Low-risk gestational trophoblastic neoplasia: evaluating the need for initial inpatient treatment during low-dose methotrexate chemotherapy

OBJECTIVE

To evaluate the need for initial inpatient treatment for patients being treated with low-dose intramuscular methotrexate for low-risk gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

Clinical notes of all patients treated with low-dose intramuscular methotrexate for low-risk GTN were analyzed and side effects noted.

RESULTS

There were no episodes of increased uterine bleeding requiring extra medical intervention. There were 7 cases of chest pain; none required a change from methotrexate chemotherapy.

CONCLUSION

Patients being treated with low-dose intramuscular methotrexate for low-risk GTN do not need to be treated routinely in the hospital for their first treatment cycle.

Role of hysterectomy in managing persistent gestational trophoblastic disease

OBJECTIVE

To evaluate incidence, indications and outcomes of hysterectomy for gestational trophoblastic disease (GTD) and compare outcomes for patients who underwent primary hysterectomy with outcomes for those who underwent adjuvant hysterectomy.

STUDY DESIGN

Using the Sheffield Trophoblastic Tumour Centre database (January 1, 1986, until June 30, 2007), patients who underwent hysterectomy were identified, along with age, antecedent pregnancy, diagnosis date, hysterectomy date and chemotherapy and pathologic findings.

RESULTS

A total of 8,860 patients were registered at Weston Park Hospital, Sheffield. Of them, 627 (7.1%) needed chemotherapy and 62 (0.71%) underwent hysterectomy. The most frequent indication was resistance to chemotherapy in 22 of 62 (35.5%), followed by major hemorrhage in 21 of 62 (33.9%). Emergent hysterectomy was performed in 22 (35.5%). Mean International Federation of Gynecology and Obstetrics risk score was 6.5. Choriocarcinoma was the most frequent pathology (23), followed by invasive mole (10) and placental site trophoblastic tumor (9). Thirty-one patients needed chemotherapy after hysterectomy, 93.5% are in remission, 7 relapsed, 3 were cured and 4 died of disease.

CONCLUSION

Incidence of hysterectomy for GTD was 1 in 140. Patients who underwent hysterectomy represent a high-risk group, often having more aggressive pathology. Hysterectomy is valuable as primary and adjuvant treatments.

Poor outcome in adolescents with high-risk Hodgkin lymphoma

This retrospective study looks at the differences between adolescents (15-19 years) and young adults (20-25 years), diagnosed with Hodgkin lymphoma and treated at the same adult institution. Outcome according to risk category was evaluated, and although there were no significant differences in the whole cohort, or low and intermediate-risk categories, high-risk adolescent patients had a significantly worse outcome compared to that of young adults. In these high-risk patients, 5-year event free survival was 43.6% in adolescents compared to 58.7% in young adults (log-rank survival p=0.03), and the 5-year overall survival in adolescents was 66.7% compared to 84.4% in the young adults (p=0.04). Possible contributing factors to this inferior outcome in these high-risk patients were explored. The difference could not be explained in terms of differences in histological subtype (p=0.5), proportion of patients with bulky (p=0.6) or extranodal disease (p=0.6), initial treatment received (chemotherapy alone compared to combination therapy, p=0.2), or proportion proceeding to high-dose treatment after initial treatment failure (p=0.6). There was no difference in the documented number of delays, dose reductions or episodes of non-compliance during initial treatment in the two high-risk age groups. A significantly greater proportion of high-risk adolescents had primary progressive disease (PPD) [eight high-risk adolescents (33.3%) compared to two high-risk young adults (7.7%), p=0.02].

Treatment of metastatic gestational trophoblastic neoplasia

Treatment of persistent gestational trophoblastic neoplasia (GTN) has been one of the success stories of modern day chemotherapy; however, occasional patients with metastatic disease still die. A potential difficulty in assessing published studies is that patient groups can be selected for treatment differently according to how risk categories are defined. The involvement of a specialist team from the outset is essential. Patients with low-risk metastatic GTN are treated successfully with single-agent chemotherapy using methotrexate or dactinomycin. Patients with high-risk metastatic disease receive combination chemotherapy regimens from the start. Worldwide experience has been accrued by use of regimens devised and tested by large centres. The high response rate and good long-term survival, as well as the tolerable acute and cumulative toxic effects, associated with use of etoposide, methotrexate and dactinomycin, alternating with cyclophosphamide and vincristine, make this protocol, or one of its variants, the current initial treatment of choice for patients. In view of the success of these regimens difficulty would be encountered in mounting a worthwhile randomised controlled trial; however, further well-designed studies are needed of novel approaches in very-high-risk and multiresistant disease.

Prevalence and consequences of androgen deficiency in young male cancer survivors in a controlled cross-sectional study

BACKGROUND

Testosterone replacement in hypogonadal males improves body composition, sexual function, and health-related quality of life. Male cancer survivors are at risk of androgen deficiency; however, when and in whom testosterone should be replaced remain unanswered questions.

OBJECTIVE

The aim of our study was to define the prevalence of androgen deficiency in this patient group through assessment of testosterone levels and related measures.

DESIGN

This was a cross-sectional, observational study of cases and controls. We recruited 176 cancer survivors and 213 controls, aged 25-45 yr.

RESULTS

Of cancer survivors, 97% had received chemotherapy and 40% radiotherapy. Cancer survivors had lower total testosterone (tT) levels than controls (mean difference 2.67 nmol/liter; 95% confidence interval 1.58-3.76; P = 0.003), and 24 of 176 (13.6%; 95% confidence interval 9.3-19.5) had a tT less than 10 nmol/liter, which was less than 2.5% centile for controls. Cancer survivors had a greater fat mass, higher fasting insulin and glucose levels, increased fatigue, and reduced sexual function and health-related quality of life. In both cohorts, the tT correlated negatively with insulin levels and negatively with body fat mass; however, the difference in tT between them was independent of fat mass. We measured tT and SHBG and calculated bioavailable testosterone. The changes in calculated bioavailable testosterone were similar to tT.

CONCLUSIONS

A significant proportion of young male cancer survivors had a frankly low tT associated with an increased fat mass and insulin level compared with controls. These factors would be predicted to improve in response to testosterone replacement therapy and provide a powerful argument for an interventional study of testosterone therapy in young male cancer survivors.

Management and outcome of healthy women with a persistently elevated β-hCG

PURPOSE

Raised serum beta human chorionic gonadotrophin (beta-hCG) not due to pregnancy can occur as a consequence of (1) gestational trophoblastic neoplasia (GTN), (2) non-gestational trophoblastic tumours, (3) a false-positive beta-hCG, (4) the menopause or (5) a high normal level. Accurate differentiation between these causes is vital to avoid potentially inappropriate investigations and therapies, which may induce infertility or other serious adverse events. Here we report the United Kingdom experience of patients with an elevated beta-hCG of initial uncertain cause and provide a clinical algorithm for the management of such cases.

METHOD

The Charing Cross and Weston Park Hospital GTN databases were screened to identify patients referred with an elevated beta-hCG who were not pregnant and had no previous diagnosis of GTN.

RESULTS

Between 1981 and 2004 fourteen women presented with persistently raised serum beta-hCG resulting in diagnostic problems. False-positive beta-hCG was excluded in all. Three patients developed gestational choriocarcinoma after 9-29 months. However, in 11 women no cause for the persistently elevated beta-hCG was found. One of these achieved chemotherapy-induced normalisation of serum beta-hCG, but the remaining 10 underwent surgery and/or chemotherapy without benefit. Thus, 71% (10/14) of patients remain well with unexplained elevated beta-hCG levels.

CONCLUSION

Elevated serum and urinary beta-hCG levels in healthy women should be investigated systematically to exclude an underlying malignant process and to avoid inappropriate surgical and medical intervention. Long-term follow-up is required as tumours may not become apparent for many months or years.

Myocardial Infarction Mortality Risk After Treatment for Hodgkin Disease: A Collaborative British Cohort Study

BACKGROUND

Myocardial infarction is a major cause of excess long-term mortality in survivors of Hodgkin disease, but limited information exists on the effects of specific chemotherapy regimens used to treat these patients on their risk of death from myocardial infarction.

METHODS

We followed a cohort of 7033 Hodgkin disease patients who were treated in Britain from November 1, 1967, through September 30, 2000, and compared their risk of myocardial infarction mortality with that in the general population of England and Wales. All statistical tests were two-sided.

RESULTS

A total of 166 deaths from myocardial infarction occurred in the cohort, statistically significantly more than expected (standardized mortality ratio [SMR] = 2.5, 95% confidence interval [CI] = 2.1 to 2.9), with an absolute excess risk of 125.8 per 100,000 person-years. Standardized mortality ratios decreased sharply with older age at first treatment, but absolute excess risks of death from myocardial infarction increased with older age up to age 65 years at first treatment. The statistically significantly increased risk of myocardial infarction mortality persisted through to 25 years after first treatment. Risks were increased statistically significantly and independently for patients who had been treated with supradiaphragmatic radiotherapy, anthracyclines, or vincristine. Risk was particularly high for patients treated with the doxorubicin, bleomycin, vinblastine, and dacarbazine regimen (SMR = 9.5, 95% CI = 3.5 to 20.6). Risk at 20 or more years after first treatment was particularly great for patients who had received supradiaphragmatic radiotherapy and vincristine without anthracyclines (SMR = 14.8, 95% CI = 4.8 to 34.5).

CONCLUSIONS

The risk of death from myocardial infarction after treatment for Hodgkin disease remains high for at least 25 years. The increased risks are related to supradiaphragmatic radiotherapy but may also be related to anthracycline and vincristine treatment.

Effect of chemotherapy on skeletal health in male survivors from testicular cancer and lymphoma

PURPOSE

There are concerns over the late effects of cancer therapy, including accelerated bone loss leading to increased risk of osteoporosis. Treatment-related bone loss is well recognized in breast and prostate cancer, due to overt hypogonadism, but there has been little evaluation of the skeletal effects of chemotherapy alone in adults. This study assesses the extent of bone loss due to previous chemotherapy in men.

EXPERIMENTAL DESIGN

The bone mineral density (BMD) of men who had received previously chemotherapy with curative intent for lymphoma or testicular cancers was compared with that of an age-matched population of men from a cancer control population that had not received chemotherapy. BMD was measured by dual-energy X-ray scanning. Additionally, measurement of sex hormones and the bone turnover markers N-telopeptide fragment of type I collagen and bone-specific alkaline phosphatase were done. All statistical tests were two sided.

RESULTS

One hundred fifteen chemotherapy-treated patients and 102 cancer controls were recruited. There was no statistical difference in BMD between the chemotherapy and control groups at either spine or hip and the mean BMD values in both groups were no lower than that of a reference population. There were no significant differences in estradiol, luteinizing hormone, and testosterone, but follicle-stimulating hormone values were significantly higher in the chemotherapy group (P=0.011). The mean values of NH2-terminal telopeptide fragment of type I collagen and bone-specific alkaline phosphatase were within the reference ranges.

CONCLUSIONS

The absence of accelerated bone loss following chemotherapy is reassuring and suggests that standard dose cytotoxic chemotherapy has no lasting clinically important direct effects on bone metabolism.

Transformed diffuse large B-cell lymphomas with gains of the discontinuous 12q12-14 amplicon display concurrent deregulation of CDK2, CDK4 and GADD153 genes

Transformation of the indolent follicular lymphoma (FL) to the aggressive diffuse large B-cell lymphoma (DLBCL) results in resistance to therapy with shortened survival. It has been demonstrated that the 12q12-14 region was mainly amplified in DLBCL cases but not in their FL counterparts. Therefore, we examined the DNA copy number and protein expression profiles for CDK2, CDK4 and GADD153, three genes that map to 12q12-14, in a set of 44 paired FL/DLBCL samples from 22 patients. The concordant amplification of these genes occurred in seven of 22 (32%) of FL cases, compared with 15 of 22 (68%) of DLBCL cases. At the protein level, 15 of 22 of the DLBCL samples (68%) showed strong staining for the CDK2 protein, compared with five of 21 of FL samples (24%). The majority of the DLBCL samples (16/22, 72%) expressed the CDK4 protein, whereas the majority of the FL samples (12/21, 57%) showed no expression of this protein. Except for one DLBCL case, no expression of the GADD153 protein could be detected. The deregulation of the CDK2 and CDK4 genes at the genetic and protein levels suggest a functional role for these genes in the transformation process and could potentially provide targets for prognostic tests or therapeutic interventions.

Twin mole and viable fetus: The case for misdiagnosis

OBJECTIVE

To report the Sheffield Trophoblast Centre experience of twin molar gestations and review this in the light of international experience.

CASE

Thirty patients with possible twin molar gestations were registered from 1986 to 2004 (during which period 7,200 cases of mole were seen). The accuracy of suspected clinical and histologic diagnoses was investigated.

RESULTS

In 10 cases twin mole/fetus had been suspected clinically but not confirmed when products of conception were examined. In 3 of these cases the pregnancy had been therapeutically terminated because of clinical (ultrasound) suspicion of coexisting molar pregnancy. In the 19 cases where twin mole/fetus was suspected, central histopathology review was possible in 14 cases. Only 7 were confirmed. In 2 further cases twin molar gestation was diagnosed on specimens referred for central review as partial mole singleton pregnancies. For confirmed cases the pregnancy outcome was term delivery in 5 cases and miscarriage in 4.

CONCLUSION

Clinical and histopathologic diagnosis of twin molar pregnancies is inaccurate in many suspected cases; therefore, a second (expert) opinion should be sought. When the diagnosis is accurate, maternal and fetal complications are common. However, in suspected cases the pregnancy may be allowed to proceed, with caution, if the mother wishes.

Persistent gestational trophoblastic neoplasia after partial hydatidiform mole incidence and outcome

OBJECTIVE

To report the Sheffield experience with persistent gestational trophoblastic neoplasia (GTN) after partial hydatidiform mole (PHM) and to review worldwide experience.

METHODS

All PHMs registered at the Sheffield Trophoblast Centre between 1991 and 2004 were included in this retrospective study. Any case of PHM leading to persistent GTN was reviewed centrally by an expert gynecologic pathologist. Clinical features, treatment and outcome were recorded.

RESULTS

During the 14-year study period 3189 PHMs were registered. Forty-one developed persistent GTN. Central histopathology review confirmed PHM in only 14 cases (0.91% of all those registered). Twelve scored low and 2 high risk according to International Federation of Gynecology and Obstetrics 2000 criteria. During the same period, 271 cases of persistent GTN originally registered as complete hydatidiform mole were reviewed; 3 were found to be PHMs (2 low, 1 high risk). In all, 15 of 17 persistent PHMs required chemotherapy.

CONCLUSION

Persistent GTN requiring chemotherapy can occasionally occur after PHM; surveillance of all cases continues to be recommended.

Postpartum choriocarcinoma presentation, management and survival

OBJECTIVE

To determine the clinical presentation and outcome of postpartum choriocarcinoma.

STUDY DESIGN

Case note review of patients with choriocarcinoma treated at the Sheffield Trophoblastic Disease Centre.

RESULTS

Thirty-five patients were identified between 1977 and 2005. Mean age was 27 years (range, 21-37). Thirty-three patients complained of persistent postpartum hemorrhage, and in 3 cases there were other symptoms. Two patients presented with nongynecologic symptoms. Mean time until diagnosis was 7 weeks postpartum (range, 0-60), with a mean delay from onset of symptoms to treatment of 7 weeks (maximum, 19). Twenty patients had metastatic disease, but this did not correlate with delay in diagnosis. The mean International Federation of Gynecology and Obstetrics score was 10. Multidrug regimens were used in most patients; however, 8 low-risk patients had a complete response with methotrexate alone. The mean survival was 7.8 years (range, 1-21). Two patients died from disease.

CONCLUSION

Postpartum choriocarcinoma presents mainly with vaginal bleeding, and there is often a delay in diagnosis despite being under the care of gynecologists. In the small numbers that present with nongynecologic symptoms there is a rapid awareness of the possibility of gestational trophoblastic neoplasia; nevertheless, the outcome may be fatal, especially in the presence of symptomatic brain metastases.

Primary bone lymphoma: a retrospective analysis

The aim of this study was to retrospectively define those patients with unequivocal primary bone lymphoma presenting to the Sheffield Lymphoma Group and document patient and tumour characteristics and management strategies, and correlate these with survival. Thirty-seven patients were documented from a total of 3148 cases of non-Hodgkin's lymphoma seen over 34 years. There were 17 males and 20 females, with a mean age of 55.4 years (range, 27-78). Pain was the most commonly presented symptom (67.5%), and the pelvis was the most frequently presented site (21.3%). Grade 2 and diffuse large B cell lymphoma comprised the majority of histologies (78.7% and 70.3%, respectively). Treatment was most often with radiotherapy alone (41.8%) or combined with CHOP-like chemotherapy (37.9%). The overall response rate was 56.7%, and 5- and 10-year survival rates were 64.5% and 49.6%, respectively. Univariate analysis showed an age of <60 years and complete response to be favourable prognostic factors. There was a trend toward better survival with combined modality therapy involving CHOP-like chemotherapy. Bone lymphoma has a better survival than other extranodal lymphomas. Younger age and complete response are favourable predictive factors. Combined modality treatment is likely to be the treatment of choice but this remains to be confirmed in large prospective multicentre studies.

Risk of Second Malignancy After Non-Hodgkin's Lymphoma: A British Cohort Study

Purpose

To assess long-term site-specific risks of second malignancy following non-Hodgkin's lymphoma (NHL) in relation to treatment and demographic factors.

Patients and Methods

A cohort of 2,456 patients with NHL who were first treated from 1973 to 2000 and were younger than 60 years from centers in the British National Lymphoma Investigation were observed, and occurrences of second malignancy was compared with expectations based on general population cancer rates in England and Wales.

Results

In total, 123 second malignancies occurred. Relative risks (RRs) were significantly elevated for all malignancies combined (RR = 1.3; 95% CI, 1.1 to 1.6) and for leukemia (RR = 8.8; 95% CI, 5.1 to 14.1) and lung cancer (RR = 1.6; 95% CI, 1.1 to 2.3). RRs of malignancy overall diminished significantly with increasing age at first treatment. Leukemia risk was significantly increased after chemotherapy (RR = 10.5; 95% CI, 5.0 to 19.3) and mixed-modality treatment (RR = 13.0; 95% CI, 5.2 to 26.7). Relative risks of lung (RR = 1.9; 95% CI, 1.1 to 3.1) and colorectal (RR = 2.1; 95% CI, 1.1 to 3.6) cancers were significantly raised following chemotherapy.

Conclusion

NHL patients are at elevated risk of developing second malignancy, particularly leukemia and lung cancer. The relative risk is greater with patients who are younger at first treatment. Chemotherapy predisposes patients toan increased risk of leukemia, and possibly lung and colorectal cancers. The role of specific drug treatments in the etiology of solid cancers after NHL deserves further investigation.

High incidence of late effects found in Hodgkin's lymphoma survivors, following recall for breast cancer screening

Assessment of late effects in a cohort of female Hodgkin's lymphoma patients treated with mantle radiotherapy, identified from the DoH breast cancer screening recall showed high mortality and frequent undiagnosed abnormalities in tissues affected by radiotherapy. With increasing age, this patient group may suffer premature cardiac and respiratory morbidity.

Quality of life and cost-effectiveness of interferon-alpha in malignant melanoma: results from randomised trial

A definitive conclusion regarding the value of low-dose extended duration adjuvant interferon-alpha therapy in the treatment of malignant melanoma is only possible once data on health-related quality of life (HRQoL) and costs have been considered. This trial randomised 674 patients to interferon alpha-2a (3 megaunits three times per week for 2 years or until recurrence) or placebo. Health-related quality of life (QoL) was to be assessed up to 60 months using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30. Data for the economic analysis, including cost information and the EQ-5D were also collected. Patients in the observation (OBS) group had significantly better mean follow-up quality of on five dimensions of the EORTC QLQ-C30 functional scales: role functioning (P = 0.033), emotional functioning (P = 0.003), cognitive functioning (P = 0.001), social functioning (P = 0.003) and global health status (P = 0.001). Patients in the OBS group had significantly better mean follow-up symptom scores on seven dimensions of the EORTC QLQ-C30 V1 symptom scales. Economic data showed that costs were 3066 pounds higher in the interferon group and produces an incremental cost per quality-adjusted life year of 41,432 pounds at 5 years. The results show that interferon has significant effects on QoL and symptomatology and is unlikely to be cost-effective in this patient group in the UK.

Randomized Phase II Study Comparing Thalidomide With Medroxyprogesterone Acetate in Patients With Metastatic Renal Cell Carcinoma

Purpose

To investigate escalating doses of thalidomide compared with medroxyprogesterone in patients with metastatic renal cell carcinoma (RCC), who had either progressed after first-line immunotherapy or who were not suitable for immunotherapy.

Patients and Methods

Thalidomide was started at 100 mg/d orally (PO) and escalated by 100 mg/d every 2 weeks to the maximum dose of 400 mg/d. Medroxyprogesterone was given at a fixed dose of 300 mg PO daily.

Results

Sixty patients were entered (thalidomide:medroxyprogesterone = 29:31; median age, 59 [thalidomide], 60 [medroxyprogesterone]; No. of patients assessable for response, 22 [thalidomide], 26 [medroxyprogesterone]). In the thalidomide arm, there was no objective response seen. The best response was SD in three patients lasting 5+, 6+, and 12 months, respectively. All patients in the medroxyprogesterone arm progressed. There was no difference in overall survival between the two arms; median survival in the thalidomide arm was 8.2 months compared with 4.8 months in the medroxyprogesterone arm (P = .62). Hazard ratio was 0.88 (95% CI, 0.67 to 1.94). Median duration of treatment was 73 days (range, 14 to 364 days) in the thalidomide arm, and 84 days (range, 7 to 175 days) in the medroxyprogesterone arm. The high incidence of toxicity in the thalidomide arm, mainly somnolence, constipation, fatigue and paraesthesia, meant that only 30.8% of patients were able to tolerate the maximum dose of 400 mg/d of treatment.

Conclusion

Thalidomide is not superior to medroxyprogesterone acetate in patients with metastatic RCC. Its risk/benefit ratio does not favor its use in this patient population.

Comparison of ABVD and Alternating or Hybrid Multidrug Regimens for the Treatment of Advanced Hodgkin's Lymphoma: Results of the United Kingdom Lymphoma Group LY09 Trial (ISRCTN97144519)

Purpose

To perform an open-label, randomized, controlled trial comparing treatment with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) with two multidrug regimens (MDRs) for advanced Hodgkin's lymphoma (HL).

Patients and Methods

Eight hundred seven patients with advanced HL (stage III to IV, or earlier stage with systemic symptoms or bulky disease) were randomly assigned between ABVD and MDR specified before randomization as alternating chlorambucil, vinblastine, procarbazine, and prednisolone (ChlVPP) with prednisolone, doxorubicin, bleomycin, vincristine, and etoposide (PABIOE), or hybrid ChlVPP/etoposide, vincristine, and doxorubicin (EVA). Radiotherapy was planned for incomplete response or initial bulk disease.

Results

At 52 months median follow-up, 212 event-free survival (EFS) events (disease progression or any death) were reported. In the primary comparison, at 3 years EFS was 75% (95% CI, 71% to 79%) for ABVD and 75% (95% CI, 70% to 79%) for MDRs (hazard ratio [HR] = 1.05; 95% CI, 0.8 to 1.37; HR more than 1.0 favors ABVD). The 3-year overall survival (OS) rates were 90% (95% CI, 87% to 93%) in patients allocated ABVD and 88% (95% CI, 84% to 91%) in patients allocated MDRs (HR = 1.22; 95% CI, 0.84 to 1.77). Patients receiving MDRs experienced more grade 3/4 infection, mucositis, and neuropathy. One occurrence of myelodysplastic syndrome was reported, but no acute leukemia was reported. When the two MDRs are compared separately with ABVD, neither the alternating nor the hybrid regimen showed a statistically significant difference from ABVD for EFS or OS. Subgroup analysis suggested that MDRs may be associated with poorer outcomes in older patients (heterogeneity test of OS older or younger than 45 years, P = .020).

Conclusion

There was no evidence of significant difference in EFS or OS between ABVD and MDRs in the trial overall or if the two MDR versus ABVD comparisons are considered separately. ABVD remains the standard for treatment of advanced HL.

High-dose chemotherapy and peripheral blood stem cell support in refractory gestational trophoblastic neoplasia

We present retrospectively our experience in the use of high-dose chemotherapy and haematopoietic stem cell support (HSCS) for refractory gestational trophoblastic neoplasia (GTN) in the largest series so far reported. In all, 11 patients have been treated at three Trophoblast Centres between 1993 and 2004. The conditioning regimens comprised either Carbop-EC-T (carboplatin, etoposide, cyclophosphamide, paclitaxel and prednisolone) or CEM (carboplatin, etoposide and melphalan) or ICE (ifosfamide, carboplatin, etoposide). Two patients had complete human chorionic gonadotrophin responses, one for 4 and the other for 12 months. Three patients had partial tumour marker responses for 1–2 months. High-dose chemotherapy and HSCS for GTN is still unproven. Further studies are needed, perhaps in high-risk patients who fail their first salvage treatment.