ReviewSecondary chemotherapy for high-risk gestational trophoblastic neoplasia☆
Introduction
Since the introduction of pharmacotherapy for the treatment of gestational trophoblastic neoplasia almost 50 years ago, the cure rate for these tumors has steadily increased and now exceeds 90% [1]. It is currently recognized that patients with nonmetastatic (FIGO Stage I) and low-risk metastatic (FIGO Stage II and III, WHO score <7) gestational trophoblastic neoplasia can be treated with single-agent chemotherapy, resulting in a survival rate approaching 100%. Patients with high-risk metastatic disease (FIGO Stage IV or WHO score ≥7) should be treated more aggressively with initial combination chemotherapy with or without adjuvant radiotherapy or surgery to achieve a cure rate of 80%–90%.
Despite this success of chemotherapy in inducing clinical complete responses in most patients with gestational trophoblastic neoplasia, approximately 5% of low-risk patients and 25% of high-risk patients will have an incomplete response to first-line sequential single-agent or multi-agent chemotherapy, respectively, or will relapse from remission. The ultimate cure rate often depends, therefore, on the success of salvage chemotherapy with or without adjuvant surgical procedures. We reviewed the records of the Brewer Trophoblastic Disease Center to determine the efficacy of secondary platinum-based chemotherapy after failure of multi-agent chemotherapy for high-risk gestational trophoblastic neoplasia.
Section snippets
Materials and methods
Twenty-six patients with high-risk gestational trophoblastic neoplasia based on WHO criteria who had failed primary, multi-drug treatment of relapsed from remission and received secondary platinum-based chemotherapy were identified from the records of the John I. Brewer Trophoblastic Disease Center of Northwestern University between 1980 and 2001. Ten patients had failed etoposide, high-dose methotrexate with folinic acid, actinomycin D, cyclophosphamide and vincristine (EMA-CO) chemotherapy.
Results
Of 26 patients with persistent/relapsed high-risk gestational trophoblastic neoplasia who received secondary platinum-based salvage chemotherapy, 19 (73%) had a complete response and 16 (61.5%) survived. Nine (90%) of 10 patients who failed primary treatment with EMA-CO had a complete clinical response to secondary chemotherapy with EMA-EP (3) or BEP (6), and six (60%) were placed into lasting remission (Table 1). Ten (63%) of 16 patients who failed primary treatment with
Discussion
Treatment of low-risk (FIGO Stages I–III, WHO score <7) gestational trophoblastic neoplasia with initial single-agent methotrexate or actinomycin D chemotherapy has resulted in cure of almost all patients [2], [3]. However, approximately 5% of patients with nonmetastatic disease and 10% –15% of patients with low-risk metastatic disease will require multi-agent chemotherapy with or without surgery to achieve remission. The EMA-CO regimen has become the most common secondary chemotherapy used for
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Presented at the XIIth World Congress on Gestational Trophoblastic, Disease, Boston, MA, USA, September 29–October 1, 2003.