Stage Information for Gestational Trophoblastic Tumors and Neoplasia
Hydatidiform Mole (HM)
Invasive Mole (Chorioadenoma Destruens)
Gestational Trophoblastic Neoplasia
Definitions of TNM and FIGO
Hydatidiform Mole (HM)
HM (molar pregnancy) is disease limited to the uterine cavity.
Invasive Mole (Chorioadenoma Destruens)Invasive mole (chorioadenoma destruens) is a locally invasive, rarely metastatic lesion.
Gestational Trophoblastic NeoplasiaDefinitions of TNM and FIGO
The American Joint Committee on Cancer (AJCC) and the Féderation Internationale de Gynécologie et d’Obstétrique (FIGO) have designated staging to define gestational trophoblastic neoplasia.[1,2] The definitions of the AJCC’s T, N, and M categories correspond to the stages accepted by FIGO. The FIGO staging and classification system is in more common use, but both systems are included for comparison. Some tumor registrars encourage the recording of staging in both systems.
AJCC TNM staging systemThe AJCC has designated staging by TNM classification to define gestational trophoblastic tumors.[1] Given the high cure rates even in the setting of metastatic disease, the traditional TNM system is of limited prognostic value. In fact, regional nodal designation is not part of the routine staging system. However, in the rare circumstance of nodal involvement, prognosis is poor.
Within the AJCC anatomic groups (I–IV), there is prognostic subclassification into low-risk (A) and high-risk (B) based upon the prognostic scoring index derived from the FIGO/WHO scoring system in Table 4 below.
Table 1. Primary Tumor (T)a| TNM Categories | FIGO Stages | |
| aReprinted with permission from AJCC: Gestational trophoblastic tumors. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 437-44. | ||
| TX | Primary tumor cannot be assessed. | |
| T0 | No evidence of primary tumor. | |
| T1 | I | Tumor confined to uterus. |
| T2 | II | Tumor extends to other genital structures (ovary, tube, vagina, broad ligaments) by metastasis or direct extension. |
Table 2. Distant Metastasis (M)a
| TNM Categories | FIGO Stages | |
| aReprinted with permission from AJCC: Gestational trophoblastic tumors. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 437-44. | ||
| M0 | No distant metastasis. | |
| M1 | Distant metastasis. | |
| M1a | III | Lung metastasis. |
| M1b | IV | All other distant metastases. |
Table 3. Anatomic Stage/Prognostic Groupsa
| Group (by Stage) | T | M | Risk Factors |
| aReprinted with permission from AJCC: Gestational trophoblastic tumors. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 437-44. | |||
| I | T1 | M0 | Unknown |
| IA | T1 | M0 | Low risk |
| IB | T1 | M0 | High risk |
| II | T2 | M0 | Unknown |
| IIA | T2 | M0 | Low risk |
| IIB | T2 | M0 | High risk |
| III | Any T | M1a | Unknown |
| IIIA | Any T | M1a | Low risk |
| IIIB | Any T | M1a | High risk |
| IV | Any T | M1b | Unknown |
| IVA | Any T | M1b | Low risk |
| IVB | Any T | M1b | High risk |
FIGO staging system (and modified World Health Organization [WHO] prognostic scoring system)
The FIGO staging system is as follows:[2]
Table 4. Gestational Trophoblastic Neoplasiaa,b| FIGO Anatomical Staging | ||||
| Stage | ||||
| I | Disease confined to the uterus. | |||
| II | GTN extends outside of the uterus, but is limited to the genital structures (adnexa, vagina, broad ligament). | |||
| III | GTN extends to the lungs, with or without known genital tract involvement. | |||
| IV | All other metastatic sites. | |||
| Modified WHO Prognostic Scoring System as Adapted by FIGOb | ||||
| Scores | 0 | 1 | 2 | 4 |
| Age | <40 | ≥40 | – | – |
| Antecedent pregnancy | mole | abortion | term | – |
| Interval months from index pregnancy | <4 | 4–6 | 7–12 | >12 |
| Pretreatment serum hCG (iu/1) | <103 | 103–104 | 104–105 | >105 |
| Largest tumor size (including uterus) | <3 | 3–4 cm | ≥5 cm | – |
| Site of metastases | lung | spleen, kidney | gastrointestinal | liver, brain |
| Number of metastases | – | 1–4 | 5–8 | >8 |
| Previous failed chemotherapy | – | – | single drug | ≥2 drugs |
| FIGO = Federation of Gynecology and Obstetrics; GTN = gestational trophoblastic neoplasia; hCG = human chorionic gonadotropin; iu = international unit; WHO = World Health Organization | ||||
| aAdapted from FIGO Committee on Gynecologic Oncology.[2] | ||||
| bTo stage and allot a risk factor score, a patient's diagnosis is allocated to a stage as represented by a Roman numeral 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, i.e., stage II:4, stage IV:9. This stage and score will be allotted for each patient. |
In addition, the FIGO staging system incorporates a modified WHO prognostic scoring system. The scores from the eight risk factors are summed and incorporated into the FIGO stage, separated by a colon (e.g., Stage II:4, Stage IV:9, etc.). Scores of 0–6 are considered low-risk and are equivalent to subclass A in the AJCC staging system below, whereas scores greater than 6 are considered high-risk and are equivalent to AJCC subclass B. This is the most common risk scoring system currently in use. Unfortunately, a variety of risk scoring systems have been published, making comparisons of results difficult.
References
- Gestational trophoblastic tumors. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, p 439.
- FIGO Committee on Gynecologic Oncology.: Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia. Int J Gynaecol Obstet 105 (1): 3-4, 2009. [PUBMED Abstract]
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