Specialty Care Advised for Gestational Trophoblastic Neoplasia Failing Monotherapy

NEW YORK AUG 19, 2008 (Reuters Health) - Women with high-risk gestational trophoblastic neoplasia, as well as those who fail initial single-agent therapy, should be referred to a specialized trophoblastic disease center to maximize the chance for cure, physicians at Northwestern University in Chicago recommend.

Gestational trophoblastic neoplasia is one of the most curable of all human tumors, Dr. John R. Lurain and colleagues note in the August issue of Obstetrics & Gynecology. However, inadequate treatment of metastatic disease can reduce survival to less than 20%.

Dr. Lurain's group reviewed records of 408 patients with choriocarcinoma and invasive mole (excluding placental-site tumor) treated at Northwestern's John I. Brewer Trophoblastic Disease Center during two periods, 1962-1978 and 1979-2006.

All cases of nonmetastatic disease were treated successfully, whereas cure rates for metastatic disease improved significantly from 78% prior to 1979 to 92% during the more recent decades. The survival rate also increased from 50% to 75% for patients with brain metastases and from 0 to 73% for those with liver or other intraabdominal metastases.

The investigators identified four factors that influenced resistance to initial chemotherapy: metastatic disease, metastatic sites other than the lung or vagina, prior unsuccessful chemotherapy at another institution, and disease duration > 4 months.

Other factors associated with chemoresistance included a diagnosis of choriocarcinoma, antecedent term gestation, and WHO score of 7 or more.

"The presence of these characteristics suggests provision of aggressive multiagent chemotherapy, often combined with surgery and brain radiation, to maximize the chance for cure," Dr. Lurain and his associates advise.

In such situations, they recommend initial therapy with etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine, "with transition to platinum-etoposide combinations with bleomycin, ifosfamide, or paclitaxel if resistance to initial therapy occurs."

They also advocate a low threshold for referral to a specialized treatment center.

SOURCE:Obstet Gynecol 2008;112:251-258.


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