Genetic studies on hydatidiform moles

Recognising gestational trophoblastic disease

Gestational trophoblastic disease (GTD) is a group of interrelated tumours originating from the placenta. Hydatidiform molar (HM) pregnancy is the most common form of GTD; this includes both partial hydatidiform molar (PHM) and complete hydatidiform molar (CHM) pregnancies. The importance of such a condition derives from its potential for persistent trophoblastic disease; this is noted to be more common after a CHM (10-20%) compared to a PHM (0.1-11%). The recent routine use of high-resolution trans-vaginal ultrasound (TVS) in early pregnancy has improved the recognition and thus pre-surgical diagnosis of molar pregnancy. Pre-surgical recognition aids planning of surgery, decreases intra-operative complications and identifies women with potential persistent trophoblastic disease. Despite the introduction of TVS, its performance in preoperative diagnosis is quite poor. This is primarily because of the histomorphometric features of the hydropic villi. A significant proportion of HM cases demonstrates minimal hydropic change in the first trimester and therefore is likely to remain unidentifiable by ultrasound examination prior to surgical evacuation, even with improved sonographer expertise. The overall sensitivity for the ultrasound diagnosis of HM is 50-86%. Ultrasound diagnosis of CHM can be made in approximately 80% of the cases, whilst ultrasound diagnosis of PHM is less accurate and nearly 70% of cases will be missed. Correlation of the ultrasonographic findings with human chorionic gonadotropin levels can further improve the recognition of HM pregnancy pre-surgery. Although ultrasound can be helpful in the diagnosis of molar pregnancies, histological confirmation is mandatory. Histological confirmation post-curettage is still the gold standard for the diagnosis of GTD. In this article, we critically evaluate the role of TVS in the pre-surgical recognition of GTD.

Distribution of the alleles at loci D16S539, D7S820, and D13S317 in hydatidiform mole genome from Chinese women and its relationship with clinical prognosis

Using polymerase chain reaction and denaturating polyacrylamide gel electrophoretic techniques, we studied 53 cases of hydatidiform moles. Of these, 41 cases were genetically complete hydatidiform moles (g-CHM) whose genome were totally paternally derived. We investigated the distribution of the alleles in the short tandem repeat sequences at loci D16S539, D7S820, and D13S317 in these cases. In particular, we analyzed the allelic distribution and potential significance in cases with traceable benign and invasive moles (i.e., persistent trophoblastic tumor [PTT]). Among 41 g-CHM cases, there were six alleles at D16S539, five alleles at D7S820 (the frequencies of alleles 9 and 10 were respectively lower and higher than those in Beijing population), and seven alleles at D13S317; the heterozygosity of loci D16S539, D7S820, and D13S317 was 0.0732, 0.0976, and 0.0732, respectively. Among 23 benign cases, there were six alleles at D16S539, four at D7S820, and six at D13S317; among 11 PTT cases, there were five alleles at D7S820 and four alleles each at D16S539 and D13S317. The frequencies of allele 9 at D16S539 and allele 10 at D7S820 were higher than in benign cases (P < 0.05). There were significant differences in frequencies of alleles 9 and 10 at D7S820 between the cases and the Beijing population, and heterozygosity at the three loci was lower in the cases than in the population. In addition, invasiveness of hydatidiform mole correlated to the frequency of allele 9 at loci D16S539 and allele 10 at D7S820.

Epigenetics and human disease

Epigenetics is comprised of the stable and heritable (or potentially heritable) changes in gene expression that do not entail a change in DNA sequence. The role of epigenetics in the etiology of human disease is increasingly recognized with the most obvious evidence found for genes subject to genomic imprinting. Mutations and epimutations in imprinted genes can give rise to genetic and epigenetic phenotypes, respectively; uniparental disomy and imprinting defects represent epigenetic disease phenotypes. There are also genetic disorders that affect chromatin structure and remodeling. These disorders can affect chromatin in trans or in cis, as well as expression of both imprinted and nonimprinted genes. Data from Angelman and Beckwith-Wiedemann syndromes and other disorders indicate that a monogenic or oligogenic phenotype can be caused by a mixed epigenetic and genetic and mixed de novo and inherited (MEGDI) model. The MEGDI model may apply to some complex disease traits and could explain negative results in genome-wide genetic scans.

Genomic imprinting, uniparental disomy and foetal growth

Genomic imprinting is an epigenetic phenomenon identified in the past 15 years. Thus, maternally imprinted genes are only expressed from the paternal allele and vice versa. The mechanism of imprinting is still far from certain, but most probably it involves differential methylation of specific sites in or near imprinted genes. Disrupted imprinting can lead to phenotypic changes, and an increasing number of resultant clinical disorders are being identified. Many of these conditions involve disordered growth and/or development, particularly prenatal.

The search for the gene for Silver-Russell syndrome

Patients with Silver-Russell syndrome display intrauterine growth restriction and other dysmorphic features. No single genetic cause for this syndrome has been found, although there are a small number of familial cases and some patients with chromosomal rearrangements. Maternal uniparental disomy of chromosome 7 has been found in approximately 7% of patients with Silver-Russell syndrome. In five of these patients exhibiting maternal uniparental disomy, no common regions of isodisomy were found, thereby ruling out the expression of a recessive allele. It is most likely that one or more imprinted genes are responsible for the phenotype of Silver-Russell syndrome. Human chromosome 7 demonstrates homology with two imprinted regions on mouse chromosomes 6 and 11, which are equivalent to human chromosome regions 7q32 and 7p11-p13, respectively. We directly analysed the imprinting status of candidate genes from chromosome 7 that mapped to homologous imprinted regions in the mouse and also had a potential role in growth. The candidates were the genes that encode the epidermal growth factor receptor and the insulin-like growth factor binding proteins-1 and -3. All three of these candidate genes are localized to chromosome region 7p11-p13. Using intragenic polymorphisms as markers, we found that all three genes showed biallelic expression in different fetal tissues. Therefore, it is unlikely that these candidate genes are directly involved in producing the phenotype of Silver-Russell syndrome. Other candidates are under analysis, including two newly identified genes that are known to be imprinted.

Genomic imprinting

In the last few years, the importance of genomic imprinting as a basic biological phenomenon has become clear. Work from different areas has demonstrated that parent-of-origin differences in phenotype occur on a regular basis. This article summarizes some of the recent advances made in this field.

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.

Examination of products of conception terminated after prenatal investigation

A large number of district general hospitals have access to diagnostic ultrasonography and other methods of prenatal diagnosis, resulting in an increased supply of freshly terminated malformed fetuses to general histopathology departments, and there is now more open discussion of malformation and greater concern over fetal wastage. General pathologists are therefore under greater pressure to produce complete and detailed descriptions of a wide range of often complex anomalies. The dismissal of specimens as "multiple congenital anomalies" is becoming increasingly unacceptable to couples who wish to embark on further pregnancies and to their medical attendants. As in other fields an understanding of the methods and terminology in clinical use and a consistent diagnostic approach should help pathologists to extract sufficient information for accurate counselling.