[The follow-up of trophoblastic disease by using an hCG-CTP enzyme immunoassay]

In the management of a chorionic disease, human chorionic gonadotropin (hCG) is the most reliable tumor marker. However, hCG has a low titer, so that it cannot be strictly distinguished from the human luteinizing hormone (hLH) by the traditional method that uses a hemagglutinin reaction (HAR) or by a radioimmunoassay (RIA). Recently, however, the detection of the beta-COOH-terminal peptide of hCG (hCG-CTP) by an enzyme immunoassay has made it possible to clearly distinguish hCG from hLH, and from April, 1987 to December, 1989, 13 trophoblastic diseases have been managed using this new technique. Results have shown that human chorionic gonadotropin-CTP, when compared to other methods of measurement, is the most sensitive tumor marker and as it is the most accurate, it should be used in careful follow-up observations of a chorionic disease.

Gestational trophoblastic disease in a 54-year old woman--a case report

A rare case of gestational trophoblastic disease (GTD) in a 54-year old Malay woman is described. A total abdominal hysterectomy with bilateral salphingo-oopherectomy was done. She was given methotrexate therapy as she had persistent high levels of serum B hCG.

Gestational trophoblastic neoplasia

Gestational trophoblastic neoplasia (GTN) constitutes a spectrum of benign and malignant diseases that are associated with conception. The majority of patients with a benign GTN (hydatidiform mole) spontaneously enter remission after evacuation; however, 15% to 20% will develop a malignant form of GTN. The malignant GTN are classified as nonmetastatic GTN and metastatic GTN. Chemotherapy is the mainstay of treatment for malignant GTN. Patients require continuous emotional support during intense medical therapy because of issues related to the treatment and future pregnancies.

"Poor prognosis" metastatic gestational trophoblastic disease: the prognostic significance of the scoring system in predicting chemotherapy failures

Twenty-eight patients with "poor prognosis" metastatic gestational trophoblastic disease were treated during a 17-year period. The primary treatment was combination chemotherapy with methotrexate, actinomycin D, and chlorambucil (MAC). Patients who failed to respond to this regimen were treated secondarily with other combinations. Adjuvant surgery and radiotherapy were used in selected cases. The overall remission rate was 89% (25 of 28): 71% for first-line treatment with MAC (20 of 28) and 62% for second-line treatment (five of eight). The response rate to MAC correlated well with the patient's score (modified World Health Organization [WHO] scoring system--1983). Seventeen patients treated with MAC had scores less than 12, and all of them achieved remission. Of 11 patients having scores of 12 or more, only three achieved remission with MAC (27%). Of the eight who did not, five achieved remission with other combinations (62%) and three died. No patient died because of chemotherapy toxicity. The WHO scoring system is a good index to select high-risk patients who need primary chemotherapy more aggressive than MAC.

Placental site trophoblastic tumor: immunohistochemical and nuclear DNA study

A rare case of placentae site trophoblastic tumor (PSTT) studied by immunohistochemistry and nuclear DNA analysis is reported. The patient, a 24-year-old Japanese female, complained of amenorrhea. Dilatation and curettage revealed a small specimen that contained trophoblastic cells and caused intractable bleeding. Pelvic sonography revealed a 5-cm mass in the posterior uterine wall with multiple cystic lesions of several sizes. The cystic lesions were shown to be dilated vessels by magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). Serum beta-hCG (beta subunit of human chorionic gonadotropin) was 3.7 ng/ml. Total abdominal hysterectomy revealed a well-circumscribed, yellow, soft mass in the posterior uterine wall. Microscopic findings were consistent with PSTT and the mitotic count was extremely low. Immunohistochemically, most of the tumor cells were intensely stained with human placental lactogen, whereas few were stained with human chorionic gonadotropin. The nuclear DNA content of the trophoblastic cells showed a sharp peak at the triploid range coexistent with a few cells of higher ploidy. This is the first report of sonographic findings and nuclear DNA analysis by spot cytometry in a case of PSTT.

Diagnostic and therapeutic curettage in gestational trophoblastic disease

From June 1976 through June 1989, 37 nonconsecutive patients underwent uterine curettage during the course of their gestational trophoblastic disease. In 22 patients (59%) trophoblastic tissue was obtained. Three (8.1%) patients sustained a uterine perforation during the procedure. In six patients curettage was performed for bleeding. There were six patients curetted during assessment for metastatic trophoblastic disease. Twenty-eight patients underwent curettage for the presumed diagnosis of nonmetastatic gestational trophoblastic disease. In retrospect, four of these women (14.3%) had insufficient criteria for the diagnosis of gestational trophoblastic disease. Of the remaining 23 patients, four (17.4%) went into clinical remission without further treatment. Ten patients (43.5%) had a transitory decline in serum beta-human chorionic gonadotropin levels that subsequently rose or plateaued. Six patients (26.1%) showed no effect from the curettage on their serum beta-human chorionic gonadotropin trend during a short period of observation. Three patients (13.0%) with nonmetastatic gestational trophoblastic disease were not observed for a possible therapeutic effect after curettage. Thus, in only 4/20 (20%) women with nonmetastatic trophoblastic disease was a therapeutic effect from curettage shown.

Gestational trophoblastic disease: what have we learned in the past decade?

Hydatidiform moles can be classified into two distinct entities: complete and partial. Complete moles are androgenetically derived, are characterized by a predominance of the 46,XX karyotype, and are associated with a significantly higher incidence of malignant sequelae than are partial moles. A subset of complete moles resulting from dispermy are heterozygous (46,XY) and appear to be associated with the greatest risk of malignancy. Free subunits of human chorionic gonadotropin, beta core fragments, and acidic variants of human chorionic gonadotropin can now be readily measured by radioimmunoassays, fluoroimmunoassays, or isoelectric focusing techniques. Determination of these markers can be of value not only in monitoring response to therapy, but also as prognostic indicators. A subgroup of patients, traditionally classified as "high risk" or poor prognosis, who show poor responses to conventional combination chemotherapy have recently been designated as "ultra-high-risk" patients. They require more complex chemotherapy and possibly surgery and radiotherapy to achieve remission. The development of chemotherapy over the past decade, including the introduction of etoposide and cisplatin into current protocols and the treatment of patients with advanced gestational trophoblastic disease, are considered in this review.

Efficacy of the metastatic survey in the staging of gestational trophoblastic disease

Between 1965 and 1987, 190 patients with nonmetastatic and 134 patients with metastatic gestational trophoblastic disease (GTD) underwent initial metastatic survey at the Southeastern Regional Trophoblastic Disease Center (Durham, NC). These patients were evaluated for characteristics which might predict the presence of high-risk metastases before a full radiographic survey was obtained. Minimal staging evaluation of all patients included history and examination, quantitative HCG level by beta-subunit radioimmunoassay, chest radiograph, and evaluation for brain and liver metastases with radionuclide or computed tomography (CT) scans. Seventeen patients had high-risk sites of metastases (i.e., those outside lungs, vagina, or pelvis). Characteristics were identified which might predict high-risk metastases: (1) all had metastases in lungs or vagina; (2) 13 of 17 (76%) had at least one other high risk factor (i.e., beta-HCG titer greater than 40,000 mIU/ml, greater than 4 months since onset of symptoms or antecedent term pregnancy; and (3) 15 of 17 (88%) had obvious symptoms or signs related to high-risk metastasis. The authors then evaluated these criteria to identify high-risk metastasis: (1) asymptomatic patients with GTD are screened for therapy with history and physical examination, HCG level, and chest radiograph or CT of the lungs; and (2) further radiographic imaging is used only for patients with signs or symptoms of high-risk metastases, identifiable lung or pelvic metastases, or other high-risk clinical factors. Using this criteria, patients with high-risk metastases were identified with sensitivity of 100% and specificity of 63%. Approximately 60% of patients did not require further radiographic evaluation.

New technique for processing paraffin-embedded tissue for Y chromosome fluorescence identification of trophoblastic disease

A new reprocessing technique for Y chromosome fluorescent body (q 12 region) detection of trophoblastic disease in previously paraffin-embedded tissues is described. Deparaffinized sections were treated with pronase and trypsin for digestion, followed by hydrolysis with HCl and acetic acid, staining with quinacrine hydrochloride fluorochrome and mounting in Sørensen's phosphate buffer (pH 5.5). Use of the technique resulted in sufficient fluorescence quality and better accuracy for Y and X heterochromatin scoring. The technique yielded the same results in retrospective formalin-fixed, paraffin-embedded trophoblastic specimens as in fresh tissues. The combinations of enzymes and acids and the dosages necessary for optimal results are discussed.

A highly sensitive and specific sandwich enzyme immunoassay for detection of human chorionic gonadotropin in trophoblastic disease

A highly sensitive and specific two-site enzyme immunoassay (EIA) kit for human chorionic gonadotropin (hCG) has been examined and applied to the detection of hormones in the serum of normal individuals and patients with trophoblastic disease. This EIA uses a solid phase coupled antibody to the unique COOH terminal peptide region of the hCG beta-subunit (beta-CTP) and an enzyme conjugated monoclonal antibody to the hCG beta-subunit. The overnight 2 step assay measured as little as 0.2 mIU/ml serum without hLH interference and a rapid one step assay was newly developed in our laboratory. Assays of serum from normal men and nonpregnant women of reproductive age indicated that most individuals did not have detectable serum levels of hCG immunoreactivity, although a minority had minute amounts. In contrast, women with non-functional ovaries had detectable levels of hCG immunoreactivity with a mean value of 0.86 mIU/ml serum. The extremely high sensitivity and specificity of the EIA in detecting hCG provides substantial advantages for the detection of early pregnancy and for monitoring trophoblastic tumors.

Gestational trophoblastic tumors

Gestational trophoblastic tumor is a term applied to invasive mole, choriocarcinoma, and placental-site trophoblastic tumor. The overall cure rate in the treatment of these gestational trophoblastic tumors now exceeds 90%. This high success rate is the result of (1) inherent sensitivity of trophoblastic tumors to chemotherapy, (2) ability to monitor therapy effectively with the use of human chorionic gonadotropin as a tumor marker, and (3) identification of prognostic factors which allows categorization of patients into high- and low-risk groups for selection of treatment. Virtually all patients with nonmetastatic and low-risk metastatic disease can be cured using single-agent methotrexate or Actinomycin-D chemotherapy. Intensive therapy with combination chemotherapy including etoposide, high-dose methotrexate and Actinomycin D and, where indicated, adjuvant radiotherapy and surgery has resulted in cure rates of 80-90% in patients with high-risk metastatic disease. The factors which are most important in determining response to treatment are: (1) clinicopathologic diagnosis of choriocarcinoma, (2) metastases to sites other than the lung or vagina, (3) number of metastases, (4) previous failed chemotherapy, and (5) WHO score greater than or equal to 8.

Recurrent trophoblastic neoplasia

An unusual case of recurrent benign trophoblastic growth occurring for the fourth time in a gravida 4, para 0, 30-year-old woman is reported. Prophylactic chemotherapy was instituted to avert the disaster again, without success. The question of her future obstetric outcome poses a formidable dilemma and no radical measures could be undertaken, as the patient hoped for a normal pregnancy.

[Endocrine active genital tumors]

Endocrinically active genital tumors are indeed rare; however, their correct classification and treatment is rather difficult. If ovarian tumors coincide with abnormal hormonal activity, thorough consideration of differential diagnosis is necessary. The WHO has agreed upon a classification of endocrinically active ovarian tumors. This grouping, which is internationally accepted, is the base of the explanations, and to these, remarks about uterine HCG-producing trophoblast diseases are added. Symptomatology of endocrinically active ovarian tumors is nonuniform, depending on the tissular origin of the tumor and the pattern of its endocrine activity. Prognosis is also quite variable. This must be taken into account for therapy. E.g., operative therapy with conservation of fertility is possible--in particular in young women--with granulosa cell tumors or androblastomas; dysgerminomas are strikingly sensitive to irradiation; chorion carcinomas respond well to chemotherapy. More difficult are clear therapeutic recommendations for the very rare forms of endocrinically active genital tumors which stem from sex cords or which are composed of different components of the complex ovarian blastema. In a supplement, the relevant literature (121 quotations) is cited.

[Uterine perforation revealing a rare placental tumor: trophoblastic tumor of the implantation site. Review of the literature. Apropos of a case]

The trophoblastic tumor of the implantation site (TTIS), recently discovered, is a peculiar and rare choriocarcinoma; the authors are reporting the 36th case in the world. Clinically, it is different from the typical choriocarcinoma by amenorrhea, frequent uterine perforations and negative pregnancy tests. The diagnosis is made histologically; most important are the monomorphic tumor cells, and especially, the immunocytochemical labelling for human chorionic gonadotropic hormone and lactogenic placental hormone permitting the differentiation of TTIS in choriocarcinoma from TTIS in non-trophoblastic tumors. Its course is highly malignant in 25 p. cent of the cases without any absolute prognostic factor at this time. The treatment is not codified; it seems that, unlike in the typical choriocarcinoma, a place of choice should be given to surgery, since the usual chemotherapy of trophoblastic tumors has not proved to be effective in this indication. On the contrary, monitoring will be supported by serum hCG assays.

Persistent ectopic syndrome

Persistent ectopic syndrome is a complication of conservative surgery for tubal pregnancy. This study is directed toward the escalating conservatism in the treatment of tubal ectopic pregnancy and its possible sequelae. Residual trophoblast propagation after initial surgery is becoming more frequent. Two cases are reported. The first woman was admitted with an acute abdomen; salpingectomy was performed to control hemorrhage from tubal rupture at the site of the previous salpingostomy. The second woman was treated by fimbrial expression. Because of the recurrence of pain, the beta human chorionic gonadotropin (BHCG) levels were measured; they indicated fresh trophoblastic activity. She was treated with methotrexate orally, 10 mg/d for 5 days. The need for BHCG surveillance of conservatively managed tubal ectopic pregnancy is stressed. The value of using methotrexate when tubal integrity persists is discussed in the light of its traditional role against trophoblastic tumours.

[Therapeutic and preventive care of trophoblastic disease in Czechoslovakia]

The authors list units of trophoblastic disease and its classification used and elaborated in the Centre for trophoblastic disease. The authors submit detailed information on the organization of diagnostic and therapeutic and preventive care of patients with trophoblastic disease in the CSSR. The authors draw attention to the establishment of a Centre for trophoblastic diseases (CTN) with the statute of a reference department. Reasons for its legalization are given. Its function and structure are described.

Hormonal contraception and trophoblastic sequelae after hydatidiform mole (a Gynecologic Oncology Group Study)

A prospective randomized study was undertaken to determine whether the administration of oral contraceptives after the evacuation of a hydatidiform mole affects the human chorionic gonadotropin serum level in a way that leads to an increased frequency in the diagnosis of postmolar trophoblastic disease. Between 1981 and 1988, 266 patients were randomly assigned to either oral contraceptives or barrier contraception after evacuation of a hydatidiform mole. Patients were followed up until serum levels of human chorionic gonadotropin were normal or until specific criteria for the diagnosis of postmolar trophoblastic disease were met. Twenty-three percent of patients receiving oral contraceptives had postmolar trophoblastic disease, whereas those using a barrier method had a rate of 33%. The median time to spontaneous regression in the oral contraceptives group was 9 weeks, whereas the median time to regression in the barrier group was 10 weeks. Twice as many patients in the barrier group became pregnant in the immediate follow-up period. We conclude that oral contraceptives are the preferred method of contraception after evacuation of a hydatidiform mole.

Radioimmunoassay of free beta-subunit of human chorionic gonadotropin in diagnosis of high-risk and low-risk gestational trophoblastic disease

A radioimmunoassay was performed with monoclonal antibody 1E5, which distinguishes free beta-subunit of human chorionic gonadotropin in the presence of intact human chorionic gonadotrophin. Serum samples were obtained from 68 pregnant women, 9 with hydatidiform mole who underwent spontaneous remission, 12 with hydatidiform mole who developed gestational trophoblastic disease, 5 with metastatic gestational trophoblastic disease of high-risk category, and 1 with choriocarcinoma concomitant with pregnancy. The concentrations of free beta-subunit of human chorionic gonadotropin and total beta-subunit were determined on the sera. The assay data were expressed as a ratio of nanograms of free beta-subunit per 1000 mIU of total beta-subunit. The ratios, analyzed by the Wilcoxon two-sample test, indicated a highly significant correlation between high ratios and the eventual diagnosis of high-risk gestational trophoblastic disease (p = 0.0019). This study suggests that the excessive production of free beta-subunit of human chorionic gonadotrophin may identify patients with high-risk gestational trophoblastic disease much earlier and identify gestational trophoblastic disease in patients during pregnancy.

The problematic first-trimester pregnancy

The first-trimester obstetric patient who is experiencing pain or bleeding may have a normal intrauterine pregnancy, a threatened miscarriage, an ectopic pregnancy, a blighted ovum or trophoblastic disease. Correlation of clinical findings, quantitative human chorionic gonadotropin levels and diagnostic ultrasound findings can maximize the efficiency of the work-up, provide a definitive prognosis and identify early ectopic pregnancy.

[Monoclonal antibodies against the beta subunit of human chorionic gonadotropin]

The aim of investigation was creation of hybridomas, which produce monoclonal antibodies to the beta-subunit of human chorionic gonadotropin (beta-hCG), characterization of monoclonal antibodies, which necessary for hCG immunoassay in biological fluids, as an immunological methods of detection of early stage of pregnancy and choriocarcinoma. 4 hybridomas, producing monoclonal antibodies to-hCG of IgG1 isotype, were created. On the base of monoclonal antibodies, which produced by D2 hybridoma cell line, test-systems for RIA of hCG in blood serum and urine were elaborated. These test-systems can be used in medical practice for diagnosis of early stages of pregnancy and choriocarcinoma.

Renal metastases of gestational trophoblastic disease: a report of eight cases

Between 1968-1984, eight women with renal metastases of gestational trophoblastic disease were treated at the Southeastern Regional Trophoblastic Disease Center. Two (1.3%) of 154 patients referred for primary therapy and six (14%) of 42 patients referred for secondary therapy of metastatic gestational trophoblastic disease had renal metastases. All eight had coexistent pulmonary metastases. Four had central nervous system and other systemic metastases. All had high-risk metastatic gestational trophoblastic disease by assessment of individual risk factors and analysis of a prognostic index score. Three women with limited systemic tumor burden are alive after receiving multiagent chemotherapy and nephrectomy.

Metastatic adnexal trophoblastic neoplasm: contribution of MR imaging

We report a case of pathologically proven metastatic trophoblastic neoplasm involving the adnexa which occurred after dilatation and curettage and chemotherapy. Duplex doppler ultrasound demonstrated increased vascularity in the adnexa. Angiography was sensitive but did not decisively distinguish between tumor in the adnexa and arteriovenous fistula in the uterus. In addition to abnormal vascularity, magnetic resonance also showed foci of abnormal signal in the adnexa not seen in the uterus and correctly suggested the presence of tumor.

In vivo release of beta human chorionic gonadotropin by luteinizing hormone releasing hormone stimulation and its clinical application as a remission criterion in patients with gestational trophoblastic disease

In vivo responses of trophoblasts to luteinizing hormone releasing hormone (LHRH) stimulation in 48 gestational trophoblastic disease patients were observed. Serum beta human chorionic gonadotropin (beta-hCG) levels after LHRH injection were significantly increased in patients with hCG values between 5 and 20 mIU/ml (minimal resistance group) but not in patients whose hCG levels were less than 5 mIU/ml (possible remission group). The sensitivity, specificity and the predictive values of LHRH stimulation test were 75.0, 91.3 and 95.5% in the possible remission group and 87.5, 20.0 and 77.8% in the minimal resistance group.

Immunohistochemistry of germ cell and trophoblastic neoplasms

The immunoprofiles of 121 germ cell and trophoblastic neoplasms were defined, using a battery of antibodies against cytokeratin (CK), vimentin (VIM), epithelial membrane antigen (EMA), placental alkaline phosphatase (PLAP), S-100 protein, leukocyte common antigen (LCA), UCHL-1, LN-2, carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), chromogranin A, Leu-7, alpha-fetoprotein (AFP), alpha-1-antitrypsin (AAT), and the beta subunit of human chorionic gonadotropin (BHCG). In addition to 85 neoplasms of testicular origin, the cases included eight ovarian germ cell tumors and 28 extragonadal neoplasms. All tissues had been subjected to formalin fixation and paraffin embedding. Similar immunoreactivity patterns were seen in gonadal and extragonadal neoplasms, gestational and nongestational choriocarcinomas, components of mixed germ cell tumors and their pure counterparts, and metastatic and primary lesions. Placental alkaline phosphatase was a sensitive marker of germ cell differentiation, and expression of this marker in the absence of EMA appeared to be a staining pattern unique to germ cell tumors. Both LCA and S100 were absent in neoplastic germ cells, and thus were useful in differentiating these tumors from malignant lymphoma and malignant melanoma, respectively. Cytokeratin was helpful in distinguishing seminomas/dysgerminomas from nonseminomatous germ cell tumors, although 10% of seminomas showed focal or diffuse cytokeratin reactivity. Finally, 75% of all germ cell neoplasms displayed NSE, calling the specificity of this determinant into question.

Human chorionic gonadotropin assays and their uses

The successful treatment of gestational trophoblastic disease has been partially achieved because of the ability to quantitate serum or urinary concentrations of human chorionic gonadotropin (hCG). Thus, the hCG assay has become essential to the clinical management of trophoblastic disease. This article reviews the various assay methods and discusses their limitations.

Update in cancer chemotherapy: genitourinary tract cancer, Part 7: Gestational trophoblastic neoplasms

Part 7 of an update of the state of the art of cancer chemotherapy of the genitourinary tract is directed to the treatment of gestational trophoblastic neoplasms. Chemotherapy is the cornerstone of treatment for gestational trophoblastic neoplasms, as these tumors are generally highly curable with chemotherapy.In early stage disease, 40 percent of cases are cured with hysterectomy. In low-risk cases, single-agent methotrexate or dactinomycin provides cure rates of over 90 percent. In high-risk disease sequential methotrexate/dactinomycin, methotrexate plus dactinomycin plus cyclophosphamide or chlorambucil, or methotrexate plus 6-mercaptopurine, or a combination protocol consisting of cyclophosphamide, hydroxyurea, dactinomycin, methotrexate, vincristine (VCR), folinic acid, and doxorubicin (CHAMOCA) produce complete remission rates in 70 to 80 percent of patients. Newer studies are under way with etoposide (VP16), cisplatin, and investigational agents to determine whether better chemotherapy regimens can be developed.

Gestational trophoblastic neoplasia: diagnosis with Doppler US

The sonographic appearance of gestational trophoblastic neoplasia is nonspecific and also seen in complete or partial hydatidiform mole, hydropic degeneration, degenerating fibroids, or ovarian dysgerminomas. Correlation with the serum human chorionic gonadotropin (hCG) level may be helpful since levels exceeding 100,000 IU/L are strongly suggestive of gestational trophoblastic neoplasia. However, low hCG levels may also be found in the presence of this disease. The authors studied six patients who were suspected of having gestational trophoblastic neoplasia. Three of the six proved to have incomplete abortions or molar degeneration. Doppler ultrasound (US) was used to record the signal in the uterine arteries of these patients. The signals were compared with those of three nongravid volunteers and three patients in the first trimester of pregnancy. Analysis of the signals in the uterine artery showed higher systolic and diastolic Doppler shifts in gestational trophoblastic neoplasia when compared with postabortal, gravid, and nongravid signals. These preliminary results indicate that Doppler US has the potential to be clinically useful in the diagnosis of gestational trophoblastic neoplasia.

Pros and cons of gynecologic tumor markers

The use of a tumor marker not only depends upon its sensitivity and specificity, but also upon its ability to influence decisions between alternative plans for patient management. Use of beta human chorionic gonadotropin (hCG) for monitoring gestational trophoblastic neoplasia has set the standard to which other assays must be compared. Beta hCG and alphafetoprotein have provided useful markers for ovarian germ cell tumors. Recently, a monoclonal antibody-based immunoassay for CA 125 antigen has been used to monitor the treatment of epithelial ovarian carcinomas. Persistent elevation of CA 125 in serum has generally reflected persistence of disease at second look surveillance procedures. CA 125 levels can, however, return to within normal limits and residual disease can be found at laparoscopy or laparotomy. CA 125 shows promise for distinguishing benign from malignant pelvic masses. Trials are currently underway to evaluate the potential of CA 125 in combination with other markers to facilitate earlier detection of occult ovarian cancer.

[Trophoblastic tumor of placental location or trophoblastic pseudotumor. Apropos of 2 cases. Review of the literature]

Two cases of trophoblastic tumor of placental site are reported, less than 30 such lesions being listed in the published literature. Identification of this tumor from among other trophoblastic lesions is facilitated by immunohistochemical and electron microscopy technics, and demonstration of histoprognostic and biologic criteria improves assessment of evolutory potential of this type of tumor and allows adaptation of therapy. Treatment at the localized stage requires early diagnosis and wide surgical excision, results of chemotherapy in metastatic forms being, inversely than with choriocarcinoma, very deceiving.

Nonmetastatic gestational trophoblastic neoplasia. Controversies in definition and management

The difficulties with the current definition of nonmetastatic gestational trophoblastic neoplasia are discussed in relation to the evaluation of length of time, amount of human chorionic gonadotropin elevation and histologic criteria used to make the diagnosis. Evaluation of the patient is described, and the effect of more-sophisticated methods of investigation on staging and on therapy is placed in perspective. More-effective, less-toxic and more-efficient chemotherapy delivery systems are available today.

Gestational trophoblastic disease and human chorionic gonadotropin measurement

Improved radioimmunometric assays for the glycoprotein human chorionic gonadotropin, its whole molecule and free beta and alpha subunits have improved the capability for trophoblast tumor detection and monitoring. New heights in survival rates have been reached with these improvements, particularly in high-risk disease.

Problems and pitfalls in the histopathologic diagnosis of gestational trophoblastic lesions

Proliferative lesions of gestational trophoblast pose problems of interpretation and pitfalls in differential diagnosis. Normally an actively proliferative and invasive tissue, healthy trophoblast shares cytologic features with malignant neoplasms. When trophoblastic hyperplasia accompanies macroscopic villous swelling, a diagnosis of hydatidiform mole (HM) is in order. Exuberant and atypical avillous trophoblast characterizes choriocarcinoma (CCA) and placental site trophoblastic tumor (PSTT). The distinction between them rests on the dimorphic composition of CCA as contrasted with the relative monomorphism of PSTT. Immunohistochemical studies contribute to the latter differential diagnosis. Unfortunately, two common conditions share morphologic features with the major lesions of gestational trophoblast. The hydropic abortus may resemble HM; the banal implantation site in normal early pregnancy and later spontaneous abortion may suggest either CCA or PSTT. Familiarity with the normal and benign variants of chorionic epithelium and thorough tissue sampling may be helpful in difficult cases. Ambiguous lesions that do not conform to conventional classification should be referred for consultation. A few, however, will not fit neatly into diagnostic categories. In such instances, a descriptive report and clear communication with the patient's physician provide the best current approach to clinical follow-up.

Ultrasonic evaluation of trophoblastic disease and the response to chemotherapy

Ultrasound is an established method of confirming the presence of a hydatidiform mole in utero. However, in agreement with other investigations, we have often noted that the appearance of this entity is less specific than originally reported. To elucidate this, the ultrasonic patterns of 26 patients with trophoblastic disease and 27 with other entities were reviewed. Since there is a paucity of literature with regard to the response of choriocarcinoma to chemotherapy, determined by ultrasound, we simultaneously studied the relationship between findings of the ultrasonograms and the levels of hCG-beta-subunit in sera. We noted variable ultrasonic features in trophoblastic disease, and the sonograms of the choriocarcinoma have occasionally been confused with those of hydatidiform mole. If special attention is directed to the thickness of the placenta-like echoes as well as the sonolucent areas within it, the diagnosis of partial hydatidiform mole may be feasible. We also noted a rough correlation between ultrasonic appearances and the hCG-beta-subunit value, determined during chemotherapy for choriocarcinoma.

Detection of early pregnancy factor-like activity in women with gestational trophoblastic tumors

The presence of immunosuppressive early pregnancy factor (EPF) in the maternal serum has so far been associated with gestation. Its presence in the serum of women with gestational trophoblastic tumors was investigated. The results indicate that while EPF activity was detected in the serum of women with choriocarcinoma, no such activity was detected in the serum of women with hydatidiform mole, leading to the novel use of EPF as a marker to distinguish these two clinical situations. Results of the experiments also suggest that EPF moiety present in the maternal serum during pregnancy may be of different molecular entity than that present in the serum of women with choriocarcinoma.

Inter- and intra-pathologist variability in the diagnosis of gestational trophoblastic neoplasia

All 190 cases of gestational trophoblastic neoplasia diagnosed in the Baltimore metropolitan area from 1975-1982 were identified. Histologic slides were requested and reviewed independently by two pathologists who agreed upon uniform criteria for the diagnosis of hydatidiform (complete) mole, invasive mole, and choriocarcinoma. A representative sample of the slides was selected and resubmitted to one of the study pathologists for a second review. The inter- and intra-pathologist variability in the diagnosis of gestational trophoblastic neoplasia was calculated using the kappa statistic (K). Our findings indicated that the variability in the diagnosis of gestational trophoblastic neoplasia was low whereas that for the related tumor of incomplete mole was high.

Adenocarcinoma of the endometrium with trophoblastic differentiation and metastases as choriocarcinoma: a case report

Nongestational choriocarcinoma is seldom observed outside of gonads or teratomas. No case of choriocarcinoma arising in endometrium is reported in the literature. Here we present a 70-year-old female with endometrial adenocarcinoma focally differentiating to choriocarcinoma, and metastasizing to liver, kidney, brain, and lung as pure choriocarcinoma. Foci of trophoblastic differentiation in the primary endometrial lesion and metastatic lesions are positive for hCG by immunocytochemical stain. This case is similar to gastrointestinal and lung carcinomas that contain trophoblastic change. Possible histogenesis of this tumor is discussed.