Vaginal metastasis in gestational trophoblastic neoplasia: Experience from Sheffield trophoblastic disease Centre and recommendations for management

Introduction: Gestational trophoblastic neoplasia (GTN) is rare in the UK, with an estimated incidence of one in 50,000 live births. Cases of vaginal metastasis are even rarer, with only eight case series reporting 187 cases over the past 40 years. Management recommendations in the literature are scarce despite the potential risk of massive, potentially life-threatening vaginal haemorrhage. Methods: This retrospective cohort study with interval analysis was performed at Sheffield Trophoblastic Disease Centre. It included all patients diagnosed with GTN with documented evidence of vaginal metastases between 1 January 1974 and 31 December 2023. Results: Twenty-five patients with GTN and vaginal metastases were identified during the study period, accounting for < 1 % of all GTN registrations during this period. All patients had chemotherapy representative of chemotherapeutic regimens employed at the time of diagnosis. Vaginal metastases were treated to resolution by chemotherapy alone in 76% of cases. In addition to chemotherapy, 12 % of patients were managed with vaginal packing, 4 % underwent localized excision, 4 % underwent internal iliac embolization, and 12 % received targeted radiotherapy. Forty-four percent of patients had repeated blood transfusions due to persistent haemorrhage associated with the vaginal metastasis. One patient died from disease, 80 % achieved complete remission (cured), and 16 % (recently diagnosed) are in remission. Conclusion: The presence of vaginal metastases in patients with GTN has little prognostic significance, and their presence should not alter management plans. Tailored treatment should be determined by patient factors, with chemotherapeutic regimens based upon World Health Organization prognostic scores. A conservative management approach should be considered, as most cases will resolve with chemotherapy alone.