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FIGO committee report

FIGO staging for gestational trophoblastic neoplasia 2000

FIGO Oncology Committee

1. Introduction The FIGO Oncology Committee at its meeting during the XXVI FIGO World Congress of Gynecology and Obstetrics in Washington DC in September 2000 revised the staging system of Gestational Trophoblastic Neoplasia GTN.. Alternative staging systems utilizing nonanatomic prognostic risk factors have been used by many clinicians. With several staging systems in widespread use, there is a problem in the collection of useful data for patient care and research, and in the comparison of management outcomes. The Committee of the International Society for the Study of Trophoblastic Diseases ISSTD. and the International Society for Gynecological Cancer IGCS. have worked to develop an inclusive staging system which might be more universally accepted. This new staging system for GTN incorporates the classical anatomical prognostic factors with other prognostic indicators identied by Bagshawe and others, and which

have been documented to be clinically useful in managing patients with GTN. It is hoped that this new staging system combining both anatomic and non-anatomic factors may gain widespread acceptance, improve patients management and serve as an example for other disease sites which may begin to incorporate tumor markers, chromosomal changes and other non-anatomic prognostic factors into their staging systems.

2. Criteria for the diagnosis of post-hydatidiform mole trophoblastic neoplasia (GTN)

Corresponding author: Dr H.Y.S. Ngan. Department of Obstetrics and Gynaecology, University of Hong Kong, Queen Mary Hospital, Hong Kong, PR China. Tel.: q1-852-28554260; fax: q1-852-2855-0947. E-mail: hysngan@hkucc.hku.hk.

1. GTN may be diagnosed when the plateau of human chorionic gonadotropin hCG. lasts for four measurements over a period of 3 weeks or longer; that is, days 1, 7, 14, 21. 2. GTN may be diagnosed when there is a rise of hCG of three 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.

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3. Investigative tools to diagnose metastases

6. Format for reporting to FIGO Annual Report In order to stage and allot a risk factor score, a patients diagnosis is allocated to a stage, as represented by Roman numerals I, II, III and IV. This is then separated by a colon from the sum of all the actual risk factor scores, expressed in Arabic numerals, e.g. stage II:4, stage IV:9. This stage and score will be allotted for each patient.

1. Chest X-ray is appropriate to diagnose lung metastases and it is chest X-rays that are used for counting the number of lung metastases to evaluate the risk score. Lung CT may be used. 2. Liver metastases may be diagnosed by ultrasound or CT scanning. 3. Brain metastases may be diagnosed by MRI or CT scanning.

7. Low and high risk group Instead of substages a and b, this revised staging requests investigators to write the actual prognostic score as stated above, but for investigators who will like to divide patients into high and low risk groups. We like to suggest that the low risk group should have a score of 0 6, and the high risk group will have a score of 7 or higher. Acknowledgement The FIGO Oncology Committee would like to thank and acknowledge the contribution and assistance received from Dr Ernest I. Kohorn as a facilitator, and all physicians who have contributed to the revision, especially those who participated in the workshops of ISSTD and IGCS.

4. FIGO anatomical staging Stage I Stage II Disease conned to the uterus GTN extends outside of the uterus, but is limited to the genital structures adnexa, vagina, broad ligament. GTN extends to the lungs, with or without known genital tract involvement All other metastatic sites

Stage III

Stage IV

5. Modied WHO prognostic scoring system as adapted by FIGO Scores Age Antecedent pregnancy Interval months from index pregnancy Pre-treatment serum hCG IUrml. Largest tumor size including uterus. Site of metastases Number of metastases Previous failed chemotherapy 0 - 40 Mole -4 - 103 1 G 40 Abortion 4 -7 103 - 104 3 - 5 cm Lung Spleen, kidney 1 4 2 Term 7 - 13 104 - 105 G 5 cm Gastrointestinal 5 8 Single Drug Liver Brain )8 2 or more drugs 4 G 13 G 105

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H.Y.S. NganU , Chair China J.L. Benedet Canada H.G. Bender Germany H.W. Jones III USA S. Pecorelli Italy G.C. Montruccoli Italy

The FIGO Oncology Committee