A hospital-based multicentric study results on gestational trophoblastic disease management status in a developing country

OBJECTIVE

To determine the clinical management of gestational trophoblastic disease in Turkey.

MATERIAL AND METHODS

An inquiry form was sent to 55 health centers including university hospitals, maternity hospitals with residency programs and maternity hospitals without residency programs in 1997. The inquiry consisted of questions about the type of classification systems in use, distribution of cases according to those classifications, use of prophylactic chemotherapy and its indications, and drug preference for single-agent or combined chemotherapies.

RESULTS

The overall response rate to the conducted inquiry was 47.1%. A clinical classification system was identified in 60% of the hospitals in Turkey. Generally, methotrexate was the most used single-agent chemotherapy. With regard to first-line combined chemotherapy, MAC (methotrexate, antinomycin-D, cyclophosphamide) was the preferred combination. EMA-CO (etoposide, methotrexate, actinomycin-D, cyclophosphamide, vincristine) was the most common used second-line chemotherapeutic regimen.

CONCLUSION

Due to insufficient data acquisition from all the medical centers and a lack of national population-based studies, it is difficult to draw a conclusion with respect to the interpretation of the data about the management protocols of gestational trophoblastic disease.

Human chorionic gonadotropin (hCG) beta-core fragment is produced by degradation of hCG or free hCG beta in gestational trophoblastic tumors: a possible marker for early detection of persistent postmolar gestational trophoblastic disease

The present study was undertaken to investigate whether human chorionic gonadotropin (hCG) beta-core fragment (hCG beta cf) was directly produced by gestational trophoblastic tumors. Immunoreactivity of hCG beta cf was demonstrated in the extracts as well as in the culture media of hydatidiform mole tissues. It was also present in the extracts of choriocarcinoma tissues, and its molar concentration exceeded that of intact hCG. The presence of hCG beta cf was then confirmed by gel chromatography and Western blot analysis. Immunohistochemistry showed localization of hCG beta cf immunoreactivity to the syncytiotrophoblasts and scattered cells in the stroma of mole tissue, and to syncytiotrophoblastic cells in choriocarcinoma. Immunoreactivity of hCG beta cf was also detected in the sera of the patients with gestational trophoblastic disease, although the hCG beta cf/hCG ratio was less than one hundredth of that in the tissue extracts. Serial measurement of serum hCG beta cf levels after mole evacuation showed that they declined much more rapidly than those of hCG and became undetectable in the patients with subsequent spontaneous resolution, while hCG beta cf remained or became detectable before the rise of hCG was observed in the patients with subsequent persistent trophoblastic disease. Taken together, these results suggest that hCG beta cf is directly produced by gestational trophoblastic tumors, and monitoring of hCG beta cf in the serum after mole evacuation may be useful for early prediction of subsequent development of postmolar persistent trophoblastic disease.

[The beta-hCG subunit, CA 125 and CA 19-9 antigen in the women with non-trophoblastic malignancy of genital tract]

OBJECTIVES

The aim of this study was preoperative estimation of serum level glicoprotein--CA 125, CA 19-9 and beta-hCG in ovarian tumors and comparison obtained values in groups divided according to postoperative pathologic examination.

MATERIALS AND METHODS

In every patients with ovarian tumors before surgery the level above mentioned antigens was evaluated and compared in following groups: malignant, non-malignant and controls. In control group cut-off values was estimated.

RESULTS

The levels of all investigated glycoproteins were significantly higher in malignant group comparing to benign and controls. The test differentiating non-malignant from malignant tumors was accepted as positive if at least one from markers level was elevated. Specificity of the test was 70%, sensitivity--94%, positive prognostic value--74%, negative prognostic value--94%. In the selected subgroups from non-malignant tumors the serum level of all glycoproteins was surprisingly high.

CONCLUSIONS

Preoperative estimation of CA 125, CA 19-9 and beta-hCG subunit in ovarian tumors permits--at negative result--with probability 93% to qualify tumor as non-malignant and sensitivity of test is 94%.

[Clinical analysis of intracranial metastases in gestational trophoblastic tumour]

OBJECTIVE

To evaluate characteristics of patients with intracranial metastases of gestational trophoblastic tumour (GTT) and determine the prognostic factors and therapeutic modality.

METHODS

We retrospectively reviewed the records of 814 GTT patients treated at Peking Union Medical College Hospital from 1984 to 1998. Of them, 382 were choriocarcinoma and 61 developed brain metastases (16.0%); 432 were invasive mole and 8 of them presented brain metastases (1.9%). Patients with brain metastases were divided into three categories: Group A, individuals with no prior chemotherapy (30 cases); Group B, patients who had received chemotherapy before transferred to our hospital (31 cases); Group C, individuals who developed brain metastases during therapy in our hospital (8 cases). Apart from 12 patients died before or during the first cycle of chemotherapy, the remaining 57 patients were treated with 5-FU combined chemotherapy or etopside, methotrexate, kengshengmycin, /vincristine, cyclophosphamide (EMA/CO) regimen, the number of courses varied from 3 to 17 cycles. The median number of chemotherapy for each patient was 8.2. Intrathecal methotrexate chemotherapy was utilized for all patients. Emergency surgical decompression was performed in 4 cases who had symptoms of highly increased intracranial pressure.

RESULTS

Apart from 12 patients died before they received regular therapy in our hospital, remission rate of other 57 patients was 71.9%. The cumulative survival rate for these 57 patients at 5 years was 45.8%. Women with no prior chemotherapy (group A) had outcomes significantly better than those who had been treated before transfer to our hospital (group B) and there were no survivors among the patients who developed brain metastases during active chemotherapy (group C) [P < 0.05 (A Vs B); P < 0.01 (A or B Vs C)].

CONCLUSIONS

Multiagent systemic chemotherapy combined with intrathecal methotrexate chemotherapy still play the key role in the management of brain metastatic GTT patients; Surgical decompression should be performed if significant neurologic symptoms are present.

Utility of commonly used commercial human chorionic gonadotropin immunoassays in the diagnosis and management of trophoblastic diseases

BACKGROUND

Patients with trophoblastic diseases produce ordinary and irregular forms of human chorionic gonadotropin (hCG; e.g., nicked hCG, hCG missing the beta-subunit C-terminal segment, hyperglycosylated hCG, and free beta subunit) that are recognized to differing extents by automated immunometric hCG (or hCG beta) assays. This has led to low or false-negative results and misdiagnosis of persistent disease. False-positive hCG immunoreactivity has also been detected, leading to needless therapy for trophoblastic diseases. Here we compare seven commonly used hCG assays.

METHODS

Standards for five irregular forms hCG produced in trophoblastic diseases, serum samples from 59 patients with confirmed trophoblastic diseases, and serum samples from 12 women with previous false-positive hCG results (primarily in the Abbott AxSYM assay) were blindly tested by commercial laboratories in the Beckman Access hCG beta, the Abbott AxSYM hCG beta, the Chiron ACS:180 hCG beta, the Baxter Stratus hCG test, the DPC Immulite hCG test, the Serono MAIAclone hCG beta tests, and in the hCG beta RIA.

RESULTS

Only the RIA and the DPC appropriately detected the five irregular hCG standards. Only the Beckman, DPC, and Abbott assays gave results similar to the RIA in the patients with confirmed trophoblastic diseases (values within 25% of RIA in 49, 49, and 54 of 59 patients, respectively). For samples that were previously found to produce false-positive hCG results, no false-positive results were detected with the DPC and Chiron tests (5 samples, median <2 IU/L), but up to one-third of samples were false positive (>10 IU/L) in the Beckman (1 of 5), Serono (2 of 9), and Baxter assays (1 of 5), and the hCG beta RIA (3 of 9; median for all assays, <5 IU/L). These samples, which produced false-positive results earlier in the Abbott AxSYM assay, continued to produce high values upon reassessment (median, 81 IU/L).

CONCLUSIONS

Of six frequently used hCG immunometric assays, only the DPC detected the five irregular forms of beta hCG, agreed with the RIA, and avoided false-positive results in the samples tested. This assay, and similarly designed assays not tested here, seem appropriate for hCG testing in the diagnosis and management of trophoblastic diseases.

Poor compliance with postmolar surveillance and treatment protocols by indigent women

OBJECTIVE

To estimate compliance by indigent women with surveillance protocols after molar pregnancy.

METHODS

Women whose molar pregnancies were evacuated at an urban, public hospital were advised to return weekly either until hCG levels decreased below 5 mIU/mL, then monthly for 6 months, or until diagnosis and treatment of gestational trophoblastic disease, then monthly for 12 months. Hormone testing was by enzyme-linked immunosorbent assay. Statistical analysis was by chi(2) tests.

RESULTS

Of 51 women identified, 11 (22%) developed trophoblastic disease. All achieved remission after chemotherapy. Five (45%) of these 11 missed at least one treatment, seven (64%) missed at least one postremission visit, and none was fully compliant with protocols. Five (13%) of the 40 remaining women were lost to follow-up before remission. Seven (18%) of the 40 women who did not receive chemotherapy complied fully with protocols, whereas five (13%) were lost to follow-up before remission, and 16 (40%) were lost before completing 6 months of follow-up. Only 15 (29%) of the 51 women completed surveillance without gestational trophoblastic disease or pregnancy. Six women conceived, and injectable medroxyprogesterone acetate was associated with a lower pregnancy rate (zero of 25 compared with six of 26 (23%), P <.01).

CONCLUSION

Most indigent women failed to comply with postmolar surveillance, although most achieved remission. Injectable medroxyprogesterone acetate is recommended for postmolar contraception in this population.

[Clinical study of four cases with malignant gestation trophoblastic tumor after mifepristone abortion]

OBJECTIVE

To describe the clinical characteristics of malignant gestational trophoblastic tumor after medical abortion used by mifepristone combined with misoprostol and its diagnosis and differential diagnosis from incomplete abortion.

METHODS

Four cases with malignant gestational trophoblast tumor after medical abortion were presented focusing on the clinical manifestation and the methods of diagnosis and differential diagnosis.

RESULTS

Irregular vaginal bleeding and abnormal high level of beta-human chorionic gonadotropin (hCG) in plasma were the common manifestation of the gestational trophoblast tumour and incomplete abortion after medical abortion. However, beta-hCG of the former after curettage was still higher by dynamic monitoring. Malignant gestational trophoblast tumor showed rich blood flow signal and low blood flow resistance index (RI, RI < 0.5) in uterus in color doppler echography, digital subtraction angiography (DSA) with abnormal enlargement of the arteria of uterine, arteriovenous fistula beside the uterine were the main characteristics of malignant gestational trophoblast tumour.

CONCLUSIONS

Pay attention to the early stage malignant gestational trophoblast tumour among patients with abnormal vaginal bleeding after medical abortion. beta-hCG and DSA were the most effective methods to diagnose and differentially diagnose choriocarcinoma from the incomplete abortion among the patients with abnormal vaginal bleeding after medical abortion.

Immunohistochemical staining properties of PCNA, Ki-67, p53, beta-hCG and HPL in trophoblastic disease

OBJECTIVE

In this study proliferating markers PCNA (proliferating cell nuclear antigen) Ki-67 and mutation of supressor gene p53 were investigated in gestational trophoblastic disease (GTL). These markers were tested by using immunostaining with beta subunits of human chorionic gonadotropin (hCG) and human placental lactogen (HPL).

MATERIAL AND METHODS

Twenty curetting samples, 20 spontaneous abortions, 16 hydatidiform moles and two choriocarcinomas were studied and compared. Hydatidiform moles were subdivided into 10 complete and six partial moles by using flow cytometry analysis. All slides were stained with PCNA, Ki-67, p53, hCG, and HPL immunohistochemically. PCNA and Ki-67 stained slides were studied quantitatively to determine the PCNA and Ki-67 index. Other slides that were stained with p53, hCG, HPL were evaluated according to staining percentage and intensity. Staining properties of all groups were compared with each other. Variance analysis and the Mann Whitney U test were used for statistical analysis. Choriocarcinomas were not included in the statistical analysis. Ki-67 and the PCNA index in two choriocarcinoma cases found 81.4% and 41%, and 44% and 64%, respectively. One case was stained in 70% with (++) intensity by p53. While both were stained in 80% with (++) intensity by hCG, one was stained in 30% field (+) intensity by HPL.

RESULTS

The four groups of complete and incomplete diagnosed hydatiform moles, spontaneous abortions and retention curettage were matched in pairs and evaluated according to the PCNA index. This index showed significant differences among the groups. The differences among the Ki-67 index, p53, hCG and HPL staining properties were not statistically significant.

CONCLUSION

Our findings showed that PCNA is a significant and useful marker for trophoblastic diseases and can be used as a prognostic factor.

Gestational trophoblastic diseases: new standards for therapy

Gestational trophoblastic disease (GTD) is a spectrum of rare neoplastic conditions that are highly curable, even in the presence of widely metastatic disease. These diseases vary from partial hydatidiform mole, which rarely metastasizes and infrequently requires treatment with chemotherapy, to choriocarcinoma, for which multi-agent chemotherapy is the standard treatment. Much has been learned regarding the epidemiology of this disease, and our understanding of the genetics underlying GTD is rapidly expanding. As technology such as ultrasonography and sensitive tests for beta-human chorionic gonadotropin have evolved, the presentation of molar pregnancy has significantly changed, although the incidence of persistent GTD has not decreased. This review highlights these recent advancements in the epidemiology, genetics, diagnosis, and treatment of gestational trophoblastic disease.

Treatment of persistent trophoblastic disease later than 6 months after diagnosis of molar pregnancy

Of 4257 patients with gestational trophoblastic disease (GTD) registered between 1986 and 1996 with the Trophoblastic Screening and Treatment Centre, Sheffield, 231 women required chemotherapy; 28 were treated 24 weeks or more after the initial evacuation of products of conception. In 18 patients late treatment was a result of a predetermined watch and wait policy on the part of the Centre; these patients formed the study group. Patients were identified from the Centre's computer database. The time interval from first evacuation (diagnosis) to start of chemotherapy was calculated for each patient. Hospital records were reviewed when the interval of observation was 24 weeks or greater to determine patient characteristics, treatment and outcome. Eighteen women were treated 'late' (according to Centre policy), with a median age of 30 years (range 21-57 years). The interval from diagnosis to treatment ranged from 24 to, in one case, 56 weeks (median 33 weeks). Fourteen of 18 women had complete moles, 3/18 had partial moles and one had unclassified disease. All women had low-risk disease and were treated with single-agent methotrexate; 17 were cured with this regimen, one also required salvage chemotherapy. In conclusion, where a successful surveillance programme is in operation for GTD, a wait and watch policy can be adopted without compromising patients whose definitive treatment is commenced more than 6 months after the initial diagnosis.

CSF/serum beta-hCG ratio in patients with brain metastases of gestational trophoblastic tumor

OBJECTIVE

To assess the accuracy of cerebrospinal fluid (CSF)/serum ratio of beta-subunit of human chorionic gonadotropin (beta-hCG) in detecting brain metastasis of gestational trophoblastic tumor (GTT).

STUDY DESIGN

The subjects were ten patients with GTT and brain metastases. Spinal puncture and veni-puncture were performed for measurement of beta-hCG titer in CSF and serum to determine the CSF/serum ratio before starting multiagent chemotherapy and/or brain irradiation.

RESULTS

Five patients manifested a CSF/serum beta-hCG ratio > 1/60, and five manifested a ratio < 1/60.

CONCLUSION

The CSF/serum beta-hCG ratio is not accurate enough to be routinely considered in the workup, management, and/or surveillance of GTT with brain metastases. Hence, it is perhaps not necessary to perform spinal puncture if the only purpose is to determine the CSF/serum ratio.

Structure, pathology and function of the N-linked sugar chains of human chorionic gonadotropin

Human chorionic gonadotropin (hCG) contains five acidic N-linked sugar chains, which are derived from three neutral oligosaccharides by sialylation. Each of the two subunits (hCGalpha and hCGbeta) of hCG contain two glycosylated Asn residues. Glycopeptides, each containing a single glycosylated Asn, were obtained by digestion of hCGalpha with trypsin, and of hCGbeta with chymotrypsin and lysyl endopeptidase. Comparative study of the sugar chains of the four glycopeptides revealed the occurrence of site-directed glycosylation. Studies of the sugar chains of hCGs, purified from urine of patients with various trophoblastic diseases, revealed that choriocarcinoma hCGs contain sialylated or non-sialylated forms of eight neutral oligosaccharides. In contrast, hCGs from invasive mole patients contain sialyl derivatives of five neutral oligosaccharides. The structural characteristics of the five neutral oligosaccharides, detected in choriocarcinoma hCGs but not in normal placental hCGs, indicate that N-acetylglucosaminyltransferase IV (GnT-IV) is abnormally expressed in the malignant cells. This supposition was confirmed by molecular biological study of GnT-IV in placenta and choriocarcinoma cell lines. The appearance of tumor-specific sugar chains in hCG has been used to develop a diagnostic method of searching for malignant trophoblastic diseases. In addition, a summary of the current knowledge concerning the functional role of N-linked sugar chains in the expression of the hormonal activity of hCG has been presented.

[Beta subunit of human chorionic gonadotropin, CA 125 antigen and CA 19-9 antigen with non-trophoblastic malignancy of genital tract. Vulval cancer]

Our investigations embraced the group of patients with vulval cancer before surgical treatment (n = 10). We measured in serum of blood the level of the total human chorionic gonadotrophin hCG, beta subunit of human Chorionic Gonadotrophin, CA 125 and CA 19-9 antigen. We ascertained significant elevation the beta subunit of hCG level in the group of women with neoplasms in comparison with control group (n = 96) and significant positive correlation between beta subunit level and degree of cancer cells maturity (r = 0.66, p < 0.05). We also ascertained strong positive correlation among beta subunit of hCG and CA 19-9 antigen level in the serum of the patients with vulval cancer (r = 0.55 and p < 0.05).

Malignant trophoblastic disease following a twin pregnancy consisting of a complete hydatiform mole and a normal fetus and placenta. A case report

We report an unusual pregnancy with a complete hydatiform mole coexisting with a normal fetus and placenta. This report stresses the importance of a correct diagnosis and the dilemmas the clinician is faced with when managing such a case. Malignant trophoblastic disease occurs in 55% of complete hydatiform mole and fetus. Two-thirds require combination chemotherapy.

An unusual presentation of gestational trophoblastic disease

We report a case of gestational trophoblastic disease leading to an acute abdomen due to a haemoperitoneum in a young multipara.

A study of early pregnancy factor activity in the sera of women with trophoblastic tumor

PROBLEM

To detect whether or not the early pregnancy factor (EPF)-like activity, or chaperonin 10, could be in the sera of patients with trophoblastic tumor in order to find another more efficient means to diagnose this kind of tumor.

METHOD OF STUDY

The rosette inhibition assay was used to detect EPF-like activity in 216 sera, collected from patients with gestational trophoblastic tumor, including 47 sera of patients with choriocarcinoma, 68 sera of patients bearing invasive mole, and 101 sera of patients with vesicular mole.

RESULTS

The accuracy of diagnosing malignant trophoblastic tumor by detecting EPF-like activity is 91.3% (105/115), with a false positive rate of 14.58% and a false negative rate of 4.8% by this method. Furthermore, the rosette inhibition titer (RIT) values have significant difference (P < 0.001) between the sera in patients with malignant trophoblastic tumor before treatment and those after treatment.

CONCLUSIONS

This study demonstrated that diagnosis of malignant trophoblastic tumor could be made with an accuracy of 91.3% by detecting EPF-like activity and that EPF-like activity could be used as an indicator to distinguish benign from malignant trophoblastic tumor.

Early detection of persistent trophoblastic tumour by serum human chorionic gonadotrophin monitoring after molar pregnancy

OBJECTIVE

To study the outcome of a multi-centred post-molar pregnancy serum human chorionic gonadotrophin (hCG) surveillance programme.

METHODS

Patients recruited into the multi-centred post-molar serum hCG surveillance programme between 1988 and 1996 were studied. The clinical data were obtained from medical records and computer database.

RESULTS

There were 616 patients in the study. Twenty-five (11%) of 224 patients with molar pregnancy and 28 (7%) of 392 patients with partial molar pregnancy were diagnosed to have persistent trophoblastic tumour (PTT) requiring chemotherapy. Of the 53 patients treated for PTT, 58.5% received intravenous methotrexate (MTX), 22.6% received both MTX and actinomycin D, and 19% received CHAMOC, a multiple chemotherapeutic regimen. Four patients receiving single drug had to change the regimen because of poor response, and all recovered and remained well. There were 3 cases of recurrence, one in each group of patients receiving single, dual or multiple agents. One patient died because of treatment complication. The rest were well with a mean follow-up of 42 months.

CONCLUSIONS

Post-molar serum hCG surveillance is important to detecting persistent trophoblastic activity. Early treatment of PTT by the appropriate chemotherapy has a near hundred percent cure and prevents the progression of PTT into more advanced trophoblastic malignancy such as choriocarcinoma.

Cytodiagnosis of placental site trophoblastic tumor. A report of two cases

BACKGROUND

Placental site trophoblastic tumor (PSTT) is a rare form of trophoblastic neoplasm. Approximately 100 cases of PSTT have been reported, but we found no report on its cytodiagnosis.

CASES

Case 1, a 39-year-old female, came to the hospital because of abnormal genital bleeding. Case 2, a 36-year-old female came because of amenorrhea for a year. In both cases, endometrial smear and intrauterine curettage suggested trophoblastic disease, and hysterectomy was performed. Laboratory data revealed a mild increase in human chorionic gonadotropin (hCG) and beta-hCG but normal human placental lactogen (hPL). In the cytologic examination, the background contained some hemorrhagic and fibrinous areas but no necrosis. Most tumor cells stained light green, were round or polygonal, and contained abundant cytoplasm. Some were palely stained and had vacuoles. Some cells showed hyperchromatism, an irregular nucleus, fine-to-coarse chromatin granules and markedly different sizes. Most of the cells were hPL positive, and a few were hCG positive.

CONCLUSION

Both cases were considered benign because of rare mitoses despite cellular pleomorphism. However, careful follow-up is required. The differential diagnosis of PSTT is difficult from cytologic and biopsy specimens alone but may be achieved with additional magnetic resonance imaging findings and positive staining of hPL and hCG.

Recent advances in gestational trophoblastic disease

Important advances continue to occur in both our understanding and management of gestational trophoblastic disease. Complete molar pregnancy is being diagnosed earlier in pregnancy which affects its clinical and pathological presentation. The use of chemotherapy in persistent gestational trophoblastic tumors continues to be refined and our understanding of the immunobiology of these tumors has substantially advanced.

Gestational trophoblastic disease. Molecular and genetic studies

For a geneticist, the gestational trophoblastic diseases are a particularly interesting group of diseases. Hydatidiform moles were one of the first of a growing number of human disorders shown to result from the phenomenon of genomic imprinting, while gestational trophoblastic tumors are unusual neoplasms in that they derive not from the patients' own tissue but from a genetically distinct pregnancy. We review here the development of our understanding of the genetics of gestational trophoblastic disease and describe how modern molecular genetic techniques can be used to aid in the management of these conditions and further our understanding of their unusual biology.

Intracytoplasmic sperm injection combined with preimplantation genetic diagnosis for the prevention of recurrent gestational trophoblastic disease

A strategy for the prevention of repeated molar pregnancies by using intracytoplasmic sperm injection (ICSI) coupled with preimplantation genetic diagnosis (PGD) with fluorescence in-situ hybridization (FISH) was developed. In this approach, complete moles which arise from dispermic fertilization are avoided by the use of ICSI. ICSI is followed by preimplantation selection against the transfer of 46,XX embryos, thus preventing complete moles resulting from a fertilization of an inactive oocyte, by a haploid X-bearing spermatozoon which subsequently duplicates. Triploid partial moles which arise mainly from dispermic fertilization may also be prevented by ICSI. The preimplantation confirmation of diploidy by FISH guards against triploid partial moles which may result from mechanisms other than dispermic fertilization. The employment of this strategy in an attempt to prevent a repeated event of molar pregnancy in a patient with a history of two previous episodes of gestational trophoblastic disease is reported.

[Trophoblastic disease in data from the Center for Trophoblastic Disease (diagnosis, therapy and results form 1955 to 1996). 1]

The authors submit an analysis of the clinical pathological material of the nationwide trophoblastic diseases centre (CTN) from 1955-1996. It comprises a total of 5735 cases of trophoblastic disease (TN). This comprises choriocarcinoma (CH) 343 times, so far the largest group of CH verified by histological examination. It comprises furthermore proliferating mole (MP) 202 times complete hydatid mole (MHK) 360 times, partial hydatid mole (MHP) 1150 times persisting trophoblastic invasion (PTI) < 330 times, trophoblastic invasion (TI) 3220 times and persisting trophoblastic disease (PTN) 130 times. The author presents the morphological classification and diagnosis of TN proposed and used in CTN on a nationwide scale. It assessment the importance of different types of TN for their treatment and prognosis. The following units are defined: 1. Trophoblastic invasion, 2. Persisting trophoblastic invasion 3. Partial hydatid mole, 4. Complete hydatid mole, 5. Proliferating mole, 6. Choriocarcinoma which comprises five different types. In trophoblastic invasion the author describes its histological and cytological variability which formerly accounted for as much as 50% false positive diagnoses. Nowadays it is doubtful only in 5%. Persisting trophoblastic invasion was defined in CTN as a new special pathological unit of TN. Usually it recedes spontaneously. Nevertheless in 3% it was in CTN an indication for chemotherapy. In partial hydatid mole and in complete hydatid mole the morphological signs were, defined, which make their differential diagnosis possible which is essential for assessment of their prognosis. After complete hydatid mole choriocarcinoma developed in CTN in 6%. After partial hydatid mole the development of choriocarcinoma was not observed so far in CTN. Proliferating mole is defined in CTN in histological terms which makes its diagnosis from curettage possible. A malignant reversal of proliferating mole was recorded in CTN in 10%. Chemotherapy of proliferating mole was essential in 15%. The mortality rate of choriocarcinoma after proliferating mole declined from the original 85% to 3% and was zero during the last 10 years. According to the CTN classification there are five types of choriocarcinoma which differ markedly as to their biological properties and response to chemotherapy. The histological types of choriocarcinoma were defined on the basis of correlation with orthological trophoblasts of 7 to 20-day-old embryos. The types are: 1. Differentiated syncytiotrophoblastic choriocarcinoma, 2. Mixed differentiated choriocarcinoma, 3. Differentiated cytotrophoblastic choriocarcinoma, 4. Non-differentiated choriocarcinoma, 5. Dissociated choriocarcinoma. Types 1 and 2 respond excellently to chemotherapy and produce high values of hCG. Type 3, 4 and 5 are not very sensitive to chemotherapy or even resistant and produce low values of hCG. Some require primary surgery. They are histologically defined forms of so-called Placental Site Trophoblastic Tumours.

Trophoblastic tumors of the testis other than classic choriocarcinoma: "monophasic" choriocarcinoma and placental site trophoblastic tumor: a report of two cases

We report two unusual forms of testicular trophoblastic tumor. One was a mixed germ cell tumor in a 19-year-old man that had a predominant component of nodules of cytotrophoblast cells with only rare syncytiotrophoblast cells. These nodules of "monophasic" choriocarcinoma were diffusely positive for human chorionic gonadotropin (hCG), which stained the syncytiotrophoblast cells more intensely; stains for human placental lactogen (HPL) highlighted only the latter cells. The second tumor occurred in a 16-month-old boy. It consisted of a pure proliferation of intermediate trophoblast cells and was identical to the placental site trophoblastic tumor of the uterus. The tumor cells showed diffuse immunoreactivity for HPL and patchy staining for hCG. Despite the occurrence of vascular wall invasion, the patient was alive and well at 8 years follow-up with no treatment other than orchiectomy. These cases show that trophoblastic tumors other than classic choriocarcinoma occur rarely in the testis. The differential diagnosis of the "monophasic" choriocarcinoma included seminoma and the solid variant of yolk sac tumor, but the tumor had larger, more irregular nuclei than those of seminoma and was not associated with distinctive yolk sac tumor patterns. The placental site trophoblastic tumor may be confused with Leydig cell tumor or choriocarcinoma, but awareness of its occurrence in the testis and the immunohistochemical findings should permit its recognition.

Hysteroscopy provides proof of trophoblastic tumors in three cases with negative color Doppler images

Color Doppler sonography has replaced pelvic arteriography as well as real-time ultrasound in the assessment of patients with gestational trophoblastic disease. In about 25% of patients in whom human chorionic gonadotropin (hCG) levels are suggestive of trophoblastic disease, there will be no evidence of abnormal vessels in the uterus. In these cases it is assumed that hCG was produced by metastatic lesions. We present here three cases in which color Doppler examination was negative and where myometrial biopsies containing tumor were obtained by means of hysteroscopy. The fact that color Doppler, in its present form, does not detect small areas of trophoblastic tumor might also have implications for other kinds of tumors. Knowledge of the exact microscopic diagnosis in molar patients with persistent disease may have an impact on management.

Gestational trophoblastic disease: a spectrum of radiologic diagnosis

Gestational trophoblastic disease (GTD) encompasses a broad spectrum of conditions that includes hydatidiform mole, invasive mole, and choriocarcinoma. Although ultrasound (US) is the examination of choice for initial diagnosis, plain radiography, angiography, computed tomography (CT), and magnetic resonance (MR) imaging all play a role in determining the presence of GTD and the extent of its complications. US shows molar gestations as alternating cystic and solid tissue that fills the entire uterus. CT and MR imaging are useful in detecting myometrial invasion, parametrial extension, and metastasis. Because each imaging technique offers a unique perspective highlighting different aspects of GTD, it is important to understand the pathophysiology and natural history of the disease. Such knowledge in turn leads to a greater understanding of the spectrum of findings seen on various kinds of radiologic images and enables the radiologist to play an important role in directing patient work-up by recognizing the implications of various findings and guiding management decisions.

Flow cytometric DNA analyses of 105 fresh hydatidiform moles, with correlations to prognosis

Cellular DNA contents of consecutive hydatidiform moles were analysed by flow cytometry of unfixed samples, freed of maternal tissue and treated with detergent and trypsin, using two external controls. DNA-diploidy was found in 62 moles, DNA-triploidy in 42 and DNA-tetraploidy in one. Two non-molar placentas and two invasive moles were found to be DNA-diploid. In 28 of 42 DNA-triploid moles, trophoblastic hyperplasia was not noted, making the discrimination between vesicular abortions with or without trophoblastic hyperplasia unwarranted on genetic grounds. A good fit was obtained to a distribution with one G0-1 peak in 49 cases, whereas 60 cases showed two peaks. Technical artifacts, created by flow cytometry, were excluded. Differences in the nuclear accessibility for the dye and degradation of DNA are unlikely causes of this heterogeneity. The existence, in vivo, of two or more cell populations with different DNA contents is a reasonable explanation. The criteria for persistent trophoblastic disease were standardised. Eight cases of persistent trophoblastic disease were observed among the 62 DNA-diploid moles (13%); no case was observed after DNA-triploid or DNA-tetraploid moles. Combining these data, with those of other studies where ploidy was determined using optimal techniques [10,13], allows the calculation of 95%-confidence-limits for the risk of persistent trophoblastic disease after a triploid mole to 0-2.7%.

Immunohistochemistry in the diagnosis of the gestational trophoblastic disease

OBJECTIVE

The gestational trophoblastic disease summarizes all types of hydatidiform moles, placental site trophoblastic tumor and choriocarcinoma. It is of clinical relevance to distinguish between complete hydatidiform mole and partial hydatidiform mole to predict prognosis of recurrency of molar pregnancy and the risk of the development of malign and metastatic gestational trophoblastic disease. Differential diagnosis of choriocarcinoma versus placental site trophoblastic tumor, carcinoma or sarcoma with low differentiation can cause problems in borderline-cases. The present study investigates the value of immunohistochemistry in the diagnosis of gestational trophoblastic disease.

METHOD

Nine cases of patients with complete hydatidiform mole, 20 cases of partial hydatidiform mole and seven cases of choriocarcinoma were analyzed for the immunohistochemical reaction with antibodies against human choriogonadotropin (hCG), human placental lactogen (hPL). placental alkaline phosphatase (PLAP), cytokeratine and vimentin.

RESULTS

Complete hydatidiform mole shows strong expression of hCG and weak expression of PLAP. Weak hCG and strong PLAP expression is found in partial hydatidiform mole. Choriocarcinoma presents strong expression of hCG and weak expression of hPL and PLAP. All tissues show positive reaction with anticytokeratine and negative reaction with anti-vimentin.

CONCLUSION

Our study proves immunohistochemistry as useful tool for differential diagnosis in borderline cases of gestational trophoblastic disease.

Magnetic resonance imaging in patients with gestational trophoblastic disease

RATIONALE AND OBJECTIVES

The authors describe the magnetic resonance (MR) imaging characteristics in patients with gestational trophoblastic disease (GTD) before and after therapy and to correlate these findings with human gonadotropin levels and the specific histology of GTD.

METHODS

Thirteen women (mean age, 30.1 years) with elevated human chorionic gonadotropin (HCG) levels and histologically proven GTD underwent MR examinations of the pelvis. Magnetic resonance imaging was performed on a 1.5-tesla unit. Axial and sagittal proton density-weighted and T2-weighted and sagittal T1-weighted sequences were obtained. Four patients underwent follow-up studies after 4 and 8 weeks to monitor the response to therapy. Gestational trophoblastic disease was histologically proven with curettage in 11 patients and with hysterectomy in two cases.

RESULTS

Nine patients had a diffusely enlarged uterus with pathologic signal intensities. In four patients, a focal tumor mass was observed. All patients showed loss of the zonal anatomy of the uterus in at least one local area. In 11 patients, no uterus zones could be identified throughout the entire uterus. Pathologic dilated tumor vessels were evident in all patients. In all four cases in which follow-up imaging studies were obtained, uterus size, signal intensities, identification of uterus zones, and uterus vessels returned to normal.

CONCLUSION

Magnetic resonance imaging shows trophoblastic tumor infiltration as diffuse uterus enlargement, focal tumor masses, loss of zonal anatomy of the uterus, and pathologic uterine vasculature; this seems to be the most reliable MR imaging finding in patients with GTD. No correlation was found between MR imaging changes and HCG levels or specific histologic types of GTD.

From the archives of the AFIP. Gestational trophoblastic disease: radiologic-pathologic correlation

Gestational trophoblastic disease (GTD) is a manifestation of an aberrant fertilization event that leads to a proliferative process and, potentially, to an invasive neoplasm. The spectrum of GTD includes hydatidiform moles (complete and partial), invasive mole, choriocarcinoma, and placental site trophoblastic disease (rare). Increased levels of human chorionic gonadotropin (beta-hCG) are associated with all forms. Ultrasonography (US), performed late in the first trimester of a pregnancy complicated by hyperemesis gravidarum, toxemia, or bleeding, is essential in the early detection of hydatidiform mole, the most common form of GTD (80% of cases). In these cases, US typically reveals a central heterogeneous mass with anechoic spaces, which correspond to hydropic villi. In cases of invasive mole, imaging may show a central uterine process (similar to that seen in noninvasive moles), occasionally with myometrial invasion. Choriocarcinoma is often seen as a mass enlarging the uterus, with a heterogeneity that correlates with necrosis and hemorrhage. Because of the widespread availability of serum measurement of beta-hCG, diagnosis of the more severe, persistent manifestations of GTD seldom depends on radiologic examinations. However, imaging studies may alert the referring physician to the diagnosis in cases of early disease. Also, imaging studies may have a problem-solving role in examining patients with recurrent GTD or a confusing clinical picture.

Serum interleukin-2 and soluble interleukin-2 receptor in gestational trophoblastic diseases

OBJECTIVE

To investigate serum interleukin-2 (IL-2) and soluble interleukin-2 receptor (SIL-2) levels in gestational trophoblastic diseases (GTD).

METHODS

Sixty-six patients with GTDs and 23 first-trimester healthy pregnant women (controls) participated in this study. According to the World Health Organization scoring system, GTDs were subgrouped into the following groups: 30 hydatidiform mole spontaneous regression (HMSR), 12 postmolar gestational trophoblastic tumors of high risk (PMHR), 14 low-risk choriocarcinomas, and ten high-risk choriocarcinomas. Before treatment, a blood sample from each case was assayed for beta-hCG by radioimmunoassay, IL-2 by IRMA, and SIL-2R by enzyme-linked immunosorbent assay. Follow-up beta-hCG assays were carried out at weekly intervals after treatment for 3 months, then monthly for 1 year.

RESULTS

Serum IL-2 levels in all subgroups of GTD were significantly lower than that of controls. Meanwhile, there were concomitant significant elevations of serum SIL-2R, showing mean rises of 3.86-fold, 3.9-fold, twofold, and 6.1-fold for cases of HMSR, PMHR, low-risk choriocarcinoma, and high-risk carcinoma, respectively. All cases of high-risk choriocarcinoma revealed abnormally high SIL-2R values. There was a significant positive correlation between serum beta-hCG and SIL-2R concentrations.

CONCLUSION

The possible causes of IL-2 decreases and SIL-2R increases may indicate a defective immune response in GTDs. The high correlation between SIL-2R level and tumor burden suggests the use of serum SIL-2R assay for disease monitoring: SIL-2R is indirect marker of tumor activity, and it is useful in the differential diagnosis of GTD because a normal value of serum SIL-2R excludes high-risk cases of choriocarcinoma.

Detection of abnormal intrauterine vascularization by color Doppler imaging: a possible additional aid for the follow up of patients with gestational trophoblastic tumors

Uterine morphology assessed by transvaginal ultrasound and the hemodynamics of intratumoral vessels assessed by color Doppler ultrasound were prospectively correlated with the clinical outcome of 25 patients with trophoblastic tumors. Twenty patients were followed without treatment (observation group) and 16 achieved complete local resolution. The four subjects with local persistence were combined with five patients referred from other institutions and received chemotherapy (treatment group). In the observation group both techniques had 100% accuracy in predicting local resolution or local persistence. Persistence was predicted 1-3 weeks before the increase of beta-human chorionic gonadotropin (beta-hCG) levels, whereas resolution was observed up to 8 weeks before the disappearance of beta-hCG. In one patient normal uterine morphology and vascularization in the presence of elevated hCG levels was associated with extrauterine spread. In the treatment group, normal uterine ultrasound morphology and negative color Doppler results had 100% negative predictive value. False-positive results were observed in two cases. We conclude that ultrasound evidence of abnormal uterine morphology or persistent vascularization on color Doppler examination with persistent hCG levels is indicative of local persistence. Normal uterine morphology with negative color Doppler results may be associated with extrauterine spread.

[Gestational trophoblastic disease. A 6-year experience at the Instituto Nacional de Perinatología]

From January, 1988 to March, 1994, 83 patients with diagnosis of gestational trophoblastic disease, were identified. Incidence was 2.4 per 1000 births. Average age of patients was 28.9 years. Forty four point five per cent of them were multiparae and in 25.3% there was the antecedent of molar pregnancy. Seventy seven point one per cent of the cases are from low socioeconomic stratum. The diagnosis was done by ultrasound in 89.1%. Instrumental uterine curettage was done in 89.1%, with histological confirmation in 100% of the cases. From the 83 cases with molar pregnancy, 74 were classified as complete moles, four, incomplete, four, invasive and one choriocarcinoma. There was follow up in all the patients with beta fraction of chorionic gonadotropin hormone; this was negative in most of the cases for eight weeks after evacuation. Oral contraceptives were indicated in 73.4% of the cases.

Placental site trophoblastic tumor: three case reports and literature review

The clinical features of three patients with placental site trophoblastic tumour (PSTT) are presented. Two patients had probable nephrotic syndrome, which was unrecognized at the time. The nephrotic syndrome disappeared after hysterectomy in one patient and the other demised after one cycle of chemotherapy. The use of hysteroscopy in one patient and the management of a pulmonary metastasis in another are described.