Advances in management of high-risk gestational trophoblastic tumors.

Multimodality therapy with combination chemotherapy employing etoposide, high-dose methotrexate, actinomycin D, cyclophosphamide and vincristine and adjuvant radiotherapy and surgery, when indicated, has resulted in cure rates of 80-90% in patients with high-risk metastatic gestational trophoblastic tumors. However, 25-30% of high-risk patients will have an incomplete response to first-line chemotherapy or will relapse from remission. Most of these patients will have a clinicopathologic diagnosis of choriocarcinoma, multiple metastases to sites other than the lung and vagina, and failed or inappropriate previous chemotherapy, resulting in very high World Health Organization scores. Salvage chemotherapy with cisplatin/etoposide, usually in conjunction with bleomycin or ifosfamide, as well as surgical resection of sites of resistant disease in selected patients, will result in a cure for most patients. Colony-stimulating factors should be used to prevent treatment delays and dose reductions. Newer anticancer agents, such as paclitaxel and gemcitibine, and high-dose chemotherapy with or without autologous bone marrow transplantation or peripheral blood stem cell support may play a role in the future management of selected patients.