Outcomes in the management of high-risk gestational trophoblastic neoplasia in trophoblastic disease centers in South America

Abstract

BackgroundSouth America has a higher incidence of gestational trophoblastic disease than North America or Europe, but whether this impacts chemotherapy outcomes is unclear. The purpose of this study was to evaluate outcomes among women with high-risk gestational trophoblastic neoplasia (GTN) treated at trophoblastic disease centers in developing South American countries.MethodsThis retrospective cohort study included patients with high-risk GTN treated in three trophoblastic disease centers in South America (Botucatu and Rio de Janeiro, Brazil, and Buenos Aires, Argentina) from January 1990 to December 2014. Data evaluated included demographics, clinical presentation, FIGO stage, WHO prognostic risk score, and treatment-related information. The primary treatment outcome was complete sustained remission by 18 months following completion of therapy or death.ResultsAmong 1264 patients with GTN, 191 (15.1%) patients had high-risk GTN and 147 were eligible for the study. Complete sustained remission was ultimately achieved in 87.1% of cases overall, including 68.4% of ultra high-risk GTN (score ≥12). Early death (within 4 weeks of initiating therapy) was significantly associated with ultra high-risk GTN, occurring in 13.8% of these patients (p=0.003). By Cox’s proportional hazards regression, factors most strongly related to death were non-molar antecedent pregnancy (RR 4.35, 95% CI 1.71 to 11.05), presence of liver, brain, or kidney metastases (RR 4.99, 95% CI 1.96 to 12.71), FIGO stage (RR 3.14, 95% CI 1.52 to 6.53), and an ultra-high-risk prognostic risk score (RR 7.86, 95% CI 2.99 to 20.71). Median follow-up after completion of chemotherapy was 4 years. Among patients followed to that timepoint, the probability of survival was 90% for patients with high-risk GTN (score 7–11) and 60% for patients with ultra-high-risk GTN (score ≥12).ConclusionTrophoblastic disease centers in developing South American countries have achieved high remission rates in high-risk GTN, but early deaths remain an important problem, particularly in ultra-high-risk GTN.

Management of liver and brain metastases in ultra-high-risk patients with gestational trophoblastic neoplasia: a single-center experience

“…Several series have also suggested that the use of low-dose induction etoposide and cisplatin may benefit GTN patients with a FIGO score [? ]13 2,6,12,20,21 , especially if their increased risk score is due to a large tumor burden or metastases to the brain, liver, or extensive metastases 6,14 owing to hemorrhagic sequelae at the tumor sites 22 .…”

“…The long-term survival is only 27% when there is metastasis to the liver, 70% with brain metastases, and 10% with both sites of metastasis 4,7 . The presence of liver, brain, or kidney metastases (relative risk [RR] 4.99, 95% confidence interval [CI] 1.96-12.71) is the strongest risk factor for death in patients with GTN 2,8 .…”

Clinical Presentation, Treatment Outcomes, and Resistance-related Factors in South American Women with Low-risk Postmolar Gestational Trophoblastic Neoplasia

“…7 Metastases at other sites were investigated as described elsewhere. 17 The hCG tests used for monitoring response to treatment were Abbott Architect (Centro de Doenças Trofoblásticas de Botucatu) and Roche Elecsys (Durand Trophoblastic Disease Center). At Oncólogos del Occidente S.A., kits by different manufacturers were used (Abbott Architect, Roche Elecsys, Siemens Immulite).…”

“…12 It is important to emphasize that prompt chemotherapy treatment with appropriate regimens and fixed and timely intervals between chemotherapy cycles limits the development of resistance and the exposure of most patients to multi-agent chemotherapy. 13,14 There are few studies on GTN treatment response in South American patients, [15][16][17][18] and most of them are single-center, hospital-based. 19 The difficulties in carrying out multicentric studies in South American countries include socioeconomic and cultural diversities, as well as language barriers (Portuguese, Spanish, English).…”

“…There are few studies on GTN treatment response in South American patients, 15 16 17 18 and most of them are single-center, hospital-based. 19 The difficulties in carrying out multicentric studies in South American countries include socioeconomic and cultural diversities, as well as language barriers (Portuguese, Spanish, English).…”