Gestational Trophoblastic Disease Treatment (PDQ®): Treatment - Health Professional Information [NCI]-High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment
Gestational Trophoblastic Disease Treatment (PDQ®): Treatment - Health Professional Information [NCI] Guide
Cycles are repeated every 2 weeks (on days 15, 16, and 22) until any metastases present at diagnosis disappear and serum beta-human chorionic gonadotropin (beta-hCG) has normalized, then the treatment is usually continued for an additional three to four cycles.
Results of a large, consecutive case series of 272 patients with up to 16 years of follow-up showed a complete remission rate of 78% using this regimen, and these results are consistent with other case series in the literature that employed EMA/CO.[3] More than two-thirds of the women who did not have a complete response or subsequently had disease recurrence could be salvaged with cisplatin-containing regimens (with or without resection of metastases), yielding a long-term cure rate of 86.2% (95% CI, 81.9%-90.5%).[3][Level of evidence: 3iiA] Among the women who had an intact uterus, about one-half of them retained their fertility. Patients with documented brain metastases received higher doses of systemic methotrexate as part of the EMA component (i.e., etoposide, methotrexate, folinic acid, and dactinomycin) of EMA/CO (1 g/m2 IV for 24 hours, followed by folinic-acid rescue, 15 mg orally every 6 hours for 12 doses starting 32 hours after methotrexate). Patients with brain metastases received an increased dose of systemic methotrexate of 1 g/m2 for 24 hours followed by folinic acid (15 mg orally every 6 hours for 12 doses starting 32 hours after methotrexate). Patients with lung metastases received cranial prophylaxis with irradiation and intrathecal methotrexate 12.5 mg every 2 weeks with the CO (i.e., cyclophosphamide and vincristine) cycles.
Examples of other regimens that have been used include the following:[1]
Brain metastases are associated with poor prognosis, particularly when liver metastases are also present.[6,7,8] However, even patients with brain metastases may achieve long-term remission in 50% to 80% of cases.[3,4,8] Patients with central nervous system (CNS) metastases receive additional therapy simultaneously with the initiation of systemic chemotherapy. Some centers utilize whole-brain irradiation (30 Gy in 2 Gy fractions) with or without intrathecal methotrexate.[6] However, some investigators omit the cranial radiation, relying on replacement of the standard dose of methotrexate in the EMA/CO regimen with the higher dose of 1000 mg/m2 IV for 24 hours on the first day, as noted above, to achieve therapeutic CNS levels.[8]
Gestational Trophoblastic Disease Treatment (PDQ®): Treatment - Health Professional Information [NCI] - High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment
Gestational Trophoblastic Disease Treatment (PDQ®): Treatment - Health Professional Information [NCI] Guide
- General Information About Gestational Trophoblastic Disease
- Cellular Classification of Gestational Trophoblastic Disease
- Stage Information for Gestational Trophoblastic Disease
- Treatment Option Overview
- Hydatidiform Mole (HM) Management
- Low-Risk Gestational Trophoblastic Neoplasia (FIGO Score 0–6) Treatment
- High-Risk Gestational Trophoblastic Neoplasia (FIGO Score ≥7) Treatment
- Placental-Site Gestational Trophoblastic Tumor Treatment
- Epithelioid Trophoblastic Tumor Treatment
- Recurrent or Chemoresistant Gestational Trophoblastic Neoplasia Treatment
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Table 2. Specifics of the EMA/CO Regimena,b,c continued...
Cycles are repeated every 2 weeks (on days 15, 16, and 22) until any metastases present at diagnosis disappear and serum beta-human chorionic gonadotropin (beta-hCG) has normalized, then the treatment is usually continued for an additional three to four cycles.
Results of a large, consecutive case series of 272 patients with up to 16 years of follow-up showed a complete remission rate of 78% using this regimen, and these results are consistent with other case series in the literature that employed EMA/CO.[3] More than two-thirds of the women who did not have a complete response or subsequently had disease recurrence could be salvaged with cisplatin-containing regimens (with or without resection of metastases), yielding a long-term cure rate of 86.2% (95% CI, 81.9%-90.5%).[3][Level of evidence: 3iiA] Among the women who had an intact uterus, about one-half of them retained their fertility. Patients with documented brain metastases received higher doses of systemic methotrexate as part of the EMA component (i.e., etoposide, methotrexate, folinic acid, and dactinomycin) of EMA/CO (1 g/m2 IV for 24 hours, followed by folinic-acid rescue, 15 mg orally every 6 hours for 12 doses starting 32 hours after methotrexate). Patients with brain metastases received an increased dose of systemic methotrexate of 1 g/m2 for 24 hours followed by folinic acid (15 mg orally every 6 hours for 12 doses starting 32 hours after methotrexate). Patients with lung metastases received cranial prophylaxis with irradiation and intrathecal methotrexate 12.5 mg every 2 weeks with the CO (i.e., cyclophosphamide and vincristine) cycles.
Examples of other regimens that have been used include the following:[1]
- MAC: Methotrexate, folinic acid, dactinomycin, and cyclophosphamide.
- Another MAC: methotrexate, dactinomycin, and chlorambucil.
- EMA: etoposide, methotrexate, folinic acid, and dactinomycin (EMA/CO without the CO).
- CHAMOCA: methotrexate, dactinomycin, cyclophosphamide, doxorubicin, melphalan, hydroxyurea, and vincristine.
- CHAMOMA: methotrexate, folinic acid, hydroxyurea, dactinomycin, vincristine, melphalan, and doxorubicin.
Brain metastases are associated with poor prognosis, particularly when liver metastases are also present.[6,7,8] However, even patients with brain metastases may achieve long-term remission in 50% to 80% of cases.[3,4,8] Patients with central nervous system (CNS) metastases receive additional therapy simultaneously with the initiation of systemic chemotherapy. Some centers utilize whole-brain irradiation (30 Gy in 2 Gy fractions) with or without intrathecal methotrexate.[6] However, some investigators omit the cranial radiation, relying on replacement of the standard dose of methotrexate in the EMA/CO regimen with the higher dose of 1000 mg/m2 IV for 24 hours on the first day, as noted above, to achieve therapeutic CNS levels.[8]
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