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Int J Gynecol Cancer 2001, 11, 73–77

WORK IN PROGRESS

The new FIGO 2000 staging and risk factor scoring


system for gestational trophoblastic disease:
Description and critical assessment
E. I. KOHORN
Yale Trophoblast Center, Yale University School of Medicine, New Haven, Connecticut
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Abstract. Kohorn EI. The new FIGO 2000 staging and risk factor scoring
system for gestational trophoblastic disease: description and critical assess-
ment. Int J Gynecol Cancer 2001;11:73–77.

The classification of the International Federation of Obstetrics and Gy-


necology (FIGO) for Trophoblastic Disease was changed at the meeting
in Washington in September 2000 by combining the basic FIGO ana-
tomic staging with the modified World Health Organization (WHO) risk
factor scoring system. This presentation outlines the new system and
provides a critical evaluation of the issues that have been resolved and
those that are still outstanding.

The Cancer Staging and Nomenclature Committee of scoring system had been accepted by WHO in 1982
the International Federation of Gynecology of Obstet- from the earlier system devised by Bagshawe(4). It is
rics (FIGO) at the time of the Washington DC meeting felt that this combined staging/scoring system will
in September 2000 promulgated significant changes to allow a more precise description of the extent of the
the classification system for trophoblastic disease and disease and of the risk factors present in trophoblastic
recommended that these be used by clinical investiga- disease.
tors for the FIGO cancer reports. These recommenda-
tions need to be approved by the national member The new 2000 FIGO classification
societies of FIGO and must be ratified by the FIGO The basic FIGO staging of disease, Stage I, II, III, and
Council. The accepted recommendations are the result IV is retained (Table 1) but the risk factors a, b, and c
of deliberations over a period of years by workshops signifying no risk factors, 1 risk factor, or 2 risk factors
at meetings of the International Society for the Study are replaced by the modified WHO scoring system.
of Trophoblastic Disease (ISSTD), the International The 1992 risk factors were a serum human chorionic
Gynecological Cancer Society (IGCS), and the Society gonadotropin (hCG) measurement of greater than
of Gynecologic Oncologists (SGO). The proposals to 40,000 mIU/ml at the time of presentation or a length
FIGO were presented in this Journal in January 2000(1). of time of disease from the index pregnancy greater
The objective of these deliberations was to simplify the than 6 months(2).
previous anatomic FIGO staging with its risk factors
devised in 1992(2) and to replace this by a classification Comments concerning the FIGO 2000
in which the basic anatomic staging is retained but the staging of gestational trophoblastic disease
risk factors are replaced by the risk factor scoring sys- The requirement that placental site trophoblastic tu-
tem of the World Health Organization (WHO)(3). That mor shall be classified as a separate entity from the
other gestational trophoblastic neoplasms is main-
tained.
Address correspondence and reprint requests to: E.I. Kohorn, MD, There shall be no stage 0 trophoblastic disease. The
333 Cedar Street, New Haven CT 06510. Email: ernest.kohorn@
yale.edu.
FIGO committee believes that inclusion of stage 0 im-
Supported by the Baumer Fund of Yale University. plies that with trophoblastic sequelae (persistent hCG)
This is not a review but report of work in progress. after evacuation of hydatidiform mole and thus the
© 2001 IGCS
74 E. I. Kohorn

Table 1. Anatomic FIGO staging system for gestational and risk score will be expressed by allotting a Roman
trophoblastic disease numeral to the stage and an Arabic numeral to the risk
Stage I Disease confined to the uterus score separated by a colon. Three examples of this
Stage II Disease outside of uterus but is limited to the gen- staging are given:
ital structures
Stage III Disease extends to the lungs with or without known Low stage, low score: 45-year-old patient requiring che-
genital tract involvement
Stage IV All other metastatic sites
motherapy 6 weeks after hydatidiform mole evacu-
ation. The hCG was 900 mlU/ml. There were no
metastases. The FIGO stage:score is I:1.
diagnosis of trophoblastic tumor, restaging would be High stage, high score: 40-year-old patient, 7 months
required so contravening one of the basic principles of after full term pregnancy who presents with 4 lung
the FIGO cancer staging systems. This requirement metastases, 1 brain metastasis 5 cm in size, and 1
implies that stages I, II, III, and IV trophoblastic dis- metastasis in each kidney. The hCG was 42,000
ease are, in fact, trophoblastic neoplasia. Please note mlU/ml. This patient is FIGO stage:score IV:15.
that throughout this presentation the term trophoblas- Low stage, high score: A patient age 44 is 8 months post
tic neoplasia will be used for trophoblastic tumor or miscarriage, has uterine bleeding and by ultrasound
malignant trophoblastic tumor. We need to abide by is found to have a 9-cm mass in the uterus. The hCG
the definitions of nomenclature recently issued by the is 18,000 mIU/ml and there is also a 5-cm nodule in
Society of Gynecologic Oncologists(5). It is recognized the vagina. Single agent chemotherapy has failed.
that hydatidiform mole and even invasive mole There are no other metastases. The FIGO stage:score
should not be regarded as a cancer(6). It therefore is II:10.
seems appropriate to regard trophoblastic disease as
the collective name for hydatidiform mole and tropho-
blastic neoplasia. Those patients who require chemo- Requirements to diagnose and stage
therapy or excisional surgery because of persistence of gestational trophoblastic neoplasia
hCG after hydatidiform mole and those who have tro- In order to implement this staging/scoring system
phoblastic metastases, have “trophoblastic neoplasia”. certain criteria for the diagnosis of gestational tropho-
The stages of gestational trophoblastic neoplasia are blastic neoplasia need to be accepted.
described in Table 1.
1 To diagnose trophoblastic neoplasia after hydatidi-
form mole evacuation requires:
FIGO risk score for gestational a) 4 values or more of plateau of hCG over at least
trophoblastic neoplasia 3 weeks; days 1,7,14, and 21.
b) A rise of hCG of 10% or greater for 3-values or
The individual prognostic scores for each category longer over at least 2 weeks; days 1,7, and 14.
shall be 0, 1, 2, and 4 for individual risk factors (Table c) The presence of histologic choriocarcinoma.
2). The changes that were agreed upon that differ from d) Persistence of hCG 6 months after mole evacua-
the previous WHO classification are: ABO blood tion.
group risk factors are eliminated and the risk factor for The level of hCG plateau is to be determined at
liver metastasis is upgraded from 2 to the highest risk the discretion of the treating physician.
group, 4. 2 To diagnose metastases the requirements are:
The identification of an individual patient’s stage a) For lung metastases, chest X-ray is adequate and

Table 2. The scoring system for the FIGO 2000 staging/scoring


FIGO SCORE 0 1 2 4
Age ⱕ 39 >39
Antecedent pregnancy Hydatidiform mole Abortion Term pregnancy
Interval months from index pregnancy <4 4–6 7–12 >12
Pretreatment hCG Milli IU/ml <103 103–104 >104–105 >105
Largest tumor size including uterus 3–4 cm 5 cm
Site of metastases Spleen Gastrointestinal tract Brain
Kidney Liver
Number of metastases identified 0 1–4 4–8 >8
Previous failed chemotherapy Single drug Two or more drugs

© 2001 IGCS, International Journal of Gynecological Cancer 11, 73–77


FIGO 2000 scoring system 75

CT scan is acceptable. Chest X-ray will be used to neoplasia. The reason that the words “more time” and
count the number of metastases for risk score “or longer” are used for the length of observation cri-
assessment. teria (section 1a and 1b) is that all participants in the
b) For the diagnosis of intra-abdominal metastases, workshops agreed that to diagnose post molar neo-
CT scanning is preferred; many institutions will plasia a minimum of 3 weeks of hCG plateau or 2
still use ultrasound for liver metastases. weeks of hCG rise was an essential requirement. Wait-
c) For the diagnosis of brain metastases, MRI is su- ing longer was permitted as this did not adversely
perior to CT scanning even with 1-cm cuts. prejudice either patient survival or the classification
3 Risk groups in the FIGO staging and scoring for itself. Many centers prefer to observe hCG plateau for
GTN. The WHO risk groups have been included in several weeks, particularly at low levels of hCG.
the new FIGO system except that the middle risk
group present in the WHO classification is elimi-
What then are the weaknesses of the new
nated. This group has usually been treated with
classification? What controversy remains?
combination chemotherapy so placing these pa-
tients in a high-risk category for management pur- The first problem is that there is no accounting in the
poses. system for hydatidiform mole, either complete or par-
a) There shall be a low risk group of GTN with a tial. Only trophoblastic neoplasia is recorded. The in-
score of 6 or less. vestigator then has to maintain a separate record of
b) There will be a high-risk group with a score of 7 hydatidiform mole. Presently the FIGO system for
or greater. cancer staging has no mechanism for change of stage.
In fact with carcinoma of the cervix there is stage 0 for
carcinoma in situ. Progression to invasive cancer, cer-
Discussion tainly micro invasive cancer, is not that rare but
Combining an anatomic FIGO system with the modi- change of stage is not permitted with the present sys-
fied WHO scoring system will provide the physicians tem and may therefore not be recorded. There is no
treating trophoblastic disease and using the FIGO clas- mechanism for noting such changes for a patient who
sification with a more precise means of reporting tro- is registered in the system as stage 0. Similarly for
phoblastic neoplasia and allow valid comparison of trophoblastic disease, stage 0 is not registered at all.
the results of treatment from different centers. Up to There may be pathophysiologic reasons for not re-
the present there has been significant variation in the garding hydatidiform mole as a premalignant entity.
manner in which individual investigators have re- However for recording trophoblast statistics, is there
ported the results of their treatment(7). The 1992 FIGO really a contravention of principle if the recording sys-
classification was popular but suffered from the dis- tem allows change of stage? With modern computer
advantage that the risk factors used, hCG and the systems we could allow stage 0 so that we have a
length of time from the index pregnancy, were not handle on the denominator of this disease. Why not
independent significant risk factors by multivariant have stage 0 → stage I, → stage IV? Such a system may
analysis. The next cancer report from FIGO that uses provide a more dynamic accounting of each patient.
the new system may clarify which risk factors will be Perhaps the trophoblastic community is not yet ready
significant by univariant analysis, which by multivari- for such radicality. FIGO has now taken a great step
ant analysis, and which may be discarded. Prior to the forward and the new classification needs validating
agreement reached at the Rome meeting of IGCS in before further changes are made. However, let us
1999, different investigators allotted the same risk fac- plan, yet move slowly and with circumspection.
tor with different values so that a patient in one center This discussion raises the question: at what stage
had a different risk score than a patient from another does one assess the disease; at the time of presentation
center(8–10). The concordance reached in the three to the primary physician, at referral to the first oncolo-
workshops has now allowed an agreed classification gist, or at the second referral to a trophoblast center?
and risk factor scoring system to go forward. It is sug- At present, staging/scoring is generally recorded
gested that this is not modified for some time so that when the patient reaches the reporting center. Is that
data may be collected on the basis of which changes really valid? Nevertheless it may be the only expedi-
may be made only if they are validated by statistical ent way of resolving this problem.
analysis. It is of philosophical and semantic note that many
There is now agreement of the criteria by which cancer classifications are mixtures of clinical and
different centers diagnose post molar trophoblastic pathologic classifications and trophoblastic disease is
© 2001 IGCS, International Journal of Gynecological Cancer 11, 73–77
76 E. I. Kohorn

a case in point. For example: a) With modern manage- equately with the appropriate combination chemo-
ment of trophoblastic disease histologic material be- therapy. That is the unfortunate truth but it should not
comes available only occasionally and treatment is in influence our classification systems and our aspira-
fact the same with or without histologic validation. tions for treating the patient correctly.
The Japanese Gynecologic Cancer Society, in fact, in- There are certain aspects of the management of tro-
fers the diagnosis of “invasive mole” on the basis of phoblastic disease that have so far not been included
the “diagnostic score”(11). b) Metastases are diagnosed in this or other discussions. The most important of
by clinical examination and radiologic investigation these concerns the measurement of hCG. It is estab-
and their precise detection depends on the sophistica- lished that the assay method used to measure hCG
tion of the available radiologic equipment. This varies must recognize all aspects of the hCG molecule. This
in different centers in different parts of the world so includes nicked hCG and hyperglycosilated hCG but
leading to possible variation in reporting metastases. not the false detection of phantom hCG. Otherwise
c) The WHO and the FIGO risk factor scoring system low or false negative results may lead to inappropriate
includes patients who have had previous unsuccessful management(12).
chemotherapy. In fact, this is one of the risk factors of These comments should in no way detract from the
independent significance by multivariant analysis and significant achievement of the trophoblastic commu-
therefore, needs to be included. Does this inclusion nity in reaching unanimity for a reporting system that
transgress the rule for change of stage in the FIGO surely is superior to its predecessors. The new FIGO
system? staging and scoring system needs to be implemented
The next difficulty arises with the means of diag- enthusiastically. It promises to provide more precise
nosing lung metastases. During the workshops there information so allowing more valid comparison of the
was great debate whether all lung metastases on CT
results of treatment by different centers throughout
scan should be counted or all metastases on chest X-
the world. FIGO for the first time embraces with con-
ray should be counted, or only metastases greater than
cordance both gynecologists and gynecologic oncolo-
2 cm or perhaps 3 cm on chest X-ray. It was finally
gists and also those centers directed by medical on-
agreed that all metastases visible on chest X-ray
cologists.
should be counted. This was done because metastases
on chest X-ray may have different diameters with dif-
ferent radiologic views and different penetration by
the radiograph. By counting all visible lesions on the References
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FIGO 2000 scoring system 77

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© 2001 IGCS, International Journal of Gynecological Cancer 11, 73–77