Gestational Trophoblastic Neoplasia Treatment at the Butaro Cancer Center of Excellence in Rwanda

Purpose Gestational trophoblastic neoplasia (GTN) is a highly treatable disease, most often affecting young women of childbearing age. This study reviewed patients managed for GTN at the Butaro Cancer Center of Excellence (BCCOE) in Rwanda to determine initial program outcomes. Patients and Methods A retrospective medical record review was performed for 35 patients with GTN assessed or treated between May 1, 2012, and November 30, 2014. Stage, risk score, and low or high GTN risk category were based on International Federation of Gynecology and Obstetrics staging and the WHO scoring system and determined by beta human chorionic gonadotropin level, chest x-ray, and ultrasound per protocol guidelines for resource-limited settings. Pathology reports and computed tomography scans were assessed when possible. Treatment was based on a predetermined protocol stratified by risk status. Results Of the 35 patients (mean age, 32 years), 26 (74%) had high-risk and nine (26%) had low-risk disease. Nineteen patients (54%) had undergone dilation and curettage and 11 (31%) had undergone hysterectomy before evaluation at BCCOE. Pathology reports were available in 48% of the molar pregnancy surgical cases. Systemic chemotherapy was initiated in 30 of the initial 35 patients: 13 (43%) received single-agent oral methotrexate, 15 (50%) received EMACO (etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine), and two (7%) received alternate regimens. Of the 13 patients initiating methotrexate, three had their treatment intensified to EMACO. Four patients experienced treatment delays because of medication stockouts. At a median follow-up of 7.8 months, the survival probability for low-risk patients was 1.00; for high-risk patients, it was 0.63. Conclusion This experience demonstrates the feasibility of GTN treatment in rural, resource-limited settings. GTN is a curable disease and can be treated following the BCCOE model of cancer care.

[1]  T. Lawrie,et al.  First-line chemotherapy in low-risk gestational trophoblastic neoplasia. , 2016, The Cochrane database of systematic reviews.

[2]  A. Binagwaho,et al.  Bringing cancer care to the poor: experiences from Rwanda , 2014, Nature Reviews Cancer.

[3]  C. Balleyguier,et al.  Actinomycin D, cisplatin, and etoposide regimen is associated with almost universal cure in patients with high-risk gestational trophoblastic neoplasia. , 2014, European journal of cancer.

[4]  C. Karema,et al.  Rwanda 20 years on: investing in life , 2014, The Lancet.

[5]  N. Sebire,et al.  Gestational trophoblastic disease: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. , 2013, Annals of oncology : official journal of the European Society for Medical Oncology.

[6]  N. Sebire,et al.  EMA/CO for high-risk gestational trophoblastic neoplasia: good outcomes with induction low-dose etoposide-cisplatin and genetic analysis. , 2013, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[7]  W. Wood,et al.  Meeting the challenge of hematologic malignancies in sub-Saharan Africa. , 2012, Blood.

[8]  L. Hadley,et al.  Challenge of pediatric oncology in Africa. , 2012, Seminars in pediatric surgery.

[9]  R. Berkowitz,et al.  Current management of gestational trophoblastic neoplasia. , 2012, Hematology/oncology clinics of North America.

[10]  Neil J Sebire,et al.  Gestational trophoblastic disease , 2010, The Lancet.

[11]  J. Schink,et al.  Management of metastatic high-risk gestational trophoblastic neoplasia: FIGO stages II-IV: risk factor score > or = 7. , 2010, The Journal of reproductive medicine.

[12]  Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia , 2009, International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics.

[13]  R. Berkowitz,et al.  Molar pregnancy: pathology and management , 2008 .

[14]  P. Farmer,et al.  Surgery and Global Health: A View from Beyond the OR , 2008, World Journal of Surgery.

[15]  B. Hancock.  hCG measurement in gestational trophoblastic neoplasia: a critical appraisal. , 2006, The Journal of reproductive medicine.

[16]  T. Powles,et al.  The significance of the time interval between antecedent pregnancy and diagnosis of high-risk gestational trophoblastic tumours , 2006, British Journal of Cancer.

[17]  G. Tulunay,et al.  Results with EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine) chemotherapy in gestational trophoblastic neoplasia , 2005, International Journal of Gynecologic Cancer.

[18]  S. Chichareon,et al.  Correlation of risk categorization in gestational trophoblastic tumor between old and new combined staging and scoring system , 2003, The journal of obstetrics and gynaecology research.

[19]  M. Moodley,et al.  Gestational trophoblastic syndrome: An audit of 112 patients. A South African experience , 2002, International Journal of Gynecologic Cancer.

[20]  G. Rustin,et al.  Low-risk persistent gestational trophoblastic disease: outcome after initial treatment with low-dose methotrexate and folinic acid from 1992 to 2000. , 2002, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[21]  R. Mclellan,et al.  Gestational trophoblastic disease. , 2001, Obstetrics and gynecology clinics of North America.

[22]  S. Kim,et al.  Effects of multiagent chemotherapy and independent risk factors in the treatment of high‐risk GTT —25 years experiences of KRI‐TRD , 1998, International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics.

[23]  M. Seckl,et al.  Management of resistant gestational trophoblastic tumors. , 1998, The Journal of reproductive medicine.

[24]  E S Newlands,et al.  EMA/CO for high-risk gestational trophoblastic tumors: results from a cohort of 272 patients. , 1997, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[25]  E. Newlands,et al.  The role of low‐dose methotrexate and folinic acid in gestational trophoblastic tumours (GTT) , 1989, British journal of obstetrics and gynaecology.

[26]  S. Soong,et al.  Treatment of nonmetastic gestational trophoblastic disease with oral methotrexate , 1988, American journal of obstetrics and gynecology.

[27]  B. Schwarz,et al.  Sonographic Findings and Clinical Correlations in Molar Pregnancy , 1980, Obstetrics and gynecology.

[28]  S. Menon,et al.  Outcome of gestational trophoblastic neoplasia: experience from a tertiary cancer centre in India. , 2014, Clinical oncology (Royal College of Radiologists (Great Britain)).