For low-risk GTN (FIGO/WHO score ≤ 6) that is resistant to first-line single-agent chemotherapy (methotrexate or actinomycin-D), what is the standard second-line treatment?

• A EMA-CO (etoposide, MTX, actinomycin-D, cyclophosphamide, vincristine) immediately
• B Switch to the other single agent (if MTX failed → actinomycin-D; if Act-D failed → MTX) ✓
• C Hysterectomy as definitive treatment
• D FA-EV (fluorouracil, actinomycin-D, etoposide, vincristine)

Explanation

For low-risk GTN resistant to first-line single-agent methotrexate, switching to actinomycin-D (or vice versa) achieves remission in > 80% of cases. Only patients with true resistance to both sequential single agents are escalated to EMA-CO combination therapy. This stepwise approach avoids unnecessary polychemotherapy toxicity in low-risk disease. EMA-CO is reserved for high-risk GTN (score ≥ 7) or low-risk disease truly resistant to two single agents.

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

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Written and medically reviewed by the StethoPrep medical team.