H. ALHusaini, H. Soudy, A. Darwish, M. Ahmed, H. Al-hashem, A. Omar, I. Madkhaly, W. Elghamry, W. Edesa, A. Eltigani, T. Elhassan, S. Alhayli.
A. Albadawi
Gestational trophoblastic neoplasia Proliferative process arising from aberrant fertilization
event that has potential to develop into invasive malignant neoplasm
Include: persistent/invasive mole, choriocarcinoma, placental site trophoblastic tumors and epitheloidtrophoblastic tumor
Highly sensitive to chemotherapy and most curable cancer (>90%)
Therapeutic decision is based on anatomic staging and prognostic score
Low-risk group can be treated with single agent chemotherapy while high-risk group require combination chemotherapy
Aim of study Review our clinical experience in the treatment of
malignant GTN over the past 30 years at King Faisal Specialist Hospital
To evaluate complete response rate to chemotherapy, and to analyze risk factors affecting patient’s response and overall survival
Methods Retrospective study 221 women were identified Diagnosed to have GTN post molar, abortion, or full-
term pregnancy (excluding placental site and epithelioid trophoblastic tumor)
Treated at KFSH, between 1979 and 2010
Patients characteristics
Variable Number=221
Median age (range)<40≥40
37 (14-55)135 (61%)86 (39%)
Antecedent pregnancyhydatidiform moleabortionterm pregnancyother
157 (71%)27 (12%)30 (14%)7 (3%)
Interval <4months4-6 months7-12 months>12 monthsunknown
130 (59%)39 (18%)14 (6%)31 (14%)7 (3%)
Pretreatment hCG<10001000- <1000010000-<100000≥100000unknown
29 (13%)43(20%)72 (33%)69 (31%)8 (4%)
Clinicopathologic typepersistent/invasive GTNchoriocarcinomaunknown
103 (46.6%)117 (53%)1 (0.4%)
Variable Number (%)
Previous chemotherapy outsideNOYes
175 (79%)46 (21%)
FIGO stageIIIIIIIV
91 (41%)17 (8%)86 (39%)27 (12%)
Prognostic score Low riskHigh riskunknown
131 (59%)88 (40%)2 (1%)
Radiation therapyYesNo
unknown
17 (8%)203 (92%)1(0.4%)
SurgeryNOYes
Uterine evacuation hysterectomy Metastatectomy
16 (7%)203 (92%)158 (71%)71 (32%)8 (4%)
Results Median follow-up was 39 months 5-year overall survival was 97%
overall survival rate of low-risk: 100% overall survival rate of high-risk: 92%
Disease category/ chemotherapy Patientsnumber
Complete remission (%)
Low risk 131 CR1: 91 (69.5%)
Single-agent methotrexate 73 39(53%)
Single-agent dactinomycin 23 20 (87%)
Combination chemotherapy(EMA-CO or BEP or MAC)
35 32 (91%)
Low risk: salvage chemotherapy
Single-agent dactinomycin 11 9 (82%)
Single-agent methotrexate 2 1 (50%)
EMA-CO 8 6 (75%)
MAC 3 1(33%)
BEP or EP 12 7(58%)
VeIP 2 2(100%)
VIP 2 1(50%)
Overall CR:118 (90%)
Disease category/ chemotherapy Patientsnumber
Complete remission (%)
High risk 88 CR1: 50 (57%)
EMA-CO 16 15 (94%)
BEP 19 10 (53%)
Etoposide/cisplatin/actinomycin 20 14 (70%)
MAC 7 2(28.5%)
High risk: salvage chemotherapy
EMA-CO 6 3 (50%)
EMA-EP 2 2(100%)
BEP or EP 7 5(71%)
MAC 8 1(12.5%)
VeIP 8 1(12.5%)
VIP 4 2 (50%)
Overall CR:64 (73%)
Recurrence after complete remission occurred in 6 (3%) patients
Median time to relapse was 4 months
Prognostic factors Number (%) OR for response to initial chemotherapy(95% CI)
P-value Overall survival
P-value
Type of pregnancymolarnon-molar
157 (71%)64 (29%)
0.9 (0.5-1.8)1.0
0.9 98%93%
0.04
Metastatic siteslung or vaginaother sites
91 (41%)35 (16%)
1.00.38 (0.87-1.74)
0.02 98%85%
0.002
Prognostic scoreLowHigh
131 (59%)88 (40%)
1.7 (0.9-3.0)1.0
0.05 100%92%
0.01
FIGO stageI-IIIII-IV
108 (49%)113 (51%)
1.00.4 (0.2-0.7)
0.005 100%94%
0.02
Age <40≥40
135 (61%)86 (39%)
1.00.9 (0.5-1.5)
0.8 96%97%
0.7
Pretreatment hCG<10001000- <1000010000-<100000≥100000
29 (13%)43 (20%)72 (33%)69 (31%)
1.01.1 (0.3-3.2)0.4 (0.1-1.08)0.67 (0.2-1.7)
0.080.80.070.4
100%97%98%95%
0.6
Interval <4months4-6 months7-12 months>12 months
130 (59%)39 (18%)14 (6%)31 (14%)
1.02 (0.8-4.6)0.6 (0.2-1.8)1.0 (0.48-2.4)
0.20.090.30.8
98%97%92%90%
0.3
Chemo-outsideNO
Yes175 (79%)46 (21%)
1.01.1 (0.5-2.1)
0.5 96.3%97.5%
0.75
Univariate Logistic regression analysis of prognostic factors for CR to initial chemotherapy and OS
Fertility outcome 38 (17%) patients became pregnant
13 of these pregnant were of high-risk group 24 (63%) delivered babies without congenital
malformations. Abnormal pregnancies occurred in 7 (18%) patients:
miscarriage (n=5) stillbirth (n=2) molar pregnancy (n=1)
Conclusion Patients with GTN have excellent prognosis if properly treated
at experienced centers Single-agent dactinomycin seems more effective than single
agent methotrexate with higher complete response rate at low-risk groups
EMACO is the preferred chemotherapy for high-risk groups Factors that significantly associated with resistant to initial
chemotherapy were advanced FIGO stage, presence of metastatic disease other than lung and vagina and high-risk prognostic score
Survival was also significantly influenced by type of antecedent pregnancy, FIGO stage, prognostic score and site of metastases
Patients can anticipate a normal future reproductive outcome