title: Low-risk persistent gestational trophoblastic disease: outcome after initial treatment with low-dose methotrexate and folinic acid from 1992 to 2000.
abstract: OBJECTIVE
  We have simplified the treatment of gestational trophoblastic disease (GTD) in order to reduce the number of patients exposed to potentially carcinogenic chemotherapy. Patients who score 0 to 8 on the Charing Cross scoring system are classified as low-risk and receive methotrexate (MTX) and folinic acid (FA), whereas those who score higher than 8 are classified as high-risk and receive the etoposide, methotrexate, and dactinomycin (EMA)/cyclophosphamide and vincristine (CO) regimen.
  
  
  METHODS
  Between 1992 and 2000, 485 women with GTD were commenced on MTX/FA at Charing Cross Hospital, London, United Kingdom. If patients developed MTX resistance or toxicity, treatment was altered according to the level of beta human chorionic gonadotropin (hCG). If serum hCG was < or = 100 IU/L, patients received dactinomycin; if hCG was greater than 100 IU/L, patients received EMA/CO.
  
  
  RESULTS
  The median duration of follow-up was 4.7 years. Overall survival was 100% and the relapse rate was 3.3% (16 of 485 patients). hCG values normalized in 324 (66.8%) of 485 patients with MTX alone, whereas 161 (33.2%) of 485 patients required a change in treatment, 11 because of MTX toxicity and 150 because of MTX resistance. Sixty-seven patients changed to dactinomycin, of whom 58 achieved normal hCG values, and nine required third-line chemotherapy with EMA/CO. hCG values normalized in 93 (98.9%) of 94 patients who changed directly to EMA/CO from MTX.
  
  
  CONCLUSIONS
  Single-agent dactinomycin has activity in patients with low-risk GTD who develop MTX resistance and whose hCG is low. Simplifying the stratification of GTD into two classes (low- and high-risk) does not compromise overall outcome and may reduce the risk of second tumors.
authors.affiliation: Department of Medical Oncology, Trophoblastic Tumour Screening and Treatment Center, Charing Cross Hospital, London, United Kingdom.
authors.forename: I A
authors.initials: IA
authors.lastname: McNeish
authors.forename: S
authors.initials: S
authors.lastname: Strickland
authors.forename: L
authors.initials: L
authors.lastname: Holden
authors.forename: G J S
authors.initials: GJ
authors.lastname: Rustin
authors.forename: M
authors.initials: M
authors.lastname: Foskett
authors.forename: M J
authors.initials: MJ
authors.lastname: Seckl
authors.forename: E S
authors.initials: ES
authors.lastname: Newlands
mesh_terms: D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage / Q000627:therapeutic use*; D006063:Chorionic Gonadotropin / Q000097:blood*; D002985:Clinical Protocols; D003520:Cyclophosphamide / Q000008:administration & dosage; D003609:Dactinomycin / Q000008:administration & dosage; D004334:Drug Administration Schedule; D005047:Etoposide / Q000008:administration & dosage; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002955:Leucovorin / Q000008:administration & dosage; D008727:Methotrexate / Q000008:administration & dosage; D011247:Pregnancy; D012306:Risk; D016019:Survival Analysis; D016896:Treatment Outcome; D014328:Trophoblastic Neoplasms / Q000097:blood / Q000188:drug therapy*; D014594:Uterine Neoplasms / Q000097:blood / Q000188:drug therapy*; D014750:Vincristine / Q000008:administration & dosage
chemical_list: D006063:Chorionic Gonadotropin; D003609:Dactinomycin; D014750:Vincristine; D005047:Etoposide; D003520:Cyclophosphamide; D002955:Leucovorin; D008727:Methotrexate