1 / 48

DIAGNOSIS, TREATMENT AND FOLLOW-UP IN AREAS OF LIMITED RESOURCES

Gestational Trophoblastic Lesions. DIAGNOSIS, TREATMENT AND FOLLOW-UP IN AREAS OF LIMITED RESOURCES . Virach Wootipoom, MD Prince of Songkla University Songkhla, Thailand. Limited resources. Gynecologic Oncologists Laboratory (hCG) Imaging Chemotherapy Radiotherapy Surgery.

blake
Download Presentation

DIAGNOSIS, TREATMENT AND FOLLOW-UP IN AREAS OF LIMITED RESOURCES

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Gestational Trophoblastic Lesions DIAGNOSIS, TREATMENT AND FOLLOW-UP IN AREAS OF LIMITED RESOURCES Virach Wootipoom, MD Prince of Songkla University Songkhla, Thailand

  2. Limited resources • Gynecologic Oncologists • Laboratory (hCG) • Imaging • Chemotherapy • Radiotherapy • Surgery

  3. Incidence of hydatidiform mole from selected studies Lancet Oncol 2003; 4: 670–78

  4. Ratios of choriocarcinoma from selected studies* Lancet Oncol 2003; 4: 670–78

  5. Age-standardised incidence rates of choriocarcinoma per 100 000 women from cancerregistry- based statistics in different areas of the world. Lancet Oncol 2003; 4: 670–78

  6. GTD variation • The reason for this variation is not understood • women over 40 years having at least a fivefold increase in risk. • previous molar is a predisposing factor

  7. GTD in South-East Asia • GTD used to be a common gynecological problem in South-East Asian countries. • The true incidence is unknown because of the lack of a tumor registry in many countries.

  8. DIAGNOSIS, TREATMENT AND FOLLOW-UP IN AREAS OF LIMITED RESOURCES • Gynecologic Oncologists • Laboratory (hCG) • Imaging • Chemotherapy • Radiotherapy • Surgery

  9. Thailand • Population (millions) : ………….… 63 • Provinces : ……………………….…… 76 • Gynecologic Oncologists : ……….. 110 • Fellowship training centers : .…… 9 • Fellowship Training (years) :. …. 2 • Society : …………….…… TGCS

  10. Hydatidiform mole

  11. Diagnosis of HM • Ultrasound has replaced all other noninvasive means for diagnosis. • Ultrasound + hCG is suggestive. • Today, US and hCG are available in nearly every areas of limited resources.

  12. Management of HM • patients should be monitored with • serum quantitative hCG values • CBC • chest X-ray • coagulation tests • renal and liver function tests • Mole should be evacuated as soon as possible.

  13. Management of HM • Suction curettage • preferred method of evacuation. • Hysterectomy • an alternative treatment in selected cases. • reduces malignant postmolar sequelae. • risk of postmolar GTN remains 3–5% • these patients should be monitored postoperatively with serial hCG levels.

  14. Prophylactic chemotherapy • May be appropriate for some specific circumstances in areas of limited resources • High-risk cases

  15. Limpongsanurak S. Prophylactic actinomycin D for high-risk complete hydatidiform mole. J Reprod Med 2001;46:110–6 • High-risk criteria • Initial hCG > 100,000 mIU/mL • Size > date • Theca lutein cysts > 6 cm • Maternal age > 40 • Associated medical problems (toxemia, hyperthyroid, embolization, DIC)

  16. Limpongsanurak S. Prophylactic actinomycin D for high-risk complete hydatidiform mole. J Reprod Med 2001;46:110–6 • one course of Actinomycin-D given. • Result : 72% decrease in malignant sequelae (14% VS 50%) • Prophylaxis may be beneficial in high-risk cases who cannot be followed closely. • considered in selected patients or special situations (poor compliance).

  17. Surveillance After Evacuation • Serial quantitative serum hCG • 48 hours of evacuation • baseline values (5 mIU/mL) • every 1–2 weeks, then at 1-2 month intervals for 6–12 months. • Reliable contraception recommended during hCG surveillance.

  18. Rationale for monitoring • Identifify patients at risk of postmolar malignant GTN. • almost all malignant sequelae occur within 6 months of evacuation.

  19. Role of general OB-GYN • They should be able to manage HM • diagnosis of postmolar GTN. • evaluating patient’s risk for referral. • Currently, suction curettage and hCG monitoring for postmolar GTN are available in nearly every areas of limited resources.

  20. PSU Management of HM(January 2002 - April 2006) • 33 complete HM • remission = 16 (64%) • low-risk GTN = 9 (36%)

  21. Gestation Trophoblastic Neoplasia (GTN)

  22. GTN Staging/classification • FIGO staging system of GTN • 1982 : anatomically based • 1992 : include two prognostic factors (Bagshawe 1976, modified by WHO in 1983) • 2000 : FIGO revised GTN staging/ classification, adopted in 2000 and published in 2002 (ISSGTD, IGCS, FIGO) • Anatomical staging into I-IV • scoring system modified from WHO

  23. FIGO Anatomical staging UICC Clinical+Morphological classn FIGO New anatomical substage Hammond Clinical classn 1967 1973 1976 1982 1983 1992 2000 Bagshawe Revised FIGO Prognostic scoring system anatomical staging Modified-WHO-scoring WHO Modified Bagshawe

  24. 4 major consensus statements • The term “GTN” is recommended for abnormal gestational trophoblastic proliferation that required Rx for potential of malignancy. • The diagnostic criteria of GTN following HM. • The recommendation of investigative tools. • The use of 2 risk groups instead of 3 as recommended by WHO • low-risk group (score ≤ 6) • High-risk group (score ≥7)

  25. Diagnostic criteria • Mostly based on • History taking • Serum β-hCG • Chest X-ray • Ultrasound • All are available in area of limited resources

  26. Current FIGO guidelines for the diagnosis and staging of GTN allow uniformityfor reporting results of treatment. • It is important to individualize treatment of patients with malignant GTN based on risk factors • Single agent therapy for low-risk. • Multiagent therapy for high-risk.

  27. Tochareonvanich, Chichareon S, Wootipoom V, et al. Correlation of risk categorization in gestational trophoblastic tumor between old and new combined staging and scoring system. J Obstet Gynaecol Res 2003;29:20-27 Comparing the treatment pattern and the outcome among the different classifications, we found that all classifications were equivalent without compromising the outcome.

  28. FIGO 2000 • User friendly • Feasible and practical in areas of limited resources, using only • complete history taking • serum β-hCG • chest X-ray • ultrasound

  29. Investigative Tools to Diagnose Metastases • Chest X-rays are appropriate for lung metastases and for counting the number of metastases. • Liver metastases may be diagnosed by US or CT scan. • Brain metastases may be diagnosed by MRI or CT scan.

  30. The diagnostic problem in the areas of limited resources may be only lacking of CT or MRI for detection of brain matastasis

  31. High-risk sites of metastases rarely occur without pulmonary metastases. (Hunter V, et al. Cancer 1990;65:1647–50) • Cerebral metastases are rare unless there are concurrent lung or vaginal metastases. • Therefore CT or MRI brain scans may be omitted in those patients without vaginal or lung metastases on chest X-ray. (TY Ng, LC Wong. Best Practice & Research Clinical Obstetrics and Gynaecology 2003;17:93–903) NOTE :40% postmolar GTN with negative chest X-rays have pulmonary lesions detected by CT scan, but small pulmonary metastases do not affect survival.

  32. Treatment of GTN in the areas of limited resources • Treatment should be limited to low-risk GTN (score ≤6). • Patients with score ≥7 should be referred to specialized center.

  33. Chemotherapy for low-risk nonmetastatic and low-risk metastatic GTN

  34. At PSU, we treat low-risk GTN patients with weekly methotrexate regimen. • 40 mg/m2 given intramuscularly every week. • This is the most cost-effective regimens when feasibility, efficacy, toxicity, and cost are taken into consideration. • Chemotherapy is continued until normal hCG is achieved, and one additional course is given.

  35. If hCG values have not decreased by 10%, treatment should be changed to alternative single-agent regimen. • In case of failure, the patient should be referred to specialized center. • Cure rate for low-risk disease ~ 100%, with recurrence rates less than 5%.

  36. Conclusion In areas of limited resources • Management of Hydatidiform mole • Appropriate treatment is avialable. • Prophylactic chemotherapy may be considered in high-risk cases.

  37. Conclusion In areas of limited resources • Management of GTN • Based on FIGO 2000 • Low-risk GTN (score ≤6) can be managed. • Weekly methotrexate is a cost effective chemotherapy.

  38. Conclusion In areas of limited resources • Management of GTN • Based on FIGO 2000 • High-risk GTN (score ≥7) should be referred to specialized center.

  39. GTD at PSU • Hydatidiform Mole (HM) • 2.8/1,000 deliveries • Gestation trophoblastic neoplasia (GTN) • 4.6/1,000 deliveries

  40. GTN PSU : CPG for the Management of GTN Investigate, stage, risk-score (FIGO 2000) hCG, CBC, BUN, Cr, LFT, TFT, Coagulogram, CXR, US, CT/MRI in +ve CXR Stage I-III low-risk (≤6) Stage IV any score or Stage I-III, high-risk (≥7) Multi-agent chemoRx (EMA-CO) Plateau or  hCG Single-agent chemoRx (weekly MTX) Plateau or rising hCG +ve Investigate -ve hCG -ve hCG EMA-CE -ve Act-D Investigate Stage I Stage II-III Plateau or  hCG 2 additional courses -ve Plateau or  hCG one addition course Weekly hCG until –ve X 3 • hCG q 1mo. x 12 mo., OCP, pregy if need • CXR q 3 mo. (in lung metas) • hCG q 1mo. X 24 mo., OCP, pregy if need • CXR q 3 mo. (lung metas) Salvage therapy

  41. Management of GTN at PSU (January 2002 - April 2006) • 57 GTN • Low-risk GTN (39 cases) • Remission = 100% • High-risk GTN (18 cases) • Remission = 77%

  42. The most important factors to assure successful therapy • Experience with gestational trophoblastic lesions • Reliable hCG assay • Experience with chemotherapy • Patient’s compliance

  43. welcome to the next IGCS 2008 Thank you for your attention

More Related