A woman 4 months post-complete hydatidiform mole evacuation develops haemoptysis. CXR shows multiple pulmonary nodules. β-hCG is 180,000 mIU/mL. She has no prior chemotherapy. WHO/FIGO prognostic scoring: antecedent pregnancy = mole (0), interval 4–6 months (1), pre-treatment hCG 100,000–999,999 mIU/mL (4), largest tumour size ≥ 5 cm (2), site of metastasis = lung (4), number of metastases 1–4 (1), prior chemotherapy = none (0). Total score is 12. What defines this as 'ultra-high risk' and what is the appropriate initial chemotherapy?
- A Score ≥ 7 defines high risk; EMA-CO (etoposide, methotrexate, actinomycin-D, cyclophosphamide, vincristine)
- B Score ≥ 12 defines ultra-high risk; immediate EMACO followed by EMA-CE on resistance
- C Score ≥ 12 defines ultra-high risk; induction low-dose etoposide-cisplatin for 1–2 cycles before EMA-CO to reduce early treatment mortality ✓
- D Score ≥ 10 defines ultra-high risk; TP/TE (paclitaxel/cisplatin alternating with paclitaxel/etoposide) as first-line
Correct answer: C. Score ≥ 12 defines ultra-high risk; induction low-dose etoposide-cisplatin for 1–2 cycles before EMA-CO to reduce early treatment mortality
Explanation
A WHO/FIGO score ≥ 7 defines high-risk GTN requiring multi-agent chemotherapy (EMA-CO). A score ≥ 12 is classified as 'ultra-high risk' GTN, associated with higher early death rate from haemorrhage or metabolic failure when treated with full-dose EMA-CO upfront. Current BGCS/Charing Cross guidelines recommend induction with low-dose etoposide (100 mg/m²) + cisplatin (20 mg/m²) for 1–2 cycles to debulk tumour volume and stabilise the patient before transitioning to EMA-CO, reducing early treatment mortality. This staged approach has improved survival in ultra-high risk GTN.
Reference: Williams Obstetrics, 26th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.