Management outcomes of gestational trophoblastic disease at Moi Teaching and Referral Hospital: An 8 year review

Abstract

Background: Gestational Trophoblastic Disease (GTD) is a curable heterogeneous group of benign and malignant diseases characterized by abnormal growth and proliferation of the trophoblasts. Benign disease is managed by suction curettage. Malignant disease is managed by either single agent or multiagent chemotherapy depending on the WHO risk score. The treatment outcomes of GTD in developing countries are not well documented. Objective: The objective of this study was to determine management outcomes of patients treated for GTD at Moi Teaching and Referral Hospital. Methods: This was a retrospective descriptive hospital-based study carried out at MTRH in Chandaria Cancer and Chronic Disease Centre records department. This was a census survey and the study population included all the medical charts of women managed for GTD from Jan 2010 to Dec 2017. The continuous variables were presented as mean, standard deviation (SD), and categorical as frequency and percentage. Bivariate and multivariate logistic regression was performed to identify the variables associated with GTD treatment outcomes. Results: A total of 85 patient charts were included in the study. The mean age of patients was 31.9 years with majority 54(63.5%) being 20-35years. Most were multiparous 64(75.3%). The main presentation was abnormal vaginal bleeding in 71(83.5%). A previous history of abortion was present in 22(25.9%), only 3(3.5%) had prior GTD. Malignant disease was present in 70(82.4%) patients, the rest 15(17.6%) had benign disease. Histopathologic diagnosis was made in 27(31.8%) of the patients with choriocarcinoma being the dominant finding in 20 (22.3%) patients. Metastasis was present in 16(18.9%) with lungs as the most frequent metastatic site 10(62.4%). Single agent (Either methotrexate or actinomycinD) was started in 41(58.5%) low risk patients.Thirteen patients 13(31.7%) failed to achieve remission and second line therapy was used. Patients on Actinomycin D achieved higher remission rates compared to those on methotrexate at 90.0% vs. 47.6% respectively. Multiple agent regimen was started in 29 high risk patients and 1 was changed to a salvage therapy. Overall,11 patients died. Complete cure was achieved in 74(87.1%) patients. Bivariate analysis showed an association between prior abortion (P=0.028) ,parity(P=0.003),Bhcg levels(0.001),WHO risk category(p=0.003) and metastases(p=0.001) with cure. Multivariate logistic regression adjusting for confounders showed that the low risk patients have more than four times higher odds of being cured, AOR: 4.44 (95% CL: 2.30, 9.10). Conclusion: The cure rate of GTD in MTRH is consistent with the high cure rates worldwide. Low WHO risk score is associated with a better prognosis. Single agent Actinomycin D has a higher efficacy compared to methotrexate in achieving remission in low risk GTN. History of prior abortion, multiparity and the typical reproductive age (20-35 years) are risk factors for GTD. Recommendations: Clinicians should have a high index of suspicion for GTD on a multiparous woman with a prior abortion presenting with vaginal bleeding.Further studies on efficacy and side effect profiles between ActinomycinD and Methotrexate in the management of gestational trophoblastic disease.