Initial management of low-risk invasive mole or choriocarcinoma

CCA: choriocarcinoma; GTN: gestational trophoblastic neoplasia; FIGO: International Federation of Gynecology and Obstetrics; WHO: World Health Organization; hCG: human chorionic gonadotropin; GI: gastrointestinal; ActD: dactinomycin; MTX: methotrexate.

* Chemotherapy for such patients is typically with either intravenous infusion of MTX and folinic acid or bolus ActD. The decision to use chemotherapy in such patients is discussed in related UpToDate content.

¶ While chemotherapy is the primary treatment for such patients, some patients (eg, heavy or bothersome uterine bleeding; substantial uterine tumor burden with low tumor burden elsewhere) are also treated with hysterectomy.

Δ High-risk features include any of the following: No metastases and no histopathologic CCA, but hCG >410,000; either metastases or histopathologic CCA, and hCG >150,000; metastatic CCA.

◊ All patients with low-risk GTN are followed with weekly hCG levels until normal (<5 mIU/mL) for three weeks and then monthly until 12 months of normal hCG levels have been documented.

§ Combination chemotherapy may include etoposide, MTX, plus ActD, alternating with cyclophosphamide and vincristine ("EMA-CO"). Regimens that incorporate etoposide and cisplatin are also effective options.

¥ Single-agent chemotherapy is typically with intramuscular MTX on an eight-day regimen alternating with folinic acid; other MTX regimens or ActD may also be used.

‡ Refer to UpToDate discussion on management of resistant or recurrent GTN for further details.

† Interval (in months) between end of antecedent pregnancy and start of chemotherapy.