnormality on CXR or CT after completion of treatment. Eight (11%) patients had residual disease on CXR alone 15 patients had residual disease on CT (19%). During follow-up, two patients (2.6%) relapsed. One of these had had a complete radiological response post-treatment whereas the other had residual disease on CT. Patients with residual lung lesions after completing treatment for GTN do not appear to have an increased chance of relapse compared to those with no residual abnormality. We continue to recommend that these patients do not require pulmonary surgery for these lesions.
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Affiliation(s)
- T Powles
- Department of Health Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College London, Palace Rd, London W68RF, UK
| | - P Savage
- Department of Health Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College London, Palace Rd, London W68RF, UK
| | - D Short
- Department of Health Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College London, Palace Rd, London W68RF, UK
| | - A Young
- Department of Health Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College London, Palace Rd, London W68RF, UK
| | - C Pappin
- Department of Health Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College London, Palace Rd, London W68RF, UK
| | - M J Seckl
- Department of Health Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College London, Palace Rd, London W68RF, UK
- Department of Health Charing Cross Gestational Trophoblastic Disease Centre, Hammersmith Hospitals Campus of Imperial College London, Palace Rd, London W68RF, UK. E-mail:
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