MANAGEMENT OF HIGH-RISK GESTATIONAL TROPHOBLASTIC DISEASE

Multimodality therapy with combination chemotherapy employing etoposid e, high-dose methotrexate, actinomycin D, cyclophosphamide and vincris tine (EMA-CO), and adjuvant radiotherapy and surgery, when indicated, has resulted in cure rates of 80-90% in patients with high-risk metast atic gestational trophoblastic tumors. However, approximately 25-30% o f high-risk patients will have an incomplete response to first-time ch emotherapy or will relapse from remission. Most of these patients will have a clinicopathologic diagnosis of choriocarcinoma, metastases to sites other than the lung and vagina, more than eight metastases and/o r failed inappropriate previous chemotherapy, resulting in very high W orld Health Organization scores. Salvage chemotherapy with cisplatin/e toposide, usually in conjunction with bleomycin or ifosfamide, as well as surgical resection of sites of resistant disease in selected patie nts, will result in a cure in most patients. New technology, such as t he use of colony-stimulating factors to prevent treatment delays and d ose reductions or high-dose chemotherapy with or without autologous bo ne marrow transplantation or peripheral blood stem cell support, may p lay an important role in the future management of patients who develop drug resistance.