Low-risk gestational trophoblastic neoplasia (FIGO score 0 to 6)
Low-risk gestational trophoblastic neoplasia is the mild form of this rare pregnancy-related cancer, usually found when the pregnancy hormone hCG fails to fall after removal of a molar pregnancy. It is cured in almost every woman with a single chemotherapy drug, methotrexate or actinomycin D, given until the hormone level is normal, and most go on to have normal pregnancies afterwards.
Overview
Gestational trophoblastic neoplasia arises from the placental trophoblast of a pregnancy, most often a complete or partial hydatidiform mole, and is unique among cancers in producing a near-perfect tumour marker, human chorionic gonadotropin (hCG), which is used for diagnosis, staging, monitoring and follow-up. After evacuation of a complete mole about 15 percent of women, and after a partial mole under 1 percent, develop neoplasia, detected by a plateau or rise in serial hCG without any need for biopsy. The FIGO 2000 scoring system combines age, antecedent pregnancy, interval, hCG level, tumour size, site and number of metastases and prior chemotherapy into a score; 6 or below is low risk and predicts response to single-agent chemotherapy. Low-risk disease is typically an invasive mole or choriocarcinoma confined to the uterus or with small lung metastases.
Single-agent chemotherapy cures nearly all patients. Methotrexate, the first drug ever to cure a metastatic cancer when Min Chiu Li used it for choriocarcinoma in 1956, is given as an eight-day regimen alternating with folinic acid (the Charing Cross schedule) or weekly, and actinomycin D as a pulsed fortnightly dose; the GOG 174 trial (Journal of Clinical Oncology 2011) found pulsed actinomycin D produced more complete responses than weekly methotrexate, though methotrexate remains first choice in many centres for its low toxicity. Treatment continues until hCG is normal and then for three consolidation cycles, and women who develop resistance switch to the other single agent or, if hCG is high, to multi-agent EMA-CO; overall survival in low-risk disease is close to 100 percent whatever the sequence. Second-curettage cures a minority with low hCG, and hysterectomy is an option for women who have completed their families. Because trophoblast expresses PD-L1 almost universally, the anti-PD-L1 antibody avelumab cured eight of fifteen women with single-agent-resistant low-risk disease in the TROPHIMMUN trial (Journal of Clinical Oncology 2020), and pembrolizumab has similar case-series support, so checkpoint inhibitors are now an option to avoid multi-agent chemotherapy. Follow-up hCG monitoring continues for a year and pregnancy is deferred until it is complete; subsequent pregnancies are normal in most cases, with a small risk of a further mole.
State of the art
- Cure with fertility preserved is the norm using a single drug.
- hCG monitoring makes it the only cancer routinely diagnosed and followed without imaging or biopsy of the tumour.
- Avelumab offers a chemotherapy-sparing option when the first drug fails.
Red cards
From the labels and guidelines behind the standard of care. Your team's thresholds win.- Emergency services nowBleeding or bruising
Bleeding that will not stop, black or bloody stools, or unexplained bruising when platelets are expected to be low.
- Emergency services nowHypophysitis or adrenal crisis
Persistent headache with extreme tiredness, nausea, dizziness on standing or low blood pressure. Vomiting, severe weakness or collapse is adrenal crisis.
- Check before combiningFood and drink: Pembrolizumab
No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
- Check before combiningFood and drink: Vincristine
Fatal if given intrathecally: label all syringes.
- Check before combiningKidneys: Etoposide
Reduce to 75% for CrCl 15-50.
- Check before combiningKidneys: Methotrexate
High-dose methotrexate requires normal renal function, hydration, urine alkalinisation and leucovorin rescue with level monitoring.
See all on the product pages:AvelumabCyclophosphamideDactinomycin (actinomycin D)EtoposideMethotrexatePembrolizumabVincristine·Printable cards in the navigator
Anatomy and lymph node drainage
- Fallopian tube fimbria (origin of high-grade serous)
- Ovary (other histologies, germ cell)
- Endometrium
- Myometrium (uterine sarcoma)
- Placental site (gestational trophoblastic)
- Cervix, transformation zone
- Vulva
- Nodes: obturator and external iliac
- Nodes: internal iliac
- Nodes: para-aortic (ovary, high uterus)
- Nodes: inguinal (vulva)
Most high-grade ovarian cancers begin at the tip of the fallopian tube; endometrial cancer lines the uterus, cervical cancer starts at the transformation zone; each drains to a different node group.
- Fallopian tube fimbria (origin of high-grade serous)
- Ovary (other histologies, germ cell)
- Endometrium
- Myometrium (uterine sarcoma)
- Placental site (gestational trophoblastic)Post-molar gestational trophoblastic neoplasia with hCG plateau or rise (commonest presentation) · Invasive mole (chorioadenoma destruens) · Low-risk gestational choriocarcinoma (FIGO score 6 or below) · Low-risk disease with lung metastases (still single-agent) · Single-agent-resistant low-risk disease (switch agent, EMA-CO or avelumab) · Quiescent gestational trophoblastic disease (low persistent hCG, observation)
- Cervix, transformation zoneLow-risk gestational choriocarcinoma (FIGO score 6 or below)
- Vulva
- obturator and external iliac
- internal iliac
- para-aortic (ovary, high uterus)
- inguinal (vulva)
Same organ: High-grade serous ovarian cancer, Low-grade serous ovarian cancer, Clear cell ovarian cancer, Mucinous ovarian cancer, Adult granulosa cell tumour of the ovary, Ovarian cancer, Endometrial cancer, Cervical cancer, Vulvar cancer, Gestational trophoblastic neoplasia, Uterine sarcoma, Vaginal cancer, POLE-ultramutated endometrial cancer, Mismatch-repair-deficient endometrial cancer, p53-abnormal endometrial cancer, including uterine serous carcinoma, Endometrial cancer with no specific molecular profile, Advanced or recurrent endometrial cancer, Uterine carcinosarcoma, Early cervical cancer and fertility-sparing surgery, Locally advanced cervical cancer, Recurrent or metastatic cervical cancer, Platinum-sensitive ovarian cancer, Platinum-resistant ovarian cancer, HPV-associated vulvar squamous cell carcinoma, HPV-independent vulvar squamous cell carcinoma (p53-mutant), Vaginal squamous cell carcinoma (HPV-associated), Vaginal adenocarcinoma (including DES-associated clear cell adenocarcinoma), High-risk gestational trophoblastic neoplasia (FIGO score 7 or more, including ultra-high-risk), Placental-site trophoblastic tumour and epithelioid trophoblastic tumour
The large majority of gestational trophoblastic neoplasia, usually detected by a rising or plateauing hCG after evacuation of a molar pregnancy; cure approaches 100 percent and fertility is preserved.
- Serum tumour markers: proper use and misuseStandard of care
Nothing recorded yet.
Nothing recorded yet.
Also on OnCo: Symptoms and red flags · Early detection roadmap.
Cases by country
No country-level case numbers. This cancer is not mapped to a GLOBOCAN site.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
Serial hCG after molar evacuation; pelvic Doppler ultrasound and chest X-ray or CT; FIGO scoring; no biopsy needed.
Single-agent methotrexate with folinic acid (eight-day regimen) or pulsed actinomycin D (GOG 174), continued until hCG normalises plus three consolidation cycles.
Switch to the alternative single agent if hCG is low; EMA-CO if hCG is high; avelumab or pembrolizumab as chemotherapy-sparing options (TROPHIMMUN).
Second uterine evacuation in selected women with low hCG; hysterectomy for women who have completed their families or with uncontrolled bleeding.
hCG monitoring for twelve months after remission, contraception during follow-up, and hCG after every future pregnancy.
Subtypes & biomarkers
top- Post-molar gestational trophoblastic neoplasia with hCG plateau or rise (commonest presentation)
- Invasive mole (chorioadenoma destruens)
- Low-risk gestational choriocarcinoma (FIGO score 6 or below)
- Low-risk disease with lung metastases (still single-agent)
- Single-agent-resistant low-risk disease (switch agent, EMA-CO or avelumab)
- Quiescent gestational trophoblastic disease (low persistent hCG, observation)
- Serial serum hCG (diagnosis, response, surveillance)
- FIGO 2000 prognostic score (0 to 6 low risk)
- Pelvic ultrasound and chest imaging for staging
- Pretreatment hCG level (predicts single-agent resistance)
- Genotyping to confirm gestational origin where uncertain
- PD-L1 expression (near universal; checkpoint inhibitor rationale)
How often this target appears
- 1956Min Chiu Li cures metastatic choriocarcinoma with methotrexate, the first chemotherapy cure of a solid tumour
- 1964Actinomycin D established as a second single agent
- 1973Charing Cross Hospital centralises registration and treatment in the United Kingdom
- 2000FIGO adopts the combined anatomical stage and prognostic score
- 2011GOG 174: pulsed actinomycin D beats weekly methotrexate on complete response
- 2020TROPHIMMUN: avelumab cures most women with single-agent-resistant low-risk disease
Dated changes read from the records linked to this cancer: approvals, regulatory steps, reported trials, guideline versions and milestones. Newest first; no date is inferred.
All 7 changes by month →- 2026-09-18This recordLow-risk gestational trophoblastic neoplasia (FIGO score 0 to 6)Facts on this page last checked
When this page itself was last checked or edited.
- 2020MilestoneAvelumabTROPHIMMUN: avelumab cures most women with single-agent-resistant low-risk disease
A milestone in how this cancer is treated.
- 2011MilestoneDactinomycin (actinomycin D)GOG 174: pulsed actinomycin D beats weekly methotrexate on complete response
A milestone in how this cancer is treated.
- 2000MilestoneDisease-specific staging and risk systems (FIGO, Ann Arbor, IPI, R-ISS, ELN, IMDC)FIGO adopts the combined anatomical stage and prognostic score
A milestone in how this cancer is treated.
- 1973MilestoneTumour markers (CEA, LDH, chromogranin, thyroglobulin)Charing Cross Hospital centralises registration and treatment in the United Kingdom
A milestone in how this cancer is treated.
- 1964MilestoneDactinomycin (actinomycin D)Actinomycin D established as a second single agent
A milestone in how this cancer is treated.
What is in development for Low-risk gestational trophoblastic neoplasia (FIGO score 0 to 6), drawn from the whole corpus: 0 items. Drugs are grouped by the most advanced trial phase they have reached anywhere; approved treatments sit under standard of care. Technologies are the methods being tested for this cancer, trials are the studies recorded here, and ideas are proposals not yet in a trial.
Nothing recorded in development for this cancer yet.
Open problems and what is being done
Methotrexate and actinomycin D have never been compared head to head with the regimens most centres use.
Which resistant patients should receive immunotherapy rather than EMA-CO is not settled.
Overtreatment of quiescent disease with persistently low hCG is a risk.
Care is centralised in only a few countries.
Trials
topTrials recruiting now
Country and place are remembered in this browser only. A postcode is sent to OpenStreetMap's Nominatim service to find coordinates when you press the button; nothing else leaves your device.
Expert centres
topExpert centres
Baltimore · cancer center | United States | 0 | 2,955 | 41,449 | #10 | ||
Lausanne · hospital | Switzerland | none recorded | 0 | 509 | 9,176 | - | |
Brussels · cancer center | Belgium | none recorded | 0 | 489 | 8,689 | - | |
Madison, WI · cancer center | United States | 0 | 424 | 10,177 | - | ||
Birmingham · hospital | United Kingdom | none recorded | 0 | 218 | 1,978 | - | |
Philadelphia, PA · consortium | United States | none recorded | 0 | 165 | 1,237 | - | |
Indianapolis, IN · cancer center | United States | 0 | 159 | 4,238 | - | ||
Kampala · cancer center | Uganda | none recorded | 0 | 102 | 1,239 | - | |
Madrid · consortium | Spain | none recorded | 0 | 96 | 630 | - | |
Chicago, IL · consortium | United States | none recorded | 0 | 42 | 482 | - | |
Butaro · cancer center | Rwanda | none recorded | 0 | 5 | 8 | - | |
Sydney · consortium | Australia | none recorded | 0 | 3 | 0 | - | |
Varanasi · cancer center | India | none recorded | 0 | 0 | 0 | - | |
Cologne · consortium | Germany | none recorded | 0 | not matched | - | - | |
Homburg · consortium | Germany | none recorded | 0 | not matched | - | - |
These are the things we can measure; they are not a ranking of quality. Each column is a field on the institution record or a count over what OnCo has linked; a centre that treats many patients with Low-risk gestational trophoblastic neoplasia but is thinly recorded here will look small.
Not known: OnCo holds no case-volume or outcome figures for centres, so none are shown. Where a national audit or registry publishes them, the centre's page links to it. Default order: Newsweek rank, then trials for this cancer, then research output.
Questions to ask
topQuestions to ask your oncologist about Low-risk gestational trophoblastic neoplasia
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Why: Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Serial serum hCG, FIGO 2000 prognostic score, Pelvic ultrasound and chest imaging for staging, Pretreatment hCG level, Genotyping to confirm gestational origin where uncertain), and what were the results?Why: These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Why: Recognised subtypes for this cancer include Post-molar gestational trophoblastic neoplasia with hCG plateau or rise, Invasive mole, Low-risk gestational choriocarcinoma.
- Is germline (inherited) genetic testing recommended for me or my family?Why: Inherited variants can change treatment and matter for relatives.
Diagnosis and staging
- For my situation (diagnosis and staging), which of the standard options do you recommend and why?Why: Guideline options include: Serial hCG after molar evacuation; pelvic Doppler ultrasound and chest X-ray or CT; FIGO scoring; no biopsy needed.
First line
- For my situation (first line), which of the standard options do you recommend and why?Why: Guideline options include: Single-agent methotrexate with folinic acid (eight-day regimen) or pulsed actinomycin D (GOG 174), continued until hCG normalises plus three consolidation cycles.
- Am I a candidate for Methotrexate, Dactinomycin (actinomycin D), and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Resistance to first agent
- For my situation (resistance to first agent), which of the standard options do you recommend and why?Why: Guideline options include: Switch to the alternative single agent if hCG is low; EMA-CO if hCG is high; avelumab or pembrolizumab as chemotherapy-sparing options (TROPHIMMUN).
- Am I a candidate for Dactinomycin (actinomycin D), Methotrexate, Etoposide or related drugs, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Surgery
- For my situation (surgery), which of the standard options do you recommend and why?Why: Guideline options include: Second uterine evacuation in selected women with low hCG; hysterectomy for women who have completed their families or with uncontrolled bleeding.
Follow-up
- For my situation (follow-up), which of the standard options do you recommend and why?Why: Guideline options include: hCG monitoring for twelve months after remission, contraception during follow-up, and hCG after every future pregnancy.
Any stage
- Are there clinical trials I could join, for example of Avelumab, Pembrolizumab?Why: Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Why: Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Why: Supportive care improves quality of life and helps patients complete treatment.
- I read that “Methotrexate and actinomycin D have never been compared head to head with the regimens most centres use”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
- I read that “Which resistant patients should receive immunotherapy rather than EMA-CO is not settled”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
Newly diagnosed? Read the first 60 days with Low-risk gestational trophoblastic neoplasia, then print the one-page appointment sheet with room for the answers.
Print this page for your appointment (your browser's print command). These prompts are for discussion; your clinical team knows your case.
Direct links plus the targets, companies, and technologies of this cancer's products.
technologies
10targets
3drugs
7companies
5terms
2key papers
3Immunotherapy is a real option for chemotherapy-resistant GTN, building on the extraordinary PD-L1 expression of trophoblast; the TROPHAMET trial is testing avelumab with methotrexate first line.
Pulsed dactinomycin is at least as good as weekly methotrexate for low-risk GTN, but many centres still prefer the multi-day methotrexate-folinic acid schedule, which was not tested here; overall cure approaches 100 percent whichever drug comes first.
Whether a woman with GTN receives one drug or several rests on this scoring system, which is why OnCo has separate low-risk and high-risk pages.
Latest papers
topQuery for this cancer: (TITLE:"Low-risk gestational trophoblastic neoplasia" OR ABSTRACT:"Low-risk gestational trophoblastic neoplasia" OR TITLE:"FIGO score 0 to 6" OR ABSTRACT:"FIGO score 0 to 6" OR TITLE:"Low-risk GTN" OR ABSTRACT:"Low-risk GTN" OR TITLE:"Post-molar gestational trophoblastic neoplasia" OR ABSTRACT:"Post-molar gestational trophoblastic neoplasia" OR TITLE:"Persistent trophoblastic disease" OR ABSTRACT:"Persistent trophoblastic disease" OR TITLE:"Invasive mole and low-risk choriocarcinoma" OR ABSTRACT:"Invasive mole and low-risk choriocarcinoma") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Low-risk gestational trophoblastic neoplasia (FIGO score 0 to 6), not a curated reading list.
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