A 32-year-old woman is diagnosed with low-risk gestational trophoblastic neoplasia (FIGO score 3) following a complete hydatidiform mole. She has been on single-agent methotrexate (weekly) for 6 weeks. Her hCG declined from 8,000 to 450 mIU/mL over the first 4 cycles but has plateaued at 420, 410, and 405 mIU/mL over the last 3 cycles. What is the most appropriate next step?
- A Switch to single-agent actinomycin-D ✓
- B Continue methotrexate for 3 more cycles as some response is seen
- C Switch to multi-agent EMA-CO chemotherapy
- D Perform total abdominal hysterectomy
Correct answer: A. Switch to single-agent actinomycin-D
Explanation
Plateau of hCG during single-agent methotrexate therapy indicates resistance to methotrexate. For low-risk GTN, the standard approach is to switch to an alternative single-agent regimen (actinomycin-D) before moving to multi-agent therapy. EMA-CO is reserved for high-risk disease or failure of single-agent therapy. Hysterectomy is not first-line for chemotherapy-sensitive disease.
Reference: FIGO Guidelines for Gestational Trophoblastic Neoplasia, 2000 ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.