title: Treatment of metastatic gestational choriocarcinoma with oral methotrexate in a combat environment.
abstract: BACKGROUND
  Gestational trophoblastic neoplasia (GTN) is a rare neoplastic complication of pregnancy. This disease can be successfully treated with parenteral intravenous or intramuscular chemotherapy. We present a case of metastatic gestational choriocarcinoma following a term pregnancy that was treated successfully with oral methotrexate therapy.
  
  
  METHODS
  A 25-year-old, G4 P4, native Afghani with a history of irregular menses since the birth of her son 6 months ago received a physical examination that was within normal limits. Pelvic examination revealed minimal blood in the vault and slight bleeding from a closed cervical os. The uterus was slightly enlarged, 5 weeks in size, and without any adnexal masses. Laboratory evaluation was significant for a positive urine and serum beta-HCG. Pelvic ultrasound examination revealed a 5-cm uterus with a 2-cm endometrial stripe. Chest radiograph revealed multiple bilateral ill-defined pulmonary nodules confirmed by computerized tomography. The patient underwent dilation and curettage productive of a moderate amount of tissue. The patient continued to have positive serum beta-HCGs and was given the presumptive diagnosis of FIGO stage III gestational choriocarcinoma. Because of the lack of intravenous chemotherapeutic agents, the patient was begun on methotrexate 0.40 mg/kg orally on days 1-5, with 9 days off. The patient completed one course of chemotherapy, followed by an interval total abdominal hysterectomy with bilateral salpingo-oophorectomy. The patient had a complete response to therapy and was treated with oral methotrexate for 2 courses after a negative serum beta-HCG. The patient tolerated the chemotherapy without any complication.
  
  
  CONCLUSIONS
  Methotrexate is routinely used in a parenteral intramuscular fashion for the treatment of gestational choriocarcinoma. Physicians should be aware that, in very limited situations, oral methotrexate in combination with hysterectomy still could offer a patient successful treatment for stage III GTN.
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Tripler Army Medical Center, Honolulu, Hawaii 96859-5000, USA. john.farley@us.army.mil
authors.forename: John H
authors.initials: JH
authors.lastname: Farley
authors.forename: R Brian
authors.initials: RB
authors.lastname: Heathcock
authors.forename: Walter
authors.initials: W
authors.lastname: Branch
authors.forename: Wilma
authors.initials: W
authors.lastname: Larsen
authors.forename: Dallas
authors.initials: D
authors.lastname: Homas
mesh_terms: D000284:Administration, Oral; D000328:Adult; D001707:Biopsy, Needle; D017024:Chemotherapy, Adjuvant; D002822:Choriocarcinoma / Q000473:pathology / Q000556:secondary* / Q000628:therapy*; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D005500:Follow-Up Studies; D031901:Gestational Trophoblastic Disease / Q000175:diagnosis* / Q000628:therapy*; D006801:Humans; D007044:Hysterectomy / Q000379:methods; D007150:Immunohistochemistry; D008727:Methotrexate / Q000627:therapeutic use*; D009362:Neoplasm Metastasis; D009367:Neoplasm Staging; D049590:Postpartum Period; D011247:Pregnancy; D018570:Risk Assessment; D016896:Treatment Outcome
chemical_list: D008727:Methotrexate