A woman previously treated for complete hydatidiform mole 8 months ago presents with irregular vaginal bleeding and serum beta-hCG of 3,200 mIU/mL. MRI brain reveals a single 1.5 cm ring-enhancing lesion. Chest CT is clear. She is FIGO WHO score 10. Which treatment is most appropriate?
- A Single-agent methotrexate with folinic acid rescue as the lesion is solitary
- B EMA-CO with concurrent intrathecal methotrexate and whole brain radiation if CNS metastasis is confirmed ✓
- C Surgical resection of the brain lesion followed by EMA-CO
- D EMA-CO alone without specific CNS-directed therapy, as blood-brain barrier penetration is adequate
Explanation
In high-risk GTN (WHO score ≥7) with CNS metastasis, EMA-CO is the backbone regimen, but CNS-directed therapy is added: systemic high-dose methotrexate (1 g/m² in EMA-CO already) combined with intrathecal methotrexate, with whole brain radiation (WBRT) used in selected cases — particularly when CNS hemorrhage risk is high or there are multiple lesions. This combined approach achieves >75% complete remission in CNS GTN. Solitary brain lesions may sometimes be managed with surgical resection in fit patients, but the oncological standard for high-risk GTN with CNS involvement remains EMA-CO plus CNS-directed therapy, not surgery first.
Reference: Williams Obstetrics, 26th ed.
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Written and medically reviewed by the StethoPrep medical team.