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Braga A, Paiva G, Barcellos M, Elias KM, Horowitz NS, Berkowitz RS. Diagnosis and Management of Molar Pregnancies. Hematol Oncol Clin North Am 2024:S0889-8588(24)00078-9. [PMID: 39242292 DOI: 10.1016/j.hoc.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2024]
Abstract
Complete and partial molar pregnancies arise from abnormal fertilization with marked proliferation of syncytiotrophoblasts. Earlier diagnosis has reduced the frequency of severe medical complications at presentation; however, the risk of progression to gestational trophoblastic neoplasia (GTN) has remained unchanged. Initial assessment should include serum hCG measurement after physical examination, laboratory testing for organ dysfunction, and Doppler ultrasound. Following uterine evacuation, pathologic assessment can distinguish complete from partial moles or non-molar gestations. Close surveillance is essential for the timely diagnosis of GTN. Cure rates and subsequent obstetrics outcomes are excellent, but all patients should be referred for psychologic support and expert level care.
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Affiliation(s)
- Antonio Braga
- Faculty of Medicine, Postgraduate Program in Medical Sciences, Fluminense Federal University, Rua Ataíde Parreiras, 100, Bairro de Fátima, Niterói, RJ 24070-090, Brazil; Department of Obstetrics and Gynecology, Rio de Janeiro Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University, Rua Laranjeiras, 180, Laranjeiras, Rio de Janeiro, RJ 22240-003, Brazil; Postgraduate Program in Applied Health Sciences, Vassouras University, Av. Expedicionário Osvaldo de Almeida Ramos, 250, Bloco 03, 2 andar, Centro, Vassouras, RJ 27700-000, Brazil.
| | - Gabriela Paiva
- Faculty of Medicine, Postgraduate Program in Medical Sciences, Fluminense Federal University, Rua Ataíde Parreiras, 100, Bairro de Fátima, Niterói, RJ 24070-090, Brazil
| | - Marcio Barcellos
- Faculty of Medicine, Postgraduate Program in Medical Sciences, Fluminense Federal University, Rua Ataíde Parreiras, 100, Bairro de Fátima, Niterói, RJ 24070-090, Brazil
| | - Kevin M Elias
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Neil S Horowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Ross S Berkowitz
- New England Trophoblastic Disease Center, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Vo TM, Hoang TT, Tran HM, Nyamakope K. Gestational Trophoblastic Neoplasia Rate and Its Related Factors in Women With a Partial Hydatidiform Mole at Tudu Hospital, Vietnam. Cureus 2024; 16:e67495. [PMID: 39310541 PMCID: PMC11416125 DOI: 10.7759/cureus.67495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2024] [Indexed: 09/25/2024] Open
Abstract
Background Minimal studies have been carried out on a partial hydatidiform mole (PHM) in Vietnam, so the treatment outcomes for patients with PHM are unknown. This study aimed to determine the occurrence rate of gestational trophoblastic neoplasia (GTN) and its related factors in women with PHM at Tu Du Hospital, Vietnam. Materials and methods This retrospective cohort study included 370 women with PHM diagnosed through a histopathological assessment following termination of pregnancy at Tu Du Hospital from January 2020 to December 2021. Survival analysis was used for GTN cumulative rate estimation and the Cox regression model for determining GTN-related factors. Results After a 1-year follow-up, 21 patients were found to have GTN, exhibiting a rate of 5.7% (95% confidence interval (CI): 3.5 - 8.4). GTN occurred 4.67±2.23 weeks following curettage with peaks at weeks 3-6. No cases of GTN were recorded eight weeks following termination by curettage. After multivariate analysis, the GTN rate was higher in patients with a history of miscarriage/termination (hazard ratio (HR)=2.84; 95% CI: 1.05-7.69). Conclusion The rate of GTN in PHM patients was 5.7%. Patients who had a history of miscarriage or termination were 2.84 times more likely to develop GTN than patients who did not.
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Affiliation(s)
- Tuan M Vo
- Obstetrics and Gynaecology (OB-GYN), University of Medicine and Pharmacy at HCMC (Ho Chi Minh City), Ho Chi Minh, VNM
| | - Tuyet T Hoang
- Obstetrics and Gynaecology (OB-GYN), University of Medicine and Pharmacy at HCMC (Ho Chi Minh City), Ho Chi Minh, VNM
| | - Hoang M Tran
- Diagnostic Radiology, University of Medicine and Pharmacy at HCMC (Ho Chi Minh City), Ho Chi Minh City, VNM
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Nagy A, Niu N, Sun T, Buza N, Hui P. Diandric triploid partial mole versus digynic nonmolar triploidy: is morphological assessment sufficient for the diagnostic distinction? Histopathology 2024. [PMID: 39031756 DOI: 10.1111/his.15247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 07/22/2024]
Abstract
AIMS Diagnostic separation of diandric triploid gestation, i.e. partial mole from digynic triploid gestation, is clinically relevant, as the former may progress to postmolar gestational trophoblastic neoplasia. The aim of the study was to investigate if the combination of abnormal histology combined with ploidy analysis-based triploidy is sufficient to accurately diagnose partial mole. METHODS AND RESULTS A genotype-phenotype correlation study was undertaken to reappraise histological parameters among 20 diandric triploid gestations and 22 digynic triploid gestations of comparable patient age, gestational weeks, and clinical presentations. Two villous populations, irregular villous contours, pseudoinclusions, and syncytiotrophoblast knuckles, were common in both groups. Villous size ≥2.5 mm, cistern formation, trophoblastic hyperplasia, and syncytiotrophoblast lacunae were significantly more common in the partial hydatidiform mole. Cistern formation had the highest positive predictive value (PPV) (93%) and highest specificity (96%) for diandric triploid gestation, although the sensitivity was 70%. Cistern formation combined with villous size ≥2.5 mm or trophoblast hyperplasia or syncytiotrophoblast lacunae had 100% specificity and PPV, but a marginal sensitivity of 60%-65%. A moderate interobserver agreement (Kappa = 0.57, Gwet's AC1 = 0.59) was achieved among four observers who assigned diagnosis of diandric triploid gestation or digynic triploidy solely based on histology. CONCLUSIONS None of histological parameters are unique to either diandric triploid gestation or digynic triploid gestation. Cistern formation is the most powerful discriminator, with 93% PPV and 70% sensitivity for diandric triploid gestation. While cistern formation combined with either trophoblastic hyperplasia or villous size ≥2.5 mm or syncytiotrophoblast lacunae has 100% PPV and specificity for diandric triploid gestation, the sensitivity is only 60% to 65%. Therefore, in the presence of triploidy, histological assessment is unable to precisely classify 35% to 40% of diandric triploid gestations or partial moles.
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Affiliation(s)
- Agnes Nagy
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Na Niu
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Center for the Precision Medicine of Trophoblastic Disease, Yale School of Medicine, New Haven, CT, USA
| | - Tong Sun
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Natalia Buza
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Center for the Precision Medicine of Trophoblastic Disease, Yale School of Medicine, New Haven, CT, USA
| | - Pei Hui
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Center for the Precision Medicine of Trophoblastic Disease, Yale School of Medicine, New Haven, CT, USA
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Aiob A, Gumin D, Zilberfarb I, Naskovica K, Sgayer I, Mikhail SM, Sharon A, Lowenstein L. Ethnic disparities in complete and partial molar pregnancy incidence: a retrospective analysis of arab and jewish women in single medical center. BMC Public Health 2024; 24:1440. [PMID: 38811887 PMCID: PMC11138058 DOI: 10.1186/s12889-024-18276-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/05/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Molar pregnancies, encompassing complete and partial moles, represent a rare and enigmatic gestational disorder with potential ethnic variations in incidence. This study aimed to investigate relations of ethnicity with risks of complete and partial molar pregnancies within an Israeli population while accounting for age differences. METHODS A retrospective study was conducted of data recorded during 2007-2021 in an academic medical center in Israel. The study population comprised 167 women diagnosed with complete or partial moles, for whom data were obtained through histological examination and P57 immunostaining. Maternal age and ethnicity were extracted from electronic medical records. Incidence rates were calculated per 10,000 live births, and a nested case-control study compared demographic characteristics and molar pregnancy incidences between Arab and Jewish women. Statistical analyses included age-adjusted comparisons, relative risk calculations and multivariate logistic regression. RESULTS The overall risk of molar pregnancy was 22 per 10,000 live births (95% confidence interval [CI] 18-25). Among Arab women, the overall risk was 21 (95% CI 17-25), and for PM and CM: 14 (95% CI 11-17) and 7 (95% CI 5-10), respectively. Among Jewish women, the overall risk was 23 (95% CI 18-29), and for PM and CM: 12 (95% CI 8-17) and 11 (95% CI 7-16), respectively. Among Arab women compared to Jewish women, the proportion of all the partial moles was higher: (65.3% vs. 51.6%, p = 0.05). The incidence of partial mole was higher among Arab than Jewish women, aged 35-39 years (26 vs. 8 per 10,000, p = 0.041), and did not differ in other age groups. After adjusting for age, the relative risk of partial moles was lower among Jews than Arabs (0.7, 95% CI 0.4-1.0, p = 0.053). For Arab compared to Jewish women, the mean age at molar pregnancies was younger: 31.0 vs. 35.1 years. However, other factors did not differ significantly between Arab and Jewish women with molar pregnancies. In multivariate analysis, Jewish ethnicity was significantly associated with a higher risk of complete molar pregnancies (OR = 2.19, 95% CI 1.09-4.41, p = 0.028). CONCLUSION This study highlights ethnic differences in molar pregnancy risk within the Israeli population. Jewish ethnicity was associated with a higher risk of complete molar pregnancies, while Arab women had a significantly higher risk of partial moles. These findings underscore the need to consider ethnicity when studying gestational disorders. Further research should seek to elucidate the underlying factors contributing to these differences.
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Affiliation(s)
- Ala Aiob
- Department of Obstetrics and Gynecology, Galilee Medical Center, POB 21, 22100, Nahariya, Israel.
- Department of Obstetrics and Gynecology, Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel.
| | - Dina Gumin
- Department of Obstetrics and Gynecology, Galilee Medical Center, POB 21, 22100, Nahariya, Israel
| | - Inna Zilberfarb
- Department of Obstetrics and Gynecology, Galilee Medical Center, POB 21, 22100, Nahariya, Israel
| | - Karina Naskovica
- Department of Obstetrics and Gynecology, Galilee Medical Center, POB 21, 22100, Nahariya, Israel
| | - Inshirah Sgayer
- Department of Obstetrics and Gynecology, Galilee Medical Center, POB 21, 22100, Nahariya, Israel
- Department of Obstetrics and Gynecology, Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Susana Mustafa Mikhail
- Department of Obstetrics and Gynecology, Galilee Medical Center, POB 21, 22100, Nahariya, Israel
- Department of Obstetrics and Gynecology, Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Avishalom Sharon
- Department of Obstetrics and Gynecology, Galilee Medical Center, POB 21, 22100, Nahariya, Israel
- Department of Obstetrics and Gynecology, Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Lior Lowenstein
- Department of Obstetrics and Gynecology, Galilee Medical Center, POB 21, 22100, Nahariya, Israel
- Department of Obstetrics and Gynecology, Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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Zhao Y, Cai L, Zhang X, Zhang H, Cai L, Zhou L, Huang B, Qian J. Hematoxylin and Eosin Staining Helps Reduce Maternal Contamination in Short Tandem Repeat Genotyping for Hydatidiform Mole Diagnosis. Int J Gynecol Pathol 2024; 43:253-263. [PMID: 37566880 PMCID: PMC11022989 DOI: 10.1097/pgp.0000000000000973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
Short tandem repeat (STR) genotyping provides parental origin information about aneuploidy pregnancy loss and has become the current gold standard for hydatidiform mole diagnosis. STR genotyping diagnostic support most commonly relies on formalin-fixed paraffin-embedded samples, but maternal contamination is one of the most common issues based on traditional unstained sections. To evaluate the influence of hematoxylin and eosin (H&E) staining on DNA quality and STR genotyping, DNA was isolated from unstained, deparaffinized hydrated, and H&E-stained tissue sections (i.e. 3 groups) from each of 6 formalin-fixed paraffin-embedded placentas. The macrodissected view field, DNA quality, and polymerase chain reaction amplification efficiency were compared among groups. STR genotyping analysis was performed in both the test cohort (n = 6) and the validation cohort (n = 149). H&E staining not only did not interfere with molecular DNA testing of formalin-fixed paraffin-embedded tissue but also had a clearer macrodissected field of vision. In the test cohort, H&E-stained sections were the only group that did not exhibit maternal miscellaneous peaks in STR genotyping results. In the validation cohort, 138 (92.62%) cases yielded satisfactory amplification results without maternal contamination. Thus, H&E staining helped to reduce maternal contamination in STR genotyping for hydatidiform mole diagnosis, suggesting that H&E-stained sections can be incorporated into the hydatidiform mole molecular diagnostic workflow.
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Shivarajpur A, Kohen B. Vaginal Bleeding in a Peri-Menopausal Woman. POCUS JOURNAL 2024; 9:9-10. [PMID: 38681151 PMCID: PMC11044943 DOI: 10.24908/pocus.v9i1.16621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Point of care ultrasound (POCUS) is a useful modality to initially identify a molar pregnancy. In this case, we describe a 51-year-old perimenopausal woman who presented to the emergency department (ED) with vaginal bleeding. A transvaginal POCUS was performed, revealing findings concerning for a molar pregnancy. These findings led to prompt diagnosis and treatment.
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Affiliation(s)
- Ambika Shivarajpur
- Department of Emergency Medicine, Memorial Hospital WestPembroke Pines, FLUSA
| | - Brian Kohen
- Department of Emergency Medicine, Memorial Hospital WestPembroke Pines, FLUSA
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Ng JS, Ilancheran A. The role of surgery in gestational trophoblastic disease: an overview. Int J Gynecol Cancer 2024; 34:409-415. [PMID: 38438170 DOI: 10.1136/ijgc-2023-004584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Gestational trophoblastic disease comprises a group of rare, and potentially malignant, conditions that arise from abnormal trophoblastic proliferation. When there is invasion and evidence of metastatic disease, gestational trophoblastic neoplasia is used. While chemotherapy is the mainstay of treatment for gestational trophoblastic neoplasia, the role of surgery has come full circle in recent years. Before the introduction of highly effective systemic treatment options, surgery was the default treatment. Surgery for gestational trophoblastic neoplasia often yielded unsatisfactory results and mortality remained high. In recent years, the role of adjuvant surgery in the management of gestational trophoblastic neoplasia has been examined with great interest. We aim to provide an overview of the various surgical approaches employed in managing gestational trophoblastic neoplasia, including their indications, techniques, and outcomes. Additionally, we discuss whether there is a role to do less in surgery for gestational trophoblastic neoplasia and describe our experience with a modified surgical technique for its treatment. By summarizing the current evidence, this article highlights the significant contributions of surgery to the holistic management of patients with gestational trophoblastic neoplasia and provides a framework on which to base management and treatment programs.
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Affiliation(s)
- Joseph S Ng
- Department of Obstetrics and Gynecology, National University of Singapore, Singapore
- Gynecologic Cancer Program, National University Cancer Institute, Singapore
| | - Arunachalam Ilancheran
- Department of Obstetrics and Gynecology, National University of Singapore, Singapore
- Gynecologic Cancer Program, National University Cancer Institute, Singapore
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Wang T, Guo W, Ren X, Lang F, Ma Y, Qiu C, Jiang J. Progress of immunotherapies in gestational trophoblastic neoplasms. J Cancer Res Clin Oncol 2023; 149:15275-15285. [PMID: 37594534 DOI: 10.1007/s00432-023-05010-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/18/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Different from other malignant gynecologic tumors, gestational trophoblastic neoplasms (GTNs) exhibit an exceptionally high cure rate primarily through chemotherapeutic interventions. However, there exists a small subset of refractory GTNs that do not respond to conventional chemotherapies. In such cases, the emergence of immunotherapies has demonstrated significant benefits in managing various challenging GTNs. PURPOSE This article aims to provide a comprehensive and systematic review of the immune microenvironment and immunotherapeutic approaches for GTNs. The purpose is to identify potential biomarkers that could enhance disease management and summarize the available immunotherapies for ease of reference. METHODS We reviewed the relevant literatures toward immunotherapies of GTNs from PubMed. CONCLUSION Current immunotherapeutic strategies for GTNs mainly revolve around immune checkpoint inhibitors (ICIs) targeting programmed death receptor 1 (PD-1) and programmed cell death ligand 1 (PD-L1). Prominent examples include avelumab, pembrolizumab, and camrelizumab. However, existing researches into the underlying mechanisms are still limited.
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Affiliation(s)
- Tong Wang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhua Xi Road, Jinan, 250012, Shandong, People's Republic of China
| | - Wenxiu Guo
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, People's Republic of China
| | - Xiaochen Ren
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhua Xi Road, Jinan, 250012, Shandong, People's Republic of China
| | - Fangfang Lang
- Maternal and Child Health Hospital of Shandong Province, Jinan, Shandong, People's Republic of China
| | - Ying Ma
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhua Xi Road, Jinan, 250012, Shandong, People's Republic of China
| | - Chunping Qiu
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhua Xi Road, Jinan, 250012, Shandong, People's Republic of China.
| | - Jie Jiang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhua Xi Road, Jinan, 250012, Shandong, People's Republic of China.
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Coopmans L, Larsson A, Joneborg U, Lok C, van Trommel N. Surgical Management of Gestational Trophoblastic Disease. Gynecol Obstet Invest 2023; 89:214-229. [PMID: 37788661 DOI: 10.1159/000534065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 09/04/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Gestational trophoblastic disease (GTD) is a rare pregnancy-related condition consisting of premalignant and malignant forms arising from proliferation of trophoblastic cells. The malignant forms are collectively referred to as gestational trophoblastic neoplasia (GTN) and are highly sensitive to chemotherapy. However, surgical procedures remain indispensable in the diagnosis and treatment of GTD. OBJECTIVES The aim of this review was to summarize surgical interventions in the treatment of GTD and GTN. We reviewed indications, efficacy, possible complications, and oncological outcomes of surgery. METHODS Three searches were performed in the databases of PubMed, Embase, and the Cochrane Library to create an up-to-date overview of existing literature on the following subjects: (1) the role of primary hysterectomy in GTD and GTN; (2) the role of second curettage in GTD and GTN; (3) fertility sparing surgery in GTN; (4) surgical management of metastases. Included articles originated from the time period 1952-2022. Articles written in English, Spanish, and French were included. OUTCOMES Thirty-eight articles were found and selected. Surgical evacuation through suction curettage is most used and advised in the treatment of GTD. A second curettage could be beneficial in patients with low hCG levels and low FIGO scores. In women who have completed their families, primary hysterectomy might be considered as the risk of subsequent GTN is lower than after suction curettage. In case of the rare forms of GTN (epithelioid trophoblastic tumor or placental site trophoblastic tumor) surgical tumor resection remains the most important step in treatment. Data on fertility sparing surgery in GTN are scarce and this treatment should be considered experimental. CONCLUSION AND OUTLOOK Surgery remains an important part of treatment of GTD and is sometimes indispensable to achieve curation. Further collection of evidence is needed to determine treatment steps.
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Affiliation(s)
- Leonoor Coopmans
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands,
| | - Agnes Larsson
- Department of Gynecologic Cancer Surgery, Karolinska University Hospital and Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Ulrika Joneborg
- Department of Gynecologic Cancer Surgery, Karolinska University Hospital and Department of Women's and Children's Health Karolinska Institutet, Stockholm, Sweden
| | - Christianne Lok
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nienke van Trommel
- Gynecological Oncology, Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Banwarth-Kuhn B, McQuade M, Krashin JW. Vaginal Bleeding Before 20 Weeks Gestation. Obstet Gynecol Clin North Am 2023; 50:473-492. [PMID: 37500211 DOI: 10.1016/j.ogc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Conditions that often present with vaginal bleeding before 20 weeks are common and can cause morbidity and mortality. Clinically stable patients can choose their management options. Clinically unstable patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy. Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids. Available data on prognosis with expectant management of pre-viable rupture of membranes in the United States are poor for mothers and fetuses.
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Affiliation(s)
| | | | - Jamie W Krashin
- Department of Obstetrics & Gynecology, University of New Mexico Health Sciences Center, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
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Vaill M, Kawanishi K, Varki N, Gagneux P, Varki A. Comparative physiological anthropogeny: exploring molecular underpinnings of distinctly human phenotypes. Physiol Rev 2023; 103:2171-2229. [PMID: 36603157 PMCID: PMC10151058 DOI: 10.1152/physrev.00040.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/26/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023] Open
Abstract
Anthropogeny is a classic term encompassing transdisciplinary investigations of the origins of the human species. Comparative anthropogeny is a systematic comparison of humans and other living nonhuman hominids (so-called "great apes"), aiming to identify distinctly human features in health and disease, with the overall goal of explaining human origins. We begin with a historical perspective, briefly describing how the field progressed from the earliest evolutionary insights to the current emphasis on in-depth molecular and genomic investigations of "human-specific" biology and an increased appreciation for cultural impacts on human biology. While many such genetic differences between humans and other hominids have been revealed over the last two decades, this information remains insufficient to explain the most distinctive phenotypic traits distinguishing humans from other living hominids. Here we undertake a complementary approach of "comparative physiological anthropogeny," along the lines of the preclinical medical curriculum, i.e., beginning with anatomy and considering each physiological system and in each case considering genetic and molecular components that are relevant. What is ultimately needed is a systematic comparative approach at all levels from molecular to physiological to sociocultural, building networks of related information, drawing inferences, and generating testable hypotheses. The concluding section will touch on distinctive considerations in the study of human evolution, including the importance of gene-culture interactions.
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Affiliation(s)
- Michael Vaill
- Center for Academic Research and Training in Anthropogeny, University of California, San Diego, La Jolla, California
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, California
- Glycobiology Research and Training Center, University of California, San Diego, La Jolla, California
| | - Kunio Kawanishi
- Center for Academic Research and Training in Anthropogeny, University of California, San Diego, La Jolla, California
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, California
- Department of Experimental Pathology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Nissi Varki
- Center for Academic Research and Training in Anthropogeny, University of California, San Diego, La Jolla, California
- Glycobiology Research and Training Center, University of California, San Diego, La Jolla, California
- Department of Pathology, University of California, San Diego, La Jolla, California
| | - Pascal Gagneux
- Center for Academic Research and Training in Anthropogeny, University of California, San Diego, La Jolla, California
- Glycobiology Research and Training Center, University of California, San Diego, La Jolla, California
- Department of Pathology, University of California, San Diego, La Jolla, California
| | - Ajit Varki
- Center for Academic Research and Training in Anthropogeny, University of California, San Diego, La Jolla, California
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, California
- Glycobiology Research and Training Center, University of California, San Diego, La Jolla, California
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Nguyen BQ, Vo TM, Phan VTT, Nguyen C, Vu H, Vo B. Clinical Features of Gestational Trophoblastic Disease in Aged Women in South Vietnam. Yonsei Med J 2023; 64:284-290. [PMID: 36996900 PMCID: PMC10067792 DOI: 10.3349/ymj.2022.0241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 02/12/2023] [Accepted: 02/20/2023] [Indexed: 04/01/2023] Open
Abstract
PURPOSE This study aimed to determine the occurrence rate of gestational trophoblastic neoplasia (GTN) and its related factors in aged women with hydatidiform mole (HM) in Tu Du Hospital, Vietnam. MATERIALS AND METHODS This retrospective cohort study included 372 women aged ≥40 years with HM diagnosed through post-abortion histopathological assessment in Tu Du Hospital from January 2016 to March 2019. Survival analysis was used for GTN cumulative rate estimation, log-rank test for group comparison, and Cox regression model for determining GTN-related factors. RESULTS After a 2-year follow-up, 123 patients were found to have GTN at a rate of 33.06% [95% confidence interval (CI): 28.30-38.10]. GTN occurrence meant that the time was 4.15±2.93 weeks with peaks at week 2 and 3 after curettage abortion. The GTN rate was remarkably higher in the ≥46-year age group than in the 40-to-45-year age group [hazard ratio (HR)=1.63; 95%CI: 1.09-2.44], as was the vaginal bleeding group compared to the non-bleeding group (HR=1.85; 95%CI: 1.16-2.96). Preventive hysterectomy and preventive chemotherapy plus hysterectomy in the intervention group reduced the GTN risk compared to the no intervention group at HRs of 0.16 (95%CI: 0.09-0.30) and 0.09 (95%CI: 0.04-0.21), respectively. Chemoprophylaxis failed to decrease the GTN risk when comparing the two groups. CONCLUSION Post-molar pregnancy GTN rate in aged patients was 33.06%, much higher than that of the general population. Preventive hysterectomy or chemoprophylaxis plus hysterectomy are effective treatment methods to support GTN risk reduction.
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Affiliation(s)
- Bac Quang Nguyen
- Department of Gynecology, National Hospital of Obstetrics and Gynecology, Hanoi, Vietnam
| | - Tuan Minh Vo
- Department of Gynecologic-Oncology, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam.
| | - Van Thi Thuy Phan
- Department of Gynecologic-Oncology, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Christopher Nguyen
- Department of Gynecologic-Oncology, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Hoang Vu
- Department of Orthodontics, Pham Ngoc Thach University of Medicine at Ho Chi Minh City, Vietnam
| | - Brian Vo
- Department of Biomedical Science, University of Missouri, Kansas City, MO, USA
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13
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Rakprasit C, Ruengkhachorn I, Therasakvichya S, Inthasorn P, Achariyapota V, Kuljarasnont S, Khemworapong K, Jareemit N. Combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios for early prediction of postmolar gestational trophoblastic neoplasia. Arch Gynecol Obstet 2023; 307:1145-1154. [PMID: 36116082 DOI: 10.1007/s00404-022-06785-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/04/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To investigate factors predicting postmolar gestational trophoblastic neoplasia (GTN) by combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios. METHODS This retrospective study enrolled patients with histopathologically proven molar pregnancy. Patients lost to follow-up before remission or developing postmolar GTN were excluded. Demographic and clinical characteristics and hCG data obtained before and after molar evacuation were collected. Area under the receiver operating characteristic curve (AUC) analysis was used to identify the hCG and hCG ratio cutoff values that predict postmolar GTN. Multivariate analysis was employed to identify independent predictors of GTN. RESULTS There were 113 complete moles, 11 partial moles, and 52 unspecified moles included in the final analysis. Of the 176 cases, 90 achieved remission and 86 developed post-molar GTN. The incidence of postmolar GTN was 48.9%, with a median time to GTN development of 5 weeks. Univariate analysis showed age, molar evacuation performed elsewhere, pre-evacuation hCG, hCG at 2nd week post-evacuation, and ratio of hCG at 2nd week post-evacuation to post-evacuation hCG significantly predict GTN. Multivariate analysis revealed an hCG value ≥ 1400 IU/L at 2nd week post-evacuation (AUC: 0.92, aOR: 6.51, 95% CI 1.28-33.16; p = 0.024) and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 (AUC: 0.88, aOR: 12.27, 95% CI 2.15-70.13; p = 0.005) to independently predict GTN. CONCLUSIONS An hCG value ≥ 1400 IU/L at 2nd week post-evacuation and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 independently and reliably predict postmolar GTN.
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Affiliation(s)
- Chanya Rakprasit
- Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Irene Ruengkhachorn
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suwanit Therasakvichya
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Perapong Inthasorn
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Vuthinun Achariyapota
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sompop Kuljarasnont
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khemanat Khemworapong
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nida Jareemit
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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14
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Watanabe E, Yokoi A, Yoshida K, Sugiyama M, Kitagawa M, Nishino K, Yamamoto E, Niimi K, Yamamoto Y, Kajiyama H. Drug library screening identifies histone deacetylase inhibition as a novel therapeutic strategy for choriocarcinoma. Cancer Med 2023; 12:4543-4556. [PMID: 36106577 PMCID: PMC9972027 DOI: 10.1002/cam4.5243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/20/2022] [Accepted: 08/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Choriocarcinoma is a rare and aggressive gynecological malignancy. The standard treatment is systemic chemotherapy as choriocarcinoma exhibits high chemosensitivity. However, refractory choriocarcinoma exhibits chemoresistance; thus, the prognosis remains very poor. This study aimed to identify novel therapeutic agents for choriocarcinoma by utilizing a drug repositioning strategy. METHODS Three choriocarcinoma cell lines (JAR, JEG-3, and BeWo) and a human extravillous trophoblast cell line (HTR-8/SVneo) were used for the analyses. The growth inhibitory effects of 1,271 FDA-approved compounds were evaluated in vitro screening assays and selected drugs were tested in tumor-bearing mice. Functional analyses of drug effects were performed based on RNA sequencing. RESULTS Muti-step screening identified vorinostat, camptothecin (S, +), topotecan, proscillaridin A, and digoxin as exhibiting an anti-cancer effect in choriocarcinoma cells. Vorinostat, a histone deacetylase inhibitor, was selected as a promising candidate for validation and the IC50 values for choriocarcinoma cells were approximately 1 μM. RNA sequencing and subsequent pathway analysis revealed that the ferroptosis pathway was likely implicated, and key ferroptosis-related genes (i.e., GPX4, NRF2, and SLC3A2) were downregulated following vorinostat treatment. Furthermore, vorinostat repressed tumor growth and downregulated the expression of GPX4 and NRF2 in JAR cell-bearing mice model. CONCLUSION Vorinostat, a clinically approved drug for the treatment of advanced primary cutaneous T-cell lymphoma, showed a remarkable anticancer effect both in vitro and in vivo by regulating the expression of ferroptosis-related genes. Therefore, vorinostat may be an effective therapeutic candidate for patients with choriocarcinoma.
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Affiliation(s)
- Eri Watanabe
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akira Yokoi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Institute for Advanced Research, Nagoya University, Nagoya, Japan
| | - Kosuke Yoshida
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Institute for Advanced Research, Nagoya University, Nagoya, Japan
| | - Mai Sugiyama
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masami Kitagawa
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Nishino
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eiko Yamamoto
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Yamamoto
- Laboratory of Integrative Oncology, National Cancer Center Research Institute, Tokyo, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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15
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Oral self-emulsifying nanoemulsion systems for enhancing dissolution, bioavailability and anticancer effects of camptothecin. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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16
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Usui H. Auxiliary and experimental diagnostic techniques for hydatidiform moles. J Obstet Gynaecol Res 2022; 48:3077-3086. [PMID: 36098274 DOI: 10.1111/jog.15422] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/28/2022] [Indexed: 11/30/2022]
Abstract
Hydatidiform moles are classified into complete hydatidiform moles (CHMs), which are androgenetic and diploid, and partial hydatidiform moles (PHM), which are triploid with two paternal chromosomes and one maternal chromosome. The incidence of gestational trophoblastic neoplasia differs substantially between CHM and PHM. However, they are occasionally difficult to diagnose. In this review, auxiliary and experimental methods based on cytogenetic features and advanced molecular detection techniques applied to the diagnosis and analysis of hydatidiform moles are summarized, including basic principles, characteristics, and clinical implications. Short tandem repeat polymorphism analysis is considered the gold standard for the genetic diagnosis of hydatidiform moles. In clinical settings, immunohistochemical analyses of p57KIP2 , an imprinted gene product, are widely used to differentiate CHMs from other conceptuses, including PHMs. Recently, new molecular genetic techniques, such as single nucleotide polymorphism arrays, have been applied to research on hydatidiform moles. In addition to insights from classical methods, such as chromosome analysis, recently developed approaches have yielded novel findings related to the mechanism underlying the development of androgenetic CHMs.
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Affiliation(s)
- Hirokazu Usui
- Department of Reproductive Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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17
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Hutchcraft ML, Miller RW. Bleeding from Gynecologic Malignancies. Obstet Gynecol Clin North Am 2022; 49:607-622. [PMID: 36122988 DOI: 10.1016/j.ogc.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Initial assessment of vaginal bleeding in gynecologic malignancies includes a thorough history and physical examination, identification of site and extent of disease, and patient goals of care. Patients who are initially hemodynamically unstable may require critical care services. Choice of treatment is disease site specific. Cervical cancer frequently is treated with chemoradiation. Uterine cancer may be treated surgically, with radiation, or pharmacologically. Gestational trophoblastic disease is treated surgically. Alternative treatment modalities include vascular embolization and topical hemostatic agents. Patients with bleeding gynecologic malignancies should be managed as inpatients in facilities with gynecologic oncology, radiation oncology, and critical care services.
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Affiliation(s)
- Megan L Hutchcraft
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kentucky Markey Cancer Center, 800 Rose Street, Lexington, KY 40536, USA.
| | - Rachel W Miller
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kentucky Markey Cancer Center, 800 Rose Street, Lexington, KY 40536, USA
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18
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Zhao Y, Huang B, Zhou L, Cai L, Qian J. Challenges in diagnosing hydatidiform moles: a review of promising molecular biomarkers. Expert Rev Mol Diagn 2022; 22:783-796. [PMID: 36017690 DOI: 10.1080/14737159.2022.2118050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Hydatidiform moles (HMs) are pathologic conceptions with unique genetic bases and abnormal placental villous tissue. Overlapping ultrasonographical and histological manifestations of molar and non-molar (NM) gestations and HMs subtypes makes accurate diagnosis challenging. Currently, immunohistochemical analysis of p57 and molecular genotyping have greatly improved the diagnostic accuracy. AREAS COVERED The differential expression of molecular biomarkers may be valuable for distinguishing among the subtypes of HMs and their mimics. Thus, biomarkers may be the key to refining HMs diagnosis. In this review, we summarize the current challenges in diagnosing HMs, and provide a critical overview of the recent literature about potential diagnostic biomarkers and their subclassifications. An online search on PubMed, Web of Science, and Google Scholar databases was conducted from the inception to 1 April 2022. EXPERT OPINION the emerging biomarkers offer new possibilities to refine the diagnosis for HMs and pregnancy loss. Although the additional studies are required to be quantified and investigated in clinical trials to verify their diagnostic utility. It is important to explore, validate, and facilitate the wide adoption of newly developed biomarkers in the coming years.
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Affiliation(s)
- Yating Zhao
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, 310003, Zhejiang Province, People's Republic of China
| | - Bo Huang
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, 310003, Zhejiang Province, People's Republic of China
| | - Lin Zhou
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, 310003, Zhejiang Province, People's Republic of China
| | - Luya Cai
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, 310003, Zhejiang Province, People's Republic of China
| | - Jianhua Qian
- Department of Gynaecology and Obstetrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, 310003, Zhejiang Province, People's Republic of China
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19
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Sileo FG, Giuliani GA, Facchinetti F, Contu G, Chiossi G, Bertucci E. Complete hydatidiform mole in higher-order multiple pregnancies. Minerva Obstet Gynecol 2022; 74:308-313. [PMID: 35642715 DOI: 10.23736/s2724-606x.21.05031-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Molar degeneration of the trophoblast is a rare, yet possible, complication of pregnancies. Complete hydatidiform mole is the most common histological type among all trophoblastic tumors and it is the result of the fertilization of an empty oocyte from two sperms or by one sperm that then duplicates. Complete mole is characterized by hydropic degeneration of abnormal chorionic villi, diffused trophoblast hyperplasia and the absence of identifiable embryonic or fetal tissue; the hyperplastic trophoblast justifies the common finding of high serum beta HCG levels. Twin molar pregnancy is an uncommon obstetric event, and even less frequent are triplet/quadruplet molar pregnancies. We hereby report a case of a complete hydatidiform mole with two coexistent fetuses in a triplet pregnancy after in vitro fertilization procedure; the pregnancy ended with a therapeutic abortion. During the follow-up, the serum beta human chorionic gonadotropin concentration started to rise, and the diagnosis of post-molar gestational trophoblastic neoplasia was made and consequently methotrexate treatment was started. Due to the rarity of this condition, there are no specific guidelines for the management of multiple pregnancies complicated by complete hydatidiform mole. We therefore performed a review of the literature including all reported cases of triplets/quadruplets pregnancies complicated by complete mole of a fetus focusing on ultrasound diagnosis, treatment and outcomes of this rare and life-threatening condition.
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Affiliation(s)
- Filomena G Sileo
- Prenatal Medicine Unit, Service of Obstetrics and Gynecology, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia A Giuliani
- Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Facchinetti
- Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Giannina Contu
- Prenatal Medicine Unit, Service of Obstetrics and Gynecology, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Chiossi
- Prenatal Medicine Unit, Service of Obstetrics and Gynecology, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Emma Bertucci
- Prenatal Medicine Unit, Service of Obstetrics and Gynecology, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy -
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20
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Auger N, Ghadirian M, Low N, Healy-Profitós J, Wei SQ. Premature mortality after pregnancy loss: Trends at 1, 5, 10 years, and beyond. Eur J Obstet Gynecol Reprod Biol 2021; 267:155-160. [PMID: 34773878 DOI: 10.1016/j.ejogrb.2021.10.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 10/08/2021] [Accepted: 10/26/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Little is known on the long-term risk of mortality following pregnancy loss. We assessed risks of premature mortality up to three decades after miscarriage, induced abortion, ectopic or molar pregnancy, and stillbirth relative to live birth. STUDY DESIGN We carried out a longitudinal cohort study of 1,293,640 pregnant women with 18,896,737 person-years of follow-up in Quebec, Canada, from 1989 to 2018. We followed the women up to 29 years after their last pregnancy event to determine the time and cause of future in-hospital deaths before age 75 years. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of miscarriage, induced abortion, ectopic pregnancy, molar pregnancy, and stillbirth with premature mortality, compared with live birth. RESULTS Premature mortality rates were higher for most types of pregnancy loss than live birth. Compared with live birth, pregnancy loss was associated with an elevated risk of premature mortality (HRmiscarriage 1.48, 95% CI 1.33, 1.65; HRinduced abortion 1.50, 95% CI 1.39, 1.62; HRectopic 1.55, 95% CI 1.35, 1.79; and HRstillbirth 1.68, 95%. CI 1.17, 2.41). Molar pregnancy was not associated with premature mortality (HR 0.87, 95% CI 0.33, 2.32). Miscarriage and induced abortion were associated with most causes of death, whereas ectopic pregnancy was associated with cardiovascular (HR 2.18, 95 % CI 1.39, 3.42), cancer (HR 1.38, 95 % CI 1.11, 1.73), and suicide-related mortality (HR 4.94, 95 % CI 2.29, 10.68). Stillbirth was associated with cardiovascular mortality (HR 4.91, 95 % CI 2.33, 10.36). CONCLUSION Pregnancy loss is associated with an elevated risk of premature mortality up to three decades later, particularly cardiovascular, cancer, and suicide-related deaths.
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Affiliation(s)
- Nathalie Auger
- University of Montreal Hospital Research Centre, Montreal, Quebec, Canada; Institut national de santé publique du Québec, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, Quebec, Canada.
| | - Mona Ghadirian
- Institut national de santé publique du Québec, Montreal, Quebec, Canada; School of Human Nutrition, McGill University, Ste-Anne-de-Bellevue, Quebec, Canada
| | - Nancy Low
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Jessica Healy-Profitós
- University of Montreal Hospital Research Centre, Montreal, Quebec, Canada; Institut national de santé publique du Québec, Montreal, Quebec, Canada
| | - Shu Qin Wei
- Institut national de santé publique du Québec, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, Sainte-Justine Research Center, University of Montreal, Montreal, Quebec, Canada
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21
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Albright BB, Myers ER, Moss HA, Ko EM, Sonalkar S, Havrilesky LJ. Surveillance for gestational trophoblastic neoplasia following molar pregnancy: a cost-effectiveness analysis. Am J Obstet Gynecol 2021; 225:513.e1-513.e19. [PMID: 34058170 PMCID: PMC9941751 DOI: 10.1016/j.ajog.2021.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Historically, published guidelines for care after molar pregnancy recommended monitoring human chorionic gonadotropin levels for the development of gestational trophoblastic neoplasia until normal and then for 6 months after the first normal human chorionic gonadotropin. However, there are little data underlying such recommendations, and recent evidence has demonstrated that gestational trophoblastic neoplasia diagnosis after human chorionic gonadotropin normalization is rare. OBJECTIVE We sought to estimate the cost-effectiveness of alternative strategies for surveillance for gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after complete and partial molar pregnancy. STUDY DESIGN A Markov-based cost-effectiveness model, using monthly cycles and terminating after 36 months/cycles, was constructed to compare alternative strategies for asymptomatic human chorionic gonadotropin surveillance after the first normal (none; monthly testing for 1, 3, 6, and 12 months; or every 3-month testing for 3, 6, and 12 months) for both complete and partial molar pregnancy. The risk of reduced surveillance was modeled by increasing the probability of high-risk disease at diagnosis. Probabilities, costs, and utilities were estimated from peer-reviewed literature, with all cost data applicable to the United States and adjusted to 2020 US dollars. The primary outcome was cost per quality-adjusted life year ($/quality-adjusted life year) with a $100,000/quality-adjusted life year willingness-to-pay threshold. RESULTS Under base-case assumptions, we found no further surveillance after the first normal human chorionic gonadotropin to be the dominant strategy from both the healthcare system and societal perspectives, for both complete and partial molar pregnancy. After complete mole, this strategy had the lowest average cost (healthcare system, $144 vs maximum $283; societal, $152 vs maximum $443) and highest effectiveness (2.711 vs minimum 2.682 quality-adjusted life years). This strategy led to a slightly higher rate of death from gestational trophoblastic neoplasia (0.013% vs minimum 0.009%), although with high costs per gestational trophoblastic neoplasia death avoided (range, $214,000 to >$4 million). Societal perspective costs of lost wages had a greater impact on frequent surveillance costs than rare gestational trophoblastic neoplasia treatment costs, and no further surveillance was more favorable from this perspective in otherwise identical analyses. No further surveillance remained dominant or preferred with incremental cost-effectiveness ratio of <$100,000 in all analyses for partial mole, and most sensitivity analyses for complete mole. Under the assumption of no disutility from surveillance, surveillance strategies were more effective (by quality-adjusted life year) than no further surveillance, and a single human chorionic gonadotropin test at 3 months was found to be cost-effective after complete mole with incremental cost-effectiveness ratio of $53,261 from the healthcare perspective, but not from the societal perspective (incremental cost-effectiveness ratio, $288,783). CONCLUSION Largely owing to the rare incidence of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after molar pregnancy, prolonged surveillance is not cost-effective under most assumptions. It would be reasonable to reduce, and potentially eliminate, current recommendations for surveillance after human chorionic gonadotropin normalization after molar pregnancy, particularly among partial moles. With any reduction in surveillance, patients should be counseled on symptoms of gestational trophoblastic neoplasia and established in routine gynecologic care.
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Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emily M Ko
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, PA
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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22
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Horowitz NS, Eskander RN, Adelman MR, Burke W. Epidemiology, diagnosis, and treatment of gestational trophoblastic disease: A Society of Gynecologic Oncology evidenced-based review and recommendation. Gynecol Oncol 2021; 163:605-613. [PMID: 34686354 DOI: 10.1016/j.ygyno.2021.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/28/2021] [Accepted: 10/04/2021] [Indexed: 12/22/2022]
Affiliation(s)
- N S Horowitz
- Brigham & Women's Hospital/Dana Farber Cancer Institute, Boston, MA, USA.
| | - R N Eskander
- University of California, San Diego, Moores Cancer Center, La Jolla, CA, USA
| | | | - W Burke
- Stony Brook Medicine, Long Island, NY, USA
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23
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Luo F, Li L, Gao Q, Li YX. Evaluation of efficacy and safety of chemotherapy in the treatment of recurrent or resistant gestational trophoblastic neoplasia: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27320. [PMID: 34622830 PMCID: PMC8500640 DOI: 10.1097/md.0000000000027320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Gestational Trophoblastic Neoplasia (GTN) is a spectrum of pregnancy-associated tumours emerging from placental tissue. Generally, GTN patients are considered to have a high rate of recovery. However, almost 25 per cent of GTN tumours resist, or have a high probability of relapsing following the first line of chemo treatment. Thus, tumours that resist or relapse requires salvage chemotherapy, sometimes accompanied by surgery. Globally, clinicians utilize a range of salvage regimens. Currently, ongoing debates are centred around choosing the best regimens in terms of safety and efficacy. Therefore, the current research aims to appraise the success and level of safeness using chemotherapy to treat patients with resistant or recurrent GTN. METHODS The authors will conduct a methodological exploration in online-based databases to find Randomized Controlled Trials related to the adoption of chemotherapy agents as treatment for resistant or recurrent GTN patients. The databases are as follows: EMBASE, PubMed, Cochrane Database Central, UpToDate, Chinese National Knowledge Infrastructure, Web of Science, and WanFang Database. The search will be limited to articles published in either English or Chinese. Moreover, the authors will also perform a search for ongoing trials on online-based clinical trial registries. Two independent authors will screen and select articles for review. A similar process will be followed by two independent authors to complete the extraction of data and evaluate the bias risk. In relevant cases, the authors will contract trial investigators to obtain related, unpublished data. The authors will use the random-effects model for pooling data in RevMan software (v5.3). RESULTS The present systematic review aims to evaluate the efficacy and level of safeness associated with using chemotherapy for resistant or recurrent GTN patients. CONCLUSION The results of the proposed systematic analysis could summarize the most recent evidence for the use of chemotherapy agents on GTN patients. ETHICS AND DISSEMINATION Since the proposed study uses pre-published data, an ethical approval is not required. REVIEW REGISTRATION NUMBER Aug 25, 2021.osf.io/rgzbn. (https://osf.io/rgzbn/).
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Affiliation(s)
- Fang Luo
- Department of Gynecology, Wuhan Puren hospital, Wuhan, Hubei, China
| | - Li Li
- Department of pathology, wuhan puren hospital, Wuhan, Hubei, China
| | - Qing Gao
- Department of Gynecology, Wuhan Puren hospital, Wuhan, Hubei, China
| | - Yu-Xia Li
- Department of Gynaecology and Obstetrics, Wuhan Children's Hospita (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
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Hoeijmakers YM, Eysbouts YK, Massuger LFAG, Dandis R, Inthout J, van Trommel NE, Ottevanger PB, Thomas CMG, Sweep FCGJ. Early prediction of post-molar gestational trophoblastic neoplasia and resistance to methotrexate, based on a single serum human chorionic gonadotropin measurement. Gynecol Oncol 2021; 163:531-537. [PMID: 34602288 DOI: 10.1016/j.ygyno.2021.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/11/2021] [Accepted: 09/21/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Clinicians are unable to provide individualized counseling regarding risk of progression for patients with a complete hydatidiform mole (CHM). We developed nomograms enabling early prediction of post-molar gestational trophoblastic neoplasia (GTN) and resistance to methotrexate (MTX) based on a single serum human chorion gonadotropin (hCG) measurement. METHODS We generated two nomograms with logistic regression: to predict post-molar GTN, and MTX resistance. For patients with high probability to progress to post-molar GTN or MTX resistance, we determined hCG cut-offs at 97.5% specificity to select patients for additional- or adjustments in current treatment. RESULTS The nomograms had a good to excellent ability to distinguish either between patients with uneventful hCG regression versus progression to post molar GTN, or between patients cured by MTX versus patients in whom resistance would occur. At 97.5% specificity, we identified 66% (95%CI 56-75) of the 149 patients who would progress to post-molar GTN, four weeks after initial curettage. For patients treated with MTX, we identified 55% (95%CI 23-83) of the 43 patients who would become resistant, preceding their third course at 97.5% specificity. CONCLUSION The nomograms and cut-off levels can be used to assist in counseling for patients diagnosed with CHM.
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Affiliation(s)
- Yvonne M Hoeijmakers
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Yalck K Eysbouts
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Rana Dandis
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joanna Inthout
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - N E van Trommel
- Center for Gynecologic Oncology Amsterdam, location Antoni van Leeuwenhoek- the Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Chris M G Thomas
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
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25
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Lin YH, Liu YC, Lee WJ. Young Female With Lower Abdominal Pain. Ann Emerg Med 2021; 77:591-612. [PMID: 34030771 DOI: 10.1016/j.annemergmed.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Yu-Hui Lin
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Chang Liu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Wei-Jing Lee
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
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Tantengco OAG, De Jesus FCC, Gampoy EFS, Ornos EDB, Vidal MS, Cagayan MSFS. Molar pregnancy in the last 50 years: A bibliometric analysis of global research output. Placenta 2021; 112:54-61. [PMID: 34274613 DOI: 10.1016/j.placenta.2021.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/01/2021] [Accepted: 07/06/2021] [Indexed: 11/18/2022]
Abstract
Molar pregnancy is a gestational trophoblastic disease characterized by an abnormal growth of placental tissues because of a nonviable pregnancy. The understanding of the pathophysiology and management of molar pregnancy has significantly increased in the recent years. This study aims to determine the characteristics and trends of published articles in the field of molar pregnancy through a bibliometric analysis. Using the Scopus database, we identified all original research articles on molar pregnancy from 1970 to 2020. Bibliographic and citation information were obtained, and visualization of collaboration networks of countries and keywords related to molar pregnancy was conducted using VOSviewer software. We obtained a total of 2009 relevant papers published between 1970 and 2020 from 80 different countries. The number of publications continued to increase through the years. However, the number of publications in molar pregnancy is still low compared to the other research fields in obstetrics and gynecology. The USA (n = 421, 32.1%), Japan (n = 199, 15.2%), and the UK (n = 191, 14.6%) contributed the greatest number of publications in this field. The top journals which contributed to the field of molar pregnancy include AJOG (n = 91), Obstetrics and Gynecology (n = 81), and the Gynecologic Oncology (n = 57). The most cited articles in molar pregnancy include papers on the genetics and chromosomal abnormalities in molar pregnancies. The focus of current research in this field was on elucidating the molecular mechanism of hydatidiform moles. Our bibliometric analysis showed the global research landscape, trends and development, scientific impact, and collaboration among researchers in the field of molar pregnancy.
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Affiliation(s)
| | | | - Eloina Faye S Gampoy
- College of Medicine, University of the Philippines Manila, Ermita, Manila, Philippines
| | - Eric David B Ornos
- College of Medicine, University of the Philippines Manila, Ermita, Manila, Philippines
| | - Manuel S Vidal
- College of Medicine, University of the Philippines Manila, Ermita, Manila, Philippines
| | - Maria Stephanie Fay S Cagayan
- Department of Pharmacology and Toxicology, College of Medicine, University of the Philippines Manila, Manila, Philippines; Division of Trophoblast Diseases, Department of Obstetrics and Gynecology, University of the Philippines - Philippine General Hospital, Taft Avenue, Manila, Philippines
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27
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Mamede R, Beja M, Djokovic D, Costa C. Invasive mole presenting as a heavily bleeding vaginal lesion 3 weeks after uterine evacuation. BMJ Case Rep 2021; 14:14/6/e242208. [PMID: 34155019 DOI: 10.1136/bcr-2021-242208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Gestational trophoblastic disease occurs in 1-3:1000 gestations worldwide. Up to one-fifth of complete hydatidiform moles undergo malignant transformation, with 2%-4% manifesting as metastatic disease. Of these, a third present with vaginal metastases, which can cause bleeding and discharge. We describe the case of a 49-year-old primiparous woman presenting with syncope and intense bleeding from an anterior vaginal lesion, 3 weeks after uterine evacuation for a presumed spontaneous abortion. A vaginal metastatic nodule was suspected; haemostasis was achieved with vaginal packing, precluding the need for surgical intervention. The patient was ultimately diagnosed with invasive mole with vaginal and lung metastases (stage III high-risk gestational trophoblastic neoplasia (GTN)) and started on multiple-agent chemotherapy. Two months later the lesion had regressed completely, and remission was reached 2 weeks later. Clinicians should consider the possibility of metastatic GTN with vaginal involvement whenever heavy vaginal bleeding follows a recent history of failed pregnancy.
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Affiliation(s)
- Rita Mamede
- Obstetrics and Gynaecology Department, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal
| | - Mariana Beja
- Obstetrics and Gynaecology Department, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal
| | - Dusan Djokovic
- Obstetrics and Gynaecology Department, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal.,Obstetrics and Gynaecology Department, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Cristina Costa
- Obstetrics and Gynaecology Department, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal.,Obstetrics and Gynaecology Department, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
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Loss of Selenoprotein Iodothyronine Deiodinase 3 Expression Correlates with Progression of Complete Hydatidiform Mole to Gestational Trophoblastic Neoplasia. Reprod Sci 2021; 28:3200-3211. [PMID: 34129219 DOI: 10.1007/s43032-021-00634-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
To investigate if differences in imprinting at tropho-microRNA (miRNA) genomic clusters can distinguish between pre-gestational trophoblastic neoplasia cases (pre-GTN) and benign complete hydatidiform mole (CHM) cases at the time of initial uterine evacuation. miRNA sequencing was performed on frozen tissue from 39 CHM cases including 9 GTN cases. DIO3, DLK1, RTL1, and MEG 3 mRNA levels were assessed by qRT-PCR. Protein abundance was assessed by Western blot for DIO3, DLK1, and RTL1. qRT-PCR and Western blot were performed for selenoproteins and markers of oxidative stress. Immunohistochemistry (IHC) was performed for DIO3 on an independent validation set of clinical samples (n = 42) and compared to normal placenta controls across gestational ages. Relative expression of the 14q32 miRNA cluster was lower in pre-GTN cases. There were no differences in protein abundance of DLK1 or RTL1. Notably, there was lower protein expression of DIO3 in pre-GTN cases (5-fold, p < 0.03). There were no differences in mRNA levels of DIO3, DLK1, RTL1 or MEG 3. mRNA levels were higher in all CHM cases compared to normal placenta. IHC showed syncytiotrophoblast-specific DIO3 immunostaining in benign CHM cases and normal placenta, while pre-GTN cases of CHM lacked DIO3 expression. We describe two new biomarkers of pre-GTN CHM cases: decreased 14q32 miRNA expression and loss of DIO3 expression by IHC. Differences in imprinting between benign CHM and pre-GTN cases may provide insight into the fundamental development of CHM.
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Huang TC, Chang KC, Chang JY, Tsai YS, Yang YJ, Chang WC, Mo CF, Yu PH, Chiang CT, Lin SP, Kuo PL. Variants in Maternal Effect Genes and Relaxed Imprinting Control in a Special Placental Mesenchymal Dysplasia Case with Mild Trophoblast Hyperplasia. Biomedicines 2021; 9:biomedicines9050544. [PMID: 34068021 PMCID: PMC8152467 DOI: 10.3390/biomedicines9050544] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/30/2021] [Accepted: 05/10/2021] [Indexed: 11/16/2022] Open
Abstract
Placental mesenchymal dysplasia (PMD) and partial hydatidiform mole (PHM) placentas share similar characteristics, such as placental overgrowth and grape-like placental tissues. Distinguishing PMD from PHM is critical because the former can result in normal birth, while the latter diagnosis will lead to artificial abortion. Aneuploidy and altered dosage of imprinted gene expression are implicated in the pathogenesis of PHM and also some of the PMD cases. Diandric triploidy is the main cause of PHM, whereas mosaic diploid androgenetic cells in the placental tissue have been associated with the formation of PMD. Here, we report a very special PMD case also presenting with trophoblast hyperplasia phenotype, which is a hallmark of PHM. This PMD placenta has a normal biparental diploid karyotype and is functionally sufficient to support normal fetal growth. We took advantage of this unique case to further dissected the potential common etiology between these two diseases. We show that the differentially methylated region (DMR) at NESP55, a secondary DMR residing in the GNAS locus, is significantly hypermethylated in the PMD placenta. Furthermore, we found heterozygous mutations in NLRP2 and homozygous variants in NLRP7 in the mother’s genome. NLRP2 and NLRP7 are known maternal effect genes, and their mutation in pregnant females affects fetal development. The variants/mutations in both genes have been associated with imprinting defects in mole formation and potentially contributed to the mild abnormal imprinting observed in this case. Finally, we identified heterozygous mutations in the X-linked ATRX gene, a known maternal–zygotic imprinting regulator in the patient. Overall, our study demonstrates that PMD and PHM may share overlapping etiologies with the defective/relaxed dosage control of imprinted genes, representing two extreme ends of a spectrum.
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Affiliation(s)
- Tien-Chi Huang
- Institute of Biotechnology, National Taiwan University, Taipei 106, Taiwan; (T.-C.H.); (J.-Y.C.); (W.-C.C.); (C.-F.M.)
| | - Kung-Chao Chang
- Department of Pathology, National Cheng Kung University Hospital, Tainan 704, Taiwan;
| | - Jen-Yun Chang
- Institute of Biotechnology, National Taiwan University, Taipei 106, Taiwan; (T.-C.H.); (J.-Y.C.); (W.-C.C.); (C.-F.M.)
| | - Yi-Shan Tsai
- Department of Radiology, National Cheng Kung University Hospital, Tainan 704, Taiwan;
| | - Yao-Jong Yang
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan 704, Taiwan;
| | - Wei-Chun Chang
- Institute of Biotechnology, National Taiwan University, Taipei 106, Taiwan; (T.-C.H.); (J.-Y.C.); (W.-C.C.); (C.-F.M.)
| | - Chu-Fan Mo
- Institute of Biotechnology, National Taiwan University, Taipei 106, Taiwan; (T.-C.H.); (J.-Y.C.); (W.-C.C.); (C.-F.M.)
| | - Pei-Hsiu Yu
- Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
- Department of Obstetrics and Gynecology, Kuo General Hospital, Tainan 700, Taiwan
| | - Chun-Ting Chiang
- Department and Graduated Institute of Forensic Medicine, College of Medicine, National Taiwan University, Taipei 106, Taiwan;
| | - Shau-Ping Lin
- Institute of Biotechnology, National Taiwan University, Taipei 106, Taiwan; (T.-C.H.); (J.-Y.C.); (W.-C.C.); (C.-F.M.)
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei 115, Taiwan
- Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei 106, Taiwan
- Center for Systems Biology, National Taiwan University, Taipei 106, Taiwan
- Correspondence: (S.-P.L.); (P.-L.K.)
| | - Pao-Lin Kuo
- Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
- Correspondence: (S.-P.L.); (P.-L.K.)
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Distinct microRNA profiles for complete hydatidiform moles at risk of malignant progression. Am J Obstet Gynecol 2021; 224:372.e1-372.e30. [PMID: 33031755 DOI: 10.1016/j.ajog.2020.09.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/24/2020] [Accepted: 09/29/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND MicroRNAs are small noncoding RNAs with important regulatory functions. Although well-studied in cancer, little is known about the role of microRNAs in premalignant disease. Complete hydatidiform moles are benign forms of gestational trophoblastic disease that progress to gestational trophoblastic neoplasia in up to 20% of cases; however, there is no well-established biomarker that can predict the development of gestational trophoblastic neoplasia. OBJECTIVE This study aimed to investigate possible differences in microRNA expression between complete moles progressing to gestational trophoblastic neoplasia and those regressing after surgical evacuation. STUDY DESIGN Total RNA was extracted from fresh frozen tissues from 39 complete moles collected at the time of uterine evacuation in Brazil. In the study, 39 cases achieved human chorionic gonadotropin normalization without further therapy, and 9 cases developed gestational trophoblastic neoplasia requiring chemotherapy. Total RNA was also extracted from 2 choriocarcinoma cell lines, JEG-3 and JAR, and an immortalized normal placenta cell line, 3A-subE. MicroRNA expression in all samples was quantified using microRNA sequencing. Hits from the sequencing data were validated using a quantitative probe-based assay. Significantly altered microRNAs were then subjected to target prediction and gene ontology analyses to search for alterations in key signaling pathways. Expression of potential microRNA targets was assessed by quantitative real-time polymerase chain reaction and western blot. Finally, potential prognostic protein biomarkers were validated in an independent set of formalin-fixed paraffin-embedded patient samples from the United States (15 complete moles progressing to gestational trophoblastic neoplasia and 12 that spontaneously regressed) using quantitative immunohistochemistry. RESULTS In total, 462 microRNAs were identified in all samples at a threshold of <1 tag per million. MicroRNA sequencing revealed a distinct set of microRNAs associated with gestational trophoblastic neoplasia. Gene ontology analysis of the most altered transcripts showed that the leading pathway was related to response to ischemia (P<.001). Here, 2 of the top 3 most significantly altered microRNAs were mir-181b-5p (1.65-fold; adjusted P=.014) and mir-181d-5p (1.85-fold; adjusted P=.014), both of which have been shown to regulate expression of BCL2. By quantitative real-time polymerase chain reaction, BCL2 messenger RNA expression was significantly lower in the complete moles progressing to gestational trophoblastic neoplasia than the regressing complete moles (-4.69-fold; P=.018). Reduced expression of BCL2 was confirmed in tissue samples by western blot. Immunohistochemistry in the independent patient samples revealed significantly lower cytoplasmic expression of BCL2 in the villous trophoblasts from cases destined for progression to gestational trophoblastic neoplasia compared with those that regressed, both with respect to staining intensity (optic density 0.110±0.102 vs 0.212±0.036; P<.001) and to the percentage of positive cells (16%±28% vs 49.4%±28.05%; P=.003). CONCLUSION Complete moles progressing to gestational trophoblastic neoplasia are associated with a distinct microRNA profile. miR-181 family members and BCL2 may be prognostic biomarkers for predicting gestational trophoblastic neoplasia risk.
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Maheut C, Rollin I, Baissas P, Panel P, Niro J. Management of uterine rupture during molar pregnancy. J Gynecol Obstet Hum Reprod 2021; 50:102058. [PMID: 33401026 DOI: 10.1016/j.jogoh.2020.102058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/14/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Abstract
Gestational trophoblastic disease (GTD) is rare and encompasses several clinicopathologic forms from pre-malignant to malignant disorders. Clinical presentation is most of the time dominated by vaginal bleeding. Only few cases of uterine rupture during GTD have been reported in literature. We present the case of a female patient admitted to the hospital for hemorrhagic shock secondary to a uterine rupture due to an undiagnosed GTD. After an emergency laparoscopy, the patient underwent total hysterectomy with bilateral salpingectomy and bilateral ovarian cystectomy. Pulmonary metastasis were discovered on imaging after stagnation of the beta-hCG level. The surgical treatment was completed by 6 cycles of Methotrexate followed by 7 cycles of Actinomycine D with a good response.
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Affiliation(s)
- Celia Maheut
- Service de Gynécologie-Obstétrique, Centre Hospitalier de Versailles, 177 Rue de Versailles, 78150, Le Chesnay-Rocquencourt, France.
| | - Isabelle Rollin
- Service de Gynécologie-Obstétrique, Centre Hospitalier de Versailles, 177 Rue de Versailles, 78150, Le Chesnay-Rocquencourt, France.
| | - Pauline Baissas
- Service de Gynécologie-Obstétrique, Centre Hospitalier de Versailles, 177 Rue de Versailles, 78150, Le Chesnay-Rocquencourt, France.
| | - Pierre Panel
- Service de Gynécologie-Obstétrique, Centre Hospitalier de Versailles, 177 Rue de Versailles, 78150, Le Chesnay-Rocquencourt, France.
| | - Julien Niro
- Service de Gynécologie-Obstétrique, Centre Hospitalier de Versailles, 177 Rue de Versailles, 78150, Le Chesnay-Rocquencourt, France.
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Oyatogun O, Sandhu M, Barata-Kirby S, Tuller E, Schust DJ. A rational diagnostic approach to the "phantom hCG" and other clinical scenarios in which a patient is thought to be pregnant but is not. Ther Adv Reprod Health 2021; 15:26334941211016412. [PMID: 34179786 PMCID: PMC8207263 DOI: 10.1177/26334941211016412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 04/19/2021] [Indexed: 12/01/2022] Open
Abstract
The scenario in which a patient tests positive for human chorionic gonadotropin (hCG) in the absence of pregnancy can pose a diagnostic dilemma for clinicians. The term "phantom hCG" refers to persistently positive hCG levels on diagnostic testing in a nonpregnant patient and such results often lead to a false diagnosis of malignancy and subsequent inappropriate treatment with chemotherapy or hysterectomy. There remains a need for a consistent and rational diagnostic approach to the "phantom hCG." This article aims to review the different etiologies of positive serum hCG testing in nonpregnant subjects and concludes with a practical, stepwise diagnostic approach to assist clinicians encountering this clinical dilemma.
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Affiliation(s)
- Oluwafunmilayo Oyatogun
- Institute for Women’s Health Research and Department of Obstetrics, Gynecology and Women’s Health, University of Missouri, 500 North Keene St Suite 203, Columbia, MO 65201, USA
| | - Mandeep Sandhu
- Institute for Women’s Health Research and Department of Obstetrics, Gynecology and Women’s Health, University of Missouri, Columbia, MO, USA
| | - Stephanie Barata-Kirby
- Institute for Women’s Health Research and Department of Obstetrics, Gynecology and Women’s Health, University of Missouri, Columbia, MO, USA
| | - Erin Tuller
- Institute for Women’s Health Research and Department of Obstetrics, Gynecology and Women’s Health, University of Missouri, Columbia, MO, USA
| | - Danny J. Schust
- Institute for Women’s Health Research and Department of Obstetrics, Gynecology and Women’s Health, University of Missouri, Columbia, MO, USA
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Gockley AA, Lin LH, Davis M, Melamed A, Rizzo A, Sun SY, Elias K, Goldstein DP, Berkowitz RS, Horowitz NS. Impact of clinical characteristics on human chorionic gonadotropin regression after molar pregnancy. Clinics (Sao Paulo) 2021; 76:e2830. [PMID: 34468539 PMCID: PMC8366901 DOI: 10.6061/clinics/2021/e2830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/24/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This study aimed to determine the effects of age, race/ethnicity, body mass index, and contraception on human chorionic gonadotropin (hCG) regression following the evacuation of a molar pregnancy. METHODS This was a retrospective cohort study of 277 patients with molar pregnancies between January 1, 1994 and December 31, 2015. The rate of hCG regression was estimated using mixed-effects linear regression models on daily log-transformed serum hCG levels after evacuation. RESULTS There were no differences in hCG half-lives among age (p=0.13) or race/ethnicity (p=0.16) groups. Women with obesity and hormonal contraceptive use demonstrated faster hCG regression than their counterparts (3.2 versus. 3.7 days, p=0.02 and 3.4 versus. 4.0 days, p=0.002, respectively). CONCLUSION Age and race/ethnicity were not associated with hCG regression rates. Hormonal contraceptive use and obesity were associated with shorter hCG half-lives, but with unlikely clinical significance. It is important to understand whether the clinical characteristics of patients may influence the hCG regression curve, as it has been proposed as a way to predict the risk of gestational trophoblastic neoplasia.
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Affiliation(s)
- Allison A. Gockley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Corresponding author. E-mail:
| | - Lawrence H. Lin
- Department of Pathology, NYU School of Medicine, New York, USA
- Centro de Doencas Trofoblasticas, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Michelle Davis
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
| | - Alexander Melamed
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Massachusetts, USA
| | - Anthony Rizzo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
| | - Sue Yazaki Sun
- Centro de Doencas Trofoblasticas, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Kevin Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Gynecologic Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, USA
- Trophoblastic Tumor Registry, New England Trophoblastic Disease Center, Boston, USA
| | - Donald P. Goldstein
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Gynecologic Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, USA
- Trophoblastic Tumor Registry, New England Trophoblastic Disease Center, Boston, USA
| | - Ross S. Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Gynecologic Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, USA
- Trophoblastic Tumor Registry, New England Trophoblastic Disease Center, Boston, USA
| | - Neil S. Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Gynecologic Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, USA
- Trophoblastic Tumor Registry, New England Trophoblastic Disease Center, Boston, USA
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Sebire NJ. Recurrent GTD and GTD coexisting with normal twin pregnancy. Best Pract Res Clin Obstet Gynaecol 2020; 74:122-130. [PMID: 33451920 DOI: 10.1016/j.bpobgyn.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/04/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
Hydatidiform mole (HM) affects around 1/1000 pregnancies, and in such cases the recurrence risk is around 1%, being greater for those with complete HM (CHM). Whilst most cases appear sporadic with unknown mechanisms, there is a distinct subgroup of patients who suffer recurrent pregnancy loss, including multiple recurrent CHM (familial recurrent biparental HM syndrome). The majority of these cases are related to maternal genetic mutations in genes related to the control of imprinting, specifically NALP7 and KHDC3L. Oocyte donation is an effective treatment allowing these patients to have successful pregnancies. Approximately 1 in 50,000 pregnancies are complicated by twin pregnancy comprising normal foetus and HM, the majority of reported cases being CHM. Such pregnancies are at significantly increased risk of complications, including pregnancy loss, early-onset preeclampsia and severe preterm delivery, but when managed conservatively the delivery of a liveborn healthy infant occurs in around one-third of cases. Regardless of management, the risk of persistent GTD in such cases appears similar to that following singleton CHM. Rarely, other conditions mimic prenatal ultrasound appearances of twin pregnancy with HM, CHM mosaicism and placental mesenchymal dysplasia, both of which have distinctive histological and genetic features.
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Affiliation(s)
- Neil J Sebire
- Trophoblastic Disease Unit, Department of Histopathology, Charing Cross Hospital Imperial Nhs Trust, London, UK.
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Immune cell composition in the endometrium of patients with a complete molar pregnancy: Effects on outcome. Gynecol Oncol 2020; 160:450-456. [PMID: 33213898 DOI: 10.1016/j.ygyno.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 11/06/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE In 15% of patients with complete hydatidiform mole (CHM), disease progresses to post-molar gestational trophoblastic neoplasia (GTN) after curettage. Tumor infiltrating lymphocytes (TILs) are essential in overcoming disease in many tumors. Infiltrating lymphocyte composition and density may influence trophoblast regression and development of post-molar GTN. We analyzed immune cell composition and density in curettaged endometrium of patients with CHM which spontaneously regressed, and of patients with CHM which progressed to post-molar GTN. METHODS Sixteen patients with CHM and spontaneous regression, and 16 patients with CHM which progressed to post-molar GTN were selected. Immune cell composition and density of natural killer (NK) cells, natural killer T (NKT)-like cells, Cytotoxic T cells, T-Regulatory and T-Helper cells, were determined by multiplex immunohistochemistry (mIHC). RESULTS Curettaged endometrium of patients with CHM and spontaneous regression contained a slightly higher number of immune cells compared to patients with CHM which progressed to post-molar GTN. NKT-like cell density was significantly higher in patients with spontaneous regression compared to patients with CHM which progressed to post-molar GTN (483 ± 296 vs.295 ± 143 (mean ± SD), p = 0.03) respectively. NKT-like cell density in the spontaneous regression group was split in 'high' and 'low' (i.e. above and below the median number of NKT-like cells). In patients with high NKT-like cell density, hCG normalized earlier than in patients with low NKT-like cell density (9.5 weeks, (range 3.7-14) vs. 12.9 weeks, (range 8.6-17.9), p = 0.05). CONCLUSION A high number of NKT-like cells in the endometrium of CHMs may contribute to spontaneous regression of molar trophoblast cells.
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Dudiak KM, Maturen KE, Akin EA, Bell M, Bhosale PR, Kang SK, Kilcoyne A, Lakhman Y, Nicola R, Pandharipande PV, Paspulati R, Reinhold C, Ricci S, Shinagare AB, Vargas HA, Whitcomb BP, Glanc P. ACR Appropriateness Criteria® Gestational Trophoblastic Disease. J Am Coll Radiol 2020; 16:S348-S363. [PMID: 31685103 DOI: 10.1016/j.jacr.2019.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 11/30/2022]
Abstract
Gestational trophoblastic disease (GTD), a rare complication of pregnancy, includes both benign and malignant forms, the latter collectively referred to as gestational trophoblastic neoplasia (GTN). When metastatic, the lungs are the most common site of initial spread. Beta-human chorionic gonadotropin, elaborated to some extent by all forms of GTD, is useful in facilitating disease detection, diagnosis, monitoring treatment response, and follow-up. Imaging evaluation depends on whether GTD manifests in one of its benign forms or whether it has progressed to GTN. Transabdominal and transvaginal ultrasound with duplex Doppler evaluation of the pelvis are usually appropriate diagnostic procedures in either of these circumstances, and in posttreatment surveillance. The appropriateness of more extensive imaging remains dependent on a diagnosis of GTN and on other factors. The use of imaging to assess complications, typically hemorrhagic, should be guided by the location of clinical signs and symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | - Maria Bell
- Sanford Health, Sioux Falls, South Dakota, American College of Obstetricians and Gynecologists
| | | | - Stella K Kang
- New York University Medical Center, New York, New York
| | | | - Yulia Lakhman
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Refky Nicola
- State University of New York Upstate Medical University, Syracuse, New York
| | | | | | | | - Stephanie Ricci
- Cleveland Clinic, Cleveland, Ohio, American College of Obstetricians and Gynecologists
| | - Atul B Shinagare
- Brigham & Women's Hospital Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Bradford P Whitcomb
- University of Connecticut, Farmington, Connecticut, Society of Gynecologic Oncology
| | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Zheng XZ, Qin XY, Chen SW, Wang P, Zhan Y, Zhong PP, Buza N, Jin YL, Wu BQ, Hui P. Heterozygous/dispermic complete mole confers a significantly higher risk for post-molar gestational trophoblastic disease. Mod Pathol 2020; 33:1979-1988. [PMID: 32404958 DOI: 10.1038/s41379-020-0566-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 04/25/2020] [Indexed: 01/29/2023]
Abstract
Hydatidiform moles are classified at the genetic level as androgenetic complete mole and diandric-monogynic partial mole. Conflicting data exist whether heterozygous complete moles are more aggressive clinically than homozygous complete moles. We investigated clinical outcome in a large cohort of hydatidiform moles in Chinese patients with an emphasis on genotypical correlation with post-molar gestational trophoblastic disease. Consecutive products of conceptions undergoing DNA genotyping and p57 immunohistochemistry to rule out molar gestations were included from a 5-year period at Beijing Obstetrics and Gynecology Hospital. Patient demographics and clinical follow-up information were obtained. Post-molar gestational trophoblastic disease or gestational trophoblastic neoplasia was determined by the 2002 WHO/FIGO criteria. A total of 1245 products of conceptions were classified based on genotyping results into 219 complete moles, 250 partial moles, and 776 non-molar gestations. Among 219 complete moles, 186 were homozygous/monospermic and 33 were heterozygous/dispermic. Among 250 partial moles, 246 were triploid dispermic, 2 were triploid monospermic, and 2 were tetraploid heterozygous partial moles. Among 776 non-molar gestations, 644 were diploid without chromosomal aneuploidies detectable by STR genotyping and 132 had various genetic abnormalities including 122 cases of various trisomies, 2 triploid digynic-monoandric non-molar gestations, 7 cases of possible chromosomal monosomy or uniparental disomy. Successful follow-up was achieved in 165 complete moles: post-molar gestational trophoblastic disease developed in 11.6% (16/138 cases) of homozygous complete moles and 37.0% (10/27 cases) of heterozygous complete moles. The difference between the two groups was highly significant (p = 0.0009, chi-square). None of the 218 partial moles and 367 non-molar gestations developed post-molar gestational trophoblastic disease. In conclusion, heterozygous/dispermic complete moles are clinically more aggressive with a significantly higher risk for development of post-molar gestational trophoblastic disease compared with homozygous/monospermic complete moles. Therefore, precise genotyping classification of complete moles is important for clinical prognosis and patient management.
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Affiliation(s)
- Xing-Zheng Zheng
- Department of Pathology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Xu-Ying Qin
- Department of Molecular Pathology, Beijing Taipu-Shunkang Institute for Laboratory Medicine, Beijing, China
| | - Su-Wen Chen
- Department of Birth Control, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Peng Wang
- Department of Molecular Pathology, Beijing Taipu-Shunkang Institute for Laboratory Medicine, Beijing, China
| | - Yang Zhan
- Department of Pathology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Ping-Ping Zhong
- Department of Pathology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Natalia Buza
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Yu-Lan Jin
- Department of Pathology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Bing-Quan Wu
- Department of Pathology, Peking University Health Sciences Center, Beijing, China
| | - Pei Hui
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA.
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Subbaiah M, Raj A, Durairaj J, Keepanasseril A. Role of hysteroscopy and ultrasound in early identification of post-molar gestational trophoblastic neoplasia. Eur J Obstet Gynecol Reprod Biol 2020; 254:33-37. [PMID: 32920420 DOI: 10.1016/j.ejogrb.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/28/2020] [Accepted: 09/04/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the role of hysteroscopy and ultrasound in early identification of gestational trophoblastic neoplasia (GTN) after molar evacuation. METHODS This was a prospective study involving 52 women with an ultrasound diagnosis of complete hydatidiform mole, attending a tertiary centre in south India between August 2016 and August 2019. Baseline characteristics such as age, serum beta-human chorionic gonadotropin(β-hCG) level, gestational age, and uterine size were noted. After the evacuation of molar pregnancy, weekly follow-up with β-hCG was performed, until three consecutive values were normal and then monthly for six months. Findings of transvaginal ultrasound and diagnostic hysteroscopy, performed on follow up at three weeks, were noted. Primary outcome was the development of GTN. Area under the curve(AUC) was calculated to assess the usefulness of these methods in early identification of GTN. RESULTS Thirteen women (25 %) developed GTN during follow up, within 6 months. Twenty six(50 %) cases had high-risk molar pregnancy. Positive findings on hysteroscopy and ultrasonography were noted in 44.2 % and 19.2 % respectively. AUC was 0.83(95 % CI, 0.70-0.97) for ultrasound and 0.82(95 % CI, 0.72-.92) for hysteroscopy. Sensitivity and specificity were 69.2 % and 97.4 % for ultrasound and it was 92.3 % and 71.8 % respectively for hysteroscopy in identifying those who developed GTN on follow-up. CONCLUSIONS Transvaginal ultrasound as well as hysteroscopy may help in early identification of women at risk of developing GTN following a molar evacuation. Being a non-invasive method with similar discriminative value, ultrasonographic evaluation may be used for early identification of women with GTN after validation in future studies.
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Affiliation(s)
- Murali Subbaiah
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India.
| | - Ashwini Raj
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India
| | - Jayalakshmi Durairaj
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India
| | - Anish Keepanasseril
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India
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Hoeijmakers YM, Sweep FCGJ, Lok CAR, Ottevanger PB. Risk factors for second-line dactinomycin failure after methotrexate treatment for low-risk gestational trophoblastic neoplasia: a retrospective study. BJOG 2020; 127:1139-1145. [PMID: 32141676 PMCID: PMC7383780 DOI: 10.1111/1471-0528.16198] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To find risk factors for second-line dactinomycin failure in patients with low-risk gestational trophoblastic neoplasia (GTN). DESIGN Retrospective multicentre study. SETTING Tertiary reference centre. POPULATION Patients with low-risk GTN, treated with dactinomycin after methotrexate (MTX) failure. METHODS Retrospective analysis of 45 patients with low-risk GTN treated with dactinomycin after MTX failure, registered between 2006 and 2018. MAIN OUTCOME MEASURES Treatment outcome and risk factors for second-line dactinomycin failure. RESULTS Thirty patients (66.7%) were cured and 15 patients (33.3%) required third-line therapy. Type of antecedent pregnancy and hCG levels pre-dactinomycin were risk factors for failure in univariate analysis (odds ratio [OR] 19.30, 95% CI 2.04-182.60, P = 0.01 and OR 2.77, 95% CI 1.18-6.50, P = 0.02, respectively). Level of hCG pre-dactinomycin remained a significant risk factor in multivariate analysis (OR 2.93, 95% CI 1.02-8.40, P = 0.045). Complete remission (CR) was achieved in 83.3% of patients with pre-dactinomycin hCG levels <10 ng/ml, in 75% with hCG levels between 10 and 20 ng/ml, in 66.7% with hCG levels between 20 and 30 ng/ml, and in 50% with hCG levels between 30 and 40 ng/ml. No patients with hCG levels >40 ng/ml achieved CR. Patients with dactinomycin failure were treated surgically and/or with multi-chemotherapy; all except one achieved CR. CONCLUSIONS Treatment with dactinomycin after MTX failure in patients with low-risk GTN resulted in CR in 66.7%. Chance of curative treatment with dactinomycin is strongly related to the hCG level. TWEETABLE ABSTRACT Chance of curative treatment with dactinomycin after MTX failure in GTN patients is strongly related to the level of hCG pre-dactinomycin.
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Affiliation(s)
- YM Hoeijmakers
- Department of Obstetrics and GynaecologyRadboud University Medical CentreNijmegenthe Netherlands
| | - FCGJ Sweep
- Department of Laboratory MedicineRadboud University Medical CentreNijmegenthe Netherlands
| | - CAR Lok
- Department of Gynaecologic OncologyAntoni van LeeuwenhoekAmsterdamthe Netherlands
- Cancer Institute AmsterdamAmsterdamthe Netherlands
| | - PB Ottevanger
- Department of Medical OncologyRadboud University Medical CentreNijmegenthe Netherlands
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Hafezi M, Chekini Z, Zamanian M. Which One Is More Prominent in Recurrent Hydatidiform Mole, Ovum or Sperm? INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2020; 14:154-158. [PMID: 32681629 PMCID: PMC7382686 DOI: 10.22074/ijfs.2020.6017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 01/14/2020] [Indexed: 11/04/2022]
Abstract
Recurrent hydatidiform mole is defined as episodes of two molar pregnancies in a female. Often, complete moles only derive androgenic nuclear genome. We described two cases with repeated molar pregnancies attempted to prevent future episodes by performing intracytoplasmic sperm injection (ICSI) and preimplantation genetic diagnosis (PGD) to assess genetic disorders. The first patient had previously six complete molar pregnancies and advised to carry out ICSI with ovum donation to achieve a normal pregnancy. The second case had previously five molar pregnancies and no XY embryos from the ICSI/PGD process. We had to (at the insistence of the patient) transfer XX embryos in this patient which resulted in a complete hydatidiform mole (CHM). Hence, available data based on our patients and previous studies demonstrated that oocyte might play a critical role in the pathophysiology of recurrent hydatidiform mole, while it has not been often considered.
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Affiliation(s)
- Maryam Hafezi
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran. Electronic Address:
| | - Zahra Chekini
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Mohammadreza Zamanian
- Department of Genetics, Reproductive Biomedicine Research Center , Royan Institute for Reproductive Biomedicine, ACECR, Tehran , Iran
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Yamamoto E, Trinh TD, Sekiya Y, Tamakoshi K, Nguyen XP, Nishino K, Niimi K, Kotani T, Kajiyama H, Shibata K, Le QT, Kikkawa F. The management of hydatidiform mole using prophylactic chemotherapy and hysterectomy for high-risk patients decreased the incidence of gestational trophoblastic neoplasia in Vietnam: a retrospective observational study. NAGOYA JOURNAL OF MEDICAL SCIENCE 2020; 82:183-191. [PMID: 32581399 PMCID: PMC7276412 DOI: 10.18999/nagjms.82.2.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/09/2019] [Indexed: 11/30/2022]
Abstract
The management of hydatidiform mole (HM) and the incidence of post-molar gestational trophoblastic neoplasia (GTN) in Vietnam has not been reported to date. This study aimed to study the incidence of HM and post-molar GTN and identify factors associated with post-molar GTN at a tertiary hospital in Vietnam. Five hundred and eighty-four patients who were treated for HM at Tu Du Hospital between January and December 2010 were included in this study. The mean age and gestational age at the first evacuation were 28.8 years old and 11.0 weeks, respectively. After the initial evacuation and pathological examination, 87 patients who were older than 40 or did not wish to have children underwent a hysterectomy, while the others underwent second curettage. All 472 patients who had human chorionic gonadotropin (hCG) ≥ 100,000 IU/L before treatment received one cycle of methotrexate with folinic acid as prophylactic chemotherapy. The incidence of HM was 11.1 per 1,000 deliveries; 47 patients (8.0%) developed post-molar GTN. Gestational week, hCG level at one week after the first evacuation, and pathological remnants were significantly associated with the development of post-molar GTN. The results of this study suggest that prophylactic chemotherapy and hysterectomy may be useful for high-risk HM patients to reduce post-molar GTN in settings in which the risk of post-molar GTN and loss to follow-up after HM are greater and hCG measurements and appropriate GTN treatments are unavailable. However, future studies on the long-term outcomes and side effects of prophylactic therapies on HM are required.
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Affiliation(s)
- Eiko Yamamoto
- Department of Healthcare Administrationy, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tien Dat Trinh
- Department of Obstetrics and Gynecology, Tu Du Hospital, Ho Chi Minh, Vietnam
| | - Yoko Sekiya
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Koji Tamakoshi
- Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Xuan Phuoc Nguyen
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Nishino
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomomi Kotani
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kiyosumi Shibata
- Department of Obstetrics and Gynecology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Quang Thanh Le
- Department of Obstetrics and Gynecology, Tu Du Hospital, Ho Chi Minh, Vietnam
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Bedrick BS, Kazarian GS, Greenwade MM, Spies N, Chen T, Maluf H, Dicke J, Thaker PH. Adenomyosis presenting as a molar pregnancy: A case report. Gynecol Oncol Rep 2020; 32:100573. [PMID: 32373693 PMCID: PMC7191572 DOI: 10.1016/j.gore.2020.100573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 11/17/2022] Open
Abstract
•We present a case of atypical adenomyosis with clinical, laboratory, and imaging findings suggestive of a molar pregnancy.•Adenomyosis causes uterine enlargement and may appear cystic on vaginal ultrasound.•Falsely elevated β-hCG in the setting of obesity and hypothyroidism may complicate diagnosing abnormal uterine bleeding.
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Affiliation(s)
| | | | - Molly M. Greenwade
- Division of Gynecologic Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Nick Spies
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Tiffany Chen
- Department of Pathology, Washington University School of Medicine, St. Louis, MO, USA
| | - Horacio Maluf
- Department of Pathology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey Dicke
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Premal H. Thaker
- Division of Gynecologic Oncology, Washington University School of Medicine, St. Louis, MO, USA
- Corresponding author at: Washington University School of Medicine, 660 South Euclid Avenue, Mail Stop 8064-37-905, St. Louis, MO 63110, USA.
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Pekcan MK, Tokmak A, Topfedaisi Ozkan N, Ozaksit G, Kosem A, Erel O, Meydanli M. Thiol/Disulfide Homeostasis in Patients with Molar Pregnancies. Fetal Pediatr Pathol 2020; 39:99-106. [PMID: 31304870 DOI: 10.1080/15513815.2019.1639090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: We aimed to investigate serum dynamic thiol and disulfide levels in patients with molar pregnancy (MP), and compare these concentrations with those of healthy pregnant women. Materials and Methods: Forty-one patients who were diagnosed with MP and 41 gestational age-matched healthy pregnant women were included in this prospective study. MP cases were separated in two groups as complete hydatidiform mole (CHM) and partial hydatidiform mole (PHM). Demographic features and thiol/disulfide homeostasis were recorded for each woman. Results: There was a significant correlation between the decrease in the total thiol and native thiol levels in MP patients. However, no significant difference was observed between CHM and PHM groups in terms of serum disulfide levels. Conclusion: OS is increased in MPs both in complete and partial moles, as determined by thiol/disulfide analysis.
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Affiliation(s)
- Meryem Kuru Pekcan
- Department of Obstetrics and Gynecology, Dr. Zekai Tahir Burak Women's Health Education and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Aytekin Tokmak
- Department of Obstetrics and Gynecology, Dr. Zekai Tahir Burak Women's Health Education and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Nazli Topfedaisi Ozkan
- Department of Obstetrics and Gynecology, Dr. Zekai Tahir Burak Women's Health Education and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Gulnur Ozaksit
- Department of Obstetrics and Gynecology, Dr. Zekai Tahir Burak Women's Health Education and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Arzu Kosem
- Department of Clinical Biochemistry, Ankara Numune Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Ozcan Erel
- Department of Clinical Biochemistry, Faculty of Medicine, Yildirim Beyazit University, Ankara, Turkey
| | - Mutlu Meydanli
- Department of Obstetrics and Gynecology, Dr. Zekai Tahir Burak Women's Health Education and Research Hospital, University of Health Sciences, Ankara, Turkey
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Yamamoto E, Nishino K, Niimi K, Watanabe E, Oda Y, Ino K, Kikkawa F. Evaluation of a routine second curettage for hydatidiform mole: a cohort study. Int J Clin Oncol 2020; 25:1178-1186. [PMID: 32144509 DOI: 10.1007/s10147-020-01640-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 02/20/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate routine second curettage for hydatidiform mole (HM) by comparing the characteristics and outcomes of developing gestational trophoblastic neoplasia (GTN). STUDY DESIGN This was a cohort study including 173 patients diagnosed with HM between January 2002 and August 2019 who were followed up at Nagoya University Hospital, Japan. After an evacuation, 105 and 68 patients were managed with the routine method (routine group) and elective method (elective group) for a second curettage, respectively. The routine second curettage was performed around 7 days after the first evacuation. Patients in the elective group underwent a second curettage if there was ultrasonographic evidence of molar remnants in the uterine cavity. Socio-clinical factors were retrospectively compared between the routine and elective groups, and between patients showing regression and those who developed GTN. RESULTS The incidence of GTN was 15.2% in the routine group and 20.6% in the elective group, and the difference was not significant (P = 0.364). The median GTN risk score was significantly higher in the routine group than in the elective group (P = 0.033). Presence of a complete HM, gestational age, and a pre-treatment human chorionic gonadotropin level of ≥ 200,000 mIU/mL were independent risk factors for GTN in molar patients. CONCLUSION The incidence of GTN was unchanged but the risk score of GTN was higher in the routine group than in the elective group. Routine second curettage may not be necessary, but further study will be needed to confirm this.
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Affiliation(s)
- Eiko Yamamoto
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Kimihiro Nishino
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kaoru Niimi
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Eri Watanabe
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yukari Oda
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kazuhiko Ino
- Department of Obstetrics and Gynecology, Wakayama Medical University School of Medicine, 811-1 Kimiidera, Wakayama, 641-0012, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Cho HW, Ouh YT, Min KJ, Lee NW, Lee S, Song JY, Hong JH, Lee JK. The impact of previous cesarean section (C/S) on the risk for post-molar gestational trophoblastic neoplasia (GTN). Gynecol Oncol 2020; 156:606-610. [DOI: 10.1016/j.ygyno.2019.11.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 11/22/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
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Sharami SRY, Saffarieh E. A review on management of gestational trophoblastic neoplasia. J Family Med Prim Care 2020; 9:1287-1295. [PMID: 32509606 PMCID: PMC7266251 DOI: 10.4103/jfmpc.jfmpc_876_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The rare presence of malignant cancerous cells afar any type of pregnancy is known as gestational trophoblastic neoplasia (GTN). GTN are benign lesions which mostly happen due to the activity of extravillous trophoblast cells and the placental villous tree development. These kinds of diseases would be occurring mainly due to the following clinicopathologic conditions: (I) existence of epithelioid trophoblastic tumor (ETT), (II) rare type of choriocarcinoma cancer, (III) gestational trophoblastic tumor of mole, and (IV) the rare malignant tumor of placental site trophoblastic tumor. OBJECTIVE This comprehensive study is trying to review the most recent approaches in comprehension of pathogenesis, more precise diagnosis, and also the most effective therapeutic procedures for patients who suffer from GTN disorders. MATERIALS AND METHOD A comprehensive research was carried out on scientific databases of Science Citation Index (SCI), MEDLINE, EMBASE, HMIC, PubMed, CINAHL, Google Scholar, Cochrane Database of Systematic Reviews (CDSR), and PsycINFO over the time period of 2005 to 2019. The keywords which applied for discovering more related records were including: Gestational trophoblastic diseases (GTD), Gestational trophoblastic neoplasia (GTN), molar pregnancy, choriocarcinoma, human chorionic gonadotropin (hCG), diagnosis, management and treatment. CONCLUSION In spite of the fact that GTN patients are treated with conventional surgical therapies or/and chemotherapy, in some patients with resistant disease, these therapies may not be effective and patients may die. Some novel remedial agents are required for decreasing the level of toxicity caused through administering conventional chemotherapy and also treating the patients who suffer from refractory or resistant disease. The newest issues are related to GTN diagnosis, process of progression of hydatidiform mole (HM) to GTN, and the issue of GTN drug resistance. In this regard, we should have a comprehensive knowledge on GTN genetics for answering all the available questions about this disorder.
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Affiliation(s)
| | - Elham Saffarieh
- Abnormal Uterine Bleeding Research Center, Semnan University of Medical Science, Semnan, Iran
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Effectiveness and toxicity of second-line actinomycin D in patients with methotrexate-resistant postmolar low-risk gestational trophoblastic neoplasia. Gynecol Oncol 2020; 157:372-378. [PMID: 32037196 DOI: 10.1016/j.ygyno.2020.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 01/30/2020] [Accepted: 02/01/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate both the outcomes and toxicity of second-line actinomycin D (ActD) chemotherapy in methotrexate (MTX) - resistant low-risk postmolar gestational trophoblastic neoplasia (GTN) with 5-day ActD versus pulsed ActD. METHODS This retrospective cohort study included patients with MTX-resistant low-risk postmolar GTN from 1974 to 2016. Second-line chemotherapy consisted of 5-day ActD (10-12 μg/kg per day for 5 days every 14 days) or biweekly ActD (1.25 mg/m2 every 2 weeks). Data on patient characteristics, disease presentation, treatment outcome, and toxicity were collected. RESULTS Sixty-eight MTX-resistant patients receiving ActD as second-line chemotherapy were identified (5-day ActD, 53 patients; pulsed ActD, 15 patients). No significant differences were observed in patient/disease characteristics and sustained remission (overall rate 72%) between second-line ActD regimens. Time to hCG remission was significantly faster (median 21 vs 47 days, p = .04) and required fewer treatment cycles (median 1 vs 2, p < .001) with 5-day ActD. Thrombocytopenia was only observed with 5-day ActD (64.6 vs 0%, p < .001). The frequency (60.4 vs 16.7%, p = .009) and severity (grade 3: 37.9 vs 0%, p = .045) of oral mucositis was significantly higher with 5-day ActD. Grade 2 alopecia was significantly more frequent (70.6 vs 16.7%, p = .02) with 5-day ActD. CONCLUSIONS While 5-day ActD and pulsed ActD achieve comparable remission rates, due to its reduced toxicity, ease of administration, and patient convenience, pulsed ActD should be the treatment of choice for MTX-resistant postmolar low-risk GTN.
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Liu Y, Zheng X, Wang Y, Li Y, Liu C. Identification of a hydatidiform mole in twin pregnancy following assisted reproduction. J Assist Reprod Genet 2019; 37:603-610. [PMID: 31833013 DOI: 10.1007/s10815-019-01650-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE The aim of this study was to identify a co-existing hydatidiform mole (HM) in twin pregnancy from the abnormal mixed-genomic products of conception (POC) after assisted reproduction by histopathological review, evaluation of p57kip2 immunostaining and short tandem repeat genotyping. METHODS Thirty-seven patients were collected with suspicion for HM by pathological morphology. They had two embryos individually transferred to their uterus after in vitro fertilization and presented two gestational sacs with undeveloped embryos or one sac with an abnormal area by ultrasonography. RESULTS Thirty patients were diagnosed as singleton pregnancy, including twenty-two non-molar gestations, six trisomy gestations, one homozygous complete mole and one heterozygous partial mole. Although six patients had ultrasonic imaging of two gestational sacs, the embryonic components in the vacant sac might fade away after transferring. Other seven patients were considered as twin pregnancy by the allelic genotype from two individual conceptions. For the patients with uniform p57kip2 positivity, excessive paternal alleles indicated the potential partial HM in the twin pregnancy. For the patients demonstrated divergent and/or discordant p57kip2 immunostaining, twin pregnancy with co-existing complete HM or mosaic conception were confirmed by genotyping of different villi population respectively. These patients were monitored by serum β-HCG, while one twin pregnancy with complete mole suffered invasive mole and received chemotherapy. CONCLUSIONS A strategy composed of selective clinicopathological screening, immunohistochemical interpretation and accurate genotyping is recommended for diagnostically challenging mixed-genomic POC of potential twin pregnancy with HM, especially to differentiate a non-molar mosaic conception from a partial mole.
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Affiliation(s)
- Yan Liu
- Department of Pathology, School of Basic Medical Sciences, Third Hospital, Peking University Health Science Center, Beijing, 100191, China.
| | - Xingzheng Zheng
- Department of Pathology, Capital Medical University Beijing Obstetrics and Gynecology Hospital, Beijing, 100123, China
| | - Yuxiang Wang
- Department of Pathology, School of Basic Medical Sciences, Third Hospital, Peking University Health Science Center, Beijing, 100191, China
| | - Yan Li
- Department of Pathology, School of Basic Medical Sciences, Third Hospital, Peking University Health Science Center, Beijing, 100191, China
| | - Congrong Liu
- Department of Pathology, School of Basic Medical Sciences, Third Hospital, Peking University Health Science Center, Beijing, 100191, China.
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Gestational Trophoblastic Neoplasia After Human Chorionic Gonadotropin Normalization Following Molar Pregnancy. Obstet Gynecol 2019; 135:12-23. [PMID: 31809433 PMCID: PMC10122913 DOI: 10.1097/aog.0000000000003566] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the incidence of gestational trophoblastic neoplasia following complete and partial molar pregnancy after reaching normal human chorionic gonadotropin (hCG) levels to guide evidence-based follow-up recommendations. DATA SOURCES MEDLINE, EMBASE, Web of Science, POPLINE, Cochrane, and ClinicalTrials.gov were searched from inception to November 2018, using the intersection of "gestational trophoblastic disease," "molar pregnancy," and "human chorionic gonadotropin" themes. METHODS OF STUDY SELECTION Search results were screened to identify cohort studies of molar pregnancy reporting gestational trophoblastic neoplasia development, with at least 6 months of intended normal hCG follow-up. TABULATION, INTEGRATION, AND RESULTS Two reviewers independently identified articles for inclusion. Data were extracted using a standardized form. For meta-analysis, cumulative incidence of gestational trophoblastic neoplasia, with CIs by the Agresti-Coull method, and pooled risk ratios (RRs) comparing complete and partial mole were calculated. Among the 19 eligible studies that reported adequate data for inclusion in the primary meta-analysis, we found low incidence of gestational trophoblastic neoplasia after normal hCG level following both complete mole (64/18,357, 0.35%, 95% CI 0.27-0.45%), and partial mole (5/14,864, 0.03%, 95% CI 0.01-0.08%). There was a significantly higher risk of gestational trophoblastic neoplasia after complete compared with partial molar pregnancy (RR 4.72, 95% CI 1.81-12.3, P=.002). Among gestational trophoblastic neoplasia cases after normal hCG level following complete mole, 89.6% occurred when the time from evacuation to normalization was 56 days or longer, and 60.7% were diagnosed beyond the commonly recommended 6-month surveillance interval. Sensitivity analyses, including those limiting to studies at low risk of bias, did not significantly affect results. We found an overall incidence of gestational trophoblastic neoplasia of 15.7% for complete mole (1,354/8,611, 95% CI 15.0-16.5%) and 3.95% for partial mole (221/5,593, 95% CI 3.47-4.50%). CONCLUSION Gestational trophoblastic neoplasia development after normal hCG level following molar pregnancy is rare. Recommendations for frequency and duration of hCG follow-up can be minimized to lessen burden on patients and informed by the type of molar pregnancy and time interval from uterine evacuation to hCG normalization. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019116414.
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Abu-Rustum NR, Yashar CM, Bean S, Bradley K, Campos SM, Chon HS, Chu C, Cohn D, Crispens MA, Damast S, Dorigo O, Eifel PJ, Fisher CM, Frederick P, Gaffney DK, Han E, Huh WK, Lurain JR, Mariani A, Mutch D, Nagel C, Nekhlyudov L, Fader AN, Remmenga SW, Reynolds RK, Sisodia R, Tillmanns T, Ueda S, Wyse E, McMillian NR, Scavone J. Gestational Trophoblastic Neoplasia, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:1374-1391. [PMID: 31693991 DOI: 10.6004/jnccn.2019.0053] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Gestational trophoblastic neoplasia (GTN), a subset of gestational trophoblastic disease (GTD), occurs when tumors develop in the cells that would normally form the placenta during pregnancy. The NCCN Guidelines for Gestational Trophoblastic Neoplasia provides treatment recommendations for various types of GTD including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor.
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Affiliation(s)
| | | | | | | | | | | | | | - David Cohn
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | | | | | | | - John R Lurain
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - David Mutch
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Christa Nagel
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | - Todd Tillmanns
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Stefanie Ueda
- UCSF Helen Diller Family Comprehensive Cancer Center
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