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

Figures & data

Table 1 Clinical Characteristics of Gestational Trophoblastic Neoplasia Patients Suffering Emergency Surgery

Age Group
<40	11 (85%)
>40	2 (15%)
Antecedent pregnancy, n(%)
Mole	3 (23%)
Term	8 (62%)
Abortion	2 (15%)
Interval from last pregnancy, months
<4	4 (31%)
4–6	1 (8%)
7–12	2 (15%)
>12	6 (46%)
hCG level at diagnosis (IU/L)
1000–10,000	1 (8%)
10,000–100,000	1 (8%)
>100,000	11 (84%)
Site of metastases
Lung	12 (92%)
Spleen	2 (15%)
Kidney	4 (31%)
Gastrointestinal tract	6 (46%)
Liver	8 (62%)
Brain	7 (54%)
FIGO stage
I	1 (8%)
IV	12 (92%)
FIGO score, mean (range)	14.8 (11–19)

Abbreviations: FIGO, International Federation of Gynecology and Obstetrics; hCG, human chorionic gonadotropin.

Table 2 Clinical Characteristics of Emergency Surgery, Postoperative Treatment Plan, and Outcome of Patients with High-Risk Gestational Trophoblastic Neoplasia

Emergency Surgery Site	Indications of Operation	Time of Emergency Occurrence	Emergency Surgical Procedure	Histopathological Diagnosis	Time From Emergency Surgery to Subsequent Chemotherapy, Mean (Range)	Chemotherapy Regimen	Outcome
Brain (n=6)	Hemorrhage (n=4)	Before chemotherapy (n=5)	Tumor resection (n=5)	Choriocarcinoma (n=5)	17.6(12–31) days	EMA/CO (n=3)	Cured (n=6)
	Herniation (n=2)	First chemotherapy (n=1)	Evacuation of hematoma only (n=1)	Invasive mole (none)		EMA/CO+FAVE+TP/TE (n=2)	Dead (none)
		After the first chemotherapy (none)		No pathological examination (n=1)		EP/EMA (n=1)
Liver (n=3)	Hemorrhage (n=3)	Before chemotherapy (none)	Partial liver resection only (n=2)	Choriocarcinoma (n=2)	8.3(1–12) days	EMA/CO (n=2)	Cured (n=1)
		First chemotherapy (n=3)	Partial liver resection+bowel resection (n=1)	Invasive mole (n=1)		EMA/CO+FAVE+TP/TE (n=1)	Dead (n=2)
		After the first chemotherapy (none)		No pathological examination (none)
Gastrointestinal tract (n=3)	Hemorrhage (n=2)	Before chemotherapy (n=1)	Bowel resection only (n=2)	Choriocarcinoma (n=2)	9.3(6–15) days	EMA/CO (n=1)	Cured (n=2)
	Perforation (n=1)	First chemotherapy (n=2)	Bowel resection+hysterectomy (n=1)	Invasive mole (n=1)		EMA/CO+FAVE+TP/TE (n=1)	Dead (n=1)
		After the first chemotherapy (n=1)		No pathological examination (none)		EMA/CO+FAVE+TP/TE+TEP+BEP+MBE+PD-1 (n=1)
Kidney (n=1)	Hemorrhage (n=1)	Before chemotherapy (n=1)	Nephrectomy (n=1)	Choriocarcinoma (none)	5 days	EMA/CO+FAVE (n=1)	Cured (n=1)
		First chemotherapy (none)		Invasive mole (n=1)			Dead (n=0)
		After the first chemotherapy (none)		No pathological examination (none)
Uterus (n=2)	Hemorrhage (n=2)	Before chemotherapy (n=2)	Hysterectomy (n=1)	Choriocarcinoma (n=2)	13.5 (8–19) days	EMA/CO (n=2)	Cured (n=2)
		First chemotherapy (none)	Cornual resection (n=1)	Invasive mole (none)			Dead (n=0)
		After the first chemotherapy (none)		No pathological examination (none)
Total (n=13)	Hemorrhage (n=12)	Before chemotherapy (n=9)	Tumor/organ resection (n=14)	Choriocarcinoma (n=9)	12.7(1–31) days	EMA/CO (n=9)	Cured (n=10)
	Non-hemorrhage (n=3)	First chemotherapy (5)	Non-tumor/organ resection (n=1)	Invasive mole (n=3)		EP/EMA (n=1)	Dead (n=3)
		After the first chemotherapy (1)		No pathological examination (n=1)		EMA/CO+other (n=5)

Abbreviations: EMA-CO, etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine; EMA-EP, etoposide, methotrexate, actinomycin D, and cisplatin; FAVE, floxuridine, actinomycin D, vincristine and etoposide; TP/TE, paclitaxel/cisplatin alternating with paclitaxel/etoposide; BEP, bleomycin, etoposide, and cisplatin; TEP, paclitaxel, etoposide, and cisplatin (TEP); MBE, methotrexate, bleomycin, etoposide; PD-1, programmed cell death protein 1.

Table 3 Clinical Characteristics of Six Patients with Gestational Trophoblastic Neoplasia and Brain Metastases

Patient	Symptoms at Emergency	Disease Site	Emergency Surgical Procedure	ICU Stay (Day)	Duration of Remission (Month)	Current Symptoms
1	Unconsciousness, mydriasis, muscle rigidity	Bilateral parietal occipital lobe	Tumor resection	5	47	Impaired vision of right eye, anisocoria
2	Left side paralysis	Right frontal lobe	Evacuation of hematoma	3	52	Impaired function of left limb
3	Headaches, dizziness	Left occipital lobe	Tumor resection+evacuation of hematoma	4	6	No obvious sequelae
4	Right side paralysis, aphasia, lethargy	Right parietal occipital lobe	Tumor resection+evacuation of hematoma	10	3	No obvious sequelae
5	Headaches, nausea, vomiting, aphasia	Left parietal occipital lobe	Tumor resection+evacuation of hematoma	15	86	No obvious sequelae
6	Headaches, nausea, vomiting, unconsciousness	Right frontal lobe	Tumor resection	4	81	No obvious sequelae

Abbreviation: ICU, intensive care unit.

Table 4 Clinical Characteristics of Patients with Gestational Trophoblastic Neoplasia Who Died After Emergency Surgery or Subsequent Treatment

Patient	Year of Treatment	Metastasis Sites	FIGO Score	Emergency Surgical Procedure	Chemotherapy	Interval Between Initial Treatment to Death	Cause of Death
1	2013	Lung, liver	13	Partial liver resection	EMA/CO*6, FAVE*2, TP+TE*1	6 months	Respiratory failure
2	2014	GI tract, lung, liver	14	Partial liver resection+bowel resection	EMA-CO	2 days	Postoperative bleeding
3	2018	Lung, GI tract, liver, kidney	19	Bowel resection	EMA/CO*4, FAVE*1, TP/TE*1, TEP*7, BEP*5, MBE*2, PD-1*9	19 months	Respiratory failure

Abbreviations: EMA-CO, etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine; EMA-EP, etoposide, methotrexate, actinomycin D, and cisplatin; FAVE, floxuridine, actinomycin D, vincristine and etoposide; TP/TE, paclitaxel/cisplatin alternating with paclitaxel/etoposide; BEP, bleomycin, etoposide, and cisplatin; TEP, paclitaxel, etoposide, and cisplatin (TEP); MBE, methotrexate, bleomycin, etoposide; PD-1, programmed cell death protein 1.

Figure 1 Preoperative and postoperative imaging findings of a patient with gestational trophoblastic neoplasia.

Notes: When the patient received the first cycle of EMA-CO regimen, she had tumor hemorrhage and brain herniation, which led to emergency tumor resection surgery. (A) Preoperative and pre-chemotherapy initiation computed CT reveals one metastasis in the left parietal lobe of the brain and two metastases in the right parietal lobe. (B) On the second day after right parietal lobe tumor resection, CT reveals that the bleeding tumor in the right parietal had been resected, and that the other tumor was still present; the CT findings of the tumor on the left are similar to the preoperative CT findings (A). (C) Before the administration of the second cycle of EMA-CO, CT reveals that the residual tumors in the right and left have reduced significantly. (D) Magnetic resonance imaging performed 2 years after surgery (1 year after chemotherapy) reveals that the tumors on both sides of the brain have disappeared.

Abbreviations: EMA-CO, etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine; CT, computed tomography.