First-line chemotherapy in low-risk gestational trophoblastic neoplasia

Department of Gynaecology, The Galway Clinic, Doughiska, Galway, Ireland.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 07/2012; 7(7):CD007102. DOI: 10.1002/14651858.CD007102.pub3
Source: PubMed


Gestational trophoblastic neoplasia (GTN) is a rare but curable disease. Patients are categorised into low or high risk groups using a variety of scoring systems. The majority of patients with low risk GTN respond to chemotherapy, however, occasionaly patients will die. A large number of regimens are used worldwide in the management of low risk GTN. The choice of the regimen is usually dependent on geographic location, prior training and current experience with the specific regimen. Regimens have significant differences in route of administration, hospitalisation and side effects and so have a bearing on healthcare cost. This review examined the studies, both randomised and non-randomised, that compared the available regimens. We found that bi-weekly "pulsed" dactinomycin was superior to weekly methotrexate in the reported doses. We believe further high quality randomised controlled trials are required to establish the best first line chemotherapy regimen for low risk GTN as the currently used chemotherapy regimens are based on the experience of the treating centres.

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    • "Persistent gestational trophoblastic neoplasia (GTN) includes hydatidiform mole, invasive mole, choriocarcinoma, and placental site tumor derived from the placenta; persistent GTN is a curable disease but can develop into a life-threatening malignancy [1–3]. Dilation-curettage and chemotherapy are suitable treatments for low-risk GTN [4, 5]. "
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    ABSTRACT: β -human chorionic gonadotropin (HCG) level is not a reliable marker for early identification of persistent gestational trophoblastic neoplasia (GTN) after evacuation of hydatidiform mole. Thus, this study was conducted to evaluate β -HCG regression after evacuation as a predictive factor of malignant GTN in complete molar pregnancy. Methods. In this cross-sectional study, we evaluated a total of 260 patients with complete molar pregnancy. Sixteen of the 260 patients were excluded. Serum levels of HCG were measured in all patients before treatment and after evacuation. HCG level was measured weekly until it reached a level lower than 5 mIU/mL. Results. The only predictors of persistent GTN are HCG levels one and two weeks after evacuation. The cut-off point for the preevacuation HCG level was 6000 mIU/mL (area under the curve, AUC, 0.58; sensitivity, 38.53%; specificity, 77.4%), whereas cut-off points for HCG levels one and two weeks after evacuation were 6288 mIU/mL (AUC, 0.63; sensitivity, 50.46%; specificity, 77.0%) and 801 mIU/mL (AUC, 0.80; sensitivity, 79.82%; specificity, 71.64%), respectively. Conclusion. The rate of decrease of HCG level at two weeks after surgical evacuation is the most reliable and strongest predictive factor for the progression of molar pregnancies to persistent GTN.
    Full-text · Article · Mar 2014 · ISRN obstetrics and gynecology
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    • "These include the optimum schedule of methotrexate (MTX) administration, the comparative benefits of single-agent therapy with MTX or dactinomycin for low-risk patients and the appropriate point to locate the cut-off values between low- and high (or intermediate)-risk patients, and hence their initial treatments. However, the development of routinely curative chemotherapy for GTT predates the introduction of randomised clinical trials in cancer treatment by a number of decades, and as these rare illnesses have extremely high cure rates with their established therapies, developing prospective trials remains challenging (Alazzam et al, 2009; Lertkhachonsuk et al, 2009). "
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    ABSTRACT: Background: Post-molar pregnancy gestational trophoblastic tumours (GTT) have been curable with chemotherapy treatment for over 50 years. Because of the rarity of the diagnosis, detailed structured information on prognosis, treatment escalations and outcome is limited. Methods: We have reviewed the demographics, prognostic variables, treatment course and clinical outcomes for the post-mole GTT patients treated at Charing Cross Hospital between 2000 and 2009. Results: Of the 618 women studied, 547 had a diagnosis of complete mole, 13 complete mole with a twin conception and 58 partial moles. At the commencement of treatment, 94% of patients were in the FIGO low-risk group (score 0–6). For patients treated with single-agent methotrexate, the primary cure rate ranged from 75% for a FIGO score of 0–1 through to 31% for those with a FIGO score of 6. Conclusion: In the setting of a formal follow-up programme, the expected cure rate for GTT after a molar pregnancy should be 100%. Prompt treatment and diagnosis should limit the exposure of most patients to combination chemotherapy. Because of the post-treatment relapse rate of 3% post-chemotherapy, hCG monitoring should be performed routinely.
    Full-text · Article · Oct 2012 · British Journal of Cancer
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    • "If first-line treatment fails, treatment with the alternate first-line agent (methotrexate or actinomycin D) or even multiagent chemotherapy are used to attain an overall survival rate of nearly 100% [5]. Treatment is continued until the serum βhCG normalizes (<5 IU/L) for at least three consecutive weeks [31]. "
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    ABSTRACT: Methotrexate was developed in 1949 as a synthetic folic acid analogue to compete with folic acid and thus interfere with cell replication. While initially developed as a potential treatment for acute lymphoblastic leukaemia, a serendipitous observation led to methotrexate's use to effect the dramatic cure of a case of advanced choriocarcinoma. This prompted the exploration for the potential of methotrexate to treat other conditions involving disordered trophoblastic tissue. Methotrexate has subsequently revolutionized the treatment of two pregnancy-related conditions-gestational trophoblastic neoplasia and ectopic pregnancy. This article reviews the development of modern treatment protocols that use methotrexate to medically treat these two important gynaecological conditions.
    Full-text · Article · Feb 2012 · ISRN obstetrics and gynecology
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