A 30-year-old woman develops choriocarcinoma after a term delivery (not a molar pregnancy). She has metastases in the lungs and vagina. WHO/FIGO score: interval from index pregnancy (term delivery) = 5 months = 1 point; pre-treatment hCG = 85,000 mIU/mL = 4 points; number of metastases = 6 = 2 points; largest metastasis = 4 cm = 1 point; site = lung + vagina = 1 point (vagina = 1); antecedent pregnancy = term = 2 points; prior chemotherapy = none = 0. Total = 11. Management:

• A Single-agent methotrexate
• B EMA-EP for primary high-risk GTN
• C Hysterectomy followed by single-agent consolidation
• D EMA-CO (etoposide, methotrexate, actinomycin-D, cyclophosphamide, vincristine) ✓

Explanation

A WHO/FIGO score ≥7 defines high-risk GTN requiring multi-agent chemotherapy. The first-line regimen for high-risk GTN is EMA-CO (etoposide, methotrexate, actinomycin-D alternating with cyclophosphamide and vincristine), which achieves cure rates exceeding 85% even with metastatic disease. EMA-EP is reserved for EMA-CO-resistant cases. Hysterectomy alone is not curative for metastatic choriocarcinoma. Single-agent chemotherapy is inappropriate for high-risk GTN (score ≥7).

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.