Gestational trophoblastic disease (GTD) is a term that incorporates a rare but important spectrum of disorders that may complicate pregnancy. GTD is most commonly associated with an abnormal conception (either a complete or partial hydatidiform mole or more rarely choriocarcinoma) but it may follow a normal delivery or non-molar abortion. Choriocarcinoma following a live birth is said to have an incidence of 1 in 50 000 births (Bagshawe et al, 1986) and to be associated with a poor prognosis (Bagshaw, 1976;Tidy et al, 1995;Bower et al, 1997). We have evaluated our experience in the management of post-partum choriocarcinoma by undertaking a retrospective analysis of all patients registered and treated for persistent trophoblastic disease (PTD) between 1987 and 1996 at Weston Park Hospital, specifically identifying those patients with post-partum choriocarcinoma. METHODSThe Weston Park Hospital database of gestational trophoblastic tumours was used to identify all women treated for histologically confirmed choriocarcinoma. Patients who presented following full-term non-molar pregnancy had their case notes studied to identify patient demographics, obstetric history, presentation, treatment and outcome.Our current management policy on referral of patients with PTD is to review and confirm the histological diagnosis of choriocarcinoma: the patient undergoes a prognostic risk assessment including full physical examination, imaging [ultrasound pelvis and abdomen, computed tomography (CT) thorax, chest X-ray] and serum β human chorionic gonadotrophin (βhCG) evaluation prior to initiation of treatment as determined by our modified Charing Cross prognostic scoring system (Sheridan et al 1993). Those patients at high risk of central nervous system involvement also undergo a CT scan of the head and a lumbar puncture (provided there is no evidence of increased intra-cranial pressure) to determine the cerebro-spinal fluid:serum βhCG ratio. RESULTSBetween January 1987 and December 1996, 225 women with PTD were treated at Weston Park Hospital. Thirty-one patients received high risk chemotherapy. In nine patients (29%) the antecedent pregnancy was a full-term non-molar pregnancy. In this group, the median age was 29 years (range 22-37), and eight of nine women were multiparous. There was no sexual preponderance in the antecedent pregnancy (four male, five female).The time interval from antecedent pregnancy to onset of symptoms ranged from 0 to 12 weeks (median 2 weeks). All nine patients presented with abnormal vaginal bleeding. In four cases this was persistent from the time of delivery, while in the other five cases the post-partum haemorrhage commenced at a median of 5 weeks after delivery (range 2-12 weeks). Only two women experienced lower abdominal pain.The interval between the antecedent pregnancy and registration for treatment ranged from 5-25 weeks (median 10 weeks). In one case 24 weeks elapsed before referral. The patient underwent three uterine evacuations and only during the final operation was tissue sent for histo...

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Summary Persistent gestational trophoblastic disease is potentially fatal, but the majority of patients are cured with chemotherapy. Any developments in treatment are therefore being directed towards maintaining efficacy and reducing toxicity. We evaluated efficacy and toxicity of methotrexate, etoposide and dactinomycin (MEA) as first-line therapy for high risk disease and etoposide and dactinomycin (EA) as second-line therapy for methotrexate-refractory low risk disease in a retrospective analysis of 73 patients (38 MEA, 35 EA) treated since 1986 at a supra-regional centre. The median follow-up period was 5.5 years and the median number of cycles received was 7. The overall complete response rate was 85% (97% for EA, 75% for MEA). Of eight patients who failed to respond, four have since died and four were cured with platinum-based chemotherapy. Alopecia was universal. Grade II or worse nausea, emesis, or stomatitis was observed in 29%, 30% and 37% respectively. Fifty-one per cent experienced grade II/III anaemia, 8% grade II or higher thrombocytopenia and 64% grade III or IV neutropenia; in six cases this was complicated by sepsis. Fifty-four per cent of patients went on to have a normal pregnancy. No patient has developed a second malignancy. In conclusion, the MEA and EA chemotherapy regimens for persistent trophoblastic disease are very well tolerated, do not appear to affect future fertility and are associated with excellent, sustained complete response rates.

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