A 28-year-old with high-risk gestational trophoblastic neoplasia (WHO score 14) on EMA-CO chemotherapy develops two brain metastases with headache and a focal seizure. Alongside modification of her systemic regimen, which agent is specifically added for central nervous system disease?
- A Intrathecal methotrexate ✓
- B Intrathecal vincristine
- C Intraventricular etoposide
- D Intrathecal dactinomycin
Correct answer: A. Intrathecal methotrexate
Explanation
Brain metastases define FIGO Stage IV disease and are managed with systemic EMA-CO modified to high-dose methotrexate, plus either whole-brain radiotherapy or craniotomy for lesions threatening herniation, together with intrathecal methotrexate to achieve therapeutic levels within the cerebrospinal fluid. Vincristine and etoposide are already systemic components of EMA-CO but are never given intrathecally due to neurotoxicity, and dactinomycin has no established intrathecal role in GTN protocols.
Reference: Williams Obstetrics, 26th ed.
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