Gestational Trophoblastic neoplasia: San Gerardo Hospital Monza

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Gestational Trophoblastic neoplasiaSan Gerardo
HospitalMonza

• Dott.ssa Cristina Bonazzi
• Caravaggio, 15-17 Maggio 2008

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GTN MONZA AIMS

• To present an italian experience of consecutive
  cases examinated with uniform diagnostic and
  therapeutic criteria.
• To underline patients features
• To evaluate outcomes - response
• - survival
• - fertility
• - long term
  effects

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GTN MONZA

• From Dicember 1981 to Dicember 2007 we observed
  208 patients, most of them referred from other
  centers.
• We used Charing Cross Hospital criteria to manage
  Hydatidiform Mole and Bagshawes score to stage
  all patients
• Our patients were divided into low, medium and
  high risk
• Biomolecular methods werent available to
  identify antecedent pregnancy so we used
  anamnestic criteria

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Patients score
Age - range 16-54 - median 41
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Chemotherapy

• Low Risk MTX-FA
• Medium Risk - sequential therapy
• - ACT-D
• - VP 16
• - EMA-CO
• High Risk EMA-CO

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Symptoms on admission

• 27 asymptomatic
• 83 vaginal bleeding (8 transfusions)
• 7 dyspnoea/chest pain
• 5 acute abdomen
• 4 haemoftoe/haemoptysis
• 4 pelvic pain
• 1 headache/visual disturbance
• 1 hematuria

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Antecedent pregnancy
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GTN MONZA

• The antecedent pregnancy was an Hydatidiform
  Mole in the 86 in Low Risk, 46 in Medium Risk
  and 35 in High Risk.
• Antecedent term pregnancy was present only in 3
  patients in Low Risk instead of 37 in High.
• In five cases 5 GTN arised from ectopic
  pregnancy.
• In five cases GTN followed termination.

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Interval from index pregnancy
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Pre-treatment serum Beta HCG

• Low risk median 34.949 mU/ml
• (range 0 185.529)
• Beta gt 20.000 mU/ml
• - 26 patients
• - 18/26 (69)
  resistances
• High risk median 227.781 mU/ml
• (range 1896.650.000)

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Metastatic disease
17 isolated lung metastasis and 2 vaginal
metastasis
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Metastatic sites74/208 (36)
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Hystologic diagnosis of Choriocarcinoma
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Low Risk

• 79/129 patients (61) achieved a complete
  response to MTX-FA
• 50/129 patients (39) developed MTX resistance
• The diagnosis of resistance was based on serum
  HCG levels rise in 15
• patients and plateau in 35 patients.
• What are the possible factors related to
  methotrexare resistance?

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Low Risk129 Pts
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Low Risk results

• - 5 patients relapsed, 2 of them belonged MTX
  resistance group.
• All patients achived a complete remission after
  polichemotherapy
• Overall survival was 97
• - 2 patients died for other cancer (lung and
  breast)
• - 1 patient for trophoblastic disease

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High Risk results

• Overall survival was 80
• 8 patients died
• 7 patients (17) disease related death
• - 5 for progression
• - 1 for
  toxicity during first course of therapy
  
• - 1 for
  leukemia (14/12 after completion of
  treatment)
• 1 patient colon cancer without
  evidence of Trophoblatic disease
• What are the possible factors affecting survival?

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High Risk40 Pts
1 leukaemia
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High Risk40 Pts

• The highest the score, the highest the mortality
• In the High Risk group 7 patients died for
  Trophoblastic disease
• Number of Deaths
• - SCORE 10-13 0/13
• 14-20
  2/15
• gt 20
  5/11
• 
  7/39

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Fertility208 Pts

• Surgical treatment
• Non conservative 56 patients
• Conservative 152 patients
• - 127 Term pregnancies in 84 pts
• - 34 Miscarriages in 26 pts
• - 2 Hydatidiform moles
• - 6 Terminations

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Second tumors

• 1 VP16 / 1 EMA-CO
• ( ) Death for cancer

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Conclusion

• GTN challenging disease
• Progress made in diagnosis and treatment of the
  disease
• Importance of Referral Centers
• Importance of a Registration system from a
  clinical and research point