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What is the best regimen for low-risk gestational trophoblastic neoplasia? A review.

A review of published and unpublished material was performed using medical databases, bibliographies and personal contact with peer experts to determine the best treatment of low-risk gestational trophoblastic neoplasia (GTN). Thirty-nine studies contained the minimum information required for inclusion in this study. Additional reports were retrieved but could not be disaggregated with sufficient accuracy to obtain valid comparative information. Four general regimen types were identified: methotrexate with/without folinic acid rescue, actinomycin, etoposide and 5-fluorouracil. The studies were compared based on effectiveness, cost and patient preference. Effectiveness and toxicity data were abstracted from the 39 studies. Intuitive assumptions about cost and preference were made to help differentiate the regimens. The following regimens were judged to be superior based on the data available: oral methotrexate, 100 mg/m2; infusional methotrexate; and pulse actinomycin. The small sample size of these 3 regimens limited the generalizability of the conclusions, but pulse actinomycin appeared to be the best choice given the data available. There is a paucity of level 1 and 2 evidence on the best chemotherapeutic management of low-risk GTN. A biochemical or consensus-based clinical definition of persistent disease and a standardized scoring system should be developed and used by future authors. The dearth of prospective, randomized information on this disease makes determination of the best practice and the choice of a best regimen problematic.