to join this Project ECHO in collaboration with ISSTD. I'm Dr. Cagayan. I'm from the Philippines. I am a trophoblastic disease specialist in the National Hospital of the Philippines and that's the University of the Philippines Philippine General Hospital. So this is just a definition of the trophoblastic disease which I think we're all now familiar with. It's characterized by an abnormal proliferation of the trophoblast. So basically when we talk of GPD, it spans a spectrum of diseases from the most benign which would be the H-Mole to some of the most malignant forms of trophoblastic disease. So for the H-Mole, we have the complete and the partial hydrophilic form. Some forms of GPN, the malignant form would be your carcinoma, invasive mole. Some other conditions would be your PSTD or your ETP. Just to give a while ago, Dr. Arita said the I in IGCS has been defined in today's session. I think we're only lacking Africa today. So just to show you that there really is a very, very different presentation or epidemiology of GPD worldwide. Dr. Chin, you were saying you only had very few rare cases of Hydra-TD4-Mole. But in the Philippines, in the hospital that I'm actually doing my consultations, we see at least an H-Mole. One H-Mole up to two in a week's time. And we have new four choriocarcinoma cases in about a month's time. So that's also one per week. So this is our presentation. So Southeast Asia and Africa have higher cases of GPD as well as the Latin Americas, right Rafael? And then this is how we manage our H-Mole. Basically, there's just two very important diagnostics. We have the ultrasound and we have the beta-HCG. If you get your early H-Mole, it's not differentiable from your abortions. But in the Philippines, we usually see patients with bigger uterus. The snowstorm, the classic snowstorm pattern is still very evident. So the factors that may influence the diagnosis, especially for your Hydra-TD4-Mole, whether it's complete or partial, will now depend on the gestational age when the patient has been seen, how good is your sonology and the type of H-Mole that is presented. So we have different types of serum HCG. We usually use the serum beta-HCG to diagnose GPD because it translates or it actually correlates very well with transvaginal ultrasound. So you can, in a way, differentiate between an abortion or an ectopic pregnancy between a complete or partial mole just by the use of your HCG and your transvaginal ultrasound. This is very basic. I just put it there. So in the Philippines, this is how we do it. If we're suspecting that the patient has Hydra-TD4-Mole, the principal goal of management is to evacuate that molar product. And before doing it, we do our baseline laboratory examinations and we make sure that they are evaluated well and treated for medical complications. We have a routine set of laboratories that we ask before doing the surgical evaluation. This is our packaged laboratories. But very important here would be the HCG and we also do chest x-rays. This is done. This is very important because we need to actually rule out the presence of complications. And in our country, the number one complication, as I think most of us will really see, is anemia. Most of our patients, almost 100% of our patients will present with bleeding. And then the other complications would be secondary to the trophoblastic proliferation. More patients will now present also with respiratory insufficiency. Now, this is now difficult during these COVID times because we're not really sure if the dyspnea, the respiratory symptoms that they are presenting is secondary to the GPD or secondary to COVID-19. So it really gives us quite a difficulty right now. The best way to evacuate, regardless of age, would still be via our suction puritans. We only do hysterectomy for older patients and those who really don't wish to have children anymore. We don't do hysterectomy. We don't do medical evacuation of the molar products. So we have a protocol on how to secure the HCG levels. Once we have done the suction puritans, we usually repeat the HCG after one week. And this is the Philippine protocol. Now, this will probably be different based on locality and region. But here in our country, this is how we do it. We do the molar evacuation. We repeat the serum beta HCG after one week. We continue monitoring the HCG every two weeks until we get two normal fibers. And then after that, monthly for six months. We're quite paranoid in terms of our patients because we see a lot of post-molar GPN conversion within the first six months to one year. That's why we do very strict HCG monitoring. And this would be the risk factors for post-molar GPN. We have a lot of patients who are quite old. They have recurrent molar pregnancies. They have multiple medical complications. If they have fecal lutein cysts, more than 6CM. And if there is discrepancy between the uterine size and the age of gestation of more than six weeks. So for chocoblastic mutation, this is now how we manage it. Most of the presentations will be the following. Similar to your HIDATI deformed mole, but in most cases, they would have presented with HIDATI deformed mole as an antecedent pregnancy. Some of our patients will also present with metastatic lesions. And symptoms referable to tumor progression. The diagnostic tests would remain the same. We would like to have doctor studies. And then our baseline metastatic workup. We don't usually use MRI for our patients. Our healthcare system does not allow for... Our patients usually have out-of-pocket expenses. And most of the patients, the trophoblastic patients that we have in the Philippines are quite poor. Or below the normal socioeconomic levels. So at most, we do the chest CT scan and brain CT scan only if we think they are needed. We follow the FIGO anatomic staging as proposed by ISSTD and Dr. Cohorn way, way back. We have the stage 1 if the tumor is confined to the uterus. 2 is outside the uterus but within the pelvis. Lung metastasis will give us a stage of 3. And other sites will be a stage of 4. Usually distant metastasis. We reassess but do not restage our patients. Especially if they come from other institutions aside from ourselves. If there is a referring doctor, we just do reassessment. But we usually do not restage them anymore. Especially if they have been started on chemotherapy. So we look for relapse, recurrence, or progression of the disease. So I think we're all on the same page as regards to the WHO prognostic scoring system. It's low risk if they have a score of 7, less than 7. And high risk if they have a score of more than 7. This is just to perhaps emphasize the following points. We look at the HCG because it tells us of the tumor burden. Interval in months, we give the higher the score. It's because the tumor growth and age and site of metastasis and number of metastasis. Because it will also tell us of a poorer prognosis and tumor burden. Perhaps in ISSTD this is where most of our problems arise in terms of counting the number of metastasis especially in the lungs. So we have different ways of diagnostic or imaging studies in terms of lungs. Some will use just the chest x-ray. We in the societies are in agreement that a chest x-ray should be enough unless you're considering micrometastasis wherein you have to have your chest CT scan. We usually do not ask for your brain CT scan or MRI anymore if the chest is negative. Our hollow abdominal ultrasound is part of the routine metastatic workup. And then if our patients have already started chemotherapy before and goes back to us or we have been referred to us then we place it again under previously failed chemotherapy. So what is the significance of this prognostic scoring if the patient is low risk? Then the chances of her developing resistance to just one agent is quite low. High risk meaning a score of 7 and above. Then we start with combination or intensive chemotherapy. So from this slide alone we know how important an accurate diagnosis is at the onset or at the outset. So this is one of the issues that we have with this patient. Is the scoring accurate? Is the staging accurate or is the scoring accurate? Because that will now tell us how to start the appropriate management. So moving on, unlike other cancers, treatment can be started without histopathologic confirmation of the disease. That's why you cannot diagnose choreocarcinoma unless you have the histopath of this patient. And if there has been no biopsy or surgical intervention then we cannot really say that this is choreocarcinoma. The gold standard, the cornerstone of treatment would still be chemotherapy regardless of how many complications the patient is. We only resort to surgery and irradiation as adjunctive forms of treatment. So for stage 1 regardless of the risk score, we only start with methotrexate or actinomycin B. It's usually a toss-up between these two agents, a single agent. If you have a stage 2 or 3 but the score is less than 7, then we also start with the single agent chemotherapy. And once we have a normal HCG, then we continue on for two consolidation courses. For metastatic disease, high risk, we can now opt to choose the combination or intensive. I do agree with Dr. Cheran a while ago. But I think ISSTD has an agreement that we start it with EMACO regardless of the number. Like stage 3, 7, it's EMACO. We hardly use the triple agent anymore unless you had resistance to the single agent and then you think that your EMACO might be too extreme. Like for example, in this case, I'm still quite inclined probably if I'm going to shift to a multiple agent, I would probably try the MEA first before going to EMACO. Just to have more room for this patient to have more choices of drugs later on and depending on the availability of the agents. And then we have three consolidation agents. So this is how we do our chemotherapy for resistant disease. If it's resistance to EMACO, then we go to your cisplatin-based regimen. This would be the contraindications to chemo. We don't use the logarithmic pattern that Netherlands is doing. What we look for is the actual value of the HCG. How do we monitor for the HCG? Usually, we ask for a repeat serum beta HCG around five days to one week from the last day of the treatment, of the previous treatment, just to make sure if we're still going to continue or shift. That's why it's very important to note the date of the HCG. When was it taken in relation to the last day? We've had a lot of delays in chemotherapy now because of the inability to secure the drugs. Our patients are being lost to follow up. In the Philippines, we have been in lockdown since March. We are now again in lockdown, so our patients are all having difficulty. And we refuse to treat, well not really refuse, but we avoid giving chemotherapy unless we have tested for COVID for our patients. Mainly to make sure that they are not immunosuppressed. And for the protection of the doctors, more and more doctors are getting sick now. Our patients die, doctors die, we're all doomed for COVID here in the Philippines. Surgery is only indicated for appropriately selected patients. And no matter, even if it's brain or liver, most of them will actually respond to just the intensive chemotherapy. So this would be the reasons why we have to do surgery. Again, I agree with Dr. Ines, the patient is not bleeding, she's stable, she's young. The HCG is relatively low, there's no indication for surgery at this point. Irradiation, these are the different protocols. In the Philippines, we give the IM protocol for betotrexate, five days intramuscular because our patients are not given folinic acid anymore, it's additional cost for our patients. So we don't give it IV, we can ask the patients to come in on outpatient basis. And this is the monitoring that we do for our patients. So that's it. That's it for us.

trophoblastic disease

hydatidiform mole

choriocarcinoma

diagnostic methods

treatment