Diagnostic reliability of simultaneous measurements of beta human chorionic gonadotropin and pregnancy-specific beta-1-glycoprotein in serum of patients with trophoblastic disease

Serum levels for beta-human chorionic gonadotropin (beta-hCG) and pregnancy-specific beta 1-glycoprotein (SP1) in patients with trophoblastic disease were measured by radioimmunoassay and enzyme-linked immunosorbent assay. The beta-hCG:SP1 ratios were below 1.0 in all 22 cases of complete hydatidiform mole and in 8 of 9 cases of partial hydatidiform mole. Two (10.5%) of 19 cases of invasive mole involving metastasis had ratios that rose above 1.0 during chemotherapy. Ratios ranged from 1.6 to 29 in 11 of 15 cases of choriocarcinoma before chemotherapy. The remaining 4 cases, diagnosed within 3 months of antecedent pregnancy, had ratios below 0.99. Thus, the difference between choriocarcinoma and nonchoriocarcinoma beta-hCG:SP1 ratios may be due to trophoblastic differentiation based on the developmental stage and with trophoblast age, or due to the mass and potential activity of trophoblastic cells.

Emergency serum and urine HCG analyses with the 'Tandem ICON' procedure

A comparison between new urine and serum enzyme immunoassay techniques and existing serum radioimmunoassay techniques for the detection of HCG in the diagnosis of ectopic and early intrauterine pregnancy was undertaken. Urine HCG estimations by enzyme immunoassay were not found to be adequate for the exclusion of ectopic pregnancy due to a false negative rate of 12.5% (2 of 16 patients). Serum HCG estimations by enzyme immunoassay were found to compare favourably with radioimmunoassay techniques in the detection of HCG in both ectopic and early intrauterine pregnancy.

Gestational trophoblastic neoplasm of the uterus: MR assessment

Magnetic resonance (MR) imaging characteristics of uterine gestational trophoblastic neoplasia were prospectively studied in nine women (aged 21-58 years). MR imaging was done at the time of initial clinical diagnosis, after each of the first two cycles of chemotherapy, and 6-9 months after initiation of chemotherapy. Sagittal and transverse MR images of the pelvis were generated with a 0.35-T superconducting magnet and the double spin-echo technique with short and long repetition times (TRs). The neoplasm distorted the MR appearance of uterine zonal structures (myometrium, endometrium, and junctional zone) and demonstrated hypervascular masses of heterogeneous signal intensity. Favorable response to chemotherapy was determined by a decrease in serum beta-subunit human chorionic gonadotropin (HCG) concentrations, and was accompanied by MR findings of regression of vascular abnormalities, development of intralesional hemorrhage, and return of normal appearance of uterine zones. The return of uterine zonal anatomy on MR images antedated definitive decrease in uterine volume. All eight patients imaged 6-9 months after initial imaging showed normal uterine volume and zonal anatomy.

Radioimmunoassay of free beta-subunit of human chorionic gonadotropin as a prognostic test for persistent trophoblastic disease in molar pregnancy

A new radioimmunoassay system was established with a monoclonal antibody (1E5) that distinguishes the free beta-subunit of human chorionic gonadotropin in the presence of intact human chorionic gonadotropin, showing only 0.23% cross-reactivity with the intact human chorionic gonadotropin molecule and virtually no cross-reactivity with other glycoprotein hormones or their beta-subunits. Serum samples, taken at initial diagnosis from nine patients with hydatidiform mole and spontaneous remission and 12 patients with subsequent progression to persistent trophoblastic disease, were assayed for free and total levels of the beta-subunit of human chorionic gonadotropin. The assay results were expressed as a ratio of nanograms of free beta-subunit per 1000 mIU of total beta-subunit. Eight of nine patients with mole and spontaneous remission had a ratio value less than 4 whereas 10 of 12 patients with subsequent persistent disease had a ratio value greater than 4. Statistical analysis with chi 2 showed a highly significant correlation of high ratios with eventual progressive disease (p = 0.0009). This study suggests that excessive production of the free beta-subunit of human chorionic gonadotropin may identify patients with a high likelihood of developing persistent trophoblastic disease.

Non-resolution of pelvic sonographic abnormality after chemotherapy for persistent trophoblastic disease--a word of caution

A case of persistent trophoblastic disease (PTD) is presented in whom pelvic sonography demonstrated persistent uterine abnormality and dilated adnexal vessels after cessation of chemotherapy. Hysterectomy was performed on account of subsequent uterine bleeding. A viable tumour was not demonstrated in the hysterectomy specimen. In the absence of haemorrhagic complications persistent sonographic abnormality should not necessarily indicate hysterectomy, especially when hCG levels are normal.

[Newly developed enzyme immunoassay for hCG-beta CTP and its significance in follow-up practice of trophoblastic disease]

An enzyme immunoassay (EIA) for hCG-beta CTP was newly developed. Anti hCG-beta CTP antibody was prepared from antiserum to the synthetic peptide corresponding to the carboxyl terminal region by immunization of rabbits with hCG-beta subunit. Specimens to be tested were reacted with the antibody labelled with peroxidase and determined with a spectrophotometer after the addition of o-phenylenediamine. It was found that the sensitivity of the assay for hCG in sera was 0.2miu/ml and that values for the assay were significantly correlated with those for the RIA assay for hCG-beta (r = 0.916, Y = 1.27X + 1.8). Cross reactivity with LH, FSH, hCG-beta or hCG-alpha was observed to be 0.18%, 0.05%, 10.4% or less than 0.011% respectively. The assay has been applied in the management of hydatidiform mole, invasive mole and choriocarcinoma, indicating its usefulness because of the increase in sensitivity roughly 25 times or 10 times as great as hemagglutination or hCG-beta RIA assay.

Gestational trophoblastic diseases: the ratio of choriogonadotropin to specific pregnancy protein, hCG/SP1, provides useful diagnostic and prognostic evidence

Serum levels of human chorionic gonadotropin (hCG), specific pregnancy protein (SP1), and hPL were measured in 675 samples from women with uneventful pregnancy, and serially from the time of presentation in 125 patients with hydatidiform mole (HM), 43 with invasive mole (IM), and 34 with choriocarcinoma (CC). In HM serum levels of hCG and SP1 declined steadily from presentation to remission; when gestational age at the time of molar evacuation was shorter than 11 weeks, hCG declined to the normal range later than SP1 (57% patients), and when the age was longer--at the same rate as SP1 (26% patients) or earlier (17% patients). Serum levels of either marker were higher in IM than in HM and tended to increase, and in CC were either lower or higher than in IM. Treatment was followed by parallel decline of either marker, although SP1 declined to the normal range later than hCG in 12% of patients with IM and in 10% with CC. The hCG/SP1 ratios in normal pregnancy declined exponentially between the beginning and 23rd week of gestation and stayed level thereafter. The ratios calculated for the gestational age at the time of initial evacuation of the uterus or delivery were close to those of normal pregnancy in 80%, slightly increased in 20% of patients with spontaneously regressing HM, and markedly increased in 70% of patients with IM and in 74% of patients with CC. The ratios tended to increase during chemotherapy. An increase in the hCG/SP1 ratio seemed to be a characteristic sign of malignant change when compared with this ratio in normal pregnancy and hydatidiform mole. Determination of SP1 for monitoring therapy seemed redundant, and hPL assay was useful for discrimination between relapse and pregnancy.

Gestational trophoblastic neoplasms

Gestational trophoblastic neoplasms have evolved from one of the most rapidly fatal malignancies to potentially one of the most curable, but these diseases have devastating emotional effects on the victims. Etiology, epidemiology, pathophysiology, diagnosis, and medical treatment are reviewed. Numerous nursing implications are discussed using crisis theory. A nursing care plan, based on nursing diagnosis, is outlined with specific nursing actions defined.

Chemotherapy for trophoblastic neoplasms in the Philippines

This paper presents a protocol currently used in the diagnosis and management of trophoblastic disease, amongst participating hospitals within the Greater Manila Area, Philippines. Using the protocol as a general guide, the results of the study of several authors were presented. The commonly used chemotherapeutic agent are methotrexate and actinomycin D depending upon local availability and price affordability. Prophylactic chemotherapy is resorted to, in view of the inconsistent monitoring of the HCG and patients either in danger of being lost to follow-up or actually fail to report for follow up. The results of the studies generally point to the facts that: trophoblastic neoplasms is indeed a problem amongst Filipino women; the success of chemotherapy is dependent upon early diagnosis, availability of a more sensitive HCG monitoring system; a wide selection of available and affordable chemotherapeutic agents and above all faithful patient compliance.

New criteria for the diagnosis of gestational trophoblastic disease

The purpose of the study was to test the hypothesis of whether the combined use of ultrasound and human chorionic gonadotropin (hCG) determinations could increase the diagnostic accuracy of sonography in the diagnosis of hydatidiform mole. The criteria used were the absence of fetal heart movement by ultrasound when the hCG level was above 82,350 mIU/mL and the presence of an hCG level in excess of 2 SD above the mean for the biometrically derived gestational age for suspected partial moles. The threshold of 82,350 mIU/mL was derived by probit analysis of the hCG serum levels of a population of normal intrauterine pregnancies prospectively examined to determine the level of hCG at which fetal heart activity would be visible by sonography. The diagnostic accuracy of these criteria was compared with the preoperative sonographic examination in 36 hydatidiform moles. When sonography was used alone, 15 of 36 cases (41.6%) did not have a definitive diagnosis on the first examination. The combination of hCG and ultrasound would have correctly identified 32 of the 36 cases (88.8%). This improvement was statistically significant (P less than .005).

Placental-site trophoblastic tumor: diagnosis, treatment, and biological behavior

The clinical history of a patient with a placental-site trophoblastic tumor is presented. The diagnostic and therapeutic value of dilatation and curettage, the human chorionic gonadotropin titer, hysteroscopy, laparoscopy, chemotherapy, and hysterectomy is discussed, as well as the possibility of metastatic disease. In this patient there was radiological evidence of pulmonary metastasis with apparent spontaneous regression. A proposal is made to change the name of this disease to gestational trophoblastic neoplasia of low potential malignancy.

Metastatic gestational trophoblastic neoplasm. A study of two cases in unusual clinical settings and review of the literature

Two cases of metastatic gestational trophoblastic neoplasms (MGTN) diagnosed by mediastinoscopic and gastroscopic biopsies, respectively, are presented. Both patients are young women who presented with hemorrhagic events involving the CNS in one case and the gastrointestinal tract in the other, with histories of recent pregnancies. Both cases belong to the group of high-risk MGTN because of the location of the metastatic lesions (CNS and liver) and because of the delayed onset of chemotherapy. One patient is in clinical remission, 3 years later, and the other succumbed to her disease. A review of the literature suggests that CNS involvement has a better prognosis than liver metastases. The patient diagnosed to have MGTN by a gastroscopic biopsy is the first reported, to the best of out knowledge. The outcome of MGTN, although greatly improved by chemotherapy, is still fatal in numerous cases in the high-risk group. Since an early diagnosis is critical for successful chemotherapy, it is advisable to perform HCG titers in the blood serum of young patients presenting with unexplained hemorrhagic events, especially in those with recent gestations.

Treatment of gestational trophoblastic tumors

A brief discussion of the definition, etiology, epidemiology, classification, and prognosis of the gestational trophoblastic tumor (GTT) is presented. Current therapeutic options are summarized. GTTs arise from fetal tissues and can be divided into three histologic categories, hydatidiform mole, chorioadenoma destruens, and choriocarcinoma. Clinically, it is classified as nonmetastatic, metastatic-low risk, or metastatic-high risk. Diagnosis is based on clinical signs and symptoms, ultrasound and X-ray examinations, and the presence of elevated serum levels of the B-subunit of human chorionic gonadotropin (hCG). Primary therapy for hydatidiform mole is evacuation of the uterine contents. Prophylaxis for metastases with actinomycin D sometimes is performed, but generally is not recommended. For persistent disease that is classified as nonmetastatic or low-risk metastatic, a methotrexate-leucovorin rescue protocol is preferred, with actinomycin D used in patients who show resistance to the regimen. Standard therapy for high-risk metastatic disease involves triple agent therapy with methotrexate, actinomycin D, and chlorambucil, but toxicity is significant. Other alternatives include the modified Bagshawe protocol, a VBC (vinblastine, bleomycin, cisplatin) regimen, cisplatin in combination with vincristine and high-dose methotrexate, and VP16-213 (etoposide) in combination with other agents. Other treatment modalities include radiation and surgery. Use of the most appropriate therapies can maximize the survival of a patient with gestational trophoblastic disease.

Familial trophoblastic disease: case report

Presented is a report of familial trophoblastic disease (repeated hydatidiform mole) which is of interest because of the double familial components. The patients were sisters who were married to two brothers.

Plasma methotrexate levels in patients with gestational trophoblastic neoplasia treated by two methotrexate regimens

Plasma methotrexate levels were measured in six patients with nonmetastatic and three patients with "low-risk" metastatic gestational trophoblastic neoplasia who were treated by two different methotrexate regimens. Five patients were treated with 16 cycles consisting of methotrexate, 1 mg/kg (days 1, 3, 5, and 7) followed in 24 hours by citrovorum factor, 0.1 mg/kg (days 2, 4, 6, and 8). Cycles alternated between intravenous and intramuscular administration. Statistical differences in plasma levels were found at 1 and 48 hours between the two routes of administration but probably were not of clinical importance. The plasma levels at the time of citrovorum factor administration were below that necessitating citrovorum factor rescue. Four patients were treated with alternating cycles of intravenous or intramuscular methotrexate, 0.5 mg/kg for 5 consecutive days without citrovorum factor. A total of 15 cycles demonstrated no difference in plasma levels at 1, 12, and 24 hours between intravenous and intramuscular administration. Statistical differences in plasma methotrexate levels were noted between the two methotrexate regimens only with intramuscular administration but were not of clinical importance. The reduced toxicity of the methotrexate-citrovorum factor may be due to the scheduling of the methotrexate and not to the citrovorum factor.

[Role of hysteroscopy in diagnosis and management of trophoblastic disease]

To confirm complete removal of trophoblastic tissues, hysteroscopy was performed in 21 patients after evacuation of hydatidiform mole with an interval of a week. In 15 of these cases, hysteroscopy employed within a week after evacuation of the mole revealed a residue of mole or necrotic decidua. Although complete removal was confirmed in 14 cases on the second hysteroscopy, re-curettage was necessary in 6 patients because necrotic tissues were still found in the uterine cavity. Possible diagnosis of invasive mole was made in 2 cases within 2 weeks after evacuation of the mole by hysteroscopic findings. Hysteroscopy was also performed in 27 patients who were suspected of having a trophoblastic disease from the clinical signs and urinary hCG titer. Hysteroscopic findings which suggested trophoblastic diseases were summarized in the following four categories; 1) the existence of vesicles, 2) buldging or 3) recess of the uterine wall with bleeding or dilated blood vessels and 4) hematoma of the uterine wall. In 9 of the 21 cases with choriocarcinoma, invasive mole or persistent trophoblastic disease, one or two of the above mentioned findings were noted. Moreover, it was possible to differentiate syncytial endometritis from trophoblastic disease from the hysteroscopic findings. Therefore, hysteroscopy seems to be a useful aid not only in confirming complete evacuation of hydatidiform mole but also in the diagnosis and management of malignant sequela.

Choriocarcinoma following term gestation

The current study reviews post-term choriocarcinoma at the New England Trophoblastic Disease Center (NETDC) in order to expand knowledge of its clinical features. Between June 1965 and June 1981, 366 patients with persistent gestational trophoblastic disease were managed at the NETDC and 15 (4.1%) of these patients had choriocarcinoma following term pregnancy. Post-term choriocarcinoma has a propensity for early metastasis with frequent involvement of the liver and brain. Metastases were detected in 13 (86.7%) patients with post-term choriocarcinoma at the time of diagnosis. Seven patients (53.8%) with metastatic post-term choriocarcinoma had hepatic and/or cerebral involvement. Complete remission was achieved in both patients with nonmetastatic disease and in 8 (61.5%) patients with metastatic disease. When the time interval from the antecedent term delivery to diagnosis was less than 4 months, 7 (87.5%) of 8 patients achieved complete remission. The 5 patients who died from post-term choriocarcinoma all had hepatic and/or cerebral involvement. Patients with post-term choriocarcinoma should undergo a meticulous metastatic evaluation and if metastases are detected these patients should be treated with primary combination chemotherapy and with the selective use of irradiation and surgical therapy.

Ten years' experience with trophoblastic tumors in Portugal

Between 1971 and 1980, 220 patients were observed and treated. The patients were classified according to various parameters: age, previous pregnancies, pathology reports of specimens obtained from the uterus, and site of metastasis. The study stressed the possibility of 100% cure in patients with hydatidiform mole, while in choriocarcinoma, late diagnosis was responsible for the failure in effective treatment.

The problems of management of gestational trophoblastic neoplasms at the University of Benin Teaching Hospital, Benin City, Nigeria

Analysis of 31 cases of gestational trophoblastic neoplasms at the University of Benin Teaching Hospital, Benin City, over a 7 1/2 year period (1/1/75 to 6/30/82) was carried out. The incidence of this disease was 1:656 deliveries. Although it was more prevalent in grandmultipara, it occurred in all parities and ages. The main clinical features were secondary amenorrhea, vaginal bleeding, uterine enlargement, and vaginal secondaries. The most common gestational antecedent event of gestational trophoblastic disease was a normal pregnancy. This was believed to have contributed to the high overall mortality of 35.5%. Numerous shortcomings during the management of these cases (inadequate laboratory facilities, shortage of reagents, shortage of drugs) were highlighted.

Monoclonal versus polyclonal antibody radioimmunoassay against the beta-subunit of human chorionic gonadotropin in patients with gestational trophoblastic neoplasia

The level of human chorionic gonadotropin (hCG) in series of sera from eight patients with gestational trophoblastic neoplasia was measured by monoclonal antibody and polyclonal antibody radioimmunoassay. A comparative analysis was performed. Three commercially available monoclonal anti-beta-subunit of hCG (beta-hCG) antibodies were evaluated and the most specific and sensitive one was chosen to develop a quantitative beta-hCG radioimmunoassay. beta-hCG radioimmunoassay kits from Nuclear Medical Systems, Inc., and Clinical Assays served as polyclonal antibody assays. Results obtained with the monoclonal antibody radioimmunoassays demonstrated a high degree of correlation (r greater than 0.95, p less than 0.01) with those obtained by the polyclonal antibody techniques; however, the sera from one patient continuously demonstrated a low level of hCG in the monoclonal antibody radioimmunoassay while registering undetectable levels in the polyclonal antibody assays. Although the monoclonal antibody radioimmunoassay appears to be specific and fairly sensitive, the results indicate that, with current technology, there is no special advantage to employing this assay to measure hCG in patients with gestational trophoblastic neoplasia.

Theca lutein ovarian cyst may be pathognomonic for trophoblastic neoplasia

Two cases are presented in which theca lutein tissue was found at the time of indicated pelvic surgery performed long after treatment for hydatidiform mole. This indicator for the presence of trophoblastic tissue was not recognized, and clinical metastatic gestational trophoblastic neoplasia subsequently developed in each patient. Theca lutein tissue found at pelvic surgery merits investigation by beta-human chorionic gonadotropin radioimmunoassay and is likely to be associated with subclinical latent trophoblastic neoplasia.

Urinary nucleic acid breakdown products as markers for trophoblastic diseases

A feasibility study on the use of urinary nucleoside markers for the management of trophoblastic disease is presented. The markers return to normal rapidly after effective therapy, whereas the human chorionic gonadotropin levels remain elevated longer before reaching normal. If this finding is valid in a larger number of patients, it may spare patients with trophoblastic disease needless continuation of chemotherapy.

Pelvic ultrasonography and the management of gestational trophoblastic disease

Pelvic ultrasonography was performed in 33 patients with persistent gestational trophoblastic disease (GTD) and the sonographic findings were compared in all patients with laparoscopic findings and histologic material from endometrial curettage and/or hysterectomy. Ultrasonography indicated trophoblastic uterine involvement in 17 patients (51.5%) and the ultrasound interpretation was histologically confirmed in all 17 patients by endometrial curettage and/or hysterectomy. Among the 16 patients in whom the uterus appeared normal by ultrasound, endometrial curettings demonstrated scanty fragments of trophoblastic tumor in 6 patients (37.5%). Furthermore, in all 16 patients in whom the uterus appeared normal by ultrasound, laparoscopy also revealed no uterine abnormalities. Ultrasonography appears to be accurate in detecting extensive trophoblastic uterine involvement and helpful in identifying resistant uterine foci. Pelvic ultrasonography should be an integral part of the pretreatment assessment of patients with persistent GTD.

Disease of the trophoblast

Molar pregnancy should always be considered as a possible diagnosis in any pregnancy that does not conform to the normal. The practice of subjecting all pregnant women to ultrasound B-scan at their first visit in some centres is commendable, but unfortunately not possible in the areas of high incidence, owing to lack of facilities. Close, regular and meticulous follow-up with facilities for radio-immunoassay of HCG is a necessity after a mole has been treated. Early detection of lesions and individualized treatment of patients, with close monitoring of progress, are essential. Where necessary, enlightened use of drugs with adjuvant surgery and occasionally radiotherapy will give the optimum chance of recovery. To achieve complete eradication of the tumour, treatment may be required even after the HCG test appears to be negative.