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GESTATIONAL TROPHOBLASTIC NEOPLASIA: Staging and classification

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Title: GESTATIONAL TROPHOBLASTIC NEOPLASIA: Staging and classification


1
GESTATIONAL TROPHOBLASTIC NEOPLASIAStaging and
classification
  • Dott.ssa Cristina Bonazzi
  • Caravaggio, 15-17 Maggio 2008

2
CLASSIFICATION
  • Its the language that the clinicians use to talk
    about a disease
  • Common language
  • - easy to understand
  • - easier to compare data and results

3
CLASSIFICATION
  • GTN challenging condition

4
HISTORY
  • 1276 Margaret Countess of Hennemberg delivered
    365 children on Good Friday
  • 1840 Lancet Wilton described chorioadenoma
    destruens with the ruptured uterus and
    hemorrhage
  • 1877 Chiari was the first who described
    chorioncarcinoma

5
HISTORY
  • 1893 Sanger proposed the first morfological
    classification
  • 1895 Marchand invented the name
    chorionepithelioma malignum and divided this into
    typical and atypical forms and related these to
    prognosis
  • 1910 Ewing suggested the basis of the modern
    histologic classification (syncyzial
    endometritis, chorioadenoma destruensmola
    invasiva, choriocarcinoma)

6
HISTORY
  • 1967 Ishizuka and Brewer produced The
    International Union against cancer
  • a clinical and morphological classification
  • - conditions related to any type of pregnancy
  • - range from the benign to the most malignant
  • form
  • - morphological groups differ in prognosis

7
(No Transcript)
8
HISTORY
  • Gestational trophoblastic diseaseThree
    classifications
  • ANATOMICAL FIGO staging (1982)
  • CLINICAL Hammond classification 1973,Dutch
  • PROGNOSTICAL Score System (Since 1976)

9
THE NIGHT OF CLASSIFICATIONANATOMICAL STAGING
ONLY
  • Its used to stage gynecological cancer with
    anatomical criteria
  • It is a logical and anatomical staging system for
    GTN
  • The disease can be staged at the time of
    diagnosis
  • In 1962 Songs classification was used by all
    chinese centers
  • In 1982 FIGO proposed an anatomical staging
    system

10
SONGS CLASSIFICATION
11
FIGO 1982
12
FIGO 1982-limitations-
  • Very different prognosis for patients into the
    same stage of disease
  • Many clinical features not considered by
    anatomical staging
  • FIGO anatomical staging not universally adopted

13

SUNRISE IN CLINICAL CLASSIFICATION
  • Non metastatic GTD/metastatic GTD different
    prognosis
  • Ross 1965clinical factors affecting the
    prognosis in the metastatic GTD group
  • - BHCG (high level)
  • - interval longer than 4 months
  • - brain and liver metastasis
  • Hammond 1973 importance of clinical factors
    confirmed more factors introduced

14
HAMMONDS CLASSIFICATION-NCI STAGING SYSTEM
15
HAMMOND CLASSIFICATION 1973
  • Divides patients with metastatic disease into
    two groups
  • - low risk
  • - high Risk
  • Patients with High risk factors required primary
    multi agents chemotherapy
  • Designated as NCI classification
  • Most popular in USA

16
DUTCH CLASSIFICATION
  • In Europe a similar classification was perform by
    Dutch Working Group for Trophoblastic Tumors

17
CLINICAL CLASSIFICATION GETTING BRIGHTER
  • Clinical classifications are more accurate in
    predicting prognosis
  • More useful in choosing therapeutical options
    (single vs multiple agents)
  • Lack of agreement in the relative importance of
    each factor

18
THE MORNING OF CLINICAL CLASSIFICATION THE
SCORING SYSTEM
  • The first in 1976 by BAGSHAWE
  • Prognostic score system
  • Different weight to different prognostic factors
  • Three groups low-medium-high
  • Three groups ? three different intensity
    chemotherapy

19
BAGSHAWE SCORE
Since 1976 it becomes the basis of management of
GTN at Charing Cross Hospital Limitation cannot
be used in developing countries
20
WHO SCORING SYSTEM 1983 - THE ORIGINAL-
Modification of Bagshawe system easier in the
developing countries
21
SCORING SYSTEM
  • The prognostic score is a good system to
    distinguish gestational trophoblastic disease in
    different level of risk
  • This differentiation allows to choose the best
    treatment option

22
FLASHING LIGHTthe same language but different
local dialects
  • Each center proposed its better score with
    omission or additions of different risk factors
    and modified the number alloted to each category
  • In 1994 Kohorn published this table with 15
    different scores

It was not possible to compare outcome of
patients
23
THE FIRST EFFORT TO UNIFY CLASSIFICATION
  • The WHO score was more predictive of prognosis
    than the FIGO anatomical staging
  • The FIGO Oncology Committee decided to add
    substages to its anatomical staging
  • In this way it was possible to combine an
    anatomic staging with a prognostical clinical
    classification
  • The new FIGO staging reached some of the criteria
    of a good classification simple, easy to
    remember and to use, risk factors easily assessed
    in any center

24
FIGO 1982
FIGO 1992 revised
Risk Factors - BetaHCGgt 100000 mU/ml -
Interval gt 6 months
25
FIGO 1992
  • Disadvantages
  • The risk factors used were not indipendent
    significant risk factors by multivariant analysis
  • Clinicians prefer to have a more comprehensive
    scoring system based on the WHO classification
    because it was a good marker of prognosis

26
Work in progress ISSGTD, IGCS, FIGO from 1992
to 2000
  • FIGO retained anatomical classification in stage
    I-II-III-IV
  • FIGO 1992 modification rejected
  • A modified WHO score was introduced

27
FIGO STAGING 2000
28
WHO SCORING SYSTEM 2000 MODIFIED-
The AB0 blood group risk factor was
eliminated The risk factor for liver metastasis
upgraded from 2 to 4 (the highest risk
score) Metastasis visible on chest radiograph
should be counted as part of the score
Low risk 0-6 medium risk high risk gt7
29
BRIGHT DAY same language same score COMBINED
FIGO STAGINGRISK FACTOR SCORING WHO
30
1)CONSENSUS ON TERMINOLOGY
  • The term GTN was recommended to avoid confusion
  • Consensus also needed for diagnosis and
    management
  • FIGO 2000 classification definies criteria for
    diagnosis of postmolar trophoblastic neoplasia
    and describes the requirements for establishing
    the presence of metastases in trophoblastic
    disease
  • The conclusion are based on multivariate analysis
    from studies from all over the world

31
2) CONSENSUS ON DIAGNOSTIC CRITERIA criteria for
diagnosis of post hydatidiform mole (GTN)
  • GTN may be diagnosed when the plateau of human
    chorionic gonadotrophin (hCG) lasts for four
    measurements over a period of 3 weeks or longer,
    that is day 1, 7, 14, 21
  • 2. GTN may be diagnosed when there is a rise of
    hCG of 3 weekly consecutive measurements or
    longer, over at least a period of 2 weeks or more
    days 1, 7, 14
  • 3. GTN is diagnosed when the hCG level remains
    elevated for 6 months or more
  • 4. GTN is diagnosed if there is a histologic
    diagnosis of choriocarcinoma

32
  • 3) CONSENSUS ON INVESTIGATIVE TOOLS TO DIAGNOSE
    METASTASES
  • Chest X-ray is appropriate to assess the lungs (
    to
  • diagnose lung metastases and numbering them
    to determine risk score).
  • Chest CT may be used
  • 2. Liver metastases may be diagnosed by
    ultrasound or CT scan
  • 3. Brain metastases may be diagnosed by magnetic
    resonance imaging (MRI) or CT scan

33
CONCLUSIONS
  • The revised FIGO 2000 GTN staging and
    classification is easier and could be used in
    majority of clinical setting in the world.
  • Future analisys using the same staging and
    classification would be more helpful.
  • Revising the data with multivariate analysis
    could identify significant and indipendent
    factors to refine further the staging system.
  • FIGO staging is difficult to utilise in
    developing countries where clinical resources are
    limited (no lab, USS or X Ray facilities)

34
Work in progress
  • Open problems
  • Hydatiform mole not included in the
    classification
  • 2) Timing for scoring and staging of the disease
  • (When does the patient need restaging?)
  • 3) Should be invasive mole in a separate risk
    category?
  • Solutions
  • Dynamic, computer-based FIGO staging and scoring
    system

35
Work in progress
  • Solutions
  • Dynamic, computer-based FIGO staging and scoring
    system
  • It allows changes in the stage and the risk
    factors score as the patientss trophoblastic
    neoplasia develops and particulary if it
    progresses
  • Modern computer technology permits these
    changes

36
Work still in progress
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