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
the International Federation of Gynecology of Obstet-
rics (FIGO) at the time of the Washington DC meeting
in September 2000 promulgated significant changes to
the classification system for trophoblastic disease and
recommended that these be used by clinical investiga-
tors for the FIGO cancer reports. These recommenda-
tions need to be approved by the national member
societies of FIGO and must be ratified by the FIGO
Council. The accepted recommendations are the result
of deliberations over a period of years by workshops
at meetings of the International Society for the Study
of Trophoblastic Disease (ISSTD), the International
Gynecological Cancer Society (IGCS), and the Society
of Gynecologic Oncologists (SGO). The proposals to
FIGO were presented in this Journal in January 2000(1).
The objective of these deliberations was to simplify the
previous anatomic FIGO staging with its risk factors
devised in 1992(2) and to replace this by a classification
in which the basic anatomic staging is retained but the
risk factors are replaced by the risk factor scoring sys-
tem of the World Health Organization (WHO)(3). That
Address correspondence and reprint requests to: E.I. Kohorn, MD,
333 Cedar Street, New Haven CT 06510. Email: ernest.kohorn@
yale.edu.
Supported by the Baumer Fund of Yale University.
This is not a review but report of work in progress.
© 2001 IGCS
scoring system had been accepted by WHO in 1982
from the earlier system devised by Bagshawe(4). It is
felt that this combined staging/scoring system will
allow a more precise description of the extent of the
disease and of the risk factors present in trophoblastic
disease.
The new 2000 FIGO classification
The basic FIGO staging of disease, Stage I, II, III, and
IV is retained (Table 1) but the risk factors a, b, and c
signifying no risk factors, 1 risk factor, or 2 risk factors
are replaced by the modified WHO scoring system.
The 1992 risk factors were a serum human chorionic
gonadotropin (hCG) measurement of greater than
40,000 mIU/ml at the time of presentation or a length
of time of disease from the index pregnancy greater
than 6 months(2).
Comments concerning the FIGO 2000
staging of gestational trophoblastic disease
The requirement that placental site trophoblastic tu-
mor shall be classified as a separate entity from the
other gestational trophoblastic neoplasms is main-
tained.
There shall be no stage 0 trophoblastic disease. The
FIGO committee believes that inclusion of stage 0 im-
plies that with trophoblastic sequelae (persistent hCG)
after evacuation of hydatidiform mole and thus the
74 E. I. Kohorn
Table 1. Anatomic FIGO staging system for gestational
trophoblastic disease
Stage I Disease confined to the uterus
Stage II Disease outside of uterus but is limited to the gen-
ital structures
Stage III Disease extends to the lungs with or without known
genital tract involvement
Stage IV All other metastatic sites
diagnosis of trophoblastic tumor, restaging would be
required so contravening one of the basic principles of
the FIGO cancer staging systems. This requirement
implies that stages I, II, III, and IV trophoblastic dis-
ease are, in fact, trophoblastic neoplasia. Please note
that throughout this presentation the term trophoblas-
tic neoplasia will be used for trophoblastic tumor or
malignant trophoblastic tumor. We need to abide by
the definitions of nomenclature recently issued by the
Society of Gynecologic Oncologists(5). It is recognized
that hydatidiform mole and even invasive mole
should not be regarded as a cancer(6). It therefore
seems appropriate to regard trophoblastic disease as
the collective name for hydatidiform mole and tropho-
blastic neoplasia. Those patients who require chemo-
therapy or excisional surgery because of persistence of
hCG after hydatidiform mole and those who have tro-
phoblastic metastases, have “trophoblastic neoplasia”.
The stages of gestational trophoblastic neoplasia are
described in Table 1.
FIGO risk score for gestational
trophoblastic neoplasia
The individual prognostic scores for each category
shall be 0, 1, 2, and 4 for individual risk factors (Table
2). The changes that were agreed upon that differ from
the previous WHO classification are: ABO blood
group risk factors are eliminated and the risk factor for
liver metastasis is upgraded from 2 to the highest risk
group, 4.
The identification of an individual patient’s stage
Table 2. The scoring system for the FIGO 2000 staging/scoring
FIGO SCORE 0 1
Age ⱕ 39
Antecedent pregnancy Hydatidiform mole
Interval months from index pregnancy <4
Pretreatment hCG Milli IU/ml <103
Largest tumor size including uterus 3–4 cm
Site of metastases
Number of metastases identified 0 1–4
Previous failed chemotherapy
© 2001 IGCS, International Journal of Gynecological Cancer 11, 73–77
and risk score will be expressed by allotting a Roman
numeral to the stage and an Arabic numeral to the risk
score separated by a colon. Three examples of this
staging are given:
Low stage, low score: 45-year-old patient requiring che-
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.
High stage, high score: 40-year-old patient, 7 months
after full term pregnancy who presents with 4 lung
metastases, 1 brain metastasis 5 cm in size, and 1
metastasis in each kidney. The hCG was 42,000
mlU/ml. This patient is FIGO stage:score IV:15.
Low stage, high score: A patient age 44 is 8 months post
miscarriage, has uterine bleeding and by ultrasound
is found to have a 9-cm mass in the uterus. The hCG
is 18,000 mIU/ml and there is also a 5-cm nodule in
the vagina. Single agent chemotherapy has failed.
There are no other metastases. The FIGO stage:score
is II:10.
Requirements to diagnose and stage
gestational trophoblastic neoplasia
In order to implement this staging/scoring system
certain criteria for the diagnosis of gestational tropho-
blastic neoplasia need to be accepted.
1 To diagnose trophoblastic neoplasia after hydatidi-
form mole evacuation requires:
a) 4 values or more of plateau of hCG over at least
3 weeks; days 1,7,14, and 21.
b) A rise of hCG of 10% or greater for 3-values or
longer over at least 2 weeks; days 1,7, and 14.
c) The presence of histologic choriocarcinoma.
d) Persistence of hCG 6 months after mole evacua-
tion.
The level of hCG plateau is to be determined at
the discretion of the treating physician.
2 To diagnose metastases the requirements are:
a) For lung metastases, chest X-ray is adequate and
2 4
>39
Abortion Term pregnancy
4–6 7–12 >12
103–104 >104–105 >105
5 cm
Spleen Gastrointestinal tract Brain
Kidney Liver
4–8 >8
Single drug Two or more drugs

CT scan is acceptable. Chest X-ray will be used to
count the number of metastases for risk score
assessment.
b) For the diagnosis of intra-abdominal metastases,
CT scanning is preferred; many institutions will
still use ultrasound for liver metastases.
c) For the diagnosis of brain metastases, MRI is su-
perior to CT scanning even with 1-cm cuts.
3 Risk groups in the FIGO staging and scoring for
GTN. The WHO risk groups have been included in
the new FIGO system except that the middle risk
group present in the WHO classification is elimi-
nated. This group has usually been treated with
combination chemotherapy so placing these pa-
tients in a high-risk category for management pur-
poses.
a) There shall be a low risk group of GTN with a
score of 6 or less.
b) There will be a high-risk group with a score of 7
or greater.
Discussion
Combining an anatomic FIGO system with the modi-
fied WHO scoring system will provide the physicians
treating trophoblastic disease and using the FIGO clas-
sification with a more precise means of reporting tro-
phoblastic neoplasia and allow valid comparison of
the results of treatment from different centers. Up to
the present there has been significant variation in the
manner in which individual investigators have re-
ported the results of their treatment(7). The 1992 FIGO
classification was popular but suffered from the dis-
advantage that the risk factors used, hCG and the
length of time from the index pregnancy, were not
independent significant risk factors by multivariant
analysis. The next cancer report from FIGO that uses
the new system may clarify which risk factors will be
significant by univariant analysis, which by multivari-
ant analysis, and which may be discarded. Prior to the
agreement reached at the Rome meeting of IGCS in
1999, different investigators allotted the same risk fac-
tor with different values so that a patient in one center
had a different risk score than a patient from another
center(8–10). The concordance reached in the three
workshops has now allowed an agreed classification
and risk factor scoring system to go forward. It is sug-
gested that this is not modified for some time so that
data may be collected on the basis of which changes
may be made only if they are validated by statistical
analysis.
There is now agreement of the criteria by which
different centers diagnose post molar trophoblastic
FIGO 2000 scoring system 75
neoplasia. The reason that the words “more time” and
“or longer” are used for the length of observation cri-
teria (section 1a and 1b) is that all participants in the
workshops agreed that to diagnose post molar neo-
plasia a minimum of 3 weeks of hCG plateau or 2
weeks of hCG rise was an essential requirement. Wait-
ing longer was permitted as this did not adversely
prejudice either patient survival or the classification
itself. Many centers prefer to observe hCG plateau for
several weeks, particularly at low levels of hCG.
What then are the weaknesses of the new
classification? What controversy remains?
The first problem is that there is no accounting in the
system for hydatidiform mole, either complete or par-
tial. Only trophoblastic neoplasia is recorded. The in-
vestigator then has to maintain a separate record of
hydatidiform mole. Presently the FIGO system for
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-
tainly micro invasive cancer, is not that rare but
change of stage is not permitted with the present sys-
tem and may therefore not be recorded. There is no
mechanism for noting such changes for a patient who
is registered in the system as stage 0. Similarly for
trophoblastic disease, stage 0 is not registered at all.
There may be pathophysiologic reasons for not re-
garding hydatidiform mole as a premalignant entity.
However for recording trophoblast statistics, is there
really a contravention of principle if the recording sys-
tem allows change of stage? With modern computer
systems we could allow stage 0 so that we have a
handle on the denominator of this disease. Why not
have stage 0 → stage I, → stage IV? Such a system may
provide a more dynamic accounting of each patient.
Perhaps the trophoblastic community is not yet ready
for such radicality. FIGO has now taken a great step
forward and the new classification needs validating
before further changes are made. However, let us
plan, yet move slowly and with circumspection.
This discussion raises the question: at what stage
does one assess the disease; at the time of presentation
to the primary physician, at referral to the first oncolo-
gist, or at the second referral to a trophoblast center?
At present, staging/scoring is generally recorded
when the patient reaches the reporting center. Is that
really valid? Nevertheless it may be the only expedi-
ent way of resolving this problem.
It is of philosophical and semantic note that many
cancer classifications are mixtures of clinical and
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-
ment of trophoblastic disease histologic material be-
comes available only occasionally and treatment is in
fact the same with or without histologic validation.
The Japanese Gynecologic Cancer Society, in fact, in-
fers the diagnosis of “invasive mole” on the basis of
the “diagnostic score”(11). b) Metastases are diagnosed
by clinical examination and radiologic investigation
and their precise detection depends on the sophistica-
tion of the available radiologic equipment. This varies
in different centers in different parts of the world so
leading to possible variation in reporting metastases.
c) The WHO and the FIGO risk factor scoring system
includes patients who have had previous unsuccessful
chemotherapy. In fact, this is one of the risk factors of
independent significance by multivariant analysis and
therefore, needs to be included. Does this inclusion
transgress the rule for change of stage in the FIGO
system?
The next difficulty arises with the means of diag-
nosing lung metastases. During the workshops there
was great debate whether all lung metastases on CT
scan should be counted or all metastases on chest X-
ray should be counted, or only metastases greater than
2 cm or perhaps 3 cm on chest X-ray. It was finally
agreed that all metastases visible on chest X-ray
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
chest X-ray there will be few patients who by virtue of
having 8 or more metastases and thus a score of 4, that
will be moved into a higher treatment group and
therefore be given perhaps unnecessary combination
chemotherapy. If the disease is diagnosed late and
there are numerous such chest metastases and there is
a high hCG level then indeed the risk score may be
greater than 7 and the patient would be treated with
multiple agent chemotherapy; but perhaps under such
circumstances that would be appropriate. It will be
interesting to determine how often this occurs when
the next FIGO report appears.
Then there is the question of how to diagnose intra-
abdominal and specifically liver or brain metastases.
Most medical centers throughout the world now have
axial tomography (CT scanning) available. How a
community allots its medical resources is a choice that
the community makes. FIGO and we physicians,
should aspire to the highest possible standard of care
and not accept practices that we regard as less than
desirable. We all recognize that certain developing
countries will have neither the facilities to make pre-
cise diagnosis nor the resources to treat patients ad-
© 2001 IGCS, International Journal of Gynecological Cancer 11, 73–77
equately with the appropriate combination chemo-
therapy. That is the unfortunate truth but it should not
influence our classification systems and our aspira-
tions for treating the patient correctly.
There are certain aspects of the management of tro-
phoblastic disease that have so far not been included
in this or other discussions. The most important of
these concerns the measurement of hCG. It is estab-
lished that the assay method used to measure hCG
must recognize all aspects of the hCG molecule. This
includes nicked hCG and hyperglycosilated hCG but
not the false detection of phantom hCG. Otherwise
low or false negative results may lead to inappropriate
management(12).
These comments should in no way detract from the
significant achievement of the trophoblastic commu-
nity in reaching unanimity for a reporting system that
surely is superior to its predecessors. The new FIGO
staging and scoring system needs to be implemented
enthusiastically. It promises to provide more precise
information so allowing more valid comparison of the
results of treatment by different centers throughout
the world. FIGO for the first time embraces with con-
cordance both gynecologists and gynecologic oncolo-
gists and also those centers directed by medical on-
cologists.
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© 2001 IGCS, International Journal of Gynecological Cancer 11, 73–77