Treatment of gestational trophoblastic disease in the 2020s
James J Clark1, Susanna Slater, Michael J Seckl
1Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, UK.
Purpose Of Review:
This review demonstrates the evidence for new systemic anticancer treatments and how they integrate within conventional management for gestational trophoblastic neoplasia (GTN). We present the evidence on atypical placental site nodules, and how they incorporate within the GTN spectrum, as well as updates regarding GTN staging and follow-up.
Recent Findings:
First-line treatment for GTN still lies in conventional chemotherapy, although the introduction of anti-PD1/PD-L1 immune checkpoint inhibitors has shown significant promise in management of relapsed disease, with responses reported in multiple relapsed choriocarcinomas as well as epithelioid trophoblastic tumours and placental site trophoblastic tumours (ETT/PSTT). Following completion of treatment, ETT/PSTT still require life-long surveillance but for other GTN, no recurrences have been detected after 7 years.
Summary:
Checkpoint inhibitors are likely to play an increasing role in the future management of GTN management. Further refinement of prognostic factors to identify those most at risk of GTN recurrence is warranted so that surveillance can be focussed on those most at risk, whilst minimizing unnecessary intervention for those at lower risk.
Insights
New systemic treatments, including immune checkpoint inhibitors, show promise for relapsed gestational trophoblastic neoplasia (GTN). Refined prognostic factors are needed to optimize surveillance for GTN patients, balancing risk and intervention.
Area of Science:
- Gynecologic Oncology
- Medical Oncology
- Immunotherapy
Background:
- Gestational trophoblastic neoplasia (GTN) encompasses a spectrum of placental-derived tumors.
- Conventional chemotherapy remains a cornerstone for first-line GTN treatment.
- Atypical placental site nodules require specific consideration within the GTN classification.
Purpose of the Study:
- To review emerging systemic anticancer treatments for GTN.
- To evaluate the integration of novel therapies with established GTN management protocols.
- To provide updates on GTN staging, follow-up, and the role of atypical lesions.
Main Methods:
- Systematic review of evidence on new systemic anticancer treatments for GTN.
- Analysis of clinical trial data and case reports on immune checkpoint inhibitors in relapsed GTN.
- Evaluation of current GTN staging and follow-up guidelines.
Main Results:
- Anti-PD1/PD-L1 immune checkpoint inhibitors demonstrate significant promise in managing relapsed GTN, including choriocarcinoma, epithelioid trophoblastic tumors, and placental site trophoblastic tumors.
- Conventional chemotherapy remains the standard first-line treatment for GTN.
- Epithelioid trophoblastic tumors and placental site trophoblastic tumors necessitate lifelong surveillance post-treatment, while other GTN types show no recurrence after seven years.
Conclusions:
- Immune checkpoint inhibitors are poised to become increasingly important in future GTN management.
- Further research is needed to refine prognostic factors for identifying patients at high risk of GTN recurrence.
- Optimizing surveillance strategies will help focus interventions on high-risk individuals while minimizing unnecessary treatments for those at lower risk.
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