Gestational trophoblastic disease: treatment results at the Brewer Trophoblastic Disease Center.

Three hundred fifty-nine patients with gestational trophoblastic disease (choriocarcinoma and invasive mole) received complete treatment at the Brewer Trophoblastic Disease Center of Northwestern University Medical School from 1962 through 1978. Data were gathered as of December 31, 1978, to permit a minimum follow-up of 2 years. An overall remission rate of 92% was achieved: 100% (185/185) for nonmetastatic disease and 83% (144/174) for metastatic disease. All 200 patients with invasive mole and 129 of 159 patients (81%) with choriocarcinoma were cured. Chemotherapy was the main form of treatment, with adjuvant surgery and radiation therapy being used in selected patients. Five factors were determined to significantly influence response to treatment in patients with metastatic disease: 1) clinicopathologic diagnosis of choriocarcinoma versus invasive mole (71 versus 100%, P much less than .0005); 2) pretreatment human chorionic gonadotropin titer greater than 100,000 IU/liter and time greater than 4 months from pregnancy event to treatment (62 versus 93%, P much less than .0005); 3) metastases to sites other than lung and/or vagina (37 versus 92%, P much less than .0005); 4) antecedent term gestation compared with hydatidiform mole, abortion, and ectopic pregnancy (56 versus 79%, P less than .02); and 5) prior unsuccessful chemotherapy compared with no previous treatment (48 versus 83%, P much less than .0005). The value of secondary chemotherapy and adjuvant irradiation was evaluated. Relapse from remission was also studied.

Gestational trophoblastic disease. The effect of duration of disease and hCG titer on response to therapy.

The height of the pretreatment hCG titer and the time interval from termination of the antecedent pregnancy to institution of treatment were determined in 352 patients with gestational trophoblastic disease in order to judge their effect, both individually and together, on response to therapy. When all patients in need of treatment for gestational trophoblastic disease, both metastatic and nonmetastatic, were considered as one group, examination of time alone, of hCG titer alone and of time and titer together each permitted the identification of patients at high risk with equal reliability (p less than 0.0005 for each). When patients with only metastatic gestational trophoblastic disease were evaluated, time and titer taken separately and together each identified those patients at high risk, but not in an equal manner (time alone, p = 0.02; titer alone, p less than 0.05; time and titer together, p less than 0.0005). Time and hCG titer, alone or in combination, did not have a statistically significant effect on outcome when patients with metastatic choriocarcinoma were considered separately. Other factors, such as metastatic site and antecedent pregnancy, seem to be more important in determining prognosis than duration of disease and hCG titer in this group of patients.

Natural history of hydatidiform mole after primary evacuation.

From 1962 to 1978, 738 patients with hydatidiform mole were referred to the John I. Brewer Trophoblastic Disease Center of Northwestern University for follow-up and human chorionic gonadotropin (hCG) testing after evacuation. There was spontaneous regression of trophoblastic disease in 596 (80.8%) of the 738 patients. Of these 596 patients, regression occurred in 11 (1.8%) by day 10 after evacuation, in 124 (20.8%) between days 11 and 30, in 255 (42.8%) between days 31 and 60, and in 206 (34.6%) between days 61 and 170. Treatment with chemotherapeutic agents was required in 142 (19.2%) of the 738 patients; 125 (16.9%) of these had invasive mole (107 nonmetastatic and 18 metastatic) and 17 (2.3%) had choriocarcinoma (13 nonmetastatic and four metastatic). All 596 patients whose hCG titers declined spontaneously to normal levels have remained well and free of disease. All 142 treated patients experienced permanent remission. Thus, all 738 patients are well and free of disease 4 to 18 years after evacuation of the hydatidiform mole. The follow-up regimen described in this report furnishes information on natural history of molar pregnancies after evacuation and provides an excellent means by which all patients can be safely managed following termination of a hydatidiform mole.

Fatal gestational trophoblastic disease: an analysis of treatment failures.

Forty-eight of 399 patients referred to the John I. Brewer Trophoblastic Disease Center of Northwestern University Medical School from 1962 to 1979 for treatment of gestational trophoblastic disease (invasive mole or choriocarcinoma) died. All patients who died had histologically documented metastatic choriocarcinoma. The time from pregnancy event to treatment was greater than 4 months and/or the pretreatment human chorionic gonadotropin titer was greater than 100,000 IU/L in 64% of these patients. Seventy-one percent of fatal cases developed in association with term pregnancies, abortions, or ectopic pregnancies rather than hydatidiform moles. Fifty percent of patients who died had metastases to the liver, brain, and/or peritoneal cavity when they first presented for treatment. The most common causes of death were hemorrhage from one or more metastatic sites (42%) and pulmonary insufficiency (31%). Factors primarily responsible for the treatment failures in these patients were: (1) presence of extensive disease at the time of initial treatment; (2) inadequate initial treatment; and (3) failure or presently used chemotherapy protocols in advanced disease. Secondary chemotherapy, radiation therapy to sites other than the brain, and adjuvant surgical procedures failed to improve survival in these high-risk patients.