- Academic Editor
†These authors contributed equally.
Background: To evaluate the chemotherapy toxicity of 5-fluorouracil (5-FU) in the treatment of invasive moles. Methods: We conducted a retrospective study of therapeutic satisfaction, recurrence, and toxicity in 17 patients treated with 5-FU in the Zhuzhou Central Hospital, from 2015 to 2020. Results: After a single-agent 5-FU treatment a complete remission of low-risk invasive moles was observed, and remission of high-risk invasive moles reached rates of 76.5%. After 4–5 chemotherapy cycles, 5-FU reduced serum human chorionic gonadotropin (hCG) to normal levels in invasive moles. Furthermore, a toxicity assessment revealed that 5-FU chemotherapy has low toxicity and is generally acceptable for patients. Conclusions: 5-FU offers high efficacy in both low-risk and high-risk invasive moles, with low chemotherapy toxicity.
Invasive mole is one subtype of gestational trophoblastic neoplasia (GTN),
characterized by the malignant transformation of embryonic trophoblast cells [1, 2]. Advances in medical diagnostic and therapeutic technologies have
significantly increased the curability of GTN, particularly through application
of effective chemotherapy. The 2000 International Federation of Gynecology and
Obstetrics (FIGO) and World Health Organization (WHO) divides GTN into risk
categories through a scoring system, with a score
Floxuridine, Act-D, etoposide, and vincristine (FAEV) constitutes the first-line treatment for both high-risk GTN, as well as low-risk disease (FIGO scores, 5–6) [5, 6]. Recently, use of the antineoplastic drug 5-fluorouracil (5-FU) for the treatment of low-risk invasive moles has achieved satisfactory results in China. Furthermore, the toxicity of this regimen appears to be fully tolerated by patients [6, 7]. Building upon this basis, a 5-FU-based combined chemotherapy has been developed. In GTN treatments, including invasive moles, 5-FU is used either as a single agent or in combination with other chemotherapeutic agents. Therefore, we conducted a retrospective analysis to determine the therapeutic efficacy and chemotherapy toxicity of 5-FU in both low-risk and high-risk invasive moles.
This was a single-center retrospective study, involving 17 cases of
invasive mole treated with 5-FU in the Zhuzhou Central Hospital, from
2015 to 2020. All patients were confirmed as having an invasive mole by
pathological diagnosis. Patients were assessed according to the WHO scoring
system [8], where a score
All patients were treated with 5-FU (0.25 g/tube, Shanghai Xudong Haipu
Pharmaceutical Co., Ltd, Shanghai, China) (daily dose of 26–27 mg/kg in 500 mL
of 5% glucose (500 mL/bottle, Hunan Kelun Pharmaceutical Co., Ltd, Changsha, Hunan, China),
administered within 6–8 hours), for 5 consecutive days. The chemotherapy cycle
was repeated every 21 days. Serum hCG was measured after each course of
chemotherapy, until levels returned to normal.
Following the FIGO guidelines recommendation, a minimum of two courses of
consolidation chemotherapy were administered following the first negative hCG
level. Remission was defined as a normal hCG level for three
consecutive weeks (hCG: 0~5 IU/L). Treatment was considered
effective if the serum hCG decreased by one logarithm within at least 18 days
after the end of each course of chemotherapy. Definition of resistance to
monotherapy chemotherapy [10]: primary resistance refers to the appearance of
monotherapy therapy in the first two courses of treatment
Close follow-up was carried out after treatment, at 3 months, 6 months, 1 year,
and 2 years after treatment. In general, pregnancy can be achieved after
Data collection following first-line treatment included disease stage, WHO prognostic risk factors and score, chemotherapy regimen, number of chemotherapy cycles, treatment response, relapse, and time to first relapse.
The medical records of 17 patients revealed a diagnosis of invasive mole, of
which 6 were low-risk and 11 were high-risk. 14 (82.35%) patients were aged
Features | N (%) | |
Age (years) | ||
14 (82.35) | ||
3 (17.65) | ||
Antecedent pregnancy | ||
Hydatidiform mole | 1 (5.88) | |
Abortion | 7 (41.18) | |
Term | 9 (52.94) | |
Largest tumors size | ||
7 (41.18) | ||
3–5 cm | 3 (17.65) | |
7 (41.18) | ||
FIGO stage | ||
I | 6 (35.29) | |
II | 3 (17.65) | |
III | 8 (47.06) | |
IV | 0 | |
FIGO scores | ||
6 (35.29) | ||
11 (64.71) | ||
Pretreatment hCG (IU/L) | ||
5 (29.41) | ||
10 |
3 (17.65) | |
10 |
9 (52.94) | |
0 | ||
Sites of metastases | ||
Lung | 5 (29.41) | |
Vagina | 2 (11.76) | |
Number of metastases | ||
0 | 10 (58.82) | |
1–4 | 7 (41.18) | |
5–8 | 0 | |
0 | ||
Chemotherapy effect | ||
Remission | 13 (76.47) | |
Resistance | 2 (11.76) | |
Relapse | 2 (11.76) | |
Toxicity | ||
Grade 2 | 4 (23.52) | |
Grade 3 | 2 (11.76) | |
Grade 4 | 1 (5.88) |
N, number; FIGO, International Federation of Gynecology and Obstetrics; hCG, human chorionic gonadotropin.
After treatment with single-agent 5-FU, 13 (76.5%) patients achieved remission, 1 (5.9%) was resistant to treatment, 2 (11.8%) relapsed, and only 1 (5.9%) patient was switched to Act-D treatment due to severe chemotherapy toxicity. All drug-resistant and relapsed patients achieved recovery after completing three courses of EMA/CO treatment.
We next analyzed remission rates in both low-risk and high-risk invasive moles. 6 (100%) low-risk patients had complete remission. Among 11 high-risk patients, 7 (63.6%) had complete remission, 1 (9.1%) was resistant to treatment, 2 (18.2%) had a relapse, and 1 (9.1%) experienced severe chemotherapy toxicity requiring a drug change (Table 2).
Patients | FIGO scores | hCG levels (IU/L) | Chemotherapy toxicity | Sites of metastases | ||||||||||
Chemotherapy cycles | ||||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | ||||
2 | 85,672 | 2056 | 242.8 | 65.8 | normal | normal | ||||||||
3 | 250,000 | 84,550 | 8422 | 502 | normal | normal | ||||||||
10 | 1160 | normal | normal | |||||||||||
11 | 66,673 | 842 | normal | normal | ||||||||||
12 | 5347 | normal | normal | |||||||||||
13 | 545,344.9 | 82,553 | 15,890 | 1480 | 85 | normal | normal | Grade 2 | ||||||
1 | 913.3 | normal* | normal | |||||||||||
4 | 100,000 | 5230 | 882 | normal | normal | Grade 2 | Lung | |||||||
5 | 1949 | normal | normal | Lung and vagina | ||||||||||
6 |
789,783 | 66,620 | 10,800 | 3440 (Act-D) | 127 | normal | normal | Grade 4 | Lung | |||||
7 | 8369.6 | 1892 | 566 | 144 | normal | normal | Grade 3 | |||||||
8 |
125,665 | 6411 | 1550 | normal | normal | |||||||||
9 | 119,730.5 | 2891 | 825 | normal | normal | Lung | ||||||||
14 |
6445 | 2832 | 580 | 166 | normal | normal | Grade 2 | Vagina | ||||||
15 | 19,862 | 453 | normal | normal | Lung | |||||||||
16 |
112,618 | 6423 | 3411 | 1560 | 566 | 408 | 625 | 2245 (EMA/CO) | 142 | normal | normal | Grade 3 | Vagina | |
17 | 100,000 | 3286.8 | 1200 | 165.4 | normal | normal | Grade 2 |
Note: *, normal indicates hCG
Next, we evaluated the serum hCG levels of all patients, both in the
pretreatment and after each treatment. Out of 5 patients with hCG
Variable | Grade 2 (moderate) | Grade 3 (severe) | Grade 4 (life-threatening or disabling AE) |
Hemoglobin | 1 | 0 | 0 |
Leukocytes | 3 | 1 | 0 |
Platelets | 1 | 1 | 0 |
Creatinine | 0 | 0 | 0 |
ALT/AST | 2 | 1 | 0 |
Mucosa | 1 | 0 | 0 |
Vomit | 4 | 2 | 1 |
No. of patients | 4 | 2 | 1 |
ALT, alanine aminotransferase; AST, aspartate aminotransferase; AE, adverse event; 5-FU, 5-fluorouracil.
Finally, we assessed the toxicity of 5-FU chemotherapy. 4 patients experienced grade 2 toxicity, 2 experienced grade 3, and 1 patient experienced grade 4 toxicity. The major chemotherapy toxicities of 5-FU experienced by the patients are gastrointestinal reactions (vomiting), low leukocyte and low hemoglobin levels, thrombocytopenia, abnormal liver function, and oral mucosal reactions. In the present study, all 4 patients with grade 2 abnormalities experienced vomiting, 1 in 4 patients experienced myelosuppression (granulocyte, hemoglobin, thrombocytopenia), 1 patient had oral mucosal ulcers, 2 patients had alanine aminotransferase (ALT) and aspartate aminotransferase (AST), and 2 patients had neutropenia. Vomiting in 2 patients was classified as chemotherapy toxicity grade 3; 1 patient had granulocytopenia and thrombocytopenia, and the other had abnormal liver function. Vomiting was observed in the patient classified as toxicity grade 4 (Tables 2,3)
At present, the cure rate for GTN through chemotherapy is close to 100%. Low-risk GTN is usually treated with a single agent (MTX, Act-D), while EMA/CO is recommended for high-risk GTN [11]. However, research into 5-FU for the treatment of GTN has mainly been conducted in China. Since the 1960s, 5-FU monotherapy has been employed for the treatment of low-risk GTN, demonstrating effective outcomes and minimal chemotherapy toxicity [12].
In the current study, we retrospectively studied 5-FU monotherapy for the treatment of high-risk and low-risk invasive moles in order to observe its therapeutic effect and chemotherapy toxicity. We found a remission rate of 76.5% (13/17) for the use of 5-FU in the treatment of invasive moles, including 100% (6/6) and 72.7% (8/11) remission rates for low-risk and high-risk invasive moles, respectively. In comparison with previous studies, the remission rates of MTX or Act-D monotherapy for the treatment of low-risk GTN are reported to be 77–94% [13]. While our remission rate for low-risk invasive moles surpasses that of MTX or Act-D monotherapy, it is important to note that our sample size is too small to fully assess the response rate of 5-FU monotherapy. However, this study still demonstrates the advantage of 5-FU in the treatment of low-risk invasive moles. Our data also demonstrate that the use of 5-FU to treat low-risk invasive moles did not lead to severe chemotherapy toxicity, with only 1 case of grade 2 toxicity reported.
For high-risk invasive moles, the remission rate here observed was 76.5%. Previous studies using a combination of EMA/CO for the treatment of high-risk invasive moles have reported remission rates of 75% [11, 14], which is consistent with our study. However, in our study, 5-FU exhibited acceptable chemotherapy toxicity for high-risk invasive moles. Only 2 out of the 11 patients experienced grade 3 and 4 toxicity, with gastrointestinal symptoms (vomiting), being the predominant chemotherapy-related toxicity event. Regarding the hematologic toxicity of EMA/CO, the incidence rates of grade 3–4 neutropenia, thrombocytopenia, and anemia were 6.9–19.5%, 4.6%, and 2.3%, respectively [15]. Some studies have reported that the probability of single-agent chemotherapy resistance is significantly greater for a FIGO 2000 score of 5–6 compared to those with scores 1–4 [16, 17]. This is considered indicative of high-risk GTN chemotherapy. Additionally, for high-risk GTN, regimens such as FAEV, or combination of 5-FU plus Act-D can also be used [18].
In our study, 1 patient, aged 42 years, with no fertility requirements, underwent a hysterectomy after recurrence and remission following 4 courses of an EMA/CO regimen. Surgery is recommended for adjuvant chemotherapy, mainly to control significant bleeding, remove drug-resistant lesions, reduce tumor burden, and shorten the course of chemotherapy 2 [19]. Hysterectomy is an alternative surgical regimen for patients at a high-risk of post-molar GTN, when fertility is not a concern. However, systemic chemotherapy, as opposed to surgery, is typically the first-choice strategy for treating lung metastases [20, 21].
In our study clearly reveals the satisfactory efficacy and low chemotherapeutic toxicity of low-dose 5-FU in the treatment of GTN. This provides an alternative reference regimen for the treatment of GTN in both low-risk and high-risk cases. In future studies, we plan to analyze a larger sample size to explore this further, especially in the context of treating high-risk GTN.
Availability of Data and Materials obtained through the corresponding author’s email.
CL and PO were responsible for analyzing the data, and composing the manuscript. MX and YT were devoted to acquiring and analyzing of the data. YT and MX were contributed to reviewing the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript, and confirmed the authenticity of all the raw data.
In this study, informed consent was obtained from all patients. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Zhuzhou Central Hospital (approval number: ZZCHEC2021124-01).
We would like to express our gratitude to all those who helped us during the writing of this manuscript.
This research received no external funding.
The authors declare no conflict of interest.
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