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Outcomes in the management of high-risk gestational trophoblastic neoplasia in trophoblastic disease centers in South America
  1. Izildinha Maestá1,
  2. Marjory de Freitas Segalla Moreira1,
  3. Jorge Rezende-Filho2,
  4. Maria Inés Bianconi3,
  5. Gustavo Jankilevich3,
  6. Silvina Otero3,
  7. Luz Angela Correa Ramirez4,5,
  8. Sue Yazaki Sun6,
  9. Kevin Elias7,
  10. Neil Horowitz7,
  11. Antonio Braga2 and
  12. Ross Berkowitz7
  1. 1Botucatu Trophoblastic Disease Center, Botucatu Medical School, Sao Paulo State University Julio de Mesquita Filho-UNESP, Botucatu, Brazil
  2. 2Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, Brazil
  3. 3Carlos G Durand Hospital Trophoblastic Disease Center, Faculty of Medicine – University of Buenos Aires, Buenos Aires, Argentina
  4. 4Botucatu Medical School, Sao Paulo State University Julio de Mesquita Filho-UNESP, Botucatu, Sao Paulo, Brazil
  5. 5University of Caldas, Manizales, Colombia
  6. 6São Paulo Hospital Trophoblastic Disease Center, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
  7. 7Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, New England Trophoblastic Disease Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Izildinha Maestá, Sao Paulo State University Julio de Mesquita Filho, Botucatu 18.618-687, Brazil; i.maesta{at}unesp.br

Abstract

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.

  • gestational trophoblastic disease
  • trophoblastic neoplasms
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Footnotes

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  • Contributors IM: conceived and designed the study, wrote the manuscript, audited data collected by MFSM from Botucatu Trophoblastic Disease Center (São Paulo State University). MM: identified and collected data from Botucatu Trophoblastic Disease Center (São Paulo State University) and from Rio de Janeiro Trophoblastic Diseases Center (Federal University of Rio de Janeiro Maternity School), wrote the manuscript. JR-F: helped with the analysis of the data from Rio de Janeiro Trophoblastic Diseases Center (Federal University of Rio de Janeiro Maternity School), contributed to the manuscript. MB: audited data collected by LACR from Durand Trophoblastic Disease Center in Buenos Aires (Carlos G. Durand Hospital), contributed to data analysis. GJ: helped with the analysis of the data from Durand Trophoblastic Disease Center in Buenos Aires (Carlos G. Durand Hospital), contributed to the manuscript. SO: helped with the analysis of the data from Carlos G. Durand Hospital, contributed to the manuscript. LR: reviewed the literature, collected and managed data from Durand Trophoblastic Disease Center in Buenos Aires (Carlos G. Durand Hospital). SYS: contributed to data analysis and interpretation. KE: conceived the analysis strategy, contributed to the manuscript. NH: contributed to data analysis and interpretation, critically revised the manuscript. AB: audited data collected by MFSM from Rio de Janeiro Trophoblastic Diseases Center (Federal University of Rio de Janeiro Maternity School). RB: supervised the study, critically revised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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