Question

Patient with post molar evacuation, now has lesion in lungs with cannon ball appearance. Which is the best management?

• A. Hysterectomy
• B. Emaco regimen
• C. Inj. methotrexate
• D. Multiple dose of Inj. methotrexate

Hint:

Cannon-ball pulmonary metastases after molar evacuation indicate high-risk gestational trophoblastic neoplasia requiring multi-agent chemotherapy.

Answer 1

The Correct Option is B

Diagnosis: High-risk Gestational Trophoblastic Neoplasia (GTN) -- Pulmonary metastasis (cannon-ball lesions on CXR) after molar evacuation = choriocarcinoma or high-risk GTN.

WHO/FIGO risk scoring: A prognostic score $\geq 7$ = high-risk GTN. Presence of pulmonary metastasis increases the score significantly.

Treatment:
Low-risk GTN (score < 7, no metastasis): Single-agent chemotherapy -- methotrexate or actinomycin D.
High-risk GTN (score $\geq 7$, metastases): Multi-agent EMACO regimen.

EMACO regimen breakdown:
Day 1 and Day 2:
- Etoposide 100 mg/m$^2$ IV
- Actinomycin D 0.5 mg IV bolus
- Methotrexate 100 mg/m$^2$ IV push + 200 mg/m$^2$ IV over 12 hr
Day 2: Folinic acid rescue
Day 8:
- Cyclophosphamide 600 mg/m$^2$ IV
- Vincristine (Oncovin) 1 mg/m$^2$ IV (max 2 mg)

Cure rate with EMACO in high-risk GTN: $\sim$75--90%.

Hysterectomy is reserved for drug-resistant cases as an adjunct.

\[\boxed{\text{EMACO regimen}}\]