Understanding and management of gestational trophoblastic disease

False-negative qualitative human chorionic gonadotropin (hCG) test result ('hook effect') with classical ultrasound findings of complete molar pregnancy: an uncommon case

False-negative qualitative Human Chorionic Gonadotropin (hCG) result is a phenomenon in which large amounts of β-hCG are produced by molar pregnancy, oversaturating the test's assay system and leading to false-negative results known as the 'prozone phenomenon' or the 'hook effect'. This can lead to misdiagnosis and delay in management despite high suspicious clinical and ultrasound findings. We report a case of an 18-year-old female who presented to our health facility with amenorrhea of 16 weeks, lower abdominal pain, soft and large fundal height for gestational age, and cramping with slight per-vaginal bleeding, and a negative urinary pregnancy test (UPT). Based on clinical presentation, ultrasound findings and a positive UPT after urine dilution, molar pregnancy was diagnosed. Aspiration was performed under ultrasound guidance, and follow-up was done as per MSF guidelines. HCPs need to be familiar with some rare cases for which the possibility of finding false-negative UPT is likely.

Hydatidiform Mole-Between Chromosomal Abnormality, Uniparental Disomy and Monogenic Variants: A Narrative Review

A hydatidiform mole (HM) or molar pregnancy is the most common benign form of gestational trophoblastic disease characterized by a proliferation of the trophoblastic epithelium and villous edema. Hydatidiform moles are classified into two forms: complete and partial hydatidiform moles. These two types of HM present morphologic, histopathologic and cytogenetic differences. Usually, hydatidiform moles are a unique event, but some women present a recurrent form of complete hydatidiform moles that can be sporadic or familial. The appearance of hydatidiform moles is correlated with some genetic events (like uniparental disomy, triploidy or diandry) specific to meiosis and is the first step of embryo development. The familial forms are determined by variants in some genes, with NLRP7 and KHDC3L being the most important ones. The identification of different types of hydatidiform moles and their subsequent mechanisms is important to calculate the recurrence risk and estimate the method of progression to a malign form. This review synthesizes the heterogeneous mechanisms and their implications in genetic counseling.

Outcomes of Gestational Trophoblastic Disease Management: A Single Centre Review

Background and Objectives: Gestational trophoblastic disease (GTD) is a group of pregnancy-related malignant and premalignant diseases. The aim of this study was to assess the prognostic value of clinical characteristics to predict treatment outcomes in women with GTD. Materials and Methods: In this retrospective study, 34 patients treated for GTD at the Division of Gynaecology and Perinatology, University Medical Centre Maribor, between 2008 and 2022 were identified. Clinical and pathological characteristics were obtained by analysing patient data records. Results: Within the cohort of 34 patients with GTD, 29 patients (85.3%) had a partial hydatidiform mole (HM) and five patients545 (14.7%) had a complete HM. Two patients with a complete HM developed a postmolar gestational trophoblastic neoplasia (GTN), which represents 5.8% of all cases. Conclusions: GTD is a rare disease that is frequently asymptomatic. The subsequent consequences of GTD, which can lead to malignant transformation, as well life-threatening disease complications, warrant training for early recognition of HMs and timely treatment and surveillance.

Immune checkpoint inhibitor using in cases with gestational trophoblastic diseases

Gestational trophoblastic neoplasias (GTNs) are chemosensitive disorders with very high cure rates. However, individuals with chemoresistant diseases pass away as a result of their illness, necessitating the use of innovative medications. Immune checkpoint inhibitors (ICIs) are a critical component of the strategy for the management of drug-resistant GTD due to the high rate of PD-1 expression and the paternal genetic inheritance in GTNs. Immunotherapy is mentioned as a potential therapeutic approach for chemotherapy-resistant GTD in the most recent worldwide recommendations. However, multicenter worldwide collaborative studies are required to give additional evidence to detect and identify prognostic markers due to the rarity of GTDs and the dearth of data in the literature.

Gene Amplification in Tumor Cells: Developed De Novo or Adopted from Stem Cells

Gene amplifications have been known for several decades as physiological processes in amphibian and flies, e.g., during eggshell development in Drosophila and as part of pathological processes in humans, specifically in tumors and drug-resistant cells. The long-held belief that a physiological gene amplification does not occur in humans was, however, fundamental questioned by findings that showed gene amplification in human stem cells. We hypothesis that the physiological and the pathological, i.e., tumor associated processes of gene amplification share at their beginning the same underlying mechanism. Re-replication was reported both in the context of tumor related genome instability and during restricted time windows in Drosophila development causing the known developmental gene amplification in Drosophila. There is also growing evidence that gene amplification and re-replication were present in human stem cells. It appears likely that stem cells utilize a re-replication mechanism that has been developed early in evolution as a powerful tool to increase gene copy numbers very efficiently. Here, we show that, several decades ago, there was already evidence of gene amplification in non-tumor mammalian cells, but that was not recognized at the time and interpreted accordingly. We give an overview on gene amplifications during normal mammalian development, the possible mechanism that enable gene amplification and hypothesize how tumors adopted this capability for gene amplification.

Case report: Conservative treatment for fertility preservation in a woman with hemoperitoneum due to an invasive mole

Background

Invasive moles are a subtype of gestational trophoblastic neoplasia (GTN) that usually develops after hydatidiform molar pregnancies. Uterine rupture in high-risk GTN is a rare and potentially catastrophic event. The treatment of invasive mole perforation with uterine rupture is particularly challenging in young women who desire fertility preservation.

Case presentation

We present the case of a 22-year-old woman with a rapidly transformed invasive mole after two evacuations for a complete molar pregnancy. Within 21 days of the second molar evacuation, the serum β-hCG level surged from 5,718 mIU/ml to 444,617 mIU/ml. An ultrasonography examination showed the uterus was 9.2×8.9×7.8 cm in size with an uneven echo area of 6.9×5.2 cm near the fundus of the uterine cavity; the convex anterior wall had no normal muscle layer, and the outer margin was about 0.24 cm from the serosal layer. The patient was diagnosed with an invasive mole. Since she desired fertility preservation, we proposed a methotrexate (MTX) chemotherapy regimen. Before the planned chemotherapy, she experienced sudden abdominal pain accompanied by a blood pressure of 76/48 mmHg and a pulse rate of 116 bpm. An emergency abdominal ultrasound scan showed acute intra-abdominal bleeding (approximately 2,000 ml), and blood tests showed a hemoglobin concentration of 7.9 g/dL. Immediate uterine artery embolization was performed, and 35 mg MTX was administered bilaterally through the uterine arteries. The next day, the serum β-hCG decreased to 83,530 mIU/ml, and the vital signs remained stable. Seven days later, the patient received a combination of etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine (EMACO), and the serum β-hCG level normalized after cycle five. At the 13-month follow-up after therapy completion, the woman was disease-free with a normal β-hCG level.

Conclusion

Our experience highlights the potential feasibility and efficacy of conservative treatment for fertility preservation in such scenarios.

Trophoblastic neoplasia on the background of developing pregnancy: a rare gynecological tumor with a chance of favorable outcome for mother and fetus

Trophoblastic neoplasias are rare tumors, accounting for less than 1 % of malignant neoplasms of the female genital tract. Trophoblastic tumors associated with developing pregnancy are extremely rare. The article presents the successful experience of diagnostics and treatment of intraplacental chorioncarcinoma associated with progressing pregnancy.

Role of microRNAs in trophoblast invasion and spiral artery remodeling: Implications for preeclampsia

It is now well-established that microRNAs (miRNAs) are important regulators of gene expression. The role of miRNAs in placental development and trophoblast function is constantly expanding. Trophoblast invasion and their ability to remodel uterine spiral arteries are essential for proper placental development and successful pregnancy outcome. Many miRNAs are reported to be dysregulated in pregnancy complications, especially preeclampsia and they exert various regulatory effects on trophoblasts. In this review, we provide a brief overview of miRNA biogenesis and their mechanism of action, as well as of trophoblasts differentiation, invasion and spiral artery remodeling. We then discuss the role of miRNAs in trophoblasts invasion and spiral artery remodeling, focusing on miRNAs that have been thoroughly investigated, especially using multiple model systems. We also discuss the potential role of miRNAs in the pathogenesis of preeclampsia.

The diagnostic value and accuracy of ultrasound in diagnosing hydatidiform mole: A systematic review and meta-analysis of the literature

INTRODUCTION

Hydatidiform moles are the most common type of gestational trophoblastic disease. Internationally the incidence of hydatidiform moles is 1-2:1000 pregnancies. Early detection of women with hydatidiform moles is preferential, as these women are at a higher risk of developing other gestational trophoblastic disease. Despite Ultrasound being the most common modality used to diagnose hydatidiform moles, its diagnostic value and accuracy throughout all trimesters remains uncertain. Thus, the aim of this review was to explore and evaluate the diagnostic value and accuracy of Ultrasound in diagnosing hydatidiform mole throughout all trimesters of pregnancy.

METHODS

The databases MEDLINE and CINAHL were searched between 2004 and 2021. Included studies were quality assessed using the Mixed Methods Appraisal Tool.

RESULTS

A total of 8 studies were included. The narrative synthesis identified four themes: Misdiagnosis, Complete and Partial molar pregnancy, Operator dependency and Gestational age. The meta-analysis highlighted although the sensitivity of ultrasound for diagnosing hydatidiform moles is relatively low at 52.2%, the specificity was high at 92.6%.

CONCLUSION

While histological examination remains the gold standard for detecting hydatidiform moles, our review made evident that ultrasound is a beneficial diagnostic tool in the detection of Hydatidiform moles, especially alongside other diagnostic investigations. This review has highlighted and collated the main barriers and facilitators to diagnosing hydatidiform moles using ultrasound.

IMPLICATION FOR PRACTICE

Findings suggest that although sonographic detection of hydatidiform moles remains a diagnostic challenge, seeking a second opinion or repeating scans before making a final diagnosis should be embedded into clinical practice.

Current Evidence on Immunotherapy for Gestational Trophoblastic Neoplasia (GTN)

Simple Summary

Gestational trophoblastic neoplasia (GTN) is a rare tumor group that arises from the malignant transformation of placental tissue. Based on the evaluation of International Federation of Gynecology and Obstetrics (FIGO) anatomic staging and FIGO prognostic score, GTN is divided into low-, high-, and ultra-high-risk groups if the score obtained is less than or equal to 6, greater than 6 or greater than 12, respectively. The standard treatment is chemotherapy, using a single agent in low-risk disease and multiagent chemotherapy in high- and ultra-high-risk GTN. In chemoresistant forms of GTN, the use of immune checkpoint inhibitors, such as anti-PD-1 or anti-PD-L1/2, could represent a new therapeutic strategy. In this study, we evaluate the available evidence on immune checkpoint inhibitors for GTN treatment.

Abstract

Background: Gestational trophoblastic disease includes a rare group of benign and malignant tumors derived from abnormal trophoblastic proliferation. Malignant forms are called gestational trophoblastic neoplasia (GTN) and include invasive mole, choriocarcinoma, placental site trophoblastic tumor and epithelioid trophoblastic tumor. Standard treatment of GTN is chemotherapy. The regimen of choice mainly depends on the FIGO prognostic score. Low-risk and high-risk GTN is treated with single-agent or multiagent chemotherapy, respectively. In the case of chemoresistance, immunotherapy may represent a new therapeutic strategy. Methods: Literature obtained from searches on PubMed concerning GTN and immunotherapy was reviewed. Results: Programmed cell death 1 (PD-1) and its ligands (PD-L1/2) are expressed in GTN. Published data on PD-1/PD-L1 inhibitors alone in GTN were available for 51 patients. Pembrolizumab is an anti-PD-1 inhibitor used in chemoresistant forms of GTN. In the TROPHIMMUN trial, Avelumab, a monoclonal antibody inhibiting PD-L1, showed promising results only in patients with GTN resistant to monochemotherapy. Conversely, in patients with resistance to multiagent chemotherapy, treatment with Avelumab was discontinued due to severe toxicity and disease progression. The association of Camrelizumab and Apatinib could represent a different treatment for forms of GTN refractory to polychemotherapy or for relapses. Conclusions: Anti-PD-1 or anti-PD-L1 might represent an important new treatment strategy for the management of chemoresistant/refractory GTN.

Extravillous trophoblast migration and invasion: Impact of environmental chemicals and pharmaceuticals

During pregnancy, the migration and invasion of extravillous trophoblasts (EVTs) into the maternal uterus is essential for proper development of the placenta and fetus. During the first trimester, EVTs engraft and remodel maternal spiral arteries allowing for efficient blood flow and the transfer of essential nutrients and oxygen to the fetus. Aberrant migration of EVTs leading to either shallow or deep invasion into the uterus has been implicated in a number of gestational pathologies including preeclampsia, fetal growth restriction, and placenta accreta spectrum. The migration and invasion of EVTs is well-coordinated to ensure proper placentation. However, recent data point to the ability of xenobiotics to disrupt EVT migration. These xenobiotics include heavy metals, endocrine disrupting chemicals, and organic contaminants and have often been associated with adverse pregnancy outcomes. In most instances, xenobiotics appear to reduce EVT migration; however, there are select examples of enhanced motility after chemical exposure. In this review, we provide an overview of the 1) current experimental approaches used to evaluate EVT migration and invasion in vitro, 2) ability of environmental chemicals and pharmaceuticals to enhance or retard EVT motility, and 3) signaling pathways responsible for altered EVT migration that are sensitive to disruption by xenobiotics.

Epigenetic Dysregulation of Trophoblastic Gene Expression in Gestational Trophoblastic Disease

Gestational trophoblastic diseases (GTDs) have not been investigated for their epigenetic marks and consequent transcriptomic changes. Here, we analyzed genome-wide DNA methylation and transcriptome data to reveal the epigenetic basis of disease pathways that may lead to benign or malignant GTDs. RNA-Seq, mRNA microarray, and Human Methylation 450 BeadChip data from complete moles and choriocarcinoma cells were bioinformatically analyzed. Paraffin-embedded tissues from complete moles and control placentas were used for tissue microarray construction, DNMT3B immunostaining and immunoscoring. We found that DNA methylation increases with disease severity in GTDs. Differentially expressed genes are mainly upregulated in moles while predominantly downregulated in choriocarcinoma. DNA methylation principally influences the gene expression of villous trophoblast differentiation-related or predominantly placenta-expressed genes in moles and choriocarcinoma cells. Affected genes in these subsets shared focal adhesion and actin cytoskeleton pathways in moles and choriocarcinoma. In moles, cell cycle and differentiation regulatory pathways, essential for trophoblast/placental development, were enriched. In choriocarcinoma cells, hormone biosynthetic, extracellular matrix-related, hypoxic gene regulatory, and differentiation-related signaling pathways were enriched. In moles, we found slight upregulation of DNMT3B protein, a developmentally important de novo DNA methylase, which is strongly overexpressed in choriocarcinoma cells that may partly be responsible for the large DNA methylation differences. Our findings provide new insights into the shared and disparate molecular pathways of disease in GTDs and may help in designing new diagnostic and therapeutic tools.

Placental spectrum features between mesenchymal dysplasia and partial hydatidiform mole coexisting with a live fetus

We report a case of a singleton hydrops pregnancy with placental gross and microscopic features between partial hydatidiform mole (PHM) and placental mesenchymal dysplasia (PMD) in a diploid live fetus. Pregnancy was complicated by early onset of growth restriction and pre-eclampsia. A female newborn was born at 29 weeks with no congenital malformations. Histology of the placenta revealed mixed phenotype of PMD and PHM, and genetic test results were normal.

Persistent gestational trophoblastic disease following ovarian molar pregnancy: A case report of a rare entity with review of the literature

Ovarian molar pregnancy, though a very rare entity, behaves like any other molar pregnancy. After surgical management, close follow-up with β-hCG surveillance is invariable to detect progression to persistent gestational trophoblastic disease.

Complete hydatidiform mole in a 52-year-old postmenopausal woman: A case report and literature review

Benign gestational trophoblastic disease generally occurs in women of reproductive age and is extremely rare in postmenopausal women. Here, the authors describe a case of complete hydatidiform mole in a 52-year-old postmenopausal woman with a history of lower abdominal bloating and vaginal bleeding. The paper summarizes the clinical manifestations, physiopathology, diagnosis, and treatment options for gestational trophoblastic disease in postmenopausal women. This study highlights that gestational trophoblastic disease can occur in postmenopausal women and that it is important to include it in the differential diagnosis of postmenopausal bleeding, to prevent delay in treatment.

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Hydatidiform mole (HM) is extremely rare in postmenopausal women.

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Patients with hydatidiform mole generally present with vaginal bleeding.

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Prophylactic chemotherapy can prevent distant metastasis of hydatidiform mole.

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Follow-up monitoring of serum β-HCG levels is vital after therapy.

Detecting retinal cell stress and apoptosis with DARC: Progression from lab to clinic

DARC (Detection of Apoptosing Retinal Cells) is a retinal imaging technology that has been developed within the last 2 decades from basic laboratory science to Phase 2 clinical trials. It uses ANX776 (fluorescently labelled Annexin A5) to identify stressed and apoptotic cells in the living eye. During its development, DARC has undergone biochemistry optimisation, scale-up and GMP manufacture and extensive preclinical evaluation. Initially tested in preclinical glaucoma and optic neuropathy models, it has also been investigated in Alzheimer, Parkinson's and Diabetic models, and used to assess efficacy of therapies. Progression to clinical trials has not been speedy. Intravenous ANX776 has to date been found to be safe and well-tolerated in 129 patients, including 16 from Phase 1 and 113 from Phase 2. Results on glaucoma and AMD patients have been recently published, and suggest DARC with an AI-aided algorithm can be used to predict disease activity. New analyses of DARC in GA prediction are reported here. Although further studies are needed to validate these findings, it appears there is potential of the technology to be used as a biomarker. Much larger clinical studies will be needed before it can be considered as a diagnostic, although the relatively non-invasive nature of the nasal as opposed to intravenous administration would widen its acceptability in the future as a screening tool. This review describes DARC development and its progression into Phase 2 clinical trials from lab-based research. It discusses hypotheses, potential challenges, and regulatory hurdles in translating technology.

A Rare Case of Early Transformation of Gestational Trophoblastic Neoplasia Following Molar Pregnancy

BACKGROUND Gestational trophoblastic disease (GTD) encompasses a group of disorders that arise from abnormal growth of trophoblastic tissue. The spectrum of GTD includes 2 major groups: benign and malignant. The benign form is a hydatidiform mole, either complete or partial; the malignant forms, referred to as gestational trophoblastic neoplasia (GTN), consist of invasive moles, choriocarcinomas, placental site trophoblastic tumors, and epithelioid trophoblastic tumors. Most patients who undergo evacuation of a hydatidiform mole by curettage have a disease-free period before a new tumor develops that can be considered malignant. In rare cases, metastasis occurs rapidly and manifests coincidentally before the hydatidiform mole can be evacuated. CASE REPORT A 19-year-old woman in Bandung City, West Java, Indonesia, was diagnosed with a molar pregnancy with early evidence of a mass in her vagina that was suspicious for stage II GTN. The early emergence of a vaginal mass was a rare case of early transformation of a molar pregnancy into GTN. CONCLUSIONS Careful evaluation is warranted of patients with characteristics typical of an intrauterine molar pregnancy who have an early presentation of a vaginal mass because of the possibility that the diagnosis could be GTN.

Cytological features of a complete hydatidiform mole in a cervicovaginal smear: A case report

Exfoliated trophoblastic cells can be seen in a cervicovaginal smear in cases of normal pregnancy or gestational trophoblastic disease (GTD) and can mimic high-grade squamous intraepithelial lesion (HSIL) or malignancy. Although they appear highly anaplastic, cytological features such as high nuclear to cytoplasmic ratio, irregular nuclear contours and scanty basophilic cytoplasm admixed with cytologically benign squamoid and endocervical cells can aid in differentiating them from malignant cells. We present a case of a 37-year-old woman with abnormal uterine bleeding for 3-months. There was no history of recent pregnancy or previous GTD. Her cervicovaginal smear showed a hypercellular smear exhibiting cytologically benign superficial and intermediate squamous cells along with clusters of benign endocervical cells with interspersed mononucleate cells. These mononucleate cells were large, with a hyperchromatic, pleomorphic nuclei, and scant basophilic cytoplasm. Cytological features were suggestive of trophoblastic cells and workup for pregnancy and GTD was advised. Her laboratory investigations showed markedly raised levels of β human chorionic gonadotropins (β-HCG) and ultrasound showed a uterine mass with snowstorm appearance. A uterine evacuation was performed after which histopathological examination showed microscopic features consistent with a complete hydatidiform mole. The rare presence of trophoblastic cells in a cervicovaginal smear can easily be confused with malignant cells and can be misleading to the pathologist. Trophoblastic cells should always be kept in mind when evaluating a cytology smear of a young patient irrespective of gestational status.

Exploiting the placenta for nanoparticle-mediated drug delivery during pregnancy

A major challenge to treating diseases during pregnancy is that small molecule therapeutics are transported through the placenta and incur toxicities to the developing fetus. The placenta is responsible for providing nutrients, removing waste, and protecting the fetus from toxic substances. Thus, the placenta acts as a biological barrier between the mother and fetus that can be exploited for drug delivery. Nanoparticle technologies provide the opportunity for safe drug delivery during pregnancy by controlling how therapeutics interact with the placenta. In this Review, we present nanoparticle drug delivery technologies specifically designed to exploit the placenta as a biological barrier to treat maternal, placental, or fetal diseases exclusively, while minimizing off-target toxicities. Further, we discuss opportunities, challenges, and future directions for implementing drug delivery technologies during pregnancy.

Folic acid versus 5- methyl tetrahydrofolate supplementation in pregnancy

Folate (vitamin B9) is widely accepted to protect against fetal neural tube defects. The main sources of dietary folate are folic acid-fortified foods and folic acid-containing dietary supplements. However, folic acid is inactive in the human body and must be converted by the liver into the active molecule 5-methyltetrahydrofolate (5-MTHF). 5-MTHF functions as a methyl donor in many metabolic reactions, including the conversion of homocysteine into methionine, the biosynthesis of glycine from serine, and the biosynthesis of DNA precursor molecules. Therefore, folate is fundamental for growth, especially in the embryonic and fetal stages. Prescription of folic acid to women in the preconception period and during pregnancy is a consolidated practice. However, it can pose health risks in certain conditions, such as megaloblastic anemia, where it will conceal megaloblastic anemia due to vitamin B12 deficiency and in cases of reduced hepatic transformation of folic acid (e.g. due to genetic variants or during some pharmacotherapies). Some of these risks can be avoided by supplementation with 5-MTHF rather than folic acid. Because 5-MTHF does not require activation, it is immediately available to mother and fetus and does not accumulate in blood like folic acid does in cases of reduced hepatic transformation. This paper reviews the advantages and disadvantages of folate supplementation with folic acid versus 5-MTHF, with a focus on maternal and fetal health.

A review on management of gestational trophoblastic neoplasia

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.

When a Differential Diagnosis Is Fundamental: Choriocarcinoma Mimicking Lung Carcinoma

Background: Choriocarcinoma is a rare malignant disease that is usually associated with a gestational event. Lung metastasis with no evident primary origin and choriocarcinoma, which mimics features of non-small-cell lung cancer, might be misdiagnosed as adenocarcinoma or large-cell carcinoma. This is a pivotal clinical concern since the tumor can lead to various symptoms, seriously affecting the quality of life and can escalate rapidly, with a high mortality rate, compared to lung cancer. Methods: We reported a case of a 37-year-old woman with a history of one-year enhancement of beta-human chorionic gonadotropin levels and only a single nodule in the right upper lobe, with no abnormal findings on the gynecological investigation. Then we retrospectively examined all cases treated in the Division of Thoracic Surgery at the European Institute of Oncology in the last twenty years (from 1998 to 2018). Results: This was the first time in our experience that choriocarcinoma presentation was with a single nodule without a gynecological finding. Moreover, the differential diagnosis between lung carcinoma and choriocarcinoma was achieved only after surgical removal. Conclusions: As confirmed by our literature search, precise and expedited differential diagnosis is essential in choriocarcinoma care (both with single or multiple metastases), to successfully remove the tumor and increase the patient’s chances of survival.

Dysregulation of Placental Functions and Immune Pathways in Complete Hydatidiform Moles

Gene expression studies of molar pregnancy have been limited to a small number of candidate loci. We analyzed high-dimensional RNA and protein data to characterize molecular features of complete hydatidiform moles (CHMs) and corresponding pathologic pathways. CHMs and first trimester placentas were collected, histopathologically examined, then flash-frozen or paraffin-embedded. Frozen CHMs and control placentas were subjected to RNA-Seq, with resulting data and published placental RNA-Seq data subjected to bioinformatics analyses. Paraffin-embedded tissues from CHMs and control placentas were used for tissue microarray (TMA) construction, immunohistochemistry, and immunoscoring for galectin-14. Of the 14,022 protein-coding genes expressed in all samples, 3,729 were differentially expressed (DE) in CHMs, of which 72% were up-regulated. DE genes were enriched in placenta-specific genes (OR = 1.88, p = 0.0001), of which 79% were down-regulated, imprinted genes (OR = 2.38, p = 1.54 × 10-6), and immune genes (OR = 1.82, p = 7.34 × 10-18), of which 73% were up-regulated. DNA methylation-related enzymes and histone demethylases were dysregulated. "Cytokine-cytokine receptor interaction" was the most impacted of 38 dysregulated pathways, among which 17 were immune-related pathways. TMA-based immunoscoring validated the lower expression of galectin-14 in CHM. In conclusion, placental functions were down-regulated, imprinted gene expression was altered, and immune pathways were activated, indicating complex dysregulation of placental developmental and immune processes in CHMs.