Management of EMA-CO resistant/refractory gestational trophoblastic neoplasia

Abstract

The majority of gestational trophoblastic neoplasia (GTN) responds extremely well to first-line, multiagent chemotherapy employing etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMA-CO). However, up to 30% of patients develop either resistance or recurrence. Although EMA-CO resistant GTN is a relatively rare disease, it can be challenging to manage. The cure rate to such a condition is highly dependent on the availability of an effective multiagent chemotherapy regimen with reasonable toxicity profile. Close monitoring of high-risk patients, early diagnosis and recognition is key for a successful outcome. Despite the primary role of chemotherapy in EMA-CO resistant disease, surgical interventions have been shown to improve survival and cure rate. A variety of multiagent chemotherapy regimens have shown efficacy in EMA-CO resistant disease. Unfortunately, to date, there is no strong evidence to suggest which regimen is the standard second-line therapy. Many patients require multiple regimens with or without surgery to achieve complete remission. Early and appropriate intervention is crucial to maximize the chance of cure. The aim of this review article is developing a comprehensive clinical guide for management of EMA-CO resistant GTN.