Experience of the gynecologic oncology unit at Ain Shams University in the treatment of gestational trophoblastic tumors

The aim of the study is to evaluate the different treatment modalities in the management of gestational trophoblastic tumors (GTT) in a tertiary care setting. One hundred and twenty patients between 16 and 55 years of age (mean 30.6) diagnosed and treated for GTT at the Gynecologic Oncologic Unit, Ain Shams University, between June 1992 and November 1998 were studied. The mean parity of the group was 2.5 (0-12) with a mean follow-up of 47.4 months (16-96). One hundred cases (83.3%) followed a molar pregnancy, while 17 (14.2%) and three (2.5%) had an antecedent abortion and term pregnancy, respectively. By adopting the National Institutes of Health Classification due to its practicality, 65 (54.1%) were nonmetastatic and 55 (45.9%) were metastatic; 17 (14.2%) low-risk metastatic and 38 (31.7%) high-risk metastatic. Forty-two patients (35%) had a hysterectomy, which was curative in 16 (13.3%). In the high-risk metastatic group, 22 patients were treated with EMA achieving a complete stable remission in 19 (86.3%) with one of the remaining three being salvaged by EMA-EP. One hundred fourteen (95%) patients are alive and well without evidence of disease with all six deaths occurring in the high-risk metastatic group. One of the deaths was due to unrelated disease (repeat variceal hemorrhage from portal hypertension), while the remaining five followed nonmolar pregnancies with four having brain and/or liver metastases and another presenting with resistant fatal acute respiratory distress syndrome (ARDS) despite optimal support. By using multivariate analysis, it was found that only the presence of brain and/or liver metastases, followed by an antecedent nonmolar pregnancy and resistance to multiple agent chemotherapy were significant as regards the prognosis of high-risk metastatic GTT. These tumors are highly curable with death almost limited to those with brain and/or liver metastases, particularly following nonmolar pregnancies. In these extremely high-risk categories, elaboration of more intensive and innovative combination chemotherapy protocols is needed in order to achieve better results than those currently reported. In addition the use of EMA instead of EMA-CO deserves to be tested in properly randomized controlled collaborative studies to reduce treatment toxicity.