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In Reply:

Trophoblastic Tumour Screening & Treatment Center, Charing Cross Hospital, London, United Kingdom

Dr Kohorn has rightly highlighted that the International Federation of Gynecology and Obstetrics finally accepted the updated prognostic scoring system that had been under discussion for several years. However, the 485 patients we reported on in McNeish et al [1] were all staged according to the Charing Cross scoring system before this agreement. We agree that the new system is a refinement of the earlier scoring system, but for low-risk patients there is little difference between them [2]. Our definition of drug resistance used was either a plateau of successive human chorionic gonadotropin values or increasing values. We have continued to use alternate-day methotrexate and folinic acid because this is effective in 67% of patients with minimal mucositis. The 5-day schedule induces more mucosal damage. All patients are warned at the start of treatment that there is a chance that they may need to change treatment to other drugs if resistance becomes apparent. Our risk-adjusted strategy of switching to single-agent dactinomycin when resistance occurs when the human chorionic gonadotropin concentration is 100 U/L results in the minimum number of patients receiving combination chemotherapy with its small but real risk of inducing second tumors. With an updated survival of 484 of 485 (99.8%), the results are clearly satisfactory, and to date, we have not seen any second tumors.

Author's Disclosures of Potential Conflicts of Interest

The author indicated no potential conflicts of interest.

REFERENCES

1. McNeish IA, Stickland S, Holden L, et al: Low-risk persistent gestational trophoblastic disease: Outcome after initial treatment with low-dose methotrexate and folinic acid from 1992 to 2000. J Clin Oncol 20:1838-1844, 2002[Abstract/Free Full Text]

2. Hancock BW, Welch EM, Gillespie AM, et al: A retrospective comparison of current and proposed staging and scoring systems for persistent gestational trophoblastic disease. Int J Gynecol Cancer 10:318-322, 2000[CrossRef][Medline]

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Related Article

• Low-Risk Persistent Gestational Trophoblastic Disease: Outcome After Initial Treatment With Low-Dose Methotrexate and Folinic Acid From 1992 to 2000
  I. A. McNeish, S. Strickland, L. Holden, G. J.S. Rustin, M. Foskett, M. J. Seckl, and E. S. Newlands
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