Temporal trends in incidence and outcome of hydatidiform mole: a retrospective cohort study

Appraisal of hydatidiform mole incidence and registration rates in Ireland following the establishment of a National Gestational Trophoblastic Disease Registry

AIMS

This study aimed to re-evaluate the incidence of hydatidiform mole (HM) and determine gestational trophoblastic disease (GTD) registration rates in Ireland following the establishment of the National GTD Registry in 2017.

METHODS

We performed a 3-year retrospective audit of HM cases (January 2017 to December 2019) reported in our centre. In 2019, we surveyed Irish pathology laboratories to determine the number of HMs diagnosed nationally and compared this data to that recorded in the National GTD Registry. Additionally, we compared both local and national HM incidence rates to those reported internationally.

RESULTS

In the 3-year local audit, we identified 87 HMs among 1856 products of conception (POCs) providing a local HM incidence rate of 3.92 per 1000 births. The 1-year pathology survey recorded 170 HMs in 6008 POCs, yielding a national incidence rate of 2.86 per 1000 births. Importantly, the local HM incidence rate exceeded the national incidence rate by 37% and the local partial HM incidence (1 in 296 births) was 64% higher than the nationally incidence rate (1 in 484 births). Notably, 42% of the HM and atypical POCs diagnosed nationally were not reported to the National GTD Registry.

CONCLUSIONS

Our study reveals increased HM incidence rates both locally and nationally compared with previous Irish studies. The higher local PHM incidence may reflect more limited access to ploidy analysis in other pathology laboratories nationally. Significantly, almost half of the women with diagnosed or suspected HM were not registered with the National GTD Centre.

Practical guidelines of the EOTTD for pathological and genetic diagnosis of hydatidiform moles

Hydatidiform moles are rare and thus most pathologists and geneticists have little experience with their diagnosis. It is important to promptly and correctly identify hydatidiform moles given that they are premalignant disorders associated with a risk of persistent gestational trophoblastic disease and gestational trophoblastic neoplasia. Improvement in diagnosis can be achieved with uniformization of diagnostic criteria and establishment of algorithms. To this aim, the Pathology and Genetics Working Party of the European Organisation for Treatment of Trophoblastic Diseases has developed guidelines that describe the pathological criteria and ancillary techniques that can be used in the differential diagnosis of hydatidiform moles. These guidelines are based on the best available evidence in the literature, professional experience and consensus of the experts' group involved in its development.

Changing Trends in the Clinical Presentation and Incidence of Molar Pregnancy in Saudi Arabia: A 30-Year Retrospective Analysis

Background Molar pregnancy (MP) incidence and clinical presentation vary significantly worldwide. Recent trends show changes in its clinical representation and incidence, particularly with the adoption of early diagnosis using first-trimester ultrasonography, which has reduced the prevalence of classical second-trimester presentations. This study aimed to analyze the changes in clinical presentation and incidence of MP among the Saudi population over the past 30 years. Methods In this retrospective study at King Fahad University Hospital, 121 complete mole (CM) pregnancy cases diagnosed and pathologically confirmed were reviewed. This included 87 cases from 2007 to 2022 (recent group) and 34 cases from 1992 to 2006 (older group). Cases of CM diagnosed before January 1992 and other diagnoses such as PM, invasive mole, or choriocarcinoma were excluded; thus, this study is focused on CM in particular. We compared patient age, gravidity, parity, abortion history, gestational age at diagnosis, hyperemesis gravidarum symptoms, anemia symptoms, and hemoglobin levels. Classical symptoms and signs related to CM were also reviewed. Data were analyzed using Microsoft Excel 2021 (Microsoft Corporation, Redmond, Washington, United States) and presented as mean, frequency, and percentage, with chi-squared tests for categorical variables; p<0.05 was considered statistically significant. Results The incidence of CM declined from 2.1 per 1,000 deliveries to 0.9 per 1,000 deliveries. Vaginal bleeding was the most common presentation in both the older (91.9%) and recent (67.6%) groups. Hyperemesis gravidarum prevalence was similar in both groups. Theca-lutein cysts were more frequent in the older group (27.5%) than the recent group (8.8%). A significant difference was observed in the occurrence of a large-for-date uterus between the older (63.20%) and recent (23.5%) groups. Notably, 14.7% of patients in the recent group were asymptomatic at diagnosis. Anemia was present in 46 cases (52.8%) of the older group but absent in the recent group, and preeclampsia occurred in 10 cases (11.4%) of the older group but not in the recent group. Conclusions Advancements in ultrasound technology, including transvaginal probes with Doppler capabilities, have enabled earlier pregnancy diagnosis, as early as five to six weeks of gestation. Many MP are now diagnosed in the first trimester without the classic clinical symptoms or "snow-storm" ultrasound appearance. The availability of sensitive beta-human chorionic gonadotropin assays has led to the early termination of these pregnancies, marking a significant shift in the management of MP.

Association between gestational trophoblastic disease (GTD) history and clinical outcomes in in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles

BACKGROUND

Gestational trophoblastic disease (GTD) usually affects young women of childbearing age. After treatment for GTD, 86% of women wish to achieve pregnancy. On account of the impacts of GTD and treatments as well as patient anxiety, large numbers of couples turn to assisted reproductive technology (ART), especially in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). But few studies have investigated whether a history of GTD affects the outcomes of IVF/ICSI in secondary infertile patients and how it occurs. We investigate whether a history of GTD affects the IVF/ICSI outcomes and the live birth rates in women with secondary infertility.

METHODS

This retrospective cohort study enrolled 176 women with secondary infertility who underwent IVF/ICSI treatment at the reproductive medical center of Nanjing Drum Tower Hospital from January 1, 2016, to December 31, 2020. Participants were divided into the GTD group (44 women with GTD history) and control group (132 women without GTD history matched from 8318 secondary infertile women). The control group and the study group were matched at a ratio of 3:1 according to patient age, infertility duration, number of cycles and body mass index (BMI). We assessed retrieved oocytes and high-grade embryos, biochemical pregnancy, miscarriage, ectopic pregnancy, gestational age at delivery, delivery mode and live birth rates.

RESULT(S)

We found a significantly reduced live-birth rate (34.1% vs 66.7%) associated with IVF/ICSI cycles in patients with a GTD history compared to those without a GTD history. The biochemical pregnancy and miscarriage rates of the GTD group were slightly higher than those of the control group. In addition, there was a difference in gestational age at delivery between the GTD and control groups (p < 0.001) but no differences in the mode of delivery (p = 0.267). Furthermore, the number of abandoned embryos in the GTD group was greater than that in the control group (p = 0.018), and the number of good-quality embryos was less than that in the control group (p = 0.019). The endometrial thickness was thinner (p < 0.001) in the GTD group. Immunohistochemistry (IHC) showed abnormal endometrial receptivity in the GTD group.

CONCLUSION(S)

The GTD history of patients undergoing IVF/ICSI cycles had an impact on the live-birth rate and gestational age at delivery, which might result from the thinner endometrium and abnormal endometrial receptivity before embryo transfer.

Advances in the diagnosis and early management of gestational trophoblastic disease

Gestational trophoblastic disease describes a group of rare pregnancy related disorders that span a spectrum of premalignant and malignant conditions. Hydatidiform mole (also termed molar pregnancy) is the most common form of this disease. Hydatidiform mole describes an abnormal conceptus containing two copies of the paternal genome, which is classified as partial when the maternal genome is present or complete when the maternal genome is absent. Hydatidiform mole typically presents in the first trimester with irregular vaginal bleeding and can be suspected on ultrasound but confirmation requires histopathological evaluation of the products of conception. Most molar pregnancies resolve without treatment after uterine evacuation, but occasionally the disease persists and develops into gestational trophoblastic neoplasia. Close monitoring of women after molar pregnancy, with regular measurement of human chorionic gonadotrophin concentrations, allows for early detection of malignancy. Given the rarity of the disease, clinical management and treatment is best provided in specialist centres where very high cure rates are achievable. This review looks at advances in the diagnosis and early management of gestational trophoblastic disease and highlights updates to disease classification and clinical guidelines. Use of molecular genotyping for improved diagnostic accuracy and risk stratification is reviewed and future biomarkers for the earlier detection of malignancy are considered.

Refined diagnosis of hydatidiform moles with p57 immunohistochemistry and molecular genotyping: updated analysis of a prospective series of 2217 cases

Immunohistochemical analysis of p57 expression and molecular genotyping accurately subclassify molar specimens into complete hydatidiform mole (CHM) and partial hydatidiform mole (PHM) and distinguish these from nonmolar specimens. Characteristics of a prospective series of potentially molar specimens analyzed in a large gynecologic pathology practice are summarized. Of 2217 cases (2160 uterine, 57 ectopic), 2080 (94%) were successfully classified: 571 CHMs (570 uterine, 1 ectopic), 498 PHMs (497 uterine, 1 ectopic), 900 nonmolar (including 147 trisomies, 19 digynic triploids, and 4 donor egg conceptions), and 56 androgenetic/biparental mosaics; 137 were complex or unsatisfactory and not definitively classified. CHMs dominated in patients aged < 21 and >45 years and were the only kind of molar conception found in the latter group. Of 564 successfully immunostained CHMs, 563 (99.8%) were p57-negative (1 p57-positive [retained maternal chromosome 11] androgenetic by genotyping). Of 153 genotyped CHMs, 148 (96.7%) were androgenetic (85% monospermic) and 5 were biparental, the latter likely familial biparental hydatidiform moles. Of 486 successfully immunostained PHMs, 481 (99%) were p57-positive (3 p57-negative [loss of maternal chromosome 11], 2 unknown mechanism). Of 497 genotyped PHMs, 484 (97%) were diandric triploid (99% dispermic) and 13 were triandric tetraploid (all at least dispermic). Of 56 androgenetic/biparental mosaics, 37 had a p57-negative complete molar component (16 confirmed as androgenetic by genotyping). p57 expression is highly correlated with genotyping, serving as a reliable marker for CHMs, and identifies molar components and androgenetic cell lines in mosaic conceptions. Correlation of morphology, p57 expression, genotyping data, and history are required to recognize familial biparental hydatidiform moles and donor egg conceptions, as the former can be misclassified as nonmolar and the latter can be misclassified as dispermic CHM on the basis of isolated genotyping results.

Decreasing incidence of registered hydatidiform moles in Denmark 1999-2014

Incidences of hydatidiform mole (HM) registered in European countries varies from 0.98/1000 to 2.17/1000 deliveries, while higher incidences have been reported in other parts of the world. We calculated the incidence by selecting data on HMs classified as ”first”, “second” and “third” from 01.01.1999 to 31.12.2014 registered in the Danish Pathology Registry, which we previously showed to be the most complete data source on the number of HMs in Denmark. In the study period, 1976 first HMs were registered; 1080 (55%) were classified as PHMs (partial HMs) and 896 (45%) as NPHMs (HMs not registered as PHMs). The average incidence of HM was 1.98/1000 deliveries. The incidence of PHM was 1.08/1000 deliveries and the incidence of NPHM was 0.90/1000 deliveries. Forty HMs were registered as second HMs; 85% (34/40) were of the same histopathological type as the first HM. The registered incidence of HM decreased from 2.55/1000 deliveries in 1999 to 1.61/1000 deliveries in 2014 (p < 0.005). The decrease in the incidence of HM was identical with a decrease in the incidence of PHM. New medical practices such as medical abortion and only forwarding selected pregnancy products for histopathologic examination may cause a declining number of HMs registered.

Practical clinical guidelines of the EOTTD for treatment and referral of gestational trophoblastic disease

BACKGROUND AND AIM

Gestational trophoblastic disease (GTD) is a heterogeneous group of disorders characterised by abnormal proliferation of trophoblastic tissue. Since GTD and its malignant sequel gestational trophoblastic neoplasia (GTN) are rare diseases, little evidence is available from randomised controlled trials on optimal treatment and follow-up. Treatment protocols vary within Europe, and even between different centres within countries. One of the goals of the 'European Organisation for Treatment of Trophoblastic Diseases' (EOTTD) is to harmonise treatment in Europe. To provide a basis for European standardisation of definitions, treatment and follow-up protocols in GTD, we composed a set of guidelines for minimal requirements and optimal management of GTD.

METHODS

Members from each EOTTD country attended multiple workshops during annual EOTTD meetings. Clinical guidelines were formulated by consensus and evidence where available. The following guidelines were discussed: diagnostics of GTD and GTN, treatment of low-risk GTN, high-risk GTN, ultra-high-risk GTN, placental site and epithelioid trophoblastic tumours and follow-up.

RESULTS

Between 40 and 65 EOTTD members from 17 European countries and 7 non-European countries attended the clinical workshops held on 6 occasions. Flow diagrams for patient management were composed to display minimum and best practice for most treatment situations. New agreed definitions of recurrence and chemotherapy resistance were formulated.

CONCLUSIONS

Despite the many differences between and within the participating countries, an important step in uniform treatment of GTD and GTN within Europe was made by the Clinical Working Party of the EOTTD. This is an example on how guidelines and harmonisation can be achieved within international networks.

Incidence and outcome of gestational trophoblastic disease in lower Egypt

BACKGROUND

Gestational trophoblastic disease (GTD) defines a spectrum of proliferative disorders of trophoblastic epithelium of the placenta. Incidence, risk factors, and outcome may differ from one country to another.

OBJECTIVE

To describe incidence, patient characteristics, treatment modalities, and outcome of GTD at Mansoura University which is a referral center of Lower Egypt.

METHODS

An observational prospective study was conducted at the GTD Clinic of Mansoura University. The patients were recruited for 12 months from September 2015 to August 2016. The patients' characteristics, management, and outcome were reported.

RESULTS

We reported 71 clinically diagnosed GTD cases, 62 of them were histologically confirmed, 58 molar (33 CM and 25 PM) in addition to 4 initially presented GTN cases. Mean age of the studied cases was 26.22 years ± 9.30SD. Mean pre-evacuation hCG was 136170 m.i.u/ml ±175880 SD. Most of the cases diagnosed accidentally after abnormal sonographic findings (53.2%). Rate of progression of CM and PM to GTN was 24.2% and 8%, respectively.

CONCLUSION

The incidence of molar pregnancy and GTN in our locality was estimated to be 13.1 and 3.2 per 1000 live births respectively. We found no significance between CM and PM regarding hCG level, time to hCG normalization, and progression rate to GTN.

Incidence of gestational trophoblastic disease in South Korea: a longitudinal, population-based study

Introduction

We investigated the rate and longitudinal trends of gestational trophoblastic disease (GTD) incidence in the Republic of Korea between 2009 and 2015 using population-based data.

Materials and Methods

Data of patients diagnosed with GTD from 2009 to 2015 were obtained from the Health Insurance Review and Assessment Service/National Inpatient Sample (HIRA-NIS) in the Republic of Korea. The HIRA annually provides the HIRA-NIS, a collection of clinical data from over one million people. For each year, the HIRA-NIS extracted records of 13% of patients admitted at any one time during the year and 1% of all remaining patients using the weighted sample method.

Results

Medical records of 370,117 women with at least one pregnancy (GTD, ectopic pregnancy, abortion, or delivery) were extracted from a total of 4,476,495 records. Of these, 372 episodes of GTD were identified in women with a mean age of 35.4 ± 0.7 years. The incidence rate of GTD was 130 ± 10 cases per 100,000 pregnancies, which was classified as hydatidiform mole (HM), invasive mole, or malignant neoplasm of the placenta with incidence rates of 110 ± 10, 20 ± 0, or 10 ± 0 cases per 100,000 pregnancies, respectively. Incidence of GTD was lowest among women in their late 20 s and early 30 s. Occurrences of HM accounted for 80.3% all GTD cases. Weighted logistic analysis indicated that while age significantly affected the incidence of GTD (odds ratio (OR): 2.46; 95% confidence interval (CI) [1.79–3.37]; P < 0.001), socioeconomic status did not (OR: 1.94; 95% CI [1.0–3.79]; P = 0.05).

Conclusions

In the Republic of Korea, we observed overall incidence rates of GTD and HM of 1.3 and 1.1 per 1,000 pregnancies, respectively, which are similar to those reported in recent Western population-based studies. We also noted that annual incidence rates of GTD stabilized from 2009 to 2015.

Hydatidiform mole: validity of the registration in the Danish National Patient Registry, the Danish Cancer Registry, and the Danish Pathology Registry 1999-2009

Purpose

To examine the validity of registration of hydatidiform mole (HM) in the Danish National Patient Registry (NPR), the Danish Cancer Registry (DCR), and the Danish Pathology Registry (DPR).

Patients and methods

We selected women registered with a first-time HM code in NPR, DCR, and DPR from 1999 to 2009. We found most women registered in DPR. For a random sample of women registered in DPR, the coding was validated by comparing with the pathology report. Completeness and positive predictive value (PPV) of registration with an HM code in NPR and DCR were calculated using DPR as the reference. Details of women registered in NPR or DCR, but not in DPR, were scrutinized.

Results

In NPR and DPR, 1,520 women were identified in total; 1,057 (70%) were found in both registries, 65 (4%) only in NPR, and 398 (26%) only in DPR. In DCR and DPR, 1,498 women were identified in total; 1,174 (78%) in both registries, 47 (3%) only in DCR, and 277 (19%) only in DPR. For 149/150 randomly selected women registered with an HM code in DPR (99%), the pathology report was consistent with the diagnosis of HM. Completeness of NPR was 73% (95% CI: 70%–75%) and PPV was 94% (95% CI: 93%–95%). Completeness of DCR was 72% (95% CI: 69%–75%) in 1999–2003 and 90% (95% CI: 87%–92%) in 2004–2009. PPV of DCR was 96% (95% CI: 95%–97%) throughout the period.

Conclusion

Validation of registry data is important before using these. For research on the number of HMs in Denmark, DPR is the most valid data source. NPR and DCR appear to be equally valid before 2004. However, for research after 2004, DCR should be preferred rather than NPR.