A case report of pelviscopic resection of invasive hydatidiform mole

RATIONALE

Invasive moles occur in the fertile period, with about 95% occurring after previous mole removal and the remaining 5% occurring after several other pregnancies.

PATIENT CONCERNS

A 27-year-old patient developed a rare invasive mole two months after a missed abortion.

DIAGNOSES

A transvaginal ultrasound scan revealed a 3.6 × 2.9 × 2.4 cm sized lesion with cystic vascular areas within it, within the myometrium of the right fundal posterior region of the uterus. There was no metastasis to other organs.

INTERVENTIONS

After administration of methotrexate, the level of beta-human chorionic gonadotropin (ß-hCG) was elevated and liver enzymes were also markedly elevated. She wanted to retain fertility for future pregnancies. After laparoscopic removal of the myometrial invasive mole, the incision site was sutured with a 3-0 V-Loc.

OUTCOMES

One year later, a natural pregnancy occurred and a cesarean section was performed at 36 weeks.

LESSONS

This is the first reported case of its type. Our case demonstrated that pelviscopic removal of an invasive mole is possible if there are no other metastases, and that future pregnancy and childbirth are still feasible in women of reproductive age.

Histopathological and clinical features of molar pregnancy

OBJECTIVE

To analyse own set of molar pregnancies and to develop clinically relevant procedures.

TYPE OF STUDY

Review article with analysis of own data.

SETTINGS

Department of Pathology 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague; Department of Obstetrics and Gynecology 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague.

INTRODUCTION

The study monitors the decrease of laboratory values of beta-subunit of hCG gonadotropin (beta-hCG) after evacuation of partial and complete hydatidiform moles in a set of 45 partial and 46 complete moles. Two case reports of invasive moles.

RESULTS

In cases of partial hydatidiform moles there was complete regression of beta-hCG in all cases, 89% regressed in six weeks, none of the women showed no subsequent elevation after reaching negativity. In cases of complete hydatidiform moles the decrease was less gradual, the negativity after six weeks was confirmed in 78%, three complete moles became malignant.

CONCLUSION

The decrease of beta-hCG after molar pregnancy termination is variable. Even if in cases of complete hydatidiform moles the risk of malignization after reaching negativity is low, beta-hCG checks are recommended at monthly intervals for 6 months. Correct diagnosis of complete mole and its differentiation from partial mole can be achieved using immunohistochemistry - p57 antibody.

Sudden death due to an invasive mole in a young primigravida: Precipitous presentation masquerading the natural manner

Pulmonary metastasis is a well-known complication of an invasive mole. However, sudden death due to haemoptysis resulting from a metastatic invasive mole is extremely rare. We report the sudden unexpected death of an 18-year-old primigravida following a molar pregnancy. The death event was complicated within a few days of presentation by a clinically unsuspected mole invading the lung vasculature with associated widespread metastatic calcifications in the liver and brain. Death was due to haemorrhagic shock as a result of massive haemoptysis resulting from the invasive mole metastasising to the pulmonary vasculature. This was substantiated with a post-mortem computed tomography and gross and histopathological findings at autopsy. This case highlights the need for a high index of suspicion about potentially life-threatening pulmonary metastasis in women with trophoblastic diseases.

Japanese trial for classification of gestational trophoblastic disease

OBJECTIVE

To evaluate the clinical usefulness of the Japanese Diagnostic Score to differentiate choriocarcinoma clinically without histologic findings from persistent gestational trophoblastic disease (GTD).

STUDY DESIGN

We reviewed the clinical records and histologic reports on all 809 patients with persistent GTD treated with surgery and chemotherapy in Japan. There were 347 cases of choriocarcinoma and 462 cases of invasive mole with histologic confirmation. We retrospectively applied the Japanese Diagnostic Score to all patients for detection of choriocarcinoma in persistent trophoblastic disease.

RESULTS

The sensitivity of the score for choriocarcinoma was 92.2%. The specificity was 93.5%. This retrospective study showed that the accuracy of this scoring system to differentiate true malignant choriocarcinoma clinically from both low risk and high risk gestational trophoblastic neoplasia without histologic findings was 92.9%.

CONCLUSION

Our trial to differentiate choriocarcinoma clinically from persistent GTD without histologic findings using a unique scoring system was successful. Proper management in the early stages strongly influences the outcome of these diseases. This scoring system should be very useful in comparing the incidence and survival rate of choriocarcinoma between nations.

[Clinical analysis of patients with lung metastasis of invasive mole before evacuation of hydatidiform mole]

OBJECTIVE

To investigate the clinical characteristics, management and outcome of patients with lung metastasis of invasive mole (IM) before evacuation of hydatidiform mole (HM).

METHODS

Clinical data of patients with hydatidiform mole (HM) and lung metastasis of IM who were diagnosed and treated at Peking Union Medical College Hospital from Jan 2004 to Jan 2006 were analyzed retrospectively. Firstly, clinical characteristics of patients with lung metastasis of IM before evacuation of HM (positive group) were compared with that of patients without lung metastasis before evacuation of HM (negative group); secondly, management and outcome of patients with lung metastasis of IM before evacuation of HM were compared with that of patients as lung metastasis of IM diagnosed in postevacuation follow-up of HM (control group).

RESULTS

A total of 37 cases with HM underwent CT scan of the chest before evacuation, 11 cases of which were diagnosed as lung metastasis, accounting for 30%. Compared with negative group, significant increases in positive group were found in gestational age of week [(15.0 +/- 4.0) versus (10.0 +/- 2.5) weeks, P = 0.026], and proportion of complete HM (91% versus 50%, P = 0.027). Between positive group and negative group, no significant differences were found in age, uterine size greater than expected for gestational age, large theca lutein cyst and pre-evacuation serum human chorionic gonadotropin-beta subunit (beta-hCG) level (P > 0.05). Compared with control group, significant decrease in positive group was found in the interval from first evacuation of HM to resolution of serum beta-hCG level, (83 +/- 18) days versus (126 +/- 31) days (P < 0.01). Also, no statistically significant differences between positive group and control group were noted in the complete resolution rate achieved, the average courses of resolution of serum beta-hCG level and disappearance or marked absorption of lung metastasis needed, and the total chemotherapy courses (P > 0.05).

CONCLUSIONS

Once HM is diagnosed, evacuation should be performed as soon as possible, the later the evacuation begins, the higher the risks of lung metastasis and chemotherapy are. It is not necessary to worry about lung metastasis before evacuation of HM, the outcome of post-chemotherapy is very good.

Recurrent partial hydatidiform mole: a report of a patient with three consecutive molar pregnancies

Hydatidiform mole (HM) is the most common form of gestational trophoblastic neoplasia and is characterized by atypical hyperplastic trophoblasts and hydropic villi. Recurrence of HM is extremely rare. Here, we report the case of a patient with three consecutive partial HMs without normal pregnancy. A 28-year-old woman with gravida 3, para 0, was referred to our hospital with a diagnosis of an invasive mole in December 2003. She had three consecutive molar pregnancies in 2000, 2001, and 2003. All three molar pregnancies were evacuated by suction curettage and the patient was followed by serial beta-human chorionic gonadotropin levels. All three moles were histologically confirmed as partial moles. In the first two molar events no additional treatment after evacuation was required, but in the last event, the beta-human chorionic gonadotropin levels increased and an invasive mole was suspected. Diagnostic workup ruled out an invasive mole and choriocarcinoma. Karyotypic analysis of the patient and her husband was normal. The patient required chemotherapy for treatment of persistent disease. Recurrent partial HM is a very rare clinical disorder. Repetitive molar pregnancy is not an indication for chemotherapy, but persistent disease does require chemotherapy.

A perplexing case of gastrointestinal haemorrhage

Choriocarcinoma is a gestational trophoblastic tumour with a high metastatic potential but presentation with gastrointestinal haemorrhage due to jejunal mucosal metastasis is very rare. A 25-year-old Nepali woman presented with severe anaemia and massive gastrointestinal haemorrhage after normal pregnancy following evacuation of a hydatiform mole. During laparotomy, the patient was found to have extensive jejunal mucosal metastases.

Gestational trophoblastic diseases: recent advances in histopathologic diagnosis and related genetic aspects

Gestational trophoblastic disease refers to a spectrum of proliferative disorders of the placental trophoblast, with a wide range of histologic appearances and clinical behaviors. This review discusses the more recent developments in the diagnosis of these entities. Changes in criteria for the histologic diagnosis of these lesions due to earlier clinical diagnosis are reviewed, and the ability to make more accurate diagnoses due to the introduction of newer antibodies such as p57 is highlighted. A discussion of epithelioid trophoblastic tumor, a newly introduced tumor subtype, with its differential diagnosis from placental-site trophoblastic tumor and squamous cell carcinoma is also presented. Last, a brief discussion on the role of genetic studies and the future direction of research in elucidating the nature of this intriguing group of lesions is presented.

[Expression of laminin and laminin receptor in gestational trophoblastic tumor and its significance]

OBJECTIVE

This study was conducted to detect the expression of laminin (LN) and laminin receptor (LN-R) in the specimens of hydatidiform mole (HM), invasive mole (IM) and choriocarcinoma(CC), respectively.

METHODS

The immunohistological staining method was used.

RESULTS

It was found that the level of the laminin expression was higher in the specimens of choriocarcinoma at more advanced stage.

CONCLUSION

The results suggest that there may be relations between the invasion and metastasis of choriocacinoma cell and the malignant degree of this disease, chemotherapy has some effect on the expression of LN and LN-R in gestational trophablastic tumor (GTT), and that LN and LN-R may be of potential value in GTT treatment. However, referring whether LN and LN-R could be used as clinical prognosticators, further studies will be needed.

[Assessment of staging and prognostic scoring system for malignant trophoblastic neoplasia]

OBJECTIVE

To assess malignant trophoblastic neoplasia with the standards of the clinical stage and prognostic factor scoring system.

METHODS

Through assessing the high-risk factors except clinical stages for 223 patients before treatment according to International Federation of Gynecology and Obstetrics (FIGO) scoring system published in 2000, appropriate treatments were selected for the different patients.

RESULTS

Forty-three of 78 cases of choriocarcinomas were with high-risk factors, the other 35 cases were with low-risk factors; 7 of 145 cases of invasive moles were with high-risk factors and the others were with low-risk factors. The primary chemotherapy principle was that one agent was used for those patients with low-risk factors and two or multiple-agents were used for those patients with high-risk factors. Among all patients, the one-year, three-year and five-year survival rates were 98.6%, 98.1% and 97.1% respectively. No patient died of drug toxicity or complication.

CONCLUSION

Selection of treatment approaches according to the prognostic assessment of malignant trophoblastic neoplasia could lead to promising survival rate with no uncurable complication and toxic effects.

[Clinical analysis of 13 cases of gestational trophoblastic tumor misdiagnosed as ectopic pregnancy]

OBJECTIVE

To evaluate clinical-pathological features, diagnosis and therapy of gestational trophoblastic tumor (GTT) misdiagnosed as ectopic pregnancy.

METHODS

From 1999 to 2003, a total of 13 patients with GTT misdiagnosed as ectopic pregnancy were retrospectively analyzed.

RESULTS

The main symptoms were amenorrhea, abdominal pain, irregular vaginal bleeding. Serum beta-human chorionic gonadotrop in (hCG) was measured in 10 patients. Eight had hCG values above 10,000 IU/L; 3 had hCG values above 50,000 IU/L. The lesions of GTT misdiagnosed as ectopic pregnancy were fallopian tube, horn of uterus, peritoneal cavity, greater omentum, recto-uterine pouch. According to standards of the International Federation of Gynecology and Obstetrics (FIGO) the 13 patients were categorized as 6 of stage I, 2 of stage II, 3 of stage III and 5 of stage IV. Histologically they included 10 cases of choriocarcinoma and 3 of invasise mole. All patients were treated by complete surgical resection combined with subsequent adjuvant chemotherapy.

CONCLUSIONS

Misdiagnosis leads to delay in therapy with resultant increased morbidity of GTT. Analysis on serial hCG is helpful to differential diagnosis between ectopic pregnancy and GTT.

[Study on the indication of surgical resection of pulmonary metastasis of malignant trophoblastic tumor]

OBJECTIVE

To investigate the indication of lung lobectomy in patients of malignant trophoblastic tumor with lung metastasis.

METHODS

Data on a total of 629 cases of malignant trophoblastic tumor of stage III-IV in Peking Union Medical College Hospital from 1990 to 2003 were reviewed. Ninety-five cases including those that underwent lung lobectomy and cases with normal level of serum human chorionic gonadotropin-beta subunit (beta-hCG, < 2 IU/L) and residual pulmonary nodules after chemotherapy were selected and studied.

RESULTS

Lung lobectomies were performed on six cases of invasive mole with lung metastasis and the pathological results were all necrotic nodules;another 35 cases of invasive mole with normal level of serum beta-hCG but residual pulmonary nodules after chemotherapy have been followed up for 6 months to 11 years and all were stable of diseases (SD). Lung lobectomies were performed on 29 cases of choriocarcinoma with lung metastasis. Among them, there were 17 cases whose pathological results were hemorrhage and necrotic tissue without trophoblastic cells (negative pathological results), while trophoblastic cells could still be detected in 12 cases of resected lung specimens (positive pathological results). Twenty-five cases of choriocarcinoma with normal serum beta-hCG but residual pulmonary nodules after chemotherapy were followed up, five cases had progress of disease (PD) and 20 were SD. There were no significant differences of age, stage and the last pregnancy between the positive and negative pathological results, SD and PD groups, respectively. However, the number of chemotherapeutic courses for decreasing beta-hCG from 10 IU/L to 2 IU/L and the total courses in the group of positive pathological results and PD group were significantly more than that of negative pathological results group and SD group (P = 0.01, P = 0.001).

CONCLUSIONS

For invasive mole, lung metastasis can be successfully treated by chemotherapy alone. Patients with residual pulmonary nodules but normal serum beta-hCG after chemotherapy can be followed up and spared lung lobectomy. For choriocarcinoma, slowly decreasing of beta-hCG from 10 IU/L to 2 IU/L is a high risk for chemoresistance, and it is an indication for thoracotomy. Progression of disease after multiple chemotherapy courses should be treated with lung lobectomy.

Partial hydatidiform mole

A case of partial hydatidiform mole is presented, occurring in a young primiparous woman after natural conception. She presented with incomplete miscarriage. Histological diagnosis of partial mole was made. Failure of beta HCG to fall resulted in the start of chemotherapy. WHO scoring placed her in low risk group. In spite of the low risk, she required third line chemotherapy for complete eradication of disease.

Galectin-1 and galectin-3 in the trophoblast of the gestational trophoblastic disease

While the presence and distribution of galectin-1 and galectin-3 in different normal trophoblast cell populations is known, no information is available regarding their occurrence in malignant trophoblast of gestational trophoblastic disease (GTD). Galectins-1 and -3 have, however, been implicated in malignancies of other tissues. Immunoreactivity for these galectins in the transformed trophoblast of invasive mole (n = 8), choriocarcinoma (n = 7) and one case of placental site trophoblastic tumor (PSTT) was compared to that of the invasive trophoblast of the normal first trimester of pregnancy implantation sites (n = 9). A large proportion of the transformed trophoblast cells of all GTD studied were positive for galectin-1 and galectin-3. Immunoreactivity was scored semiquantitatively to include both the prevalence among the trophoblast cells and the intensity of staining. Immunoreactivity for both galectin-1 and galectin-3 in gestational trophoblastic disease is increased (significant differences at p < 0.05, Mann-Whitney Rank Sum Test). This finding may suggest a possible implication of galectins-1 and -3 in the invasiveness of the transformed trophoblastic cell, although the exact physiological significance of this finding remains to be determined.

Pathology of gestational trophoblastic diseases

Gestational trophoblastic disease (GTD) is a heterogeneous group of diseases. This used to include partial and complete hydatidiform moles, invasive mole, choriocarcinoma and placental site trophoblastic tumour. In recent years, new entities, including epithelioid trophoblastic tumour, have been added to this family. Non-neoplastic and neoplastic lesions derived from implantation site and chorion intermediate trophoblast have been gaining attention in the literature. New markers for trophoblasts have been identified facilitating histological diagnosis in cases with unusual clinical or pathological features. It is worth noting that histological distinction between hydropic abortion and partial mole and between complete and partial moles, especially at early gestational age, may be difficult. It may not be possible to predict progress of the heterogeneous group of GTD from histopathological features, except probably in placental site trophoblastic tumour. Alternative biological markers may be explored for better patient management.

[Invasive hydatiform mole in a postmenopausal woman]

Gestational trophoblastic disease occurs rarely in postmenopausal women. We report the case of a 51 year-old postmenopausal woman with an invasive complete mole. Invasive mole should be distinguished from choriocarcinoma, by a thorough sampling showing infiltrative molar villi associated with a prominent trophoblastic proliferation. Gestational trophoblastic diseases in postmenopausal women can represent malignant changes of trophoblastic remnants of a prior pregnancy after a period of latency or correspond to a possible current pregnancy as demonstrated by an ovarian corpus luteum of pregnancy in our patient. The unusual finding in our case is that the gestational trophoblastic disease follows a pregnancy occurring after a biologically confirmed menopause.

[Evaluation of surgical resection of pulmonary metastasis of trophoblastic tumour]

OBJECTIVE

To evaluate the role of lung lobectomy in the patients of tumor with lung metastases.

METHODS

A total of 45 cases of trophoblastic tumor with pulmonary metastases treated by lung lobectomy from 1985-2002 at PUMC hospital was retrospectively analyzed. Seven cases were diagnosed as invasive mole and thirty-eight as choriocarcinoma.

RESULTS

Lung lobectomy was performed in all of these patients after several courses of chemotherapy. Seven cases of invasive mole reached complete remission. Eleven cases of choriocarcinoma with stage IIIa had received average 13 courses of chemotherapy, 10 of them reached complete remission. Seventeen cases of choriocarcinoma with stage IIIb had received average 14.3 courses of chemotherapy, 11 of them reached complete remission. Ten cases of choriocarcinoma with stage IV had received average 15 courses of chemotherapy, six of them reached complete remission. In the 45 patients, histologic examination disclosed haemorrhagic necrotic tissue in 27 patients, 17 of them reached complete remission (63%). Histologic examination also revealed fibrosis around the focus in 16 patients, 14 of them reached complete remission (88%). Tuberculosis was found in 2 patients.

CONCLUSIONS

Although the development of effective chemotherapy has resulted in improved survival of patients with gestational trophoblastic tumor, lung lobectomy remains an important adjunct treatment in a selected subset of patients. Pathological examinations can help to estimate the prognosis.

[Mismatch repair gene promoter methylation and expression in hydatidiform moles and the malignant transformation]

OBJECTIVE

In this study, we assayed promoter hypermethylation and protein expression of the mismatch repair gene (MMR) hMLH1 and hMSH2 in gestational trophoblastic diseases to understand the significance of MMR promoter methylation and expression in the pathogenesis and malignant transformation of hydatidiform mole.

METHODS

DNA was extracted from chorion of early pregnancies, partial hydatidiform moles, complete hydatidiform moles, and invasive moles were over digested by methylation sensitive endonuclease Hpa II. Then the promoters were amplificated by polymerase chain reaction. The protein was detected by immunohistochemistry.

RESULTS

In the normal placenta, neither hMLH1 nor hMSH2 promoter methylation was detected. Expression of hMLH1 and hMSH2 in cytotrophoblasts was strongly positive, and that was negative or weakly positive in syncytiotrophobasts. In all normal chorion, expression of hMLH1 and hMSH2 in cytotrophoblasts was strongly positive. In partial hydatidiform mole and complete hydatidiform mole, the methylation of hMLH1 and hMSH2 promoters was significantly higher than that of early placenta (P < 0.05), and the protein expression in cytotrophoblasts was significantly lower (P < 0.05). In the invasive mole, hMLH1 and hMSH2 promoter methylation were not significantly different as compared with the partial hydatidiform mole and complete hydatidiform mole (P > 0.05). Expression of hMLH1 in the invasive mole (54.5%, 6/11) was not significantly different as compared with the partial hydatidiform mole and complete hydatidiform mole (P > 0.05). But expression of hMSH2 in the invasive mole (36.4%, 4/11) was weaker than that in complete hydatidiform mole (P = 0.044). Promoter methylation and less expression of hMSH2 had correlations in complete hydatidiform mole or invasive mole.

CONCLUSIONS

Strong expressions of hMLH1 and hMSH2 in the cytotrophoblasts of normal placenta may keep the genome stability. Promoter methylation and down-regulation of hMLH1 and hMSH2 are probably involved in the pathogenesis of hydatidiform mole.

Expressions of p53, proliferating cell nuclear antigen, and Ki-67 in gestational trophoblastic diseases

OBJECTIVE

This study was done to determine whether the expressions of p53, PCNA, and Ki-67 could differentiate spontaneous abortions with hydropic changes from gestational trophoblastic diseases.

MATERIALS AND METHODS

Twenty partial hydatidiform moles, 21 complete hydatidiform moles, nine invasive hydatidiform moles, three choriocarcinomas and 19 first trimester hydropic spontaneous abortions were evaluated by means of immunohistochemical methods with antibodies to p53, PCNA, and Ki-67 in this study.

RESULTS

The Ki-67, PCNA, and p53 immunoreactivity was significantly higher in the gestational trophoblastic disease group than in the spontaneous abortion group with hydropic changes. None of the three parameters provided reliable discrimination among gestational trophoblastic disease subgroups.

CONCLUSION

Our findings suggest that expressions of Ki-67, proliferating cell nuclear antigen and p53 can be used to differentiate between spontaneous abortion with hydropic changes and gestational trophoblastic disease when all three markers are used together.

The relationship between expression of c-ras, c-erbB-2, nm23, and p53 gene products and development of trophoblastic tumor and their predictive significance for the malignant transformation of complete hydatidiform mole

OBJECTIVE

The aims of this retrospective study by means of immunohistochemical staining were (1) to study the expression of c-ras, c-erbB-2, p53, and nm23 gene products in complete hydatidiform moles that progress to gestational trophoblastic tumor and in those that remit spontaneously after evacuation, and (2) to estimate the predictive value of the expression of these four gene products in malignant transformation of complete hydatidiform mole.

METHODS

Clinical data of patients with complete hydatidiform mole were obtained by retrospective chart review. Formalin-fixed paraffin sections of 50 cases of complete mole that progressed to gestational tumor and 32 cases of complete mole that remitted spontaneously were studied immunohistochemically for c-ras, c-erbB-2, p53, and nm23 proteins. The prognostic value of the proteins for the malignant transformation of complete mole was analyzed by multiple logistic regression and stepwise logistic estimation. Sections of 30 cases of invasive mole and 19 cases of choriocarcinoma were also immunohistologically studied for expression of the proteins.

RESULTS

Expression of c-erbB-2 and p53 gene products was significantly increased and expression of nm23 and c-ras products was remarkably decreased in complete hydatidiform moles that progressed into postmolar tumor compared with those that remitted spontaneously after evacuation. There was no significant difference in the expression of the four genes in invasive mole and in choriocarcinoma. A logistic estimation model for predicting malignant transformation of complete mole was established based on the expression of gene products. When the expression of four gene products was used, the predictive sensitivity of the regression model was 86.0%, and the specificity was 75.0%. The positive predictive value was 84.3%, the negative predictive value was 77.4%. Logistic stepwise regression analysis showed that the altered expression of c-erbB-2 and nm23 products had strong predictive value, while the expression of c-ras and p53 products had no significant predictive value for the malignant transformation of complete mole.

CONCLUSION

The altered expression of c-ras, c-erbB-2, nm23, and p53 gene products may be important in the pathogenesis of gestational trophoblastic tumor. The decreased expression of nm23 protein and increased expression of c-erbB-2 protein are strong predictors for the malignant transformation of complete mole.

Current understandings of the molecular genetics of gestational trophoblastic diseases

Gestational trophoblastic disease (GTD) is a heterogeneous group of diseases characterized by abnormally proliferating trophoblastic tissues. This includes partial and complete hydatidiform moles, invasive mole, choriocarcinoma and placental site trophoblastic tumour. Cytogenetic studies revealed that hydatidiform moles contain either solely (as in complete moles) or an excess (as in partial moles) of paternal contribution to the genome. Genomic imprinting is believed to play a pivotal role in the pathogenesis of hydatidiform moles. However its precise role and mechanism remains poorly understood. Hydatidiform mole carries a potential of malignant transformation. Similar to other human cancers, malignant transformation in gestational trophoblastic tumours is likely a multistep process and involves multiple genetic alterations including activation of oncogenes and inactivation of tumour suppressor genes. In addition, expression of telomerase activity, altered expression of cell--cell adhesion molecules and abnormal expression of matrix metalloproteinases have also been reported in GTD. These represent disruption of the delicate balance and regulation of cellular processes including proliferation, differentiation, apoptosis and invasion. The significance of these alterations in the pathogenesis and malignant transformation of gestational trophoblastic diseases is reviewed in this paper.

Increased expression of interleukin-1 beta is associated with persistence of the disease and invasion in complete hydatidiform moles (CHM)

Complete hydatidiform moles (CHM), a post-conceptual pathologic condition of the placenta, have a high prevalence rate (12/1,000 deliveries) in Kerala, India. This study addresses the expression of IL-1 alpha and beta by immunohistochemistry in relation to persistence and invasion of the disease. Mild to moderate expression of IL-1 alpha in the villous cytotrophoblasts, syncytiotrophoblasts and decidua of the first trimester in the normal placenta and all gestational ages in the molar placenta were observed. IL-1 beta expression was observed in the extravillous trophoblasts, syncytiotrophoblasts and decidua in both the normal and molar placentae and also in the villous cytotrophoblasts and the stromal Haufbaur cells in molar placentae. Strong expression of IL-1 beta in the placenta suggests its involvement in placental physiology supporting earlier reports. Higher expression of IL-1 beta correlated well with the invasive and persistent nature of the tumour and holds potential as a marker of persistence and invasion in CHM.

[Ovarian implantation of the embryo in IVF and ET--early mole with proliferative trophoblast]

OBJECTIVE

Case report of a very rare case of ovarian implantation after IVF and ET treated by laparoscopy.

DESIGN

Case report.

SETTING

Institute for the Care of Mother and Child, Prenatal Diagnostic Centre and Trophoblastic Disease Centre, Prague, Institute for Postgraduate Medical Education, Prague.

RESULTS

We observed implanted product of conception found within the ovarian stroma 35 days after ET. At laparoscopy, the genital sac appeared as an inconspicious haemorrhagic cyst, 2 cm in diameter. After dissection, in the intact sac appeared amorphous 2 mm embryo and 3 mm yolk sac. The trophoblast of the anchoring chorionic villi exhibited marked hyperproliferation and was classified as a proliferating mole.

CONCLUSION

The intact early product of conception exhibited trophoblastic hyperplasia.

Expressions of proliferation markers (Ki-67, proliferating cell nuclear antigen, and silver-staining nucleolar organizer regions) and of p53 tumor protein in gestational trophoblastic disease

OBJECTIVE

This study was undertaken to determine whether the expressions of 3 proliferation markers (Ki-67, proliferating cell nuclear antigen, and silver-staining nucleolar organizer regions) and of p53 tumor protein could differentiate spontaneous abortions from gestational trophoblastic diseases and also discriminate among gestational trophoblastic disease subgroups.

STUDY DESIGN

Twenty-two partial hydatidiform moles, 17 complete hydatidiform moles, 6 invasive hydatidiform moles, and 20 nonhydropic spontaneous abortions (control group) were evaluated by means of immunohistochemical techniques with antibodies to Ki-67, proliferating cell nuclear antigen, and p53. One-step silver staining was used to detect silver-staining nucleolar organizer regions.

RESULTS

The expressions of Ki-67, proliferating cell nuclear antigen, silver-staining nucleolar organizer regions, and p53 were significantly higher in the gestational trophoblastic disease group than in the control group. The results of linear discriminant analysis showed that silver-staining nucleolar organizer region count had the highest sensitivity and specificity (93.3% and 100%, respectively) for distinguishing gestational trophoblastic disease from spontaneous abortion. Sensitivity and specificity for discriminating gestational trophoblastic disease from spontaneous abortion increased to 100% when all four markers were used together. Proliferating cell nuclear antigen was found to be the best discriminating variable for differentiating among gestational trophoblastic disease subgroups.

CONCLUSION

Our findings suggest that expressions of Ki-67, proliferating cell nuclear antigen, silver-staining nucleolar organizer regions, and p53 may aid in the diagnosis of gestational trophoblastic diseases. These fairly rapid, simple, and economic techniques could serve as a useful adjunct to conventional methods in the diagnosis of gestational trophoblastic diseases.

Hydatidiform mole in 59-years-old woman: a case report

We describe a clinical data and histopathological findings in hydatidiform mole found in 59-years-old woman. The patient was admitted to Hospital with vaginal bleeding. Diagnostic curettage revealed hydatidiform mole VI group according to Hertig-Sheldon classification. The patient underwent transabdominal hysterectomy and bilateral oophorosalpingectomy. The serum level of beta-HCG has decreased from initially observed 128.6 U/l to less than 3 U/l after 3 courses of MTX therapy. Patient is under every-six-month observation. No further treatment is planned.

Mola invasiva--special form of GTD

Invasive hydatidiform mole is a relative rare form of gestational trophoblastic disease (GTD). Most of hydatidiform moles remit after evacuation but some of them have the tendency to invade the myometrium. In some rare cases the trophoblastic tissue can be found in other tissues like lungs, vulva, vagina or broad ligament. The aim of the study was to demonstrate some of clinical, immunohistochemical and DNA analysis findings of a patient with a previous diagnosis of a complete hydatidiform mole.

Expression pattern alterations of syndecans and glypican-1 in normal and pathological trophoblast

Syndecans (syn-1, -2, -3, -4) and glypican-1 are proteoglycans expressed during development in association with changes in tissue organization and differentiation. They participate in the modulation of growth factor actions and in cell-cell and cell-matrix adhesion. The expression of syn-1, -2, -3, -4, and glypican-1 has been studied in normal human placenta and in gestational trophoblastic disease such as hydatidiform mole, invasive mole, and choriocarcinoma, using immunohistochemistry and western blots. Syndecan-3 was not expressed in normal or pathological tissues. During normal gestation, the other proteoglycans showed a specific staining pattern, which for some was modified during pregnancy. For instance, syn-1 was only expressed in syncytiotrophoblast; syn-4 was mainly localized in the villous and extravillous cytotrophoblast in the first trimester, whereas at term it was expressed in the syncytiotrophoblast. The most striking results are the altered expression patterns of syndecans and glypican-1 in pathological tissues. These proteoglycans showed a progressive decrease of immunostaining related to the increase of severity of trophoblastic disease, in particular in invasive mole and choriocarcinoma. In addition, dysregulation in the localization of the expression patterns was observed for syn-2 and -4. Because changes in syndecan expression enable cells to become more or less responsive to their micro-environment, the down-regulation and/or dysregulation of syndecans in relation to the degree of severity of trophoblastic diseases provides new insights into the progression of these pathologies.

Diagnosis and treatment of the malignant gestational trophoblastic tumor with pulmonary metastasis complicated with pulmonary tuberculosis

OBJECTIVE

To evaluate the diagnosis and treatment for malignant gestational trophoblastic tumor (MGTT) with pulmonary metastasis complicated with pulmonary tuberculosis.

METHODS

To analyze ten cases of MGTT with pulmonary metastasis complicated with pulmonary tuberculosis in our hospital from 1980 to 1997 retrospectively.

RESULTS

From the x-ray film, there are great resemblances between MGTT with pulmonary metastasis and pulmonary tuberculosis. Of 10 patients, 7 of them were examined out pulmonary tuberculosis during the chemotherapy of MGTT. Pulmonary tuberculosis appeared six months before chemotherapy in three cases. All of the patients were treated with multiagent chemotherapy. Seven patients achiceved a complete remission, 2 patients developed drug resistance and died of cerebral haemorrhage and cerebral herniation, 1 woman who had achieved a complete remission from MGTT for 14 months died of miliary tuberculosis.

CONCLUSION

It is very important to make differential diagnosis of the MGTT with pulmonary metastasis complicated with pulmonary tuberculosis. Trying to avoid excessive anti-tumor treatment owing to mistake pulmonary tuberculosis for pulmonary metastasis, and avoiding missing an opportunity of anti-tuberculosis treatment because of missed diagnosis should be emphasized.

DOC-2/hDab2, a candidate tumor suppressor gene involved in the development of gestational trophoblastic diseases

Gestational trophoblastic diseases comprise a spectrum of interrelated diseases including partial mole, complete mole and gestational choriocarcinoma. Using reverse transcriptase PCR (RT-PCR) analysis, we identified higher levels of DOC-2/hDab2 expression in the normal trophoblast cells in culture than in choriocarcinoma cell lines. Subsequent study using immunohistochemistry showed high levels of DOC-2/hDab2 protein expression in normal trophoblast tissues but significantly lower levels of expression in gestational trophoblastic disease tissues, particularly in complete mole and choriocarcinoma. When DOC-2/hDab2 was transfected into the choriocarcinoma cell lines, Jar, JEG and BeWo, the stable transfectants showed significantly reduced growth rate in culture. These data suggest that down regulation of DOC-2/hDab2 may play an important role in the development of gestational trophoblastic diseases.

DNA polymorphism analysis of a case of complete hydatidiform mole coexisting with a fetus

A complete hydatidiform mole coexisting with a fetus is a rare condition. The diagnosis is often difficult because of the morphological similarity to a partial mole, but is crucial to management in the postmolar course. We present a case of molar pregnancy coexisting with a fetus in which DNA polymorphism analysis revealed a different genetic origin for the fetal and molar parts. This is the only known case of a complete mole in a twin pregnancy complicated by pre-eclampsia followed by maternal pulmonary oedema. During follow-up, the patient developed a clinically invasive mole which was successfully treated with chemotherapy. In this case, genetic analysis unequivocally diagnosed a twin pregnancy consisting of a complete hydatidiform mole and a fetus.

Magnetic resonance imaging in patients with gestational trophoblastic disease

RATIONALE AND OBJECTIVES

The authors describe the magnetic resonance (MR) imaging characteristics in patients with gestational trophoblastic disease (GTD) before and after therapy and to correlate these findings with human gonadotropin levels and the specific histology of GTD.

METHODS

Thirteen women (mean age, 30.1 years) with elevated human chorionic gonadotropin (HCG) levels and histologically proven GTD underwent MR examinations of the pelvis. Magnetic resonance imaging was performed on a 1.5-tesla unit. Axial and sagittal proton density-weighted and T2-weighted and sagittal T1-weighted sequences were obtained. Four patients underwent follow-up studies after 4 and 8 weeks to monitor the response to therapy. Gestational trophoblastic disease was histologically proven with curettage in 11 patients and with hysterectomy in two cases.

RESULTS

Nine patients had a diffusely enlarged uterus with pathologic signal intensities. In four patients, a focal tumor mass was observed. All patients showed loss of the zonal anatomy of the uterus in at least one local area. In 11 patients, no uterus zones could be identified throughout the entire uterus. Pathologic dilated tumor vessels were evident in all patients. In all four cases in which follow-up imaging studies were obtained, uterus size, signal intensities, identification of uterus zones, and uterus vessels returned to normal.

CONCLUSION

Magnetic resonance imaging shows trophoblastic tumor infiltration as diffuse uterus enlargement, focal tumor masses, loss of zonal anatomy of the uterus, and pathologic uterine vasculature; this seems to be the most reliable MR imaging finding in patients with GTD. No correlation was found between MR imaging changes and HCG levels or specific histologic types of GTD.

Invasive mole presenting as a spinal extradural tumor: case report

The most common sites of metastatic lesions that are caused by an invasive mole are lung, liver, and brain. Spinal spread is very rare. We present a 24-year-old patient with paraparesis that was caused by an extradural spinal invasive mole. Surgery, for decompression and biopsy, and subsequent chemotherapy resulted in complete recovery.

[Risk of malignant changes in hydatidiform mole complicated with pregnancy induced hypertension]

OBJECTIVE

To investigate the prognosis of patients of hydatidiform mole (HM) who complicated with pregnancy induced hypertension (PIH) and to suggest that PIH may serve as a risk factor for malignant change in molar pregnancy.

METHODS

From 1962 to 1992, 161 patients of HM including 33 cases with PIH and 128 cases of normotension were managed and followed at the PLA General Hospital. The definition of malignant sequelae was that abnormal hCG level was lasting at least 8 weeks after molar evacuation or metastatic lesions was found.

RESULTS

15 of 33 patients with PIH developed metastatic invasive moles (45.5%) and 13 of them metastatic tumors were found before molar evacuation. 12 of 128 cases of normotension had malignant thanges including 1 choriocarcinoma and 11 invasive mole (9.4%) and among them only one had metastatic lesions before molar evacuation.

CONCLUSIONS

The incidence (45.5%) of malignant changes in patients complicated with PIH was significantly higher than that in normotensive patients (9.4%) (P < 0.01). In addition, they had early metastatic lesions. This study suggests that PIH may serve as a risk factor for malignant change in molar pregnancy.

Transcriptional and posttranscriptional mechanisms in epidermal growth factor regulation of human chorionic gonadotropin (hCG) subunits and hCG receptor gene expression in human choriocarcinoma cells

Epidermal growth factor (EGF) stimulates the secretion of hCG in choriocarcinoma cells. However, the molecular mechanisms involved in this EGF action have never previously been investigated. The present study investigated them as well as EGF regulation of the hCG/LH (LH) receptor gene in JEG-3 human choriocarcinoma cells. The JEG-3 cells contain multiple EGF receptor messenger RNA (mRNA) transcripts and a single 170-kilodalton immunoreactive receptor protein. The human EGF can bind to the receptor protein and stimulate the receptor autophosphorylation as well as the phosphorylation of four other membrane proteins. Culturing JEG-3 cells with recombinant human EGF resulted in a dose- and time-dependent increase in hCG secretion. The maximal effect was seen at 100 ng/ml EGF, with a time lag of about 5 h. Tyrosine kinase, but not protein kinase-C or protein kinase-A, signaling was involved in the EGF action to increase hCG secretion. The EGF-induced increase in hCG secretion was not due to an increase in cell number or differentiation into multinuclear syncytia. EGF treatment resulted in a dose- and time-dependent increase in steady state levels of hCG alpha and hCG beta mRNAs. This increase was due to the stabilization of subunit mRNA transcripts. The increase in subunit mRNAs preceded the increase in hCG secretion. The EGF treatment resulted in a dose- and time-dependent decrease in steady state levels of the hCG/LH receptor mRNA transcripts. The decrease was due to a transcriptional inhibition of receptor gene. EGF treatment paradoxically stabilized hCG/LH receptor protein. In summary, EGF treatment up-regulates hCG subunits gene expression and down-regulates hCG/LH receptor mRNAs involving transcriptional and posttranscriptional mechanisms in JEG-3 human choriocarcinoma cells.

[Complete invasive mole in a 50-year old woman]

A 50-year-old woman was admitted for hysterectomy due to persistent vaginal bleeding and enlargement of the uterus. Before operation a significant increased beta-HCG was measured. Histologic examination of uterine contents obtained by aspiration showed trophoblastic disease. An decrease in beta-HCG was registered postoperatively. However, two weeks later it rose again and the patient started treatment with methotrexate. It is recommended that the treatment of patients with invasive gestational trophoblastic disease is centralized.

Decreased expression of epidermal growth factor and its receptor in the malignant transformation of trophoblasts

BACKGROUND

Gestational trophoblastic neoplasms comprise the neoplastic spectrum of nonmalignant hydatidiform mole, invasive hydatidiform mole, and truly malignant choriocarcinoma. Increasing evidence indicates that epidermal growth factor (EGF) acts as an enhancer of trophoblast function to produce human chorionic gonadotropin and that EGF and its receptor may provide a growth advantage to certain carcinoma cells. The current study was undertaken to evaluate a possible link between malignant transformation of trophoblast and expression of EGF and EGF receptor.

METHODS

Cytologic localization and cellular levels of expression of EGF and EGF receptor in hydatidiform mole, invasive hydatidiform mole, and choriocarcinoma tissue specimens were examined by the avidin-biotin immunoperoxidase techniques with monoclonal antibodies against EGF and EGF receptor.

RESULTS

EGF in hydatidiform mole and invasive mole was localized in syncytiotrophoblasts, whereas cytologic localization of EGF receptor in hydatidiform mole and invasive mole was observed in both cytotrophoblasts and syncytiotrophoblasts. By contrast, EGF and EGF receptor in choriocarcinoma were exhibited in cytotrophoblastic and syncytiotrophoblastic elements. Most (72%) hydatidiform moles immunostained intensely for EGF and EGF receptor, whereas most (78%) choriocarcinomas immunostained slightly for EGF and EGF receptor. Invasive mole occupied the middle position in the staining intensity for EGF and EGF receptor, between hydatidiform mole and choriocarcinoma, with 50% of the cases exhibiting moderate staining.

CONCLUSIONS

The simultaneous expression of EGF and EGF receptor in the neoplastic trophoblasts implies that EGF may act in an autocrine-paracrine manner in trophoblastic neoplasms. Furthermore, the results obtained suggest that cytologic expression of EGF and EGF receptor in trophoblastic neoplasms decreases in the malignant transformation of trophoblast.

Flow cytometric analysis of cellular DNA and RNA contents of hydatidiform mole. Two significant parameters indicating malignant nature and prognosis

The cellular DNA and RNA contents of trophoblastic tissue of 86 patients with trophoblastic disease and chorionic tissue of 10 patients in early pregnancy were analysed by flow cytometry (FCM) and strict follow-up was carried out. The result showed the rate of accurate diagnosis by DNA and RNA determinations were 60.0% and 85.7% respectively in benign moles; 86.7% and 86.7% in invasive moles; and 100% and 100% in choriocarcinoma. Statistically the pseudopositive percentage of RNA was clearly lower than that of DNA (0.01 < P < 0.05). In addition, the trophoblastic cells in curetted molar tissue and the uterine tissue later proved by surgery of 10 invasive moles were simultaneously assayed for comparing their DNA and RNA contents, showing statistical significance (P < 0.001). The DNA and RNA contents in different cellular cycles were analysed by FCM and there was no statistical significance among benign, malignant moles and choriocarcinoma (P > 0.05). Our study suggests that aneuploidy DNA content may be an indicator for malignant tendency and the RNA parameter rather than DNA is more sensitive for the prognosis of hydatidiform mole.

Under-registration of gestational trophoblastic disease in the Swedish Cancer Registry

The paper presents a study of completeness of registration of hydatidiform mole and gestational trophoblastic neoplasia in the Swedish Cancer Registry. The study is based on patients treated in Stockholm County, Sweden from 1971 through 1986. Non-notified cases were identified through a computerized register covering nearly all hospital admissions in the region and local hospital patient register. The results show that 25% of the cases with a diagnosis of hydatidiform mole were not included in the cancer register. Of all patients treated for trophoblastic malignancy, 66% were not recorded in the Cancer Registry. The frequent absence of histopathological confirmation in cases with malignant trophoblastic disease was probably the main factor contributing to the observed under-registration. The study indicates that the Swedish Cancer Registry alone does not provide sufficient data for studies on the incidence of gestational trophoblastic disease.

Placental site trophoblastic tumor. Diagnosis, clinical behavior and treatment

Placental site trophoblastic tumor is a rare trophoblastic neoplasm with the potential for metastatic disease and death. Difficulty diagnosing these tumors and predicting their biologic behavior has clouded attempts to successfully outline individual treatment plans. This review details current knowledge of the origin and clinical behavior of this rare form of trophoblastic disease. The use of various markers to predict clinically aggressive behavior is reviewed critically, and treatment is recommended on the basis of recently published clinical series.

Clinical significance of hysterography in the diagnosis of choriocarcinoma and invasive mole

From 1963 through 1988, a total of 194 hysterographies were performed for 111 patients. Three types of abnormalities were observed on the hysterogram: filling defect, intramural invasion of the uterine wall by the contrast medium; and intravasation of the contrast medium into the pelvic veins. The pathology and clinical significance of three types of abnormalities were studied. The results showed that hysterography demonstrated better images than pelvic arteriography and B-scan for the diagnosis of choriocarcinoma and invasive mole, especially when combined with B-scan/or pelvic arteriography, a greater accuracy was achieved.

[Evaluation of hysterography in the diagnosis of choriocarcinoma and invasive mole]

From 1963 through 1985, 181 hysterography were performed for 101 patients. The diagnostic accuracy of hysterography was 92.3%. There were no false positive findings, though a negative result may be obtained in patients whose intramural lesion does not communicate with the uterine cavity, as proved by operative findings. Three types of abnormalities were observed on the hysterogram: (1) filling defect, (2) intramural invasion of the uterine wall by the contrast medium and (3) extravasation of the contrast medium into the pelvic veins. The filling defect was usually observed in patients with (1) residual molar tissue in the uterine cavity, (2) intramural lesion and (3) intrauterine adhesions. The above three conditions can be differentiated by the characteristic shape of the filling defect. If it is used in combination with either or both of the other two procedures, ie., B-ultrasound and pelvic arteriography the accuracy of diagnosis will be further improved.

Elevated sera levels of SP-1 induced by chemotherapy in patients with metastatic gestational trophoblastic diseases

6 patients with invasive mole and 5 patients with choriocarcinoma were treated from 1983 till 1986. Serum samples were analyzed by simultaneous determining of pregnancy-specific beta-1-glycoprotein (SP-1) using enzyme-linked immunosorbent assay (ELISA) and beta subunit of human chorionic gonadotropin (beta-hCG) using Serono radioimmunoassay kit. In 2 patients with metastatic gestational trophoblastic disease (MGTD) SP-1 peaks were found during chemotherapy. In patients with MGTD with normalized beta-hCG levels a repeated, temporary elevation of isolated SP-1 levels was observed within some months following chemotherapy. After the last isolated peak of SP-1 the pulmonary metastases disappeared. This phenomenon was interpreted as a consequence of the oncolytic process in the affected tissue. In 1 patient with nonmetastatic choriocarcinoma SP-1 ELISA pseudoreaction was found. To recognize these pseudoreactions, a control plate with nonimmunized rabbit IgG was used, simultaneously with SP-1 determinations.