Central nervous system involvement in gestational trophoblastic neoplasia

Objective: To evaluate characteristics of patients with central nervous system (CNS) lesions of gestational trophoblastic disease and determine prognostic and therapeutic implications applicable to management.

Methods: Nine patients among 56 cases of malignant gestational trophoblastic neoplasia (GTN) were analyzed prospectively in a single institution between the years 1990 and 1997 with at least two years of follow-up. Brain metastases were documented by physical exam and computed tomography scan or magnetic resonance imaging. In terms of therapy, all of the patients received an etoposide, methotraxate, actinomycin, cyclosphamide and vincristine (EMA-CO) regimen for 5 to 9 courses. To prevent unexpected intracranial hemorrhage, all patients received radiation therapy. No intrathecal chemotherapy was given. Remission was defined as three weekly beta-hCG levels below assay sensitivity (<5 mIU/ml).

Results: The mean age of the patients at diagnosis was 29.6 years. While two of the patients initially presented with symptoms related to cranial involvement, five were diagnosed during routine investigation for metastasis in malignant GTD and the remaining two developed cerebral metastases during the therapy. Besides central nervous system involvement, six had additional lung, two had hepatic and splenic and one had pelvic metastases. Overall survival was 66.6%. Two patients had a fulminant clinical course and were lost one month after initial diagnosis.

Conclusion: Early diagnosis via computed tomography of the head and beta-hCG serum testing along with aggressive, multiagent intervention (EMA-CO) have greatly improved patient prognosis of this once highly fatal condition.

Brain metastases; Trophoblast; Chemotherapy; Intracranial hemorrhage; Choriocarcinoma

[1] Bagshawe K. D.: "Risk and prognostic factors in trophoblastic neoplasia ". Cancer, 1976, 38, 1373.

[2] Athanassiou A., Begen! R.H. J., Newlands E. S. et al.: "Central nervous system metastases of choriocarcinoma". Cancer, 1983, 52, 1728.

[3] Ayhan A., Tuncer S., Tamr M., Erbengi A.: "Central nervous system involvement in gestational trophoblastic neoplasia". Acta Obstet. Gynecol. Scand., 1996, 75, 548.

[4] Schecter N. R., Mychalczak B., Jones W., Spriggs D.: "Prognosis of patients treated with whole brain radiation therapy for metastatic gestational trophoblastic disease". Gynecol. Oneal., 1998, 68, 183.

[5] Jones W., Wagner-Reis K. M., Lewis J. L.: Gynecol. Oneal., 1990, 38, 234.

[6] Altmtas A., Vardar M.A., Andogan N. et al.: "Chonocarcmoma metastatic to mandibular gingiva". Eur. Sur. Oneal., 1996.

[7] Small W., Lurain J. R., Shetty R. M. et al.: "Gestational trophoblastic disease metastatic to the brain". Radiology, 1996, 200, 277.