State of the Art: Gestational Trophoblastic Lesions - PowerPoint PPT Presentation

1 / 32
About This Presentation
Title:

State of the Art: Gestational Trophoblastic Lesions

Description:

Gestational Trophoblastic Lesions Treatment beyond single agents Barry Hancock (Sheffield, UK) International Gynecologic Society Meeting 2006 Which group of patients? – PowerPoint PPT presentation

Number of Views:190
Avg rating:3.0/5.0
Slides: 33
Provided by: WendyW76
Category:

less

Transcript and Presenter's Notes

Title: State of the Art: Gestational Trophoblastic Lesions


1
State of the Art Gestational Trophoblastic
Lesions
  • Treatment beyond single agents
  • Barry Hancock
  • (Sheffield, UK)
  • International Gynecologic Society Meeting 2006

2
(No Transcript)
3
(No Transcript)
4
(No Transcript)
5
Which group of patients?
  • Risk (WHO score, Dutch classification)
  • Prognosis (Hammond)
  • Stage (Song, FIGO)
  • Choriocarcinoma risk (Japan)
  • Criteria for treatment

6
Two scenarios
  • Single agent resistance
  • High risk disease

7
Single agent resistance
  • Alternative single agent
  • Combination chemotherapy
  • (EMA-CO, MAC, EA etc)

8
Single agent resistance
  • For low risk non-metastatic disease single
    agent chemotherapy is 60-90 successful
  • Second line multi-agent therapy is virtually
    always (gt95) successful in dealing with single
    agent resistance

9
Is intensive chemotherapy necessary for all high
risk patients?
Benefits
Risks
? Higher CR
? Over treatment
? Less salvage treatment
? Higher financial costs
? Shorter treatment period
? More toxicity
10
What is the evidence base?
  • One randomized controlled trial
  • Lots of small-moderate sized series
  • One retrospective comparative study

11
Primary treatment for high risk GTN
  • MAC (MTX, dactinomycin, chlorambucil or
    cyclophosphamide)
  • EMA-CO (etoposide, MTX, dactinomycin,
    cyclophosphamide,
    vincristine)
  • EMA/MEA
  • CHAMOCA (cyclophosphamide, hydroxyurea,
    dactinomycin, MTX,
    vincristine, doxorubicin)
  • CHAMOMA ( melphalan)
  • FME (FU, MTX, etoposide)

Previously single agent MTX!
12
Primary remission rates in high risk GTN
  • MAC 63-80
  • CHAMOCA 82
  • MAC vs CHAMOMA 73 vs 65
  • EMA-CO gt80
  • EMA/MEA/FME 75-80

13
Salvage treatment in high risk GTN
  • EMA-EP (EMA - etoposide, cisplatin)
  • BEP (bleomycin, etoposide, cisplatin)
  • CEC (cyclophosphamide, etoposide, cisplatin)
  • MISC (high dose chemotherapy, carboplatin/paclitax
    el,
  • paclitaxel/etoposide and paclitaxel/cisplatin
    doublet)

14
Salvage treatment
  • 20-60 success

15
Surgery
16
Toxicity
  • EP-EMA
  • CHAMOCA
  • EMA-CO
  • MAC
  • EMA/MEA/FME

17
Toxicity
  • Multi-treated patients
  • Potential mortality whatever is chosen

18
Acute toxicity
  • Alopecia
  • Neutropenia
  • Anemia
  • Nausea/vomiting
  • Stomatitis
  • Neutropenic sepsis
  • Thrombocytopenia

19
Long-term toxicity
  • Increased second malignancy
  • Premature menopause
  • Unknown!

20
  • Staff Nurse Ellen Zitek in BBCs Casualty
  • Treated for cancer after a molar pregnancy

21
(No Transcript)
22
FIGO SCORING 0 1 2 4
Age lt 40 ? 40 - -
Antecedent pregnancy Mole Abortion Term -
Interval months from index pregnancy lt 4 4 - lt 7 7 - lt 13 ? 13
Pre-treatment serum hCG (IU/L) lt 103 103 - lt 104 104 - lt 105 ? 105
Largest tumour size (including uterus) cm lt 3 3 - lt 5 ? 5 -
Site of metastases Lung Spleen, kidney Gastro-intestinal Liver, brain
Number of metastases - 1-4 5-8 gt 8
Previous failed chemotherapy - - Single drug 2 or more drugs
23
Chemotherapy for High Risk GTN(Sheffield UK)
M/AE
  • Day 1 MTX 100mg/m2 iv Folinic acid
    rescue
  • Day 8, 9, 10 Dactinomycin 500µg iv
  • Etoposide 100mg/m2 iv
  • et seq 7 days

24
Sheffield Trophoblast Centre, UK1986-2005
Registration
8211
Persistent GTN
25
Methotrexate resistant GTN

Median follow-up 8 years
Late deaths 0
2nd malignancy 0
Further pregnancy gt60
26
High risk GTN
27
Cure rates in GTN
1st line Salvage
Low risk (70-90) 75 99
High risk (10-30) 75 95
Overall 98 cure
28
Conclusion
  • The majority of patients are curable whatever
    the risk or stage
  • It doesnt seem to matter which regimen you
    choose as long as it works and you are familiar
    with it!
  • Specialist center skills may be more important
    than the actual therapy
  • But - occasional patients still die despite
    multiple chemotherapy and surgical
    interventions

29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
Methotrexate in high riskGTN (Sheffield, UK
1973-86)
Median follow-up 24y
Late deaths 0
2nd malignancies 0
AVC - dactinomycin, vincristine, cyclophosphmide
Write a Comment
User Comments (0)
About PowerShow.com