Management of metastatic high-risk gestational trophoblastic neoplasia figo stages II-IV: Risk factor score ≥ 7

OBJECTIVE: To evaluate treatment of metastatic highrisk gestational trophoblastic neoplasia (GTN), including durable complete response rates to chemotherapy, factors affecting response to therapy, and overall survival. STUDY DESIGN: Forty women with metastatic highrisk GTN (International Federation of Gynecology and Obstetrics [FIGO] stages II-IV, score ≥ 7) completed treatment between 1986 (when EMA-CO became the standard chemotherapy for high-risk disease) and 2009, including 26 who were treated primarily and 14 who were treated secondarily. Patients who had incomplete responses or developed resistance to EMA-CO or other methotrexate-containing regimens were treated with drug combinations employing etoposide and a platinum agent with or without bleomycin or ifosfamide. Adjuvant radiotherapy and surgery were used in selected patients. Clinical response and survival as well as factors affecting outcomes were analyzed retrospectively. RESULTS: The overall survival rate was 90% (36 of 40): 92% (24/26) for primary treatment and 86% (12/14) for secondary treatment. Twenty-one patients (53%) had durable complete clinical responses to initial treatment, 15 patients (37%) developed resistance to initial chemotherapy but were subsequently placed into lasting remission with platinumbased chemotherapy with or without surgery and 4 patients (10%) died of widespread metastatic disease. Durable complete clinical response to initial chemotherapy was significantly influenced by FIGO stage (II and III, 63%, vs. IV, 31%, p=0.05) and risk factor score (< 12, 71%, vs. ≥ 12, 32%, p<0.02). Survival was also significantly associated with both FIGO stage (II and III, 100%, vs. IV, 69%, p<0.01) and score (< 12, 100%, vs. ≥ 12, 79%, p<0.05). CONCLUSION: The use of EMA-CO chemotherapy as primary treatment and platinum-based chemotherapy along with surgical excision of resistant disease as secondary treatment for patients with metastatic high-risk GTN resulted in a survival rate of 90%. All patients who died had FIGO stage IV and risk factors scores ≥ 12.