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Definitions of Metabolic Syndrome

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    Definitions of Metabolic Syndrome Definitions of Metabolic Syndrome Presentation Transcript

    • How to follow-up patients
      • Professor Gordon Rustin
      • Director of Medical Oncology
      • Mount Vernon Cancer Centre
      • Northwood
      • UK
    • Why do we follow-up patients who have had germ cell tumors?
      • To detect relapse: in the belief that earlier detection improves chance of cure
      • To detect contralateral testis tumors
      • To manage late toxicity
      • For reassurance, support and counselling
      • To collect data
    • First indication of relapse in TE08 stage I surveillance trial Rustin et al J Clin Oncol 25: 1310-15, 2007 6% 4 Chest + abdo + pelvic CT 1% 1 Chest CT 8% 5 Chest X-ray 39% 26 Abdominal CT 3% 2 Markers + abdominal mass 1% 1 Markers + palpable mass 42% 28 Markers
    • Characteristics of relapse following therapy for germ cell tumour Analysis of 96 relapses in 547 patients achieving remission Median time to relapse 6 months (1-89), 85% within 18 months Elevated markers 54% Retro-peritoneal nodes 58% Lung 26% Liver 15% CNS 8% Flechon et al European Urology 48, 957-964: 2005
    • Relapses > 2 years after completion of therapy for germ cell tumours
      • 119 / 3704 ( 3.2% ) Nonseminoma
      • 150 / 5880 ( 2.6% ) Seminoma
        • 10-year cause-specific survival
        • 68% in all patients
        • 50% in patients relapsing with vital malignant tumour
        • 100% in those with teratoma/ necrosis before or after salvage chemotherapy.
      • Oldenburg, Martin & Fossa J Clin Oncol 24: 5503-11, 2006
    • Localization of late relapses Oldenburg, Martin & Fossa J Clin Oncol 24: 5503-11, 2006 Site Nonseminoma Seminoma Retroperitoneum 236 51% 34 55% Mediastinum 43 9% 17 27% Lung/Pleura 77 17% 2 3% Neck/Supraclavicular 30 7% 9 15% Pelvis 20 4% 1 2% Other 53 12% 3 5% AFP 207 49% HCG 100 24%
    • Adapting frequency of follow-up investigations to risk of relapse Risk Nonseminoma Seminoma >10% Monthly 3 monthly 5-10% 2 monthly 4 monthly 1-5% 3-4 monthly 6 monthly 0.3-1% 6-12 monthly 12 monthly <0.3% discharge unless TD discharge or residual mass
    • ESMO Minimum Clinical Recommendations for Follow-up of NSGCT stage 1 on surveillance Clincal review, chest X-ray, and serum HCG & AFP monthly for 1 year 2 monthly for 2 nd year, 4 monthly 3 rd year, 6 monthly year 4 to 8 CT scans after 3 and 12 months Huddart RA, Ann Oncol; 18 suppl 2, ii42-ii43, 2007
    • ESMO Minimum Clinical Recommendations for Follow-up of NSGCT after chemotherapy Clinical review, chest X-ray, and HCG & AFP 2 monthly for 1 year, 3 monthly for 2 nd year 6 monthly to 5 years then annually CT scans only as clinically indicated Huddart RA, Ann Oncol; 18 suppl 2, ii42-ii43, 2007
    • Royal Marsden Minimum Clinical Recommendations for Follow-up for stage 1 seminoma on surveillance Clincal review and serum HCG, AFP & LDH 3 monthly for 2 years 4 monthly for 3 rd year, 6 monthly year 5 and 6 12 monthly years 6-10 Chest X-ray alternate visits for 2 years then annually to 5 years CT scans abdomen only unless pelvis at high risk at 6, 12, 18, 24, 36, 48, and 60 months Van As et al BJC 2008
    • ESMO Minimum Clinical Recommendations for Follow-up for stage 1 seminoma after adjuvant therapy Chest X-ray and clinical examination at 1 month, Then three monthly for 2 years Then 6 monthly to 5 years Pelvic CT in patients treated by paraaortic strip (and abdominal CT in patients treated by carboplatin) at year 1,2 and 5 Huddart RA Ann Oncol 18, Suppl2; ii40-ii41, 2007
    • ESMO Minimum Clinical Recommendations for Follow-up of seminoma after metastatic disease If normal CT scan: follow-up as for stage 1 If abnormal post-treatment CT scan: repeat CT scan every 6 months until normal or abnormalities stabilised A PET scan may help identify residual active cancer Consider biopsy or resection for large residual or growing masses Huddart RA Ann Oncol 18, Suppl2; ii40-ii41, 2007
    • Risks of excess CT scans
      • Typical chest CT has an associated radiation dose equivalent to 400 chest X-rays (8 vs 0.02 mSv) (Royal College of Radiologists, 1998)
      • Whole trunk CT produces dose of 10 to 30 mSv
      • Typical whole trunk CT scan associated with a 1:1000 risk of cancer/leukaemia
    • Definitions of Metabolic Syndrome NCEP definition Norwegian definition At least 3 of: At least 2 of: BP > 130/85 or medication BP > 140/90 or medication Waist circum > 102 BMI > 30 Fasting glucose > 5.6 mmol/l Self reported diabetes / medication Triglycerides > 1.7 mmol/l Cholesterol > 5.2 mmol/l or medication HDL cholesterol < 1.0 mmol/l
    • Investigations to be performed at 2, 5 and 10 years to detect late effects of therapy for germ cell tumors Blood pressure Creatinine Fasting cholesterol, HDL, LDL , triglycerides and glucose FSH, LH and testosterone ? Hip examination ? Osteoporosis screen
    • Questions related to follow-up of patients with germ cell
      • How many different follow-up schedules should be running?
      • Could follow-up be nurse led?
      • Is AFP necessary if pure seminoma?
      • Is LDH of value in follow-up?
      • Is Chest X-Ray necessary if no lung metastases at time of treatment for metastases?
    • LDH should not be measured routinely in follow-up of germ cell tumours 125 of 494 stage I patients had elevated LDH at relapse but in no case was it the first or only sign of relapse Ackers & Rustin BJC 94; 1231-2, 2006 499 patients on surveillance or follow up 26 of 1777 samples (1.4%) true positive, 137 (7.7%) false positive Only elevated marker at relapse in 1 of 15 relapses. Contributed to relapse detection in 4 of 35 (11%) seminomas Venkitaraman et al BJU Int 100; 30-32, 2007
    • Malignant teratoma 32 years after treatment of germ cell tumor confined to testis. Pavic M , Meeus P , Treilleux I , Droz JP . Urology. 2006 Apr;67(4):846 Is this the latest relapse after treatment of a germ cell tumour?
    • How should we organise our follow-up to detect the rare very late relapse? Relapse after 10 years is seen in < 1% of germ cell patients These patients can be cured by treatment that usually includes surgery Patients should be warned about late relapse but their rarity should not lead to prolonged follow-up