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

DIAGNOSIS,TREATMENTANDFOLLOW-UPINAREASOFLIMITEDRESOURCES,VirachWootipoom,MDPrinceofSongklaUniversitySongkhla,Thailand,GestationalTrophoblasticLesions,Limitedresources,GynecologicOncologistsLaboratory(hCG)ImagingChemotherapyRadiotherapySurgery,LancetOncol2003;4:67078,Incidenceofhydatidiformmolefromselectedstudies,LancetOncol2003;4:67078,Ratiosofchoriocarcinomafromselectedstudies*,Age-standardisedincidenceratesofchoriocarcinomaper100000womenfromcancerregistry-basedstatisticsindifferentareasoftheworld.,LancetOncol2003;4:67078,GTDvariation,Thereasonforthisvariationisnotunderstoodwomenover40yearshavingatleastafivefoldincreaseinrisk.previousmolarisapredisposingfactor,GTDinSouth-EastAsia,GTDusedtobeacommongynecologicalprobleminSouth-EastAsiancountries.Thetrueincidenceisunknownbecauseofthelackofatumorregistryinmanycountries.,GynecologicOncologistsLaboratory(hCG)ImagingChemotherapyRadiotherapySurgery,DIAGNOSIS,TREATMENTANDFOLLOW-UPINAREASOFLIMITEDRESOURCES,Population(millions):.63Provinces:.76GynecologicOncologists:.110Fellowshiptrainingcenters:.9FellowshipTraining(years):.2Society:.TGCS,Thailand,Hydatidiformmole,Ultrasoundhasreplacedallothernoninvasivemeansfordiagnosis.Ultrasound+hCGissuggestive.Today,USandhCGareavailableinnearlyeveryareasoflimitedresources.,DiagnosisofHM,ManagementofHM,patientsshouldbemonitoredwithserumquantitativehCGvaluesCBCchestX-raycoagulationtestsrenalandliverfunctiontestsMoleshouldbeevacuatedassoonaspossible.,Suctioncurettagepreferredmethodofevacuation.Hysterectomyanalternativetreatmentinselectedcases.reducesmalignantpostmolarsequelae.riskofpostmolarGTNremains35%thesepatientsshouldbemonitoredpostoperativelywithserialhCGlevels.,ManagementofHM,Prophylacticchemotherapy,MaybeappropriateforsomespecificcircumstancesinareasoflimitedresourcesHigh-riskcases,LimpongsanurakS.ProphylacticactinomycinDforhigh-riskcompletehydatidiformmole.JReprodMed2001;46:1106,High-riskcriteriaInitialhCG100,000mIU/mLSizedateThecaluteincysts6cmMaternalage40Associatedmedicalproblems(toxemia,hyperthyroid,embolization,DIC),LimpongsanurakS.ProphylacticactinomycinDforhigh-riskcompletehydatidiformmole.JReprodMed2001;46:1106,onecourseofActinomycin-Dgiven.Result:72%decreaseinmalignantsequelae(14%VS50%)Prophylaxismaybebeneficialinhigh-riskcaseswhocannotbefollowedclosely.consideredinselectedpatientsorspecialsituations(poorcompliance).,SurveillanceAfterEvacuation,SerialquantitativeserumhCG48hoursofevacuationbaselinevalues(5mIU/mL)every12weeks,thenat1-2monthintervalsfor612months.ReliablecontraceptionrecommendedduringhCGsurveillance.,Rationaleformonitoring,IdentififypatientsatriskofpostmolarmalignantGTN.almostallmalignantsequelaeoccurwithin6monthsofevacuation.,TheyshouldbeabletomanageHMdiagnosisofpostmolarGTN.evaluatingpatientsriskforreferral.Currently,suctioncurettageandhCGmonitoringforpostmolarGTNareavailableinnearlyeveryareasoflimitedresources.,RoleofgeneralOB-GYN,PSUManagementofHM(January2002-April2006),33completeHMremission=16(64%)low-riskGTN=9(36%),GestationTrophoblasticNeoplasia(GTN),GTNStaging/classification,FIGOstagingsystemofGTN1982:anatomicallybased1992:includetwoprognosticfactors(Bagshawe1976,modifiedbyWHOin1983)2000:FIGOrevisedGTNstaging/classification,adoptedin2000andpublishedin2002(ISSGTD,IGCS,FIGO)AnatomicalstagingintoI-IVscoringsystemmodifiedfromWHO,1967,UICC,Clinical+Morphologicalclassn,1973,Clinicalclassn,Hammond,1976,Bagshawe,Prognosticscoringsystem,1982,FIGO,Anatomicalstaging,1983,WHO,ModifiedBagshawe,1992,FIGO,Newanatomicalsubstage,2000,RevisedFIGO,anatomicalstagingModified-WHO-scoring,Theterm“GTN”isrecommendedforabnormalgestationaltrophoblasticproliferationthatrequiredRxforpotentialofmalignancy.ThediagnosticcriteriaofGTNfollowingHM.Therecommendationofinvestigativetools.Theuseof2riskgroupsinsteadof3asrecommendedbyWHOlow-riskgroup(score6)High-riskgroup(score7),4majorconsensusstatements,Diagnosticcriteria,MostlybasedonHistorytakingSerum-hCGChestX-rayUltrasoundAllareavailableinareaoflimitedresources,CurrentFIGOguidelinesforthediagnosisandstagingofGTNallowuniformityforreportingresultsoftreatment.ItisimportanttoindividualizetreatmentofpatientswithmalignantGTNbasedonriskfactorsSingleagenttherapyforlow-risk.Multiagenttherapyforhigh-risk.,Tochareonvanich,ChichareonS,WootipoomV,etal.Correlationofriskcategorizationingestationaltrophoblastictumorbetweenoldandnewcombinedstagingandscoringsystem.JObstetGynaecolRes2003;29:20-27,Comparingthetreatmentpatternandtheoutcomeamongthedifferentclassifications,wefoundthatallclassificationswereequivalentwithoutcompromisingtheoutcome.,FIGO2000,UserfriendlyFeasibleandpracticalinareasoflimitedresources,usingonlycompletehistorytakingserum-hCGchestX-rayultrasound,InvestigativeToolstoDiagnoseMetastases,ChestX-raysareappropriateforlungmetastasesandforcountingthenumberofmetastases.LivermetastasesmaybediagnosedbyUSorCTscan.BrainmetastasesmaybediagnosedbyMRIorCTscan.,ThediagnosticproblemintheareasoflimitedresourcesmaybeonlylackingofCTorMRIfordetectionofbrainmatastasis,High-risksitesofmetastasesrarelyoccurwithoutpulmonarymetastases.(HunterV,etal.Cancer1990;65:164750)Cerebralmetastasesarerareunlessthereareconcurrentlungorvaginalmetastases.ThereforeCTorMRIbrainscansmaybeomittedinthosepatientswithoutvaginalorlungmetastasesonchestX-ray.(TYNg,LCWong.BestPractice17:93903),NOTE:40%postmolarGTNwithnegativechestX-rayshavepulmonarylesionsdetectedbyCTscan,butsmallpulmonarymetastasesdonotaffectsurvival.,TreatmentofGTNintheareasoflimitedresources,Treatmentshouldbelimitedtolow-riskGTN(score6).Patientswithscore7shouldbereferredtospecializedcenter.,Chemotherapyforlow-risknonmetastaticandlow-riskmetastaticGTN,AtPSU,wetreatlow-riskGTNpatientswithweeklymethotrexateregimen.40mg/m2givenintramuscularlyeveryweek.Thisisthemostcost-effectiveregimenswhenfeasibility,efficacy,toxicity,andcostaretakenintoconsideration.ChemotherapyiscontinueduntilnormalhCGisachieved,andoneadditionalcourseisgiven.,IfhCGvalueshavenotdecreasedby10%,treatmentshouldbechangedtoalternativesingle-agentregimen.Incaseoffailure,thepatientshouldbereferredtospecializedcenter.Curerateforlow-riskdisease100%,withrecurrencerateslessthan5%.,ManagementofHydatidiformmoleAppropriatetreatmentisavialable.Prophylacticchemotherapymaybeconsideredinhigh-riskcases.,Conclusion,Inareasoflimitedresources,ManagementofGTNBasedonFIGO2000Low-riskGTN(score6)canbemanaged.Weeklymethotrexateisacosteffectivechemotherapy.,Conclusion,Inareasoflimitedresources,ManagementofGTNBasedonFIGO2000High-riskGTN(score7)shouldbereferredtospecializedcenter.,Conclusion,Inareasoflimitedresources,GTDatPSU,HydatidiformMole(HM)2.8/1,000deliveriesGestationtrophoblasticneoplasia(GTN)4.6/1,000deliveries,PSU:CPGfortheManagementofGTN,GTN,Investigate,stage,risk-score(FIGO2000),StageI-IIIlow-risk(6),hCG,CBC,BUN,Cr,LFT,TFT,Coagulogram,CXR,US