Treatment of low risk gestational trophoblastic disease

Role of Adjuvant Hysterectomy in Management of High-Risk Gestational Trophoblastic Neoplasia

Objectives

The objectives of the study were to investigate the role of and indications for adjuvant hysterectomy in patients with high-risk gestational trophoblastic neoplasia.

Methods

We retrospectively analyzed records of patients identified as having undergone adjuvant hysterectomy for high-risk gestational trophoblastic neoplasia at First Hospital of Xi’an Jiaotong University, Xi’an, China, between 1985 and 2005. Therapeutic response was defined as complete with normalization of human chorionic gonadotropin (hCG) concentration, partial response with a decrease of more than 50%, and no response with a decrease of 50% or less. Complete remission was defined as normal hCG at 3 consecutive weekly assays without clinical evidence of disease.

Results

A total of 21 patients (72.4%) showed an initial therapeutic response after surgery and 8 (27.6%) had no response. The initial therapeutic response was complete in 8 patients (27.6%) and partial in 13 (44.8%). During follow-up of 6 to 168 months, all 21 patients with an initial response and 2 of 8 patients without an initial response ultimately achieved complete remission (23 of 29 patients, 79.3%). Three patients (10.3%) had recurrence after primary remission; 2 patients (6.90%) died. Metastases outside of lungs or pelvic organs, number of metastases, presurgery chemoresistance to multidrug regimens, especially with 2 or more failed protocols, were considered possible reasons for decreased effectiveness of hysterectomy.

Conclusions

Our study suggests that timely adjuvant hysterectomy is likely to benefit cautiously selected patients with high-risk gestational trophoblastic neoplasia. Although preoperative metastases limited to pelvic organs or lungs should not be considered an absolute contraindication, adjuvant hysterectomy should generally not be performed in the presence of distant metastases beyond the pelvic organs and lungs.

Comparison of pulsed actinomycin D versus 5-day methotrexate for the treatment of low-risk gestational trophoblastic disease

OBJECTIVE

To determine the effectiveness of 2 standard chemotherapy regimens for low-risk gestational trophoblastic disease according to the International Federation of Gynecology and Obstetrics (FIGO) staging system.

METHODS

From 2008 until 2010, 75 women with low-risk gestational trophoblastic disease received either pulsed actinomycin D (n=50) or 5-day methotrexate (n=25). The primary remission rate, the duration of treatment, the number of treatment courses, and the adverse effects were compared.

RESULTS

The complete remission rates were 90% for the actinomycin D group and 68% for the methotrexate group (P=0.018). The mean number of chemotherapy courses administered to achieve complete remission (including courses of second-line therapy) was 3.1 in the methotrexate group and 5.3 in the actinomycin D group (P=0.01). No major adverse effects were experienced in either treatment group and there were no significant differences in terms of adverse effects. Second-line chemotherapy was indicated for 11 patients.

CONCLUSION

Based on the present study, pulsed actinomycin D seems to be an appropriate first-line treatment for patients with low-risk gestational trophoblastic disease.

Combination chemotherapy with 5-fluorouracil, methotrexate and etoposide for patients with high-risk gestational trophoblastic tumors: A report based on our 11-year clinical experiences

OBJECTIVES

To evaluate the efficacy, toxicity, and survival of patients with high-risk gestational trophoblastic tumors (GTTs) treated with the 5-fluorouracil (5-FU), methotrexate (MTX) and etoposide (VP-16) regimen.

METHODS

Between 1992 and 2003, 26 consecutive patients with FIGO-defined high-risk GTTs were treated with 5-FU, MTX and VP-16 regimen. Among them, 9 patients had received prior chemotherapy. Remission rate, causes of treatment failure, and toxicity were analyzed retrospectively.

RESULTS

After treatment with 5-FU, MTX and VP-16 regimen, 21 of 26 gained complete respond (80.8%). Two patients were performed adjuvant hysterectomy and both cured ultimately. Five developed resistance (19.2%), and 1 died of widespread metastases (3.8%). All 5 patients who developed resistance were treated with multidrug regimen of etoposide, methotrexate, and actionmycin D alternating with cyclophosphamide and vincristine (the EMA/CO); 4 were salvaged and 1 died of refractory disease. No ones relapsed. WHO grade 4 leukocytopenia and thrombocytopenia with the 5-FU, MTX and VP-16 regimen occurred in 9.0% and 2.4%, respectively, of the total 167 cycles; other toxic effects were acceptable and manageable. With mean follow up of 37 months, neither relapse nor secondary tumor was observed.

CONCLUSIONS

According to our 11 years of clinical observation, 5-FU, MTX and VP-16 chemotherapy is one of effective multiagent regimen for patients with high-risk GTTs. Its toxicity is mild and manageable. For patients with high-risk and refractory GTTs, this new triple salvage chemotherapy regimen may be an effective alternative.