How do you manage intracranial metastases from gestational trophoblastic neoplasia?

High risk gestational trophoblastic neoplasia with brain metastases is rare, and treatment has evolved over the past few decades and centered on multi-agent chemotherapy. The most well-cited regimen is EP-EMA (etoposide, 150 mg/m; cisplatin, 75 mg/m, intravenous, day 1; etoposide, 100 mg/m; methotrexate, 300 mg/m; dactinomycin, 0.5 mg, intravenous, day 8, every two weeks). This regimen has demonstrated good intracranial response, and cure rates of 75% with early surgical resection (Ngan et al., Int J Gynaecol Obstet 2018 ).

I would reserve RT for progression after failure of this regimen or in the case of oligometastatic disease, for which surgery is not feasible. When feasible, radiosurgery would be preferred. Given the high (80-90%) five ...