Definitions of Metabolic Syndrome

484 views

Published on

Published in: Health & Medicine, Business
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
484
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
17
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Definitions of Metabolic Syndrome

  1. 1. How to follow-up patients Professor Gordon Rustin Director of Medical Oncology Mount Vernon Cancer Centre Northwood UK
  2. 2. 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
  3. 3. First indication of relapse in TE08 stage I surveillance trial Markers 28 42% Markers + palpable mass 1 1% Markers + abdominal mass 2 3% Abdominal CT 26 39% Chest X-ray 5 8% Chest CT 1 1% Chest + abdo + pelvic CT 4 6% Rustin et al J Clin Oncol 25: 1310-15, 2007
  4. 4. 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
  5. 5. 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
  6. 6. 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%
  7. 7. 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
  8. 8. 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 2nd year, 4 monthly 3rd year, 6 monthly year 4 to 8 CT scans after 3 and 12 months Huddart RA, Ann Oncol; 18 suppl 2, ii42-ii43, 2007
  9. 9. 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 2nd year 6 monthly to 5 years then annually CT scans only as clinically indicated Huddart RA, Ann Oncol; 18 suppl 2, ii42-ii43, 2007
  10. 10. 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 3rd 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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?
  17. 17. 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
  18. 18. 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?
  19. 19. 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

×