A patient is diagnosed with FIGO Stage II low-risk gestational trophoblastic neoplasia (GTN) following a molar pregnancy. The FIGO/WHO risk score is 3. Which chemotherapy regimen is most appropriate?
- A Single-agent methotrexate with folinic acid rescue (8-day protocol) ✓
- B Single-agent actinomycin-D (pulse protocol) as MTX has inferior response in post-molar GTN
- C EMA-CO (etoposide, methotrexate, actinomycin-D, cyclophosphamide, vincristine) as first-line
- D Single-agent methotrexate (50 mg/m² weekly IM) without folinic acid rescue
Explanation
For FIGO Stage I–II GTN with WHO/FIGO risk score <7 (low-risk), single-agent chemotherapy is the standard, with complete remission rates >90%. Single-agent methotrexate (MTX) with folinic acid (leucovorin) rescue using the 8-day Bagshawe/Charing Cross protocol (MTX 1 mg/kg IM on days 1, 3, 5, 7 + folinic acid on days 2, 4, 6, 8) achieves the best remission rates (80–90%) and is preferred over actinomycin-D for most patients. Actinomycin-D (B) is used when MTX fails or is contraindicated (hepatic dysfunction). EMA-CO (C) is reserved for high-risk GTN (WHO score ≥7) or resistant low-risk disease. Weekly MTX without folinic acid (D) has lower efficacy than the 8-day protocol and is not recommended.
Reference: Williams Obstetrics, 26th ed.
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