Fatal gestational trophoblastic disease: an analysis of treatment failures.

Forty-eight of 399 patients referred to the John I. Brewer Trophoblastic Disease Center of Northwestern University Medical School from 1962 to 1979 for treatment of gestational trophoblastic disease (invasive mole or choriocarcinoma) died. All patients who died had histologically documented metastatic choriocarcinoma. The time from pregnancy event to treatment was greater than 4 months and/or the pretreatment human chorionic gonadotropin titer was greater than 100,000 IU/L in 64% of these patients. Seventy-one percent of fatal cases developed in association with term pregnancies, abortions, or ectopic pregnancies rather than hydatidiform moles. Fifty percent of patients who died had metastases to the liver, brain, and/or peritoneal cavity when they first presented for treatment. The most common causes of death were hemorrhage from one or more metastatic sites (42%) and pulmonary insufficiency (31%). Factors primarily responsible for the treatment failures in these patients were: (1) presence of extensive disease at the time of initial treatment; (2) inadequate initial treatment; and (3) failure or presently used chemotherapy protocols in advanced disease. Secondary chemotherapy, radiation therapy to sites other than the brain, and adjuvant surgical procedures failed to improve survival in these high-risk patients.