Management and outcome of gestational trophoblastic neoplasia patients with brain metastasis: Ten years’ experience in a trophoblastic referral center (460)

Abstract

<b>Objectives:</b> To determine the clinical outcome of gestational trophoblastic neoplasia patients with brain metastasis. <b>Methods:</b> A review of records of all women with brain metastasis from gestational trophoblastic neoplasia from January 1, 2010, to December 31, 2019, was done. Patients' sociodemographic and clinical-pathologic profiles were described. Using the Kaplan-Meier survival curve, the survival time was determined. <b>Results:</b> A total of 19 patients were included; 13(68.42%) patients had neurological symptoms upon diagnosis and one (5.26%) patient had these symptoms during treatment. The most common neurological symptom was headache. Sixteen patients had the World Health Organization (WHO) prognostic score of >12, two had >7, and one had 3 (A case of tumor recurrence ten years after remission from her low-risk GTN). Nine patients (47.36%) had single brain metastasis, three (15.78%) had two, three (15.78%) had three, one (5.26%) had five, and two (10.52%) were reported to have multiple lesions. The location for brain metastasis was known in eighteen patients and was not identifiable in one due to massive hemorrhage. The location of the brain metastases were as follows: parietal (<i>n</i> = 3), frontal (<i>n</i> = 2), occiput (<i>n</i> = 2), temporal (<i>n</i> = 1), frontotemporal (<i>n</i> = 1), frontoparietal (<i>n</i> = 1), frontal and parietal (<i>n</i> = 2), cerebral and cerebellar (<i>n</i> = 1), parietal and occipital (<i>n</i> = 1), parietal, posterior, and occiput (<i>n</i> = 1), frontal and medial (<i>n</i> = 1), frontoparietal, frontal and thalamus (<i>n</i> = 1), and parietal and superior sagittal sinus (<i>n</i> = 1). The size of brain metastasis ranged from 0.2 to 4.0 cm. All received EMACO with an increase in the Methotrexate infusion to 1 g/m² as first-line treatment. Three (15.78%) patients were given induction chemotherapy with Etoposide 100 mg/m² and Cisplatin 20 mg/m². Fifteen (78.94%) patients underwent concomitant whole brain radiation at a dose of 2,000-3,000 cGy (in 10 fractions of 200-300 cGy), and two were given intrathecal Methotrexate 12.5 mg. The most common tox- icities from EMACO chemotherapy were infections in 84.21% (16/19), hypokalemia in 73.68% (14/19), and anemia grade 2-4 in 69.42% (13/19). Nine out of thirteen (69.23%) patients diagnosed with neurological symptoms achieved biochemical remission. One patient who had neurological symptom during the course of treatment was given palliative care. Four out of four (100%) patients who had no neurological symptoms achieved biochemical remission. Three (15.78%) patients had resistance to EMACO and were given EP-EMA. Four (21.05%) patients underwent an adjunctive hysterectomy. Two patients had a histopathologic result of choriocarcinoma, and one had an invasive mole. Two (10.52%) patients died of cerebral hemorrhage during treatment. One patient (5.26%) could not continue her chemotherapy because she got pregnant before her first consolidation course. The median follow-up was 25.35 months. Six patients were contacted, and five (83.33%) had resumed a normal life. There were fourteen early deaths. Causes of death were cerebral hemorrhage in nine (64.28%) patients, gastrointestinal hemorrhage in two (14.28%) patients, pulmonary embolism in two (14.28%) patients and pulmonary hemorrhage in one (7.14%) patient. After excluding early deaths, the proportion of patients surviving between 1 to 3 years was at 84% and those surviving past 3 years was 76%. The median survival was approximately 2.5 years. <b>Conclusions:</b> Brain metastasis continues to bear a poor prognosis despite the early institution of chemotherapy.