Compliance and outcomes of 5-day intramuscular methotrexate for low risk gestational trophoblastic neoplasia at Kigali University Teaching Hospital, Rwanda

Abstract

OBJECTIVE: Gestational trophoblastic neoplasia (GTN) complicates approximately 8% of all gestational trophoblastic diseases and its management requires systemic chemotherapy. This study assessed the feasibility and outcomes of low-risk GTN patients treated with intramuscular (IM) 5-day Methotrexate (MTX) at Kigali University Teaching Hospital (CHUK) in Rwanda. METHODS: A retrospective cross-sectional chart review was conducted at CHUK from September 2015 to September 2017. Inclusion criteria were patients treated for low risk GTN with IM 5-day Methotrexate and for those who experienced remission, a one-year follow up. RESULTS: Of 44 patients, molar pregnancy preceded GTN in 90.2% of cases and 75.6% were invasive mole by either pathologic report or clinical suspicion of invasion on ultrasound. Factors associated with an increased resistance to treatment included pretreatment β-HCG levels >100,000 mIU/ml (26.7%), tumor size of >3cm (22%) and FIGO/WHO score of 5 or 6 (20% and 33.3%, respectively). Pretreatment hysterectomy was associated with a decreased number of Methotrexate cycles needed for remission and increased response rates. Primary remission on 5-day IM Methotrexate was achieved in 80.49% of patients. Three (6.8%) patients were lost to follow up during the treatment course. Initiation of an outpatient Methotrexate protocol increased adherence. Stomatitis and neutropenia were the most common side effects at 60.9% and 41.5%, respectively, responsible for a mean of 2.3 cycles delayed, but did not impact outcomes. CONCLUSIONS: Five day IM Methotrexate regimen at CHUK was found to be feasible and effective in the treatment of low risk GTN in a low resource setting. Patients with low risk GTN with factors contributing to a FIGO/WHO score of 5 or 6 have higher rates of resistance to singleagent Methotrexate, requiring alternative chemotherapy regimens.