Gestational trophoblastic neoplasia (GTN) is a proliferative malignant process arising from abnormal fertilization that has the potential to develop into an invasive cancer. This study reviewed 221 cases of GTN treated over 30 years at a hospital in Saudi Arabia. The results showed that GTN is highly sensitive to chemotherapy, with an overall survival rate of 97% and complete response rates of 90% for low-risk and 73% for high-risk patients. Prognostic factors associated with decreased response to initial chemotherapy and survival included advanced FIGO stage, presence of metastases other than lung/vagina, and high-risk prognostic score. With proper treatment, patients can expect a normal ability to become pregnant in the future.

1. H. ALHusaini, H. Soudy, A. Darwish, M. Ahmed, H. Al-hashem, A. Omar,
I. Madkhaly, W. Elghamry, W. Edesa, A. Eltigani, T. Elhassan, S. Alhayli.
A. Albadawi

2. Gestational trophoblastic neoplasia
 Proliferative process arising from aberrant fertilization
event that has potential to develop into invasive
malignant neoplasm
 Include: persistent/invasive mole, choriocarcinoma,
placental site trophoblastic tumors and epitheloid
trophoblastic tumor
 Highly sensitive to chemotherapy and most curable
cancer (>90%)
 Therapeutic decision is based on anatomic staging and
prognostic score
 Low-risk group can be treated with single agent
chemotherapy while high-risk group require
combination chemotherapy

3. Aim of study
 Review our clinical experience in the treatment of
malignant GTN over the past 30 years at King Faisal
Specialist Hospital
 To evaluate complete response rate to chemotherapy,
and to analyze risk factors affecting patient’s response
and overall survival

4. Methods
 Retrospective study
 221 women were identified
 Diagnosed to have GTN post molar, abortion, or full-
term pregnancy (excluding placental site and
epithelioid trophoblastic tumor)
 Treated at KFSH, between 1979 and 2010

5. Patients characteristics

6. Variable Number=221
Median age (range)
<40
≥40
37 (14-55)
135 (61%)
86 (39%)
Antecedent pregnancy
hydatidiform mole
abortion
term pregnancy
other
157 (71%)
27 (12%)
30 (14%)
7 (3%)
Interval
<4months
4-6 months
7-12 months
>12 months
unknown
130 (59%)
39 (18%)
14 (6%)
31 (14%)
7 (3%)
Pretreatment hCG
<1000
1000- <10000
10000-<100000
≥100000
unknown
29 (13%)
43(20%)
72 (33%)
69 (31%)
8 (4%)
Clinicopathologic type
persistent/invasive GTN
choriocarcinoma
unknown
103 (46.6%)
117 (53%)
1 (0.4%)

7. Variable Number (%)
Previous chemotherapy outside
NO
Yes
175 (79%)
46 (21%)
FIGO stage
I
II
III
IV
91 (41%)
17 (8%)
86 (39%)
27 (12%)
Prognostic score
Low risk
High risk
unknown
131 (59%)
88 (40%)
2 (1%)
Radiation therapy
Yes
No
unknown
17 (8%)
203 (92%)
1(0.4%)
Surgery
NO
Yes
 Uterine evacuation
 hysterectomy
 Metastatectomy
16 (7%)
203 (92%)
158 (71%)
71 (32%)
8 (4%)

8. Results
 Median follow-up was 39 months
 5-year overall survival was 97%
 overall survival rate of low-risk: 100%
 overall survival rate of high-risk: 92%

9. Disease category/ chemotherapy Patients
number
Complete remission (%)
Low risk 131 CR1: 91 (69.5%)
Single-agent methotrexate 73 39(53%)
Single-agent dactinomycin 23 20 (87%)
Combination chemotherapy
(EMA-CO or BEP or MAC)
35 32 (91%)
Low risk: salvage chemotherapy
Single-agent dactinomycin 11 9 (82%)
Single-agent methotrexate 2 1 (50%)
EMA-CO 8 6 (75%)
MAC 3 1(33%)
BEP or EP 12 7(58%)
VeIP 2 2(100%)
VIP 2 1(50%)
Overall CR:
118 (90%)

10. Disease category/ chemotherapy Patients
number
Complete remission (%)
High risk 88 CR1: 50 (57%)
EMA-CO 16 15 (94%)
BEP 19 10 (53%)
Etoposide/cisplatin/actinomycin 20 14 (70%)
MAC 7 2(28.5%)
High risk: salvage chemotherapy
EMA-CO 6 3 (50%)
EMA-EP 2 2(100%)
BEP or EP 7 5(71%)
MAC 8 1(12.5%)
VeIP 8 1(12.5%)
VIP 4 2 (50%)
Overall CR:
64 (73%)

11.  Recurrence after complete remission occurred in 6
(3%) patients
 Median time to relapse was 4 months

12. Prognostic factors Number (%) OR for response to initial chemotherapy
(95% CI)
P-value Overall
survival
P-value
Type of pregnancy
molar
non-molar
157 (71%)
64 (29%)
0.9 (0.5-1.8)
1.0
0.9 98%
93%
0.04
Metastatic sites
lung or vagina
other sites
91 (41%)
35 (16%)
1.0
0.38 (0.87-1.74)
0.02 98%
85%
0.002
Prognostic score
Low
High
131 (59%)
88 (40%)
1.7 (0.9-3.0)
1.0
0.05 100%
92%
0.01
FIGO stage
I-II
III-IV
108 (49%)
113 (51%)
1.0
0.4 (0.2-0.7)
0.005 100%
94%
0.02
Age
<40
≥40
135 (61%)
86 (39%)
1.0
0.9 (0.5-1.5)
0.8 96%
97%
0.7
Pretreatment hCG
<1000
1000- <10000
10000-<100000
≥100000
29 (13%)
43 (20%)
72 (33%)
69 (31%)
1.0
1.1 (0.3-3.2)
0.4 (0.1-1.08)
0.67 (0.2-1.7)
0.08
0.8
0.07
0.4
100%
97%
98%
95%
0.6
Interval
<4months
4-6 months
7-12 months
>12 months
130 (59%)
39 (18%)
14 (6%)
31 (14%)
1.0
2 (0.8-4.6)
0.6 (0.2-1.8)
1.0 (0.48-2.4)
0.2
0.09
0.3
0.8
98%
97%
92%
90%
0.3
Chemo-outside
NO
Yes
175 (79%)
46 (21%)
1.0
1.1 (0.5-2.1)
0.5 96.3%
97.5%
0.75
Univariate Logistic regression analysis of prognostic factors for CR to initial chemotherapy and OS

13. Fertility outcome
 38 (17%) patients became pregnant
 13 of these pregnant were of high-risk group
 24 (63%) delivered babies without congenital
malformations.
 Abnormal pregnancies occurred in 7 (18%) patients:
 miscarriage (n=5)
 stillbirth (n=2)
 molar pregnancy (n=1)

14. Conclusion
 Patients with GTN have excellent prognosis if properly treated
at experienced centers
 Single-agent dactinomycin seems more effective than single
agent methotrexate with higher complete response rate at low-
risk groups
 EMACO is the preferred chemotherapy for high-risk groups
 Factors that significantly associated with resistant to initial
chemotherapy were advanced FIGO stage, presence of
metastatic disease other than lung and vagina and high-risk
prognostic score
 Survival was also significantly influenced by type of
antecedent pregnancy, FIGO stage, prognostic score and site of
metastases
 Patients can anticipate a normal future reproductive outcome