O&G · Gynaecological oncology — gestational trophoblastic disease
Post-molar gestational trophoblastic neoplasia: FIGO 2000 staging and WHO prognostic score, risk-stratified chemotherapy, hCG surveillance and the near-universal cure
Also known as Post-molar GTN · Persistent gestational trophoblastic neoplasia · Persistent trophoblastic disease · Invasive mole · Choriocarcinoma · Gestational trophoblastic tumour · Placental-site trophoblastic tumour
Exam-exhaustive FRANZCOG fellowship topic on gestational trophoblastic neoplasia after molar evacuation (post-molar GTN): the FIGO 2000 anatomic staging (I uterus; II genital tract; III lungs; IV other sites) and the WHO eight-variable prognostic score reproduced verbatim, the 0-6 low-risk versus 7 or more high-risk cut-off, the low-dose methotrexate-folinic acid regimen, pulsed actinomycin-D, the EMA-CO regimen for high-risk disease, the FIGO hCG diagnostic criteria and surveillance schedule, the survival figures and subsequent pregnancy advice. Anchored to the FIGO 2025 update, the FIGO Oncology Committee 2000 staging, Kohorn 2001, McNeish 2002, the Alifrangis 2013 EMA-CO cohort, the Albright 2020 meta-analysis and Soper 2021. Cross-links the early-pregnancy gestational trophoblastic disease topic.
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- A rising or plateauing hCG after molar evacuation is post-molar GTN until proven otherwise — the diagnosis is biochemical, made by the FIGO hCG criteria
- Never biopsy a vaginal metastasis — trophoblast is wildly vascular and the bleeding is torrential; pack it
- Never start chemotherapy for a phantom hCG (heterophile antibody) — confirm with a urine test first; a positive serum with a negative urine excludes true hCG
- Do not start full-dose multi-agent chemotherapy in ultra-high-risk disease without low-dose induction — sudden tumour lysis causes fatal haemorrhage, acidosis and organ failure
- A pregnancy during surveillance resets the hCG clock and confounds the diagnosis — reliable contraception throughout follow-up is mandatory
- Score 5 or 6 with metastases, choriocarcinoma histology or a very high hCG predicts single-agent failure — consider multi-agent from the outset
A 34-year-old woman had a suction evacuation for a complete hydatidiform mole six weeks ago. She has been well, using reliable contraception, but her serial hCG values have plateaued — 820, 845, 810 and 830 IU/L across four weekly tests. This is not a fluctuating normal recovery; it is post-molar GTN by the FIGO hCG-plateau criterion. Your job is to confirm the hCG is real (exclude a new pregnancy and phantom hCG), stage and score her with the FIGO 2000 system, register her with the regional trophoblast centre, and start single-agent chemotherapy for what is almost certainly low-risk disease that will be cured with fertility preserved. The FIGO staging and scoring reproduced verbatim, the methotrexate-folinic acid regimen, and the 95-per-cent-plus cure rate are the three things a fellowship candidate must defend.[1][4][5]
References13ShowHide
- [1]FIGO Oncology Committee FIGO staging for gestational trophoblastic neoplasia 2000. FIGO Oncology Committee. Int J Gynaecol Obstet, 2002.PMID 12065144
- [2]Ngan HY, Bender H, Benedet JL, Jones H, Montruccoli GC, Pecorelli S Gestational trophoblastic neoplasia, FIGO 2000 staging and classification. Int J Gynaecol Obstet, 2003.PMID 14763174
- [3]Kohorn EI The new FIGO 2000 staging and risk factor scoring system for gestational trophoblastic disease: description and critical assessment. Int J Gynecol Cancer, 2001.PMID 11285037
- [4]Ngan HYS, Seckl MJ, Berkowitz RS, Xiang Y, Golfier F, Sekharan PK, Braga A, Garrett A Diagnosis and management of gestational trophoblastic disease: 2025 update. Int J Gynaecol Obstet, 2025.PMID 40631439
- [5]McNeish IA, Strickland S, Holden L, Rustin GJ, Foskett M, Seckl MJ, Newlands ES Low-risk persistent gestational trophoblastic disease: outcome after initial treatment with low-dose methotrexate and folinic acid from 1992 to 2000. J Clin Oncol, 2002.PMID 11919242
- [6]Osborne RJ, Filiaci V, Schink JC, Mannel RS, Alvarez Secord A, Kelley JL, Provencher D, Covens AL, Lage JM Phase III trial of weekly methotrexate or pulsed dactinomycin for low-risk postmolar gestational trophoblastic neoplasia: a gynecologic oncology group study. J Clin Oncol, 2011.PMID 21263100
- [7]Soper JT Gestational Trophoblastic Disease: Current Evaluation and Management. Obstet Gynecol, 2021.PMID 33416290
- [8]Alifrangis C, Agarwal R, Short D, Fisher RA, Sebire NJ, Harvey R, Savage PM, Seckl MJ EMA/CO for high-risk gestational trophoblastic neoplasia: good outcomes with induction low-dose etoposide-cisplatin and genetic analysis. J Clin Oncol, 2013.PMID 23233709
- [9]Bolis G, Bonazzi C, Landoni F, Mangili G, Vergadoro F, Zanaboni F, Mangioni C EMA/CO regimen in high-risk gestational trophoblastic tumor (GTT). Gynecol Oncol, 1988.PMID 2846414
- [10]Bower M, Newlands ES, Holden L, Short D, Brock C, Rustin GJS, Bagshawe KD EMA/CO for high-risk gestational trophoblastic tumors: results from a cohort of 272 patients. J Clin Oncol, 1997.PMID 9215835
- [11]Sebire NJ, Foskett M, Short D, Savage P, Stewart W, Thomson M, Seckl MJ Shortened duration of human chorionic gonadotrophin surveillance following complete or partial hydatidiform mole: evidence for revised protocol of a UK regional trophoblastic disease unit. BJOG, 2007.PMID 17516969
- [12]Albright BB, Shorter JM, Mastroyannis SA, Ko EM, Schreiber CA, Sonalkar S Gestational Trophoblastic Neoplasia After Human Chorionic Gonadotrophin Normalization Following Molar Pregnancy: A Systematic Review and Meta-analysis. Obstet Gynecol, 2020.PMID 31809433
- [13]Ghorani E, Kaur B, Fisher RA, Short D, Joneborg U, Carlson JW, Akarca A, Marafioti T, Quezada SA, Sarwar N, Seckl MJ Pembrolizumab is effective for drug-resistant gestational trophoblastic neoplasia. Lancet, 2017.PMID 29185430