title: Conservative Chemotherapy in Gestational Trophoblastic Disease: Experience With Etoposide, Methotrexate, and Dactinomycin Chemotherapy.
abstract: OBJECTIVE
  The goal of this study was to evaluate the efficacy, toxicity, and survival of patients in our institution treated by EMA (etoposide, methotrexate [MTX], and dactinomycin) chemotherapy for 3 groups of patients: ones that had low-risk gestational trophoblastic disease (GTD) that was resistant to MTX (group A), those with high-risk GTD (group B), and the group having low-risk GTD but the cancer being metastatic (group C).
  
  
  METHODS
  The medical records of 58 patients who received EMA chemotherapy in groups A, B, and C in the 2000 to 2012 period at St Mary's Hospital were examined. Clinical characteristics, chemotherapy responses, causes of treatment failure, and cases of drug toxicity were analyzed retrospectively.
  
  
  RESULTS
  Treatment with the EMA regimen resulted in primary remission in 52 (96%) of 54 patients and resistance in 2 of the patients (3%). In the resistance group, one belonged to group B and was treated with etoposide, MTX, and actinomycin D with cyclophosphamide and vincristine (EMA-EP) and the other belonged to group A and died of refractory disease. World Health Organization (WHO) grade 4 leukocytopenia and thrombocytopenia with the EMA regimen occurred in 6% and 0.4% of the cycles, respectively; the other toxic effects were acceptable and manageable. Median cycles of EMA chemotherapy during the treatment were 7, 8, and 8 in groups A, B, and C, respectively. There was some reduction in total chemo cycle and toxicity, as compared with a previously reported study using the alternative cyclophosphamide and vincristine regimen. Among the EMA treated patients, 1 patient with a second malignancy of breast cancer was documented. In addition, 5 child births for the treated patients were recorded during the follow-up period of mostly 10 years.
  
  
  CONCLUSIONS
  The EMA chemotherapy seemed to reduce treatment duration and the relapse rate without increasing the adverse effects in patients with MTX resistance and low-risk GTD, but having confirmed metastatic lesions. Although this study had some limitations regarding the high-risk GTD, our findings will provide a basis for the use of EMA chemotherapy when cyclophosphamide and vincristine is contraindicated due to toxicity.
authors.affiliation: *Department of Obstetrics and Gynecology, Uijeongbu St Mary's Hospital, Uijeongbu City; and †Department of Obstetrics and Gynecology, Seoul St Mary's Hospital, Seoul, South Korea.
authors.forename: Seung Won
authors.initials: SW
authors.lastname: Byun
authors.forename: Tae Chul
authors.initials: TC
authors.lastname: Park
authors.forename: Seog Nyeon
authors.initials: SN
authors.lastname: Bae
mesh_terms: D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D003609:Dactinomycin / Q000008:administration & dosage; D019008:Drug Resistance, Neoplasm; D005047:Etoposide / Q000008:administration & dosage; D005260:Female; D005500:Follow-Up Studies; D031901:Gestational Trophoblastic Disease / Q000188:drug therapy* / Q000473:pathology; D006801:Humans; D008727:Methotrexate / Q000008:administration & dosage; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D011247:Pregnancy; D011379:Prognosis; D016879:Salvage Therapy
chemical_list: D003609:Dactinomycin; D005047:Etoposide; D008727:Methotrexate