Placental site trophoblastic tumor (PSTT): a case report and review of the literature

Placental site trophoblastic tumor (PSTT), also known as atypical choriocarcinoma, syncytioma, chorioepitheliosis or trophoblastic pseudotumor, is a rare gestational trophoblastic disease (0.25-5% of all trophoblastic tumors) and it is composed by neoplastic proliferation of intermediate trophoblasts at placental implantation site. It consists of aggregates or sheets of large, polyhedral to round, predominantly mononucleated cells with a characteristic vascular and myometrial invasion. Main differential diagnoses are gestational choriocarcinoma (GC) and epitelioid trophoblastic tumor (ETT). We present a case of PSTT in a 25-year-old woman. Neoplastic cells showed moderate/high nuclear pleomorphism, abundant amphophilic, eosinophilic and clear cytoplasm, numerous mitotic figures (10 mitoses/10 HPF), and myometrial invasion. Other features are necrosis, vascular invasion with replacement of myometrial vessels by tumor cells and hemorrhage. The patient showed typical low serum β-hCG levels and high serum humane placental lactogen (hPL) levels.

Diagnosing and treating rare lesions in a low resource setting: lessons from ahybrid epithelioid trophoblastic tumor and choriocarcinoma

OBJECTIVE

To raise awareness of the existence of a rare type of malignant trophoblastic tumor and discuss the diagnostic challenges and management of this lesion in a low resource setting.

CASE REPORT AND INTERVENTION

A 35 -year -old G⁶P³ woman was referred to our facility on account of persistent vaginal bleeding due to a suspected incomplete miscarriage with a cervical mass. Her serum β-HCG was elevated (36,900 mIU/ml) and examination showed a bleeding cervical mass. An initial histopathological diagnosis of moderately differentiated squamous cell carcinoma was reviewed to epithelioid trophoblastic tumor resulting in an extra-fascial hysterectomy. A final histopathological diagnosis of hybrid Epithelioid Trophoblastic Tumor and Choriocarcinoma (ETT/CC) was made after external review and immunohistochemistry. She received subsequent chemotherapy.

CONCLUSION

Epithelioid trophoblastic tumor and its hybrids are difficult to diagnose. They may be diagnosed as moderately differentiated squamous cell carcinoma especially in low resource settings where cervical squamous cell carcinoma is relatively more common. A high index of suspicion, a serum β HCG test and close collaboration between clinicians and pathologists can help make the diagnosis.

FUNDING

None.

Case report of pulmonary epithelial trophoblastic tumor in a young female patient

INTRODUCTION

An epithelial trophoblastic tumor (ETT) is a kind of rare trophoblastic tumor that may have the correlation with a prior gestational event. Especially, the one that appears in the lung is extremely rare.

CASE SUMMARY

Here, we present a 24-year-old female patient with the chief complain of vaginal bleeding for more than 1 month, who was found to have a large mass (7.5 × 4.5 cm) in the right lower lobe, and it was finally confirmed as lung ETT by postoperative pathology after a successful radical resection of the pulmonary lobe.

CONCLUSIONS

As the reason of an extreme rare occurrence of the ETT, doctors can easily misdiagnose the disease. When the patient was found to have a mass with irregular vaginal bleeding and a high level of beta-human chorionic gonadotropin, we need to consider ETT. Currently, surgery is still the most effective method.

Non trophoblastic source of human chorionic gonadotropin - problem in diagnostic accuracy

Human chorionic gonadotropin (hCG) is a polypeptide hormone studied as far as 1912, but researchers has no complete knowledge concerning its biological function. Since 1970' it is known that hCG can be found not only in the urine and serum of pregnant, but in choriocarcinoma and testicular cancer patients. Up-to-date one can distinguish four subtypes of hCG differing in secondary carbohydrate chains configuration as well as it regular and glycosylated forms, but non trophoblastic sources of this hormone, such as pituitary are still not widely known. The article gives an overlook on hCG studies in order to help clinicians in taking wise, evidence based decisions in asymptomatic patients with elevated hCG.

Epithelioid trophoblastic tumor: report of two cases in postmenopausal women with literature review and emphasis on cytological findings

BACKGROUND

Epithelioid trophoblastic tumor (ETT) is a rare gestational trophoblastic neoplasm of intermediate trophoblasts. It was first described by Shih and Kurman [Am J Surg Pathol 1998;22:1393-1403] who outlined its clinicopathologic characteristics in 14 cases, establishing it as a distinct entity of gestational trophoblastic tumors. It represents 1.39% of all gestational trophoblastic diseases. Most cases are reported in reproductive-age women following a prior gestation with a time interval between 2 weeks and 30 years. ETT is extremely rare in postmenopausal women. It is commonly misdiagnosed as a squamous cell carcinoma (SCC), poorly differentiated carcinoma or another gestational trophoblastic tumor. Limited data is available regarding its cytological features on Pap smears.

CASES

We report 2 cases of uterine ETT occurring in postmenopausal women. In both cases, an initial diagnosis of an SCC and a poorly differentiated carcinoma was rendered. We highlight the features of ETT helpful in differentiating it from other mimickers with emphasis on rarely reported cytological features of this neoplasm.

CONCLUSION

ETT is a rare tumor with characteristic cytological features, but is commonly confused with SCC. A high index of suspicion is needed to make the correct diagnosis or to raise the consideration of ETT, especially in cases with an increased β-human chorionic gonadotropin.

[Hydatidiform mole and malignant trophoblastic tumors initiated by hydatidiform mole. Standards and innovation of diagnosis and treatment]

Malignant trophoblastic tumors are hormone and hormone-dependent allografts initiated by, in the most cases, hydatidiform mole. The absence of methodological principles for monitoring of women after evacuation of hydatidiform mole often leads to late detection of the disease, inadequate chemotherapy conducted in clinics with no experience of treatment, followed by the development of drug-resistant tumors and worse prognosis. This paper analyzes the problem at the moment.

CT and MRI of early intrauterine pregnancy

OBJECTIVE

The objective of this article is to describe the CT and MRI findings of early intrauterine pregnancy.

CONCLUSION

Early pregnancy should be considered when CT or MRI shows a fluid-filled cystlike structure in the uterus of a woman of reproductive age especially if there is a coexistent ovarian corpus luteum cyst.

May platelet count be a predictor of low-risk persistent gestational trophoblastic disease?

PURPOSE

The aim of this paper was to determine whether platelet count could be used as an early marker to predict low-risk persistent trophoblastic disease (PTD) from complete hydatidiform mole (CHM).

METHODS

This study included 27 PTD, 30 CHM, and 30 healthy pregnant women. All patients were evaluated with respect to age, gestational age, parity, BMI, and platelet count. All women had low-risk disease using FIGO and WHO scoring systems.

RESULTS

There were no significant differences in terms of age, gestational age, parity, BMI between the groups (P > 0.05, for all). Platelet levels were lower in patients with low-risk PTD compared with CHM and healthy pregnant group (P = 0.001 and P < 0.0001, respectively). Platelet levels were also found to be lower in patients with CHM than in healthy pregnancies (P = 0.006). There was a negative relationship between platelet count and low-risk PTD (r = 0.47, P < 0.0001) in the study. The receiver operating characteristic curve analysis revealed a high diagnostic value for platelet count with respect to low-risk PTD with an area under curve of 0.80 (95% confidence interval = 0.89-0.90), sensitivity = 77% and specificity = 75%.

CONCLUSION

Platelet count was significantly decreased in low-risk PTD compared with CHM and healthy pregnant controls. Platelet count can be used as a reliable marker for the early detection of low-risk PTD.

New discoveries on the biology and detection of human chorionic gonadotropin

Human chorionic gonadotropin (hCG) is a glycoprotein hormone comprising 2 subunits, alpha and beta joined non covalently. While similar in structure to luteinizing hormone (LH), hCG exists in multiple hormonal and non-endocrine agents, rather than as a single molecule like LH and the other glycoprotein hormones. These are regular hCG, hyperglycosylated hCG and the free beta-subunit of hyperglycosylated hCG. For 88 years regular hCG has been known as a promoter of corpus luteal progesterone production, even though this function only explains 3 weeks of a full gestations production of regular hCG. Research in recent years has explained the full gestational production by demonstration of critical functions in trophoblast differentiation and in fetal nutrition through myometrial spiral artery angiogenesis. While regular hCG is made by fused villous syncytiotrophoblast cells, extravillous invasive cytotrophoblast cells make the variant hyperglycosylated hCG. This variant is an autocrine factor, acting on extravillous invasive cytotrophoblast cells to initiate and control invasion as occurs at implantation of pregnancy and the establishment of hemochorial placentation, and malignancy as occurs in invasive hydatidiform mole and choriocarcinoma. Hyperglycosylated hCG inhibits apoptosis in extravillous invasive cytotrophoblast cells promoting cell invasion, growth and malignancy. Other non-trophoblastic malignancies retro-differentiate and produce a hyperglycosylated free beta-subunit of hCG (hCG free beta). This has been shown to be an autocrine factor antagonizing apoptosis furthering cancer cell growth and malignancy. New applications have been demonstrated for total hCG measurements and detection of the 3 hCG variants in pregnancy detection, monitoring pregnancy outcome, determining risk for Down syndrome fetus, predicting preeclampsia, detecting pituitary hCG, detecting and managing gestational trophoblastic diseases, diagnosing quiescent gestational trophoblastic disease, diagnosing placental site trophoblastic tumor, managing testicular germ cell malignancies, and monitoring other human malignancies. There are very few molecules with such wide and varying functions as regular hCG and its variants, and very few tests with such a wide spectrum of clinical applications as total hCG.

[Imaging of gestational trophoblastic disease]

INTRODUCTION

Trophoblastic diseases correspond to a very heterogeneous group.

OBJECTIVE

To establish the importance of imaging in the management of trophoblastic diseases.

PATIENTS AND METHODS

Retrospective study from 1995 to 2008, including all patients with a gestational throphoblastic disease in our department.

RESULTS

Seventy-four cases were identified with 58 molar pregnancies, 14 trophoblastic tumors and two cases of hydatiform mole coexistent with a twin live fetus. Ultrasound's sensibility in case of hydatiform moles was 75.86%. It was sharply more important in case of a complete mole with a detection rate of 96.15% against 28% in case of partial mole. In trophoblastic tumors, ultrasound coupled with Doppler had shown signs of invasion in half of the cases. Four patients presented with lung metastases. Magnetic resonance imaging was performed in two cases.

DISCUSSION AND CONCLUSION

Ultrasound is of high-performance in the positive diagnosis of complete moles. Furthermore, it shows signs of invasion in case of trophoblastic tumors. In those cases, a radiological assessment guides the management even in the absence of histological proofs.

[Case report and literature review of epithelioid trophoblastic tumor]

OBJECTIVE

To evaluate the clinical characteristics of epithelioid trophoblastic tumor (ETT).

METHODS

Six cases of ETT treated in Women's Hospital, School of Medicine, Zhejiang University from 2005 to 2007 were retrospectively analyzed, together with a literature review.

RESULTS

Six cases of ETT were diagnosed pathologically after surgery. The age of patients ranged from 27 to 46 years. The most common presentation was abnormal vaginal bleeding (5/6). The preceding gestational events were hydatidiform mole in 1 case, abortion in 2 cases, and term delivery in 3 cases. The interval between the preceding gestation and the diagnosis of ETT ranged from 15-48 months. The serum human chorionic gonadotropin (hCG) level was 46-121.47 IU/L. Four cases presented with metastasis, including lung metastasis in all of the 4 cases, liver metastasis in 1 case, and pancreas metastasis in another 1 case. The main therapies were surgery combined with chemotherapy. All of the 6 cases received total abdominal hysterectomy, and 1 case also had lung lobectomy. One case had a recurrence but refused any treatment again, and was lost to follow up; the therapy of 1 case unfinished; another 4 cases were without evidence of disease 9 to 19 months after surgery.

CONCLUSIONS

The confirmation of ETT diagnosis is difficult before surgery. Surgical management is mostly recommended in ETT. The role of chemotherapy in ETT is not clear yet.

Elevated hCG Outside of Pregnancy—Diagnostic Considerations and Laboratory Evaluation

Human chorionic gonadotropin (hCG) is a glycoprotein hormone produced by trophoblastic tissues, and its identification is frequently relied upon to establish the diagnosis of pregnancy. Entities other than pregnancy, such as false-positive hCG results, pituitary hCG, exogenous hCG, and both trophoblastic and nontrophoblastic neoplasias, can also cause laboratory assays for hCG to show positive results. Because of their rarity, these conditions are not commonly recognized, and the steps to differentiate between them are not widely known. Discriminating between the causes of elevated hCG in nonpregnant patients can be confusing. An understanding of the differential diagnosis and awareness of available diagnostic modalities are essential for accurate diagnosis and avoidance of potentially harmful treatments.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to state the importance of types of human chorionic gonadotropin (hCG), recall their presence in both trophoblastic and nontrophoblastic neoplasias, and explain how important it is to distinguish between the various causes of an elevated serum hCG to avoid harmful treatments.

Epithelioid trophoblastic tumor of the lung

Epithelioid trophoblastic tumor (ETT) is a rare type of gestational trophoblastic disease and only 25 cases have been reported so far. It was first proposed by Mazur and Kurman in 1994 as an unusual type of trophoblastic tumor that is distinct from placental site trophoblastic tumor and choriocarcinoma and has features resembling carcinoma. A case of ETT of the lung in a 38-year-old Japanese woman is reported. The patient had suffered from a hydatidiform mole at the age of 27 years, and had four normal deliveries at the ages of 24, 31, 35 and 37 years. Because no tumor lesions were detected in the uterus, the patient was suspected of having metastatic choriocarcinoma with multiple lesions in the lung accompanied by an elevated level of human chorionic gonadotropin (hCG). In order to make an exact diagnosis, a partial resection of metastatic foci in the lung was performed. Microscopically, the tumor showed hemorrhagic necrotic foci and was composed of mainly mononuclear tumor cells and some giant tumor cells resembling trophoblastic cells. Immunohistochemical examination showed that a few large cells were stained positively for hCG, and that other cells were positive for human placental lactogen, pregnancy-specific beta1-glycoprotein, cytokeratin 7 and inhibin-alpha. In the ultrastructure, the tumor cells contained large nuclei and rich organella with desmosomes and well-formed filaments. The diagnosis of ETT was confirmed from the findings as described above.

Trophogram, an immunohistochemistry-based algorithmic approach, in the differential diagnosis of trophoblastic tumors and tumorlike lesions

Recent histopathologic and molecular studies of trophoblastic cells in the normal placenta and in a variety of trophoblastic diseases have revealed that the latter recapitulate the differentiation of normal trophoblast in the early developing placenta. This new knowledge, especially the identification and characterization of the protein markers expressed in human trophoblast, not only helps elucidate the pathogenesis of trophoblastic lesions but also provides a repertoire of immunohistochemical markers that may facilitate the diagnosis of various trophoblastic diseases. This article reviews the recent advances in the trophoblast-associated markers that have been reported to be useful in the differential diagnosis of trophoblastic tumors and tumorlike lesions. Moreover, a "trophogram," which is a stepwise and rational immunohistochemistry-based approach, will be introduced. The trophogram may prove to be useful in assisting the differential diagnosis of various trophoblastic diseases in diagnostic pathology.

Uterine epithelioid trophoblastic tumor in an African green monkey (Chlorocebus aethiops sabaeus)

A uterine mass was detected on physical exam in a multiparous African green monkey as an incidental finding, and the well-circumscribed mass was removed via hysterectomy. Histologically, the mass consisted of sheets, nests, and cords of uniform intermediate trophoblastic cells with eosinophilic or clear cytoplasm. These neoplastic cells aggregated around blood vessels, forming islands of viable tumor cells amid extensive areas of coagulative necrosis with calcification in a 'geographic' pattern of necrosis. Immunohistochemistry of the trophoblastic cells revealed strong and diffuse staining for pancytokeratin AE1/3 and p63, with weak and moderate staining for human placental lactogen and placental alkaline phosphatase, respectively. Immunohistochemical staining for smooth muscle actin, epithelial membrane antigen, and human chorionic gonadotropin was negative. Overall, the histologic and immunohistochemical features of this tumor were consistent with those of epithelioid trophoblastic tumor. This rare tumor type has not been reported previously to occur in African green monkeys.

Cyclin E and p16 Immunoreactivity in Epithelioid Trophoblastic Tumor???An Aid in Differential Diagnosis

Epithelioid trophoblastic tumor (ETT) is a relatively uncommon trophoblastic tumor that can be confused with several trophoblastic and nontrophoblastic lesions, notably the placental site nodule and invasive squamous carcinoma of the cervix. In this report, we analyzed the immunoreactivity of two cell cycle-regulated proteins, cyclin E and p16, in ETTs, placental site nodules and cervical squamous carcinomas to determine whether they are useful in their differential diagnosis. Other trophoblastic lesions were also evaluated. Using an H-score based on both percentage of positively stained cells and immunointensity, we found that ETTs demonstrated a much higher cyclin E staining score than placental site nodules (P<0.0001) permitting distinction of ETTs and placental site nodules with a sensitivity of 94.7% at a specificity of 91.7% using a cutoff H-score value of >40. Only two placental site nodules had scores above the cutoff and both showed morphologic features that placed them in an intermediate position between a typical placental site nodule and an ETT, so-called "atypical PSN." p16 immunoreactivity, was not detected in any of the ETTs and placental site nodules, whereas it was strongly and diffusely positive in the vast majority of cervical squamous carcinomas examined (83/87 cases) (P<0.001). Therefore, cyclin E expression is useful in distinguishing an ETT from a placental site nodule and p16 expression is useful in distinguishing an ETT from a cervical squamous carcinoma. The majority of other types of trophoblastic lesions showed diffuse and intense nuclear immunoreactivity for cyclin E whereas none were positive for p16.

Serous carcinoma of the endometrium with choriocarcinomatous differentiation: a case report and review of the literature indicate the existence of 2 prognostically relevant tumor types

Nongestational choriocarcinomas rarely occur outside the gonads or teratomas. We report a serous carcinoma of the endometrium with a choriocarcinomatous component and review of the literature. A 61-year-old woman underwent hysterectomy and bilateral salpingo-oophorectomy for a serous carcinoma with choriocarcinomatous component. Immunohistochemistry showed a strong p53 staining of the serous component and the cytotrophoblastic cells of the choriocarcinomatous component; the syncytiotrophoblast was negative. The initial serum human chorionic gonadotropin (hCG) was 225,000 IU/L. Postoperatively, the patient developed diffuse pulmonary metastatic disease. Despite chemotherapy, the patient died 2 months after initial diagnosis. Abstracting the data from the reported cases and from the literature, it can be assumed that 2 different tumor types exist. The first one is morphologically and clinically more related to the gestational choriocarcinoma with strongly elevated serum hCG levels, early onset of (distant) metastatic disease, and consecutively rapid and often fatal clinical course. The second type presents as an endometrial carcinoma with single syncytiotrophoblast-like cells, associated with low serum hCG, no distant metastatic disease, and, consequently, a better prognosis. The prognostically relevant component for long-time survival in the latter variant is the nontrophoblastic component.

Primary peritoneal carcinoma: a rare neoplasm with pleomorphic trophoblastic morphology

We report a case of primary peritoneal carcinoma with trophoblastic morphology in a 78-year-old woman, diagnosed by histological and immunohistochemical analysis of surgically resected specimens, including the omentum and part of the small bowel. Microscopically, the resected specimens showed diffuse infiltration of a poorly differentiated tumor. Numerous large, often multinucleated cells were seen, and mitotic figures were frequent. Immunohistochemical staining showed a positive reaction for most cytokeratins, EP4, EMA, CA-125, Glut1, WT1, beta-hCG and PLAP. We reached a diagnosis of primary peritoneal carcinoma with trophoblastic morphology. To our knowledge this morphology of a primary peritoneal carcinoma has not been described previously.

Epithelioid trophoblastic tumor: a case report

Epithelioid trophoblastic tumor is a rare and distinctive pathologic entity within the complex family of gestational trophoblastic disease. We describe a case of epithelioid trophoblastic tumor occurring in a 34-year-old woman, who presented with a large uterine tumor 3 years following an uncomplicated pregnancy. The clinicopathologic findings in this case are typical of this unusual entity and consistent with current literature, with the exception of negative beta-human chorionic gonadotrophin levels. The distinguishing features from other intermediate trophoblastic tumors and tumor-like lesions are discussed.

Persistent trophoblast disease following partial molar pregnancy

OBJECTIVE

Human chorionic gonadotrophin (hCG) follow-up data were analysed retrospectively in all patients registered in the Hydatidiform Mole Registry at the Royal Women's Hospital, Melbourne from January 1992 to January 2001 to determine the risk of persistent trophoblast disease following partial molar pregnancy and to review the present follow-up protocol of patients suffering from partial hydatidiform molar pregnancy (PHM).

METHODS

Demographic factors were determined for all 344 cases with a review diagnosis of PHM, included age, history of previous hydatidiform mole, gestation length, hCG levels and compliance with follow-up.

FINDINGS

Six of the 344 patients diagnosed with PHM required treatment with single-agent methotrexate and folinic acid rescue. All six patients achieved and maintained a complete biochemical remission after chemotherapy. hCG regression assays were analysed for 235 patients: 225 patients had at least one normal hCG measurement during follow-up, of whom 152 (64.7%) patients obtained normal values within 2 months after evacuation. All patients obtained normal levels within 32 weeks after evacuation of the partial hydatidiform mole. Only 63 (25.6%) patients completed the recommended follow-up program. No patient who achieved normal hCG levels required chemotherapy because of a recurrent gestational trophoblastic tumour.

RECOMMENDATIONS

This study indicates that 1.7% of all partial mole pregnancy patients needed treatment for malignant sequelae. In contrast, no patient diagnosed with partial mole had a biochemical or clinical relapse after achieving normal levels of hCG, consistent with previous studies. Patients who have had a partial hydatidiform mole should be followed by hCG assays until normal levels are achieved and then follow-up can be safely discontinued.

[Syndrome of persistent low levels of human chorionic gonadotrophin (hCG)]

OBJECTIVE

To analyze the syndrome of persistent low levels of hCG in terms of its etiology, classification, diagnosis, and management.

DESIGN

Retrospective analysis.

SETTING

Center for Trophoblastic Disease in Czech Republic, Institute for Care of Mother and Child, Prague, Institute of Postgraduate medical education, IPVZ, Prague

METHODS

An analysis of the syndrome of persistent low levels of hCG recorded in CTN in 29 women in the years 1979-2005 by the immunoluminesence method which can quantitatively assess variable levels of hCG in blood and urine. A comparison was made of our findings with results of a similar studies having been done in England and USA.

RESULTS

Persistent low levels of hCG (PLL) can be differentiated according to cause. 1. PLL-F False positive, also known as Phantom hCG, often caused by heterogenous antibodies. 2. PLL-H Of hypophysial origin, mainly in perimenopause and menopause. 3. PLL-Q Quiescent with trophoblastic disease in history, of trophoblastic origin. 4. PLL-U Undetermined, in history without trophoblastic disease, but in the past with physiological or pathological pregnancy. Assuming also to be of trophoblastic origin. All types of PLL lead in practice to the wrong diagnosis of trophoblastic disease and to a high percentage (40-80%) of needless chemotherapy and operations. In no case of PLL did chemotherapy or operations have an effect on PLL and thus are contraindicated. PLL-Q and PLL-U require continuous clinical and laboratory monitoring and repeated examinations with sophisticated visualization methods. The percentage of developing malignant trophoblastic tumors after PLL-Q and PLL-U is unclear. Extreme incidence was established in 7-25%. PLL-Q and PLL-U are considered as a marker of persistent trophoblastic invasion. Its detection by visualization methods in any organ localization before it turns into a limited solid tumor is excluded by it microscopic dissociative structure.

CONCLUSION

The syndrome of persistent low levels of hCG (PLL) lately affects all gynecological and obstetrical workplaces. According to cause it can be divided into: 1. PLL false positive, 2. PLL of hypophysial origin, 3.PLL quiescent with trophoblastic disease in the history, 4. PLL undetermined, in history without trophoblastic disease. In the last two items mentioned above we assume to be of trophoblastic origin. Their morphological base is persistent trophoblastic invasion. The syndrome of PLL often leads to the wrong diagnosis of trophoblastic disease and to needless chemotherapy and operations. In this work was described the diagnosis of PLL, its classification, cause, and management. The percentage of PLL turned into malignant trophoblastic disease is unknown and ranges from 7-25% and requires monitoring in an accredited, national center for trophoblastic disease.

Clinical utility of hyperglycosylated hCG in serum taken before hydatidiform mole evacuation to predict persistent trophoblastic disease

OBJECTIVE

Human chorionic gonadotropin (hCG) is widely used in the management of hydatidiform mole and persistent trophoblastic disease (PTD). Studies on hyperglycosylated human chorionic gonadotropin (invasive trophoblast antigen, ITA) in PTD are limited. In serum samples taken before evacuation of molar pregnancies we measured the concentrations of free hCG beta-subunit (free hCGbeta), "total" hCG (hCG+hCGbeta) and ITA, and determined whether ITA, the two other hCG analytes, or the calculated ratios of hCGbeta/hCG+hCGbeta, hCGbeta/ITA and hCG+hCGbeta/ITA could predict the later development of PTD.

DESIGN

A retrospective study based on blood specimens collected in the Dutch Central Registry for Hydatidiform Moles. The study group comprised 97 patients with hydatidiform moles who did not develop PTD after mole evacuation and 33 patients who did develop PTD.

METHODS

Serum samples from 130 patients with hydatidiform mole with or without PTD were assayed using specific (radio)immunoassays for free hCGbeta, total hCG, and ITA. From these analytes we also calculated the ratios hCGbeta/hCG+hCGbeta, hCGbeta/ITA, and hCG+hCGbeta/ITA. To predict the development of PTD from these analytes and parameters we performed receiver-operating characteristic (ROC) curve analysis, resulting in areas under the curve (AUCs) that represented the diagnostic accuracy which was rated in a range from excellent (AUC >0.9 or <0.1) to poor (AUC 0.4-0.6).

RESULTS

The diagnostic accuracy of ITA was moderate (0.618) and not different from that of free hCGbeta (0.610) and hCG+hCGbeta (0.622).

CONCLUSIONS

ITA as well as the other analytes and parameters in serum taken prior to evacuation from patients with molar pregnancies cannot be used to predict the subsequent development of persistent trophoblastic disease.

[Diagnostic significance of tumor markers for gynecologic malignancies]

Gynecologic malignancies include ovarian cancer, uterine cervical cancer, endometrial cancer, and trophoblastic neoplasms. With ovarian tumors, due to their location within the abdominal cavity, it is difficult to make a preoperative pathological diagnosis of cancer without laparotomy. From this point of view, the use of tumor markers that consist of carbohydrate antigens, such as CA 125, in addition to diagnostic imaging are useful in the diagnosis of ovarian cancer. SCC antigen, a marker for squamous cell carcinoma, is clinically useful in the management of advanced cervical cancer. At present, there are no useful tumor markers for endometrial cancer that exhibit both high sensitivity and specificity, although CA 125 is often used in clinical practice. Finally, human chorionic gonadotropin (hCG) serves as an ideal tumor marker for trophoblastic disease; however, the incidence of trophoblastic neoplasms has decreased dramatically with the incorporation of strict clinical management of post-molar disease as well as with the overall decrease in the number of pregnancies.

Human chorionic gonadotropin in cancer

Human chorionic gonadotropin (hCG) is mainly used for detection and monitoring of pregnancy and pregnancy-related disorders but it is also an extremely sensitive and specific marker for trophoblastic tumors of placental and germ cell origin. Thus treatment of relapsing choriocarcinomas and testicular germ cell tumors is often initiated on the basis of rising hCG levels even in the absence of clinical or histological evidence of a relapse. While these tumors mostly produce the intact heterodimeric hormone consisting of an alpha (hCGalpha), and a beta subunit (hCGbeta), many nontrophoblastic tumors produce only hCGbeta This is usually a sign of aggressive disease and elevated serum levels of hCGbeta are strongly associated with poor prognosis. Elevated serum levels are observed in 45-60% of patients with biliary and pancreatic cancer and in 10-30% of most other cancers. Methods that detect hCG and hCGbeta together are mainly used for measurement of hCG-like immunoreactivity in serum. However, the reference range for hCG is 5-8 fold higher than that for hCGbeta and thus moderately elevated levels can be identified only with a specific and sensitive hCGbeta assay.

Placental site trophoblastic tumor of the uterine cervix occurring from undetermined antecedent pregnancy

A cervical polyp complicated by severe hemorrhage was removed from a 43-year-old Japanese woman (gravida 0), who had undergone tubectomy on the right side 10 years previously. The polyp was diagnosed by immunohistochemical studies as placental site trophoblastic tumor of the cervix, but no metastatic foci were found in any other uterine site. The tumor was further demonstrated by PCR polymorphisms to possess two genomic DNA of the patient and her husband. Serum beta-hCG and urinary hCG titers were both low, which rapidly fell to 0.8 mIU/mL after a total hysterectomy and remained 0.2 mIU/mL after dismission. She has been uneventful for 3 years.

[Difficulties and biases of interpretation in cases of the trophoblast disease]

The trophoblastic disease (TD) is an unifying term for the nosologicunits: Mola hydatidosa, Mola hydatidosa invasivum, Chorionepithelioma. This kind of trophoblast pathology has geographic differences in the expression but the its overall incidence is not high. The clinicians often fail to consider the possibility of trophoblastic disease due to its low incidence rate. The forms of TD have clinical manifestations that are not specific. There are principles, which taken into account, could help the clinicians put the right diagnosis. Two cases of the clinical practice are reviewed in maintenance of this opinion.

Successful salvage therapy of resistant gestational trophoblastic disease with etoposide, methotrexate, actinomycin-d, etoposide, cisplatin (EMA/EP)

A 26-year-old woman who had been treated for nonmetastatic gestational trophoblastic tumor with three courses of methotrexate with folinic acid rescue and had been lost to follow up for 4 years was referred with the fractional curettage diagnosis of choriocarcinoma that had been performed for abnormal vaginal bleeding. Her serum beta human chorionic gonadotropin (betahCG) was 706000 mIU/mL and there were multiple pulmonary metastatic foci. The uterus was 12 weeks pregnant-size and a 6 x 6-cm tumor mass was seen within the anterior uterine wall at ultrasonography. Following total abdominal hysterectomy etoposide, methotrexate, actinomycin-D, vincristine and cyclophosphamide (EMA/CO) regimen was given. Whole brain radiation of 30 Gy in 3 weeks for brain metastasis, discovered in magnetic resonance imaging was given after the first course. Since serum betahCG levels plateaued after three courses of chemotherapy and multiple pulmonary metastases persisted, treatment was shifted to etoposide, methotrexate, actinomycin-D, etoposide, cisplatin (EMA/EP) regimen. She was in remission after three courses of chemotherapy.

Epithelioid trophoblastic tumor (ETT) initially interpreted as cervical cancer

The epithelioid trophoblastic tumor (ETT) is a rare form of trophoblastic disease and shows a wide spectrum of differential diagnoses and clinical behavior. A 53-year-old woman presented with ETT presumably originated in spontaneous delivery of 25 years ago and was initially diagnosed as cervical cancer on cervical punch biopsy followed by radical hysterectomy. The uterus showed a small tumor restricted to the cavum with no cervical infiltration, resembling ETT in histologic and immunohistochemical features. The difficulties and clues in distinguishing ETT from nontrophoblastic lesions are discussed.

Analysis of human choriogonadotropin core 2 o-glycan isoforms

Measurements of human choriogonadotropin (hCG) isoforms containing core 2 o-glycans may be useful for diagnosis of Down Syndrome pregnancies and trophoblastic disease. As shown here, this isoform is also present in pituitary extracts, early pregnancy urine, and urine of postmenopausal women. Although, measurements of hCG isoforms may be useful in several clinical settings, this remains to be determined due to the lack of suitable standards and the difficulties of comparing data obtained in different laboratories. Here, we report that monoclonal antibodies B152 and CTP104 recognize the third (Ser132) and fourth (Ser138) o-glycans, respectively, in the carboxyterminal portion of the hCG beta-subunit. The proximity of these sites prevents B152 and CTP104 from binding simultaneously to isoforms containing core 2 o-glycans. Unlike B152, which binds only the core 2 isoform, CTP104 recognizes both glycan moieties. By measuring hCG with CTP104 in the presence and absence of B152, one can quantify both isoforms using the same readily available standard.

CD10 expression in epithelial tissues and tumors of the gynecologic tract: a useful marker in the diagnosis of mesonephric, trophoblastic, and clear cell tumors

We tested 417 cases of formalin-fixed, paraffin-embedded normal or hyperplastic gynecologic tissues as well as neoplasms involving the gynecologic tract with a monoclonal antibody against CD10 (clone 56C6), with special emphasis on epithelial and epithelial-like structures and tumors. CD10 was always expressed in mesonephric remnants (mesonephric remnants of the uterine cervix, epoophoron, rete ovarii) and tumors (mesonephric adenocarcinoma of the uterine cervix, tumors of wolffian origin of the broad ligament and ovary). CD10 was also positive in the syncytiotrophoblast, cytotrophoblast, and intermediate trophoblast of normal gestations, partial and complete moles, choriocarcinoma, and placental site trophoblastic tumors. Finally, CD10 was positive in several metastatic neoplasms to the gynecologic tract (100% in metastatic renal clear cell and intestinal carcinomas and melanomas). In contrast, CD10 was almost invariably negative in müllerian epithelia of the female genital tract and in their corresponding tumors, with the exception of focal expression found in squamous epithelia and tumors with squamous differentiation. Thus, the expression of CD10 may be useful in the establishing the diagnosis of mesonephric and trophoblastic tumors and in the differential diagnosis between gynecologic clear cell carcinoma (always negative) and metastatic clear cell carcinoma of renal origin.

Clinicopathologic profile of gestational trophoblastic disease

Much debate exists on factors predicting the development of persistent gestational trophoblastic disease (pGTD). Diagnosis is still limited by following persistently elevated or rising postevacutation beta-human chorionic gonadotropin (beta-hCG) titers. The aim of the present work was to evaluate the hypothesis that the presence of c-erbB-2 oncogene amplification and expression, in combination with parameters such as DNA-content and karyotype of the sex chromosomes, confer an increased risk of developing pGTD. Clinicopathological characteristics were evaluated in 36 cases of gestational trophoblastic diseases (GTD) and analyzed for c-erbB-2 amplification and protein p185 expression using differential polymerase chain reaction (DPCR) and immunohistochemical (IHC) techniques. The DNA-content was determined by image analysis on Feulgen stained nuclear cell preparations and karyotyping for XY chromosomes was performed by fluorescence in situ hybridization (FISH). The data was correlated with histopathological characteristics of GTD. Seventy-five percent (n = 27) of the examined cases showed spontaneous regression after evacuation, including 2 patients who received additional chemotherapy. Twenty-five percent (n = 9) resulted in a persistent or metastatic disease. The median time between antecedent pregnancy and GTD was 45.4 months. Complete remission was achieved in all patients with pGTD after administration of chemotherapeutic agents or adjuvant surgical procedures. Cases with cerbB-2 amplification and expression in combination with DNA hyperploidy showed higher proliferation and more aggressive behavior (2 complete hydatidiform moles with lung and liver metastases, 2 invasive moles and 1 choriocarcinoma). XY karyotype was evident in the choriocarcinoma and in 2 complete hydatidiform moles with advanced stage and DNA hyperploidy. From these results we conclude that c-erbB-2 amplification and/or protein expression in combination with DNA-content show a significant correlation with the proliferative and aggressive potential of GTD, suggesting their combined use as a possible marker for pGTD.

ACOG. Committee opinion: number 278, November 2002. Avoiding inappropriate clinical decisions based on false-positive human chorionic gonadotropin test results

Clinically significant false-positive human chorionic gonadotropin (hCG) test results are rare. However, some individuals have circulating factors in their serum (eg, heterophilic antibodies or nonactive forms of hCG) that interact with the hCG antibody and cause unusual or unexpected test results. False-positive and false-negative test results can occur with any specimen, and caution should be exercised when clinical findings and laboratory results are discordant. Methods to rule out the presence of interfering substances include using a urine test, rerunning the assay with serial dilutions of serum, preabsorbing serum, and using another assay. Physicians must decide whether the risks of waiting for confirmation of results outweigh the risks of failing to take immediate medical action. Patients should be notified if they are at risk for recurrent false-positive hCG test results, and this information should be included in the patient's medical record.

Trusting numbers: uncertainty and the pathology laboratory

Diagnostic laboratories are increasingly seen as no more than "factories" that generate fast, reliable test results. The dangers of complacency about the use of tests are highlighted by recent cases of unnecessary surgery and chemotherapy based solely on false-positive test results. There are many causes of misleading laboratory data that can potentially lead to clinical mismanagement. Re-emphasis of the value of patient-relevant communication between the requesting doctor and the laboratory, and better undergraduate and postgraduate education about the appropriate use of tests, will help reduce the risks of test results leading to harm.

Persistent gestational trophoblastic disease presenting as left hemiparesis in a Jamaican teenager

A 19-year-old woman, who delivered a macerated stillborn at 32 weeks' gestation and had persistent postpartum vaginal bleeding, presented with a left hemiparesis three and a half months after delivery. A clinical diagnosis of persistent gestational trophoblastic disease (GTD) was made, based on quantitative serum beta-hCG of more than 200,000 IU/ml, cannon ball metastases on chest X-ray and two ring enhancing lesions, metastases, in the right parietal lobe on Computed Axial Tomography (CAT) scan of the brain. Despite combination chemotherapy, with methotrexate, cyclophosphamide and actinomycin D, her condition worsened and she died.

Detection of hCG in trophoblastic disease. The USA hCG reference service experience

hCG is a glycoprotein hormone composed of two dissimilar subunits. This hormone is not only heterogeneous in peptide structure but also in combination of subunits and carbohydrate structure. Common hCG-related molecules include hCG, hyperglycosylated hCG, nicked hCG, hCG missing the beta-subunit C-terminal peptide, free alpha-subunit, free beta-subunit, nicked free b-subunit and urine beta-core fragment. This article discusses the structures these hCG-related molecules and their occurrences in early pregnancy, 7-week to term pregnancy, hydatidiform mole (preevacuation and postevacuation), persistent gestational trophoblastic disease, choriocarcinoma and other malignancies. Multiple serum hCG tests are evaluated, and their abilities to detect the multiple hCG-related molecules are investigated. The accuracy of different serum hCG tests in detecting hCG and hCG-related molecules in patients with gestational trophoblastic diseases is evaluated. The findings of persistent low hCG values in the absence of pregnancy or an identifiable malignancy are examined. In addition, the false positive hCG assay problem is discussed. False positive hCG tests have led to many incidences in which gestational trophoblastic disease has been erroneously diagnosed and needlessly treated. hCG tests are identified that give a disproportionate number of false positive results. Finally, guidelines are presented for selecting an hCG test.

Gestational trophoblastic disease

OBJECTIVE

To provide standards for the diagnosis and treatment of patients with hydatidiform mole and gestational trophoblastic tumours (GTT).

OPTIONS

Prognostic factors useful for treatment decisions in GTT are defined with patients classified as low-, medium-, and high-risk groups.

OUTCOMES

Improved mortality and morbidity.

EVIDENCE

Evidence was gathered using Medline for relevant studies and articles from 1980 to 2001 with specific reference to diagnosis, treatment options, and outcomes. The quality of evidence of Recommendations has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.

RECOMMENDATIONS

1. Suction curettage is the preferred method of evacuation of the hydatidiform mole (III-C). Post-operative surveillance with hCG assays is essential (II-3B). 2. Low-risk patients with both non-metastatic and metastatic disease should be treated with single-agent chemotherapy, either methotrexate or dactinomycin (II-3B). 3. Medium-risk patients should usually be treated with multi-agent chemotherapy, either MAC or EMA (III-C); single-agent chemotherapy may also be used (III-C). 4. High-risk patients should be treated with multi-agent chemotherapy EMA/CO, with selective use of surgery and radiotherapy (II-3B). Salvage chemotherapy with EP/EMA and surgery should be employed in resistant disease (III-C). 5. Placental site trophoblastic tumour that is non-metastatic should be treated with hysterectomy (III-C). Metastatic disease should be treated with chemotherapy, most commonly EMA/CO (III-C).6. Women should be advised to avoid pregnancy until hCG levels have been normal for six months following evacuation of a molar pregnancy and for one year following chemotherapy for gestational trophoblastic tumour. The combined oral contraceptive pill is safe for use by women with GTT (III-C).

VALIDATION

These guidelines have been reviewed and approved by the Policy and Practice Guidelines Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC), the Gynaecologic Oncologists of Canada (GOC), the Society of Canadian Colposcopists (SCC), and by Executive and Council of the SOGC.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada.

[The clinical analysis and results of treatment of the patients with gestational trophoblastic disease]

OBJECTIVES

The aim of this work was to establish the dependence between the results of treatment and clinical stage and prognostic factors of the patients with gestational trophoblastic disease.

MATERIALS AND METHODS

The retrospective analysis of 1259 patients with Gestational Trophoblastic Disease (GTD) observed in years of 1977-1995 in the Maria Skłodowska-Curie Memorial Cancer and Institute of Oncology in Warsaw, Poland was made. Out of them 281 had recommendation for treatment. The mean age of the examined women was 34.5 years and treated patient 38.0 years. The clinical structure of the treated patients according to clinical stages: I--202 (72.1%), II low risk--17(6.1%), II high risk--4 (1.4%), III low risk--22 (7.9%), III high risk--26 (9.3%), IV--9 (3.2%). The clinical structure of the treated patients by histopathological type: hydatidiform mole 148 (52.7%), invasive mole 34 (12.1%), choriocarcinoma 93 (33.1%), without histopathological diagnosis 6 (2.1%). The distribution of the treated patients by antecedent pregnancy: hydatidifrom mole 166 (59.1%), spontaneous abortion 47 (16.7%), ectopic pregnancy 9 (3.2%) term delivery 59 (21%).

RESULTS

Among 281 patients who received chemotherapy 79 of them underwent surgery. In the group of 281 treated patients, 267 (95%) are alive without the signs of disease, 11 (3.9%) died, 1 (0.4%) is alive with the symptoms of disease, 2 (0.7%) were lost of observation.

CONCLUSIONS

1. Among the observed patients with GTD 23% needed treatment. 2. The most common histopathological type of observed patients was hydatidiform mole. 3. General treatment of patients with GTD consists of chemotherapy. 4. The results of treatment should be seen as successful since 96.5% of patients survived 5 years. 5. Survival of patients with GTD depends on clinical stage and risk factors.

Placental peptides as markers of gestational disease

The human placenta produces a wide range of important peptides, of which an intricate balance is required throughout pregnancy. In a gestational disease, this balance may be disturbed and the identification of such changes may be used to detect a particular pathology or to ascertain its severity. This review considers the role and association of various placental peptide markers associated with the major gestational diseases including intrauterine growth retardation, pre-term labour, pre-eclampsia, chromosomal disorders, gestational diabetes and trophoblastic disease. Potential markers that may prove more reliable and specific in their diagnostic value and that may be used for identifying patients at risk are also discussed. The importance of the new fields of genomics and proteomics in the future discovery of new peptide markers is illustrated.