title: Management of drug resistant gestational trophoblastic neoplasia.
abstract: OBJECTIVE
  To determine the outcome of secondary management in drug-resistant gestational trophoblastic neoplasia (GTN).
  
  
  METHODS
  Sixteen of 60 patients with GTN (8 low-risk and 8 high-risk) who developed resistance to primary chemotherapy were studied retrospectively. Primary chemotherapy was methotrexate-folinic acid rescue (MTX-FA) for low risk and etoposide/methotrexate/actinomycin D/cyclophosphamide/vincristine (EMA-CO) for high risk. Secondary chemotherapy for the low-risk group was either actinomycin D or EMA-CO, depending on serum beta human chorionic gonadotropin (hCG) levels at resistance. For the high-risk group, etoposide/methotrexate/actinomycin D/cisplatinum (EMA-EP) or bleomycin/etoposide/cisplatin (BEP) was given. Third-line chemotherapy was vincristine/actinomycin D/cyclophosphamide (VAC) or vincristine/ iphosphamide/cisplatin (VIP). Surgery and radiotherapy were used in selected patients.
  
  
  RESULTS
  Survival after salvage therapy in low-risk patients was 100%: 2 with EMA-CO and 6 with actinomycin D. Of high-risk cases 75% were cured with EMA-EP or BEP. Third-line chemotherapy was given in 2 patients: 1 was lost to follow-up and the other died. Survival was significantly influenced by both hCG level at the start of secondary therapy and site of metastasis.
  
  
  CONCLUSIONS
  Prognosis in GTN is excellent. Optimization of treatment strategies for those who develop drug resistance remains a key challenge.
authors.affiliation: Department of Gynecologic Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India. drshilpamukesh@gmail.com
authors.forename: Shilpa M
authors.initials: SM
authors.lastname: Patel
authors.forename: Ava
authors.initials: A
authors.lastname: Desai
mesh_terms: D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D018997:Chorionic Gonadotropin, beta Subunit, Human / Q000097:blood; D002945:Cisplatin / Q000008:administration & dosage; D003520:Cyclophosphamide / Q000008:administration & dosage; D003609:Dactinomycin / Q000008:administration & dosage; D019008:Drug Resistance, Neoplasm; D005047:Etoposide / Q000008:administration & dosage; D005260:Female; D031901:Gestational Trophoblastic Disease / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology; D006801:Humans; D007069:Ifosfamide / Q000008:administration & dosage; D002955:Leucovorin / Q000008:administration & dosage; D008727:Methotrexate / Q000008:administration & dosage; D009362:Neoplasm Metastasis; D011247:Pregnancy; D012189:Retrospective Studies; D014594:Uterine Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology; D014750:Vincristine / Q000008:administration & dosage
chemical_list: D018997:Chorionic Gonadotropin, beta Subunit, Human; D003609:Dactinomycin; D014750:Vincristine; D005047:Etoposide; D003520:Cyclophosphamide; D002945:Cisplatin; D002955:Leucovorin; D007069:Ifosfamide; D008727:Methotrexate