H E B A M . I S M A I LC L I N I C A L F E L L O W G Y N A E - O N C O L O G Y U N I T

K A A U H

GESTATIONAL TROPHOBLASTIC DISEASE

The Journey of GTD began in 1956, when the sensitivity of Gestational trophoblastic neoplasia (GTN ) was found to Methotraxate

Bagshawe (1970)

Between 1970 and 1980 Actinomycin D were introduced

GTD• Incidence in north America and Europe 1.5/1000 live birth• Far east, 1 per 120 pregnancies. ( Indonesia 1:85)• South Africa, 1.26 per 1,000 deliveries • Can follow any type of pregnancy• Definition covers : moler pregnancy, invasive mole,

choriocarcinoma, PSTT and ETT• Moler pregnancy could be complete (CHM) or partial (PHM)

Bracken et al Epidemiol Rev 1984;6:52-75. Aziz et al Adv Exp Med Biol 1984;176:165-75. Osamor et al J Obstet Gynaecol 2002;22:423-5.

PREVALENCE OF GTD IN SAUDI ARABIA

• 0.94 per 1,000 deliveries• 2.2 per 1,000 deliveries• 1 per 676 live birth • 1.26 per 1,000 deliveries

Khashoggi , Saudi Med J 2000;24:1329-33.Chattopadhyay et al Saudi Med J 1985;6:441-53.Felemba Reprod Med J 1998;43:11-3.Anfinan N, Sait K Sait H Eur J Obs Gyn Reproductive Biol 2014 Sept

GTD

Pre-Malignant

• Complete Mole

• Partial Mole

Malignant

• Invasive mole

• Choriocarcinoma

• Placental site trophoblastic tumours

Seckl et al Lancet 2000 and palmeiri et al Lancet 2005

GTN

• Involves: persistent GTD , invasive mole, choriocarcinoma, PSTT and ETT

• 7 % of CHM and 0.5 % of PHM persist and develop GTD( Europe)

• Canada: 30 %• Saudi Arabia: 25.9%

Altieri et al Lancet Oncol 2003;4:670-8.Curry et al obstet Gynecol 1989: 73: 357-62.Anfinan N, Sait K ,Sait H Eur J Obs Gyn Reproductive Biol 2014 Sept

CRITERIA USED TO DIAGNOSE GTN

• Plateauing of hCG level over at least three weeks,• A 10 % or greater rise in hCG for three or more

values over at least two weeks , • Persisence of hCG six months after molar

evacuation

Kohorn , J Reprod Med 2002;47:445-50.

GTN

Once the patient has been diagnosed with GTN the following work up need to be done: • CXR• Pelvic / abdominal ultrasound , • CT Brain as an initial work up .

Since year 2000 we globally thankfully reach to a kind of uniform classification system which started to show effect on the way how to report the data and compare data together.

The scoring system validated in 2000 and adapted by WHO and FIGO and its current classification most of us follow hopefully.

FIGO Risk Factor Scoring

This Calculator is available in SGTD website for every bodyNumber of visitor to use the calculator is = 10214

September 2014 October 2014

LOW RISK GTN

• Various treatment regimens have been researched over the last four decades

• Regimens vary in their efficacy, route of administration and side effect

• Generally patients are treated with single agent chemotherapy

• Commonest regimens are : Methotrexate with or without Folinic acid or Dactinomycin.

• Various scheduling protocols. • High cure rate irrespective of the treatment regimen

LOW RISK GTN

• The overall success of this group of patients was 88.46%

• Our KAAUH experience showed a success rate of 80.9 %

McNeish et al J Clin Oncol 2002;20:1838-44.Homesley et al Obstet Gynecol 1988;72:413-8.Osborne et al J Clin Oncol 2011:29:825-31.Anfinan N, Sait K ,Sait H Eur J Obs Gyn Reproductive Biol 2014 Sept

HIGH RISK GTD

• EMA-CO regimen has been the standard of care in managing high-risk GTN; its reported success rate is up to 78%.

• We had ( KAAUH) Ten high-risk patients with modified WHO scores > 7. They received the EMA-CO regimen and had complete remission

Curry et al Obstet Gynecol 1989;73:357-62.Anfinan N, Sait K ,Sait H Eur J Obs Gyn Reproductive Biol 2014 SEPT

SURVIVAL OF GTN

• The survival rate for high risk were reported as 60 % and 94 % for low risk

• In our KAAUH experience: the survival rate of the high-risk patients was 90.9 %, but that of low-risk patients was 95.8%.

Curry et al Obstet Gynecol 1989;73:357-62.Gilani et al J Cancer Res Ther 2013;9:38-43.Anfinan N, Sait K ,Sait H Eur J Obs Gyn Reproductive Biol 2014 Sept

GTD REGISTRYDiagnosis GTD

Persistent GTD(10 – 20%)

Chemotherapy

Normal Life 99.8%

Registration

No Further Problem

In the UK there are three registries for GTD and100 % of patients with GTD are now registered.Death from GTN is no more accepted especially in a low risk group.

SAUDI GTD REGISTRY

SAUDI GTD REGISTRY

Objective

• Ensure Adequate Follow Up Of Patient With Molar Pregnancy And Early Detection Of GTN

• If GTN is diagnosed. treatment Is coordinated With an Expert In the field. GTD team will help in the referral arrangement .

• To Get exact Incidence Of GTD In Saudi Arabia.

G e s t a t i o n a l T r o p h o b l a s t i c D i s e a s e R e g i s t r y i n t h e K i n g d o m o f S a u d i A r a b i aW E B S I T E – Q U I C K G U I D E

www. gtdregistry.sa.com

HOW TO REGISTER –FOR PHYSICIAN

How to Register –For Physician

• While on the website’s home page find the “Register” link which is illustrated below

ACCOUNT LOGON

• Locate the Logon form at the top-right corner of the website page. Supply the User ID and Password then hit the “Sign In” button.

ACCOUNT LOGON

• Once you are logged in you will be presented with alerts relating to patients, test results and private messages.

REGISTERING A PATIENT

After hitting Patient Register link, the patient registration form will display and the data entry will be available for the following

• Patient demographics• Gestational Trophoblastic Information

• OBSTETRIC HISTORY EVENTS• CLINICAL PRESENTATION• FINAL EVALUATION

AFTER REGISTERING A PATIENT

• After a successful registration Saudi GTD team will be following the registered patient with you.

• Saudi GTD team will follow the patient’s progress until the disease is cleared.

ALERTSSMS and E mail Alerts are sent to the treating

physicians when:• An hCG Schedule is due for patient.• An hCG has not been entered or is delayed.• The hCG level is not going down or rising• Suspected GTN by the SGTD registry team• There are new referrals for you.

IF GTN IS DIAGNOSED AND THE PATIENT NEEDS EVALUATION AND CHEMOTHERPY

•Locally•Referral center

REFERRING PATIENTS

• Hit the Referral option to bring out the “Order Referral” link. Hit this link.

REFERRING PATIENTS

REFERRAL LIST

• Locate the menu link “Referral List” from the Sidebar.

REFERRING PATIENTS

REFERRAL LIST

REFERRAL

• After a referral is accepted, both the doctor who registered and the doctor referred to will be able to manage the patient by:• Order a new HCG• Enter HCG results• Refer the patient• Read patient progress

MOH

WWW.GTDREGISTRY.SA .COM

HOW ARE WE DOING?

PHYSICIAN ACCEPTIBILITYAND REFERAL

WWW.GTDREGISTRY.SA .COM

HOW ARE WE DOING?

WE NOW HAVE OVER 700 PHYSICIANS (OBSTETRICS AND GYNECOLOGY) IN SAUDI

ARABIA REGISTERED

PUBLIC AWARNESS

WWW.GTDREGISTRY.SA .COM

HOW ARE WE DOING?

ARABIC INFORMATION ABOUT GTD ON THE WEB SITE

MAKING DEATH FROM DISEASE OF TROPHOBLAST SOMETHING IN THE PAST

W W W . G T D R E G I S T R Y . S A . C O M

OUR DREAM………

Acknowledgment

Prof. Khalid Sait GTD Registry DirectorDr. Nisrin Anfinan - GTD Registry CoordinatorDr . Heba M Ismail GTD Registry coordinatorDr. Asem Sabghatallah - GTD Registry CoordinatorDr Hussain Basalamah – Awarness programDr Rami Zourob- Public relationHesham K Sait Awarness Program

Faten Anfanan - GOU Secretary

Rowaida Al Mehy - GOU Secretary

Reem Qubaidi - Health Educator

Amal Al Montasheri - Nurse JCSP

Maribi Marqueses - GOU Office Assistant

Prof. Jim Bentley - International Advisor

Prof. Abdullah Hussain Basalamah - General Advisor

THANK YOU

WWW.GTDREGISTRY.SA .COM