Title: GESTATIONAL TROPHOBLASTIC NEOPLASIA: Staging and classification
1GESTATIONAL TROPHOBLASTIC NEOPLASIAStaging and
classification
- Dott.ssa Cristina Bonazzi
- Caravaggio, 15-17 Maggio 2008
2CLASSIFICATION
- Its the language that the clinicians use to talk
about a disease - Common language
- - easy to understand
- - easier to compare data and results
3CLASSIFICATION
- GTN challenging condition
4HISTORY
- 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
5HISTORY
- 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)
6HISTORY
- 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)
8HISTORY
- Gestational trophoblastic diseaseThree
classifications - ANATOMICAL FIGO staging (1982)
- CLINICAL Hammond classification 1973,Dutch
- PROGNOSTICAL Score System (Since 1976)
9THE 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
10SONGS CLASSIFICATION
11FIGO 1982
12FIGO 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
14HAMMONDS CLASSIFICATION-NCI STAGING SYSTEM
15HAMMOND 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
16DUTCH CLASSIFICATION
- In Europe a similar classification was perform by
Dutch Working Group for Trophoblastic Tumors
17CLINICAL 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
18THE 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
19BAGSHAWE SCORE
Since 1976 it becomes the basis of management of
GTN at Charing Cross Hospital Limitation cannot
be used in developing countries
20WHO SCORING SYSTEM 1983 - THE ORIGINAL-
Modification of Bagshawe system easier in the
developing countries
21SCORING 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
22FLASHING 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
23THE 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
24FIGO 1982
FIGO 1992 revised
Risk Factors - BetaHCGgt 100000 mU/ml -
Interval gt 6 months
25FIGO 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
26Work 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
27FIGO STAGING 2000
28WHO 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
29BRIGHT DAY same language same score COMBINED
FIGO STAGINGRISK FACTOR SCORING WHO
301)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
312) 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
33CONCLUSIONS
- 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)
34Work 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
35Work 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
36Work still in progress