Fernanda Freitas1, Antonio Braga2, Mauricio Viggiano3, Luis Guillermo Coca Velarde4, Izildinha Maesta5, Elza Uberti6, Jose Mauro Madi7, Daniela Yela8, Karayna Fernandes9, Eduardo Silveira10, Elaine Leal11, Sue Yazaki Sun12, Ana Paula Vieira Dos Santos Esteves13, Jorge Rezende Filho13, Joffre Amim Junior13, Kevin M Elias14, Neil S Horowitz14, Ross S Berkowitz14. 1. Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil. 2. Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil. Electronic address: antonio.braga@ufrj.br. 3. Goiania Trophoblastic Disease Center, Clinics Hospital of Goias Federal University, Goiania, GO, Brazil. 4. Postgraduate Program in Medical Sciences, Fluminense Federal University, Niterói, RJ, Brazil. 5. Botucatu Trophoblastic Disease Center, Clinical Hospital of Botucatu Medical School, Department of Gynecology and Obstetrics, São Paulo State University-UNESP, Botucatu, SP, Brazil. 6. Porto Alegre Trophoblastic Disease Center, Mario Totta Maternity Ward, Irmandade da Santa Casa de Misericórdia Hospital, Porto Alegre, RS, Brazil. 7. Caxias do Sul Trophoblastic Disease Center, General Hospital of Caxias do Sul, School of Medicine, Center for Biological and Health Sciences, Caxias do Sul University, Caxias do Sul, RS, Brazil. 8. Campinas Trophoblastic Disease Center, University of Campinas, Campinas, SP, Brazil. 9. Jundiai Trophoblastic Disease Center, Jundiai Medical School, Jundiai, SP, Brazil. 10. Santos Trophoblastic Disease Center, Guilherme Álvaro Hospital, Santos, SP, Brazil. 11. Rio Branco Trophoblastic Disease Center, Clinics Hospital of Acre, Rio Branco, AC, Brazil. 12. São Paulo Hospital Trophoblastic Disease Center, Paulista School of Medicine, São Paulo Federal University, São Paulo, SP, Brazil. 13. Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Antonio Pedro University Hospital of Fluminense Federal University, Rio de Janeiro, RJ, Brazil; Postgraduate Program in Perinatal Health, Faculty of Medicine, Maternity School of Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil. 14. New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Abstract
OBJECTIVE: To investigate GTN lethality among Brazilian women comparing cases of death by GTN with those who survived, thereby identifying factors associated with GTN lethality. METHODS: We retrospectively reviewed medical records of women with GTN treated at ten Brazilian GTN Reference Centers, from January 1960 to December 2017. We evaluated factors associated with death from GTN and used Cox proportional hazards regression models to identify independent variables with significant influence on the risk of death. RESULTS: From 2186 patients with GTN included in this study, 2092 (95.7%) survived and 89 (4%) died due to GTN. When analyzing the relative risk (RR), adjusted for WHO/FIGO score, patients with low risk disease had a significantly higher risk of death if they had choriocarcinoma (RR: 12.40), metastatic disease (RR: 12.57), chemoresistance (RR: 3.18) or initial treatment outside the Reference Center (RR: 12.22). In relation to patients with high-risk GTN, these factors were significantly associated with death due to GTN: the time between the end of antecedent pregnancy and the initiation of chemotherapy (RR: 4.10), metastatic disease (RR: 14.66), especially in brain (RR: 8.73) and liver (RR: 5.76); absence of chemotherapy or initial treatment with single agent chemotherapy (RR: 10.58 and RR: 1.81, respectively), chemoresistance (RR: 3.20) and the initial treatment outside the Reference Center (RR: 28.30). CONCLUSION: The risk of mortality from low and high-risk GTN can be reduced by referral of these patients to a Reference Center or, if not possible, to involve clinicians in a Reference Center with consultation regarding management.
OBJECTIVE: To investigate GTN lethality among Brazilian women comparing cases of death by GTN with those who survived, thereby identifying factors associated with GTN lethality. METHODS: We retrospectively reviewed medical records of women with GTN treated at ten Brazilian GTN Reference Centers, from January 1960 to December 2017. We evaluated factors associated with death from GTN and used Cox proportional hazards regression models to identify independent variables with significant influence on the risk of death. RESULTS: From 2186 patients with GTN included in this study, 2092 (95.7%) survived and 89 (4%) died due to GTN. When analyzing the relative risk (RR), adjusted for WHO/FIGO score, patients with low risk disease had a significantly higher risk of death if they had choriocarcinoma (RR: 12.40), metastatic disease (RR: 12.57), chemoresistance (RR: 3.18) or initial treatment outside the Reference Center (RR: 12.22). In relation to patients with high-risk GTN, these factors were significantly associated with death due to GTN: the time between the end of antecedent pregnancy and the initiation of chemotherapy (RR: 4.10), metastatic disease (RR: 14.66), especially in brain (RR: 8.73) and liver (RR: 5.76); absence of chemotherapy or initial treatment with single agent chemotherapy (RR: 10.58 and RR: 1.81, respectively), chemoresistance (RR: 3.20) and the initial treatment outside the Reference Center (RR: 28.30). CONCLUSION: The risk of mortality from low and high-risk GTN can be reduced by referral of these patients to a Reference Center or, if not possible, to involve clinicians in a Reference Center with consultation regarding management.