Purpose: To evaluate patients with vaginal lesions in gestational trophoblastic disease and determine prognostic and therapeutic implications applicable to management. Methods: Twelve patients among 75 cases of gestational trophoblastic neoplasia were analyzed retrospectively between 1990 and 1997. Vaginal metastases were documented by physical examination and biopsy. Two patients received MAC III regimen (5 and 7 courses), 4 patients received EMA-CO regimen for 2 to 11 courses, while 6 were administered methotrexate alone. Remission was defined as 3 weekly β hCG levels below assay sensitivity (<5 mIU/ml). Results: The mean age of the patients was 25.4 years. While 10 of the patients presented initially with hemorrhage and bloody leukorrhea, the remaining 2 were diagnosed during a routine study of hydatidiform mole. The sites of involvement were almost always the anterior distal vaginal wall. Five cases had additional lung and I case had lung, liver, spleen and brain metastases. Three of the patients who received methotrexate as monotherapy did not respond to therapy and were switched to EMA-CO. Overall sur­vival was 91.6%. One patient died in the first month of the initial therapy. Conclusion: The presence of large vaginal metastases should be classified as a high-risk factor and these patients must be treated by multiple agent chemotherapy.