Combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios for early prediction of postmolar gestational trophoblastic neoplasia.

PURPOSE: To investigate factors predicting postmolar gestational trophoblastic neoplasia (GTN) by combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios. METHODS: This retrospective study enrolled patients with histopathologically proven molar pregnancy. Patients lost to follow-up before remission or developing postmolar GTN were excluded. Demographic and clinical characteristics and hCG data obtained before and after molar evacuation were collected. Area under the receiver operating characteristic curve (AUC) analysis was used to identify the hCG and hCG ratio cutoff values that predict postmolar GTN. Multivariate analysis was employed to identify independent predictors of GTN. RESULTS: There were 113 complete moles, 11 partial moles, and 52 unspecified moles included in the final analysis. Of the 176 cases, 90 achieved remission and 86 developed post-molar GTN. The incidence of postmolar GTN was 48.9%, with a median time to GTN development of 5 weeks. Univariate analysis showed age, molar evacuation performed elsewhere, pre-evacuation hCG, hCG at 2nd week post-evacuation, and ratio of hCG at 2nd week post-evacuation to post-evacuation hCG significantly predict GTN. Multivariate analysis revealed an hCG value ≥ 1400 IU/L at 2nd week post-evacuation (AUC: 0.92, aOR: 6.51, 95% CI 1.28-33.16; p = 0.024) and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 (AUC: 0.88, aOR: 12.27, 95% CI 2.15-70.13; p = 0.005) to independently predict GTN. CONCLUSIONS: An hCG value ≥ 1400 IU/L at 2nd week post-evacuation and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 independently and reliably predict postmolar GTN.

Rare Presentation of Chorioadenoma Destruens as Acute Haemoperitoneum Mimicking Ruptured Ectopic Pregnancy.

Gestational trophoblastic neoplasms (GTN) are proliferative degenerative disorders of placental elements and include complete or partial mole (90%), invasivemole (5-8%), choriocarcinoma (1-2%) and placental site tumor (1-2%). Chorioadenoma destruens is a trophoblastic tumor, characterized by myometrial invasion through direct extension or via venous channels. We present a case of invasive mole eroding uterus and uterine vasculature, causing sudden rupture of uterus with massive haemoperitoneum mimicking ectopic pregnancy. A 20 year old G1P0 at 6 weeks gestation presented in Casualty of Kasturba Hospital complaining of severe acute onset lower abdominal pain for one hour. Clinical examination revealed shock. Sonography suggested ectopic pregnancy and immediate exploratory laparotomy was decided. On laparotomy, 2000cc of haemoperitoneum was noted. Grape like vesicles protruding through fundal perforation with profuse active bleeding was seen. Bleeding persisted despite evacuation. Step wise uterine devascularisation failed to achieve haemostasis. Total abdominal hysterectomy was performed as a life saving measure.

MRI of the placenta - a short review.

While ultrasound is still the gold standard method of placental investigation, magnetic resonance imaging (MRI) has certain benefits. In advanced gestational age, obese women, and posterior placental location, MRI is advantageous due to the larger field of view and its multiplanar capabilities. Some pathologies are seen more clearly in MRI, such as infarctions and placental invasive disorders. The future development is towards functional placental MRI. Placental MRI has become an important complementary method for evaluation of placental anatomy and pathologies contributing to fetal problems such as intrauterine growth restriction.

Contribution of referent pathologists to the quality of trophoblastic diseases diagnosis.

OBJECTIVE: To evaluate the contribution of referent pathologists (RPs) to the quality of diagnosis of trophoblastic diseases and to study the level of diagnostic agreement between the initial pathologists and the RPs. METHODS: This observational retrospective study was carried between 1 November 1999 and 11 January 2011 using the database of the French Trophoblastic Disease Reference Centre in Lyon. All files for hydatiform moles (HMs), trophoblastic tumours and non-molar pregnancies for which there was an initial suspicion of trophoblastic disease were included, whenever there was rereading of the slides by an RP. A total of 1851 HMs and 150 gestational trophoblastic tumours were analysed. RESULTS: When the initial pathologist diagnosed a complete mole, the RP confirmed the diagnosis in 96% of cases. When the initial pathologist diagnosed a partial mole, the RP confirmed the diagnosis in only 64% of cases. For trophoblastic tumours, when the initial pathologist diagnosed a choriocarcinoma, the RP confirmed the diagnosis in 86% of cases. When the initial anatomopathology suggested an invasive mole, the diagnosis was confirmed in 96% of cases. Finally, when the initial diagnosis was a placental site trophoblastic tumour or an epithelioid trophoblastic tumour, the RP confirmed the diagnosis in 60 and 100% of cases, respectively. CONCLUSION: A systematic policy of rereading of slides for all suspicious moles improves the quality of management of trophoblastic diseases at a national level.

An invasive mole with pulmonary metastases in a 55-year-old postmenopausal Syrian woman: a case report and review of the literature.

BACKGROUND: Invasive mole is a subtype of gestational trophoblastic neoplasms (GTNs) that usually develops from the malignant transformation of trophoblastic tissue after molar evacuation. Invasive moles mostly occur in women of reproductive age, while they are extremely rare in postmenopausal women. CASE PRESENTATION: We present the case of a 55-year-old postmenopausal Syrian woman who was admitted to the emergency department at our hospital due to massive vaginal bleeding for 10 days accompanied by constant abdominal pain with diarrhea and vomiting. Following clinical, laboratory and radiological examination, total hysterectomy with bilateral salpingo-oophorectomy was performed. Histologic examination of the resected specimens revealed the diagnosis of an invasive mole with pulmonary metastases that were diagnosed by chest computed tomography (CT). Following surgical resection, the patient was scheduled for combination chemotherapy. However, 2 weeks later the patient was readmitted to the emergency department due to severe hemoptysis and dyspnea, and later that day the patient died in spite of resuscitation efforts. CONCLUSION: Although invasive moles in postmenopausal women have been reported previously, we believe our case is the first reported from Syria. Our case highlights the difficulties in diagnosing invasive moles in the absence of significant history of gestational trophoblastic diseases. The present study further reviews the diagnostic methods, histological characteristics and treatment recommendations.

Nephrotic syndrome associated with invasive mole: a case report.

Gestational trophoblastic disease describes a number of gynaecological tumours that originate in the trophoblast layer, including hydatidiform mole (complete or partial), placental site trophoblastic tumour, choriocarcinoma and gestational trophoblastic neoplasia (GTN). Invasive moles are responsible for most cases of localized GTN. Two cases of GTN previously reported in the literature exhibited membranous glomerulonephritis (MGN). However, histologic examinations in our case did not reveal evidence of MGN. Clinical features and pathologic findings were consistent with minimal change disease associated with an invasive mole. In the present case, we observed complete remission of nephrotic syndrome following removal of the invasive mole.

Gestational trophoblastic disease: experience at Nawabshah Hospital.

BACKGROUND: Gestational Trophoblastic Disease (GTD) is a heterogeneous group of diseases that includes partial and complete hydatidiform mole, invasive mole, choriocarcinoma and placental site trophoblastic tumour. The incidence of GTD varies in different parts of the world. The malignant potential of this disease is higher in South East Asia in comparison to western countries. Objectives of study were to determine the frequency, clinical presentation and management outcomes of GTD. This retrospective, descriptive case series was conducted in the Department of Obstetric and Gynaecology Nawabshah Medical College Hospital, from 1st Jan 2007 to 30th Dec 2007. METHODS: The case records of all the gestational trophoblastic cases during study period were analysed regarding their history, clinical examination, investigations, treatment and follow-up. The main outcomes were measured in terms of duration, antecedent pregnancy, investigations, treatment and the follow-up. RESULTS: There were a total of 1056 Obstetric admissions during the study period, which included 30 cases of trophoblastic disease with a frequency of GTD was 28 per 1000 live births. Of these 30 cases, 21 (70%) patients had hydatidiform mole, 7 (23.3%) patients had invasive disease and 2 (6.6%) patients had choriocarcinoma. Twenty three patients (76.6%) received chemotherapy while 25 (83.3%) patients had suction evacuation and 4 (13.3%) patients underwent hysterectomy. Among all patients, 29 (96.7%) fully recovered and 1 (3.3%) died because of extensive disease; metastasis extending up to brain. CONCLUSION: Frequency of GTD was higher compared to national and international studies. The disease was common in extremes of ages, low para and grand multiparous women. Hydatidiform mole was the commonest type of trophoblastic disease in these patients. Most common presenting complaint was bleeding per vagina followed by pain in lower abdomen.

Gestational trophoblastic disease: experience at a tertiary care hospital of Sindh.

OBJECTIVE: To determine the frequency, clinical presentation and management outcomes of Gestational Trophoblastic Disease (GTD). STUDY DESIGN: Descriptive case series. PLACE AND DURATION: Department of Gynaecology and Obstetrics, Liaquat University of Medical and Health Sciences, Jamshoro, from March 2003 to March 2004. PATIENTS AND METHODS: The case records of all the gestational trophoblastic cases during study period were analyzed regarding their illness history, clinical examination, investigations, treatment and follow-up. The main outcomes were measured in terms of duration, antecedent pregnancy, investigations, treatment and the follow-up. RESULTS: There were a total of 1030 obstetric admissions during the study period, which included 23 cases of trophoblastic disease. Hence, frequency of GTD was 1 per 45 live births. Of these 23 cases, 19 (82.6%) patients had hydatidiform mole and 4 patients had malignant trophoblastic disease. Eight patients (34.7%) received chemotherapy while rest of the patients had suction evacuation and follow-up. Among all patients, 21 (91.3%) fully recovered and 2 (8.69%) died because of extensive disease; metastasis extending upto brain. CONCLUSION: Frequency of trophoblastic disease was high in this series compared to world and national literature. Therefore, emphasis should be on the early diagnosis of disease as proper management in the early stages strongly influences the outcome of disease. Suction evacuation and follow-up are ideal treatments for benign trophoblastic disease.

[Clinical and radiological features of gestational trophoblastic tumors]. / Tumeurs trophoblastiques gestationnelles: aspects cliniques et radiologiques.

Gestational trophoblastic disease incorporates a group of diseases which differ from each other by their regressive evolution, their evolution to metastasis and to recurrence. It is a severe disease that affects women of childbearing age. Gestational trophoblastic tumors (GTT) are the malignant forms of gestational trophoblastic diseases. They are always a result of pregnancy, more often molar pregnancy (hydatidiform mole). The most common type of gestational trophoblastic tumors (GTT) is the invasive mole because, in most cases, the diagnosis is made when cancer is still confined to the uterus. Choriocarcinoma is a more rare type of tumor, often developing distant metastases. When there is a progression to a trophoblastic tumor, the assessment of locoregional extension and distant metastases is essential to establish an appropriate treatment protocol. We here report three clinical cases of GTT by describing their clinical presentations and the use of imaging techniques in the diagnosis and management of these disorders.

[Sensitivity, specificity, predictive positive and negative value of the main clinical signs and symptoms of hydatiform mole]. / Sensibilità, specificità, valore predittivo positivo e negativo dei principali segni clinici e sintomi della mola idatidea.

AIM: Especially in the first weeks of pregnancy, complete and partial hydatiform moles are not easily detected by sonography, symptoms and clinical signs. Due to the rarity of moles, it is possible that they may be confused with abortive pregnancies until the pathological examination. The aim of this study is to identify the sensitivity, specificity, predictive positive and negative value of the main symptoms and clinical signs of molar pregnancies. METHODS: Thirteen molar pregnancies have been detected after pathological examination from January 2003 to July 2005 in Perugia. Their main clinical signs and symptoms are compared with those recorded in 288 abortive pregnancies, 56 ectopic pregnancies and 27 Hyperemesis gravidarum, observed in the same period. RESULTS: Vaginal bleeding and pelvic pain are the most sensitive symptoms and have the highest predictive negative values. The size of the uterus greater for date is the most specific sign. Pelvic pain with hyperemesis, and uterus size greater for date have the highest predictive positive values, but the lowest sensitivity. CONCLUSIONS: A mole should be excluded in patients with hyperemesis and pelvic pain, and in patients with uterus size greater for date. In the first case, a hyperemesis gravidarum may be diagnosed and, in the second one, a twin pregnancy may be confirmed with a sonographic scan.

Manejo clínico de la neoplasia trofoblástica gestacional: presentación de un caso / Clinical management of gestational trophoblastic neoplasia: presentation of a case

La enfermedad trofoblástica gestacional es una entidad poco frecuente que se produce por una proliferación anormal de la placenta. Engloba un diverso espectro de entidades histológicas, que conllevan a su vez diversas implicaciones clínicas. Unas son de carácter benigno (mola parcial y mola completa, placentomegalia, nódulo del sitio placentario) y otras de carácter maligno, estas últimas reciben en común la denominación de Neoplasia Tofoblástica Gestacional (NTG) y tienen un alto potencial de metastatización. Forman parte de las NTG: la mola invasiva, el tumor trofoblástico del sitio placentario, el tumor trofoblástico epitelioide y el coriocarcinoma gestacional. Lo más común es que la NTG debute tras la aparición de una gestación molar, pero también es posible que ocurra tras otro tipo de evento obstétrico como una gestación a término, o una gestación ectópica. Es pues de vital importancia realizar un correcto seguimiento tras evacuar una gestación molar, realizando una monitorización de los valores séricos de la BhcG y sospechando una enfermedad trofoblástica persistente ante los supuestos que posteriormente describiremos.La principal herramienta terapéutica para la NTG es el uso de la quimioterapia, aunque también se puede optar por la cirugía endeterminados casos. Habrá que valorar de modo individualizado en función de la histología, score pronóstico y deseos genésicos futuros de la paciente. Afortunadamente, la tasa de supervivencia y de curación de la NTG con un tratamiento y seguimiento adecuado es muy elevada. (AU)

Gestational trophoblastic disease is a rare entity that is caused by an abnormal proliferation of the placenta. It encompasses adiverse spectrum of histological entities, which carry various clinical implications. Some of them are benign (partial mole and complete mole, placentomegaly, placental site nodule) and others of a malignant nature, which are known as Gestational TrophoblasticNeoplasia (GTN) and have a high potential for metastasization. Are part of the GTN: invasive mole, trophoblastic tumor of theplacental site, trophoblastic tumor epithelioid and gestational choriocarcinoma. The most common is that NTG debuts after theappearance of a molar gestation, but it also may occur after another type of obstetric event such as a term gestation, or an ectopicgestation. It is therefore of vital importance to carry out a correct follow-up after evacuating a molar gestation, monitoring the serumvalues of BhcG and suspecting a persistent trophoblastic disease in the event that we will later describe. The main therapeutic toolfor NTG is the use of chemotherapy, although surgery can also be chosen in certain cases. It will be necessary to assess individuallyaccording to histology, prognostic score and future genetic desires of the patient. Fortunately, the survival and cure rate of NTG with proper treatment and follow-up is very high. (AU)

[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.

Management of gestational trophoblastic diseases in Japan--a review.

In Japan we have a standardized protocol for the management of gestational trophoblastic diseases issued by the Japan Society of Obstetrics & Gynecology in 1988. Hydatidiform moles should be treated by evacuating the uterus. Patients must then be followed up until serial weekly serum hCG titres fall to undetectable levels. Our hCG regression curve post-evacuation is quite useful for the detection of persistent trophoblastic diseases. Persistent trophoblastic diseases develop in about 10-15 per cent of patients after molar evacuation in Japan. We classify persistent trophoblastic diseases into three groups: (1) post-molar persistent hCG; (2) invasive mole or metastatic moles; and (3) choriocarcinoma. Investigations into any possible metastases are carried out as soon as possible in affected patients. Post-molar persistent hCG presents no focus or histological findings except persistent elevated hCG, although single agent chemotherapy is required. In the other two groups with focus, it is very difficult to get histological specimens to make accurate diagnoses unless surgery is done. For the selection of the most appropriate chemotherapy, what we call a 'Diagnostic Score' is applied to differentiate choriocarcinoma from invasive moles or metastatic moles clinically in patients falling into these two groups. This unique 'Diagnostic Score' for the detection of choriocarcinoma plays an important role in initial management in our protocol.

Partial hydatidiform moles: a review.

The current study was undertaken in an effort to identify the clinical characteristics and natural history of partial moles. Three cases recently managed at Tripler Army Medical Center and 52 cases collected from the medical literature were reviewed. The mean age of the women at diagnosis was 25.6 years. The mean gestational age at diagnosis was 23.8 weeks. The most common presenting symptom was vaginal bleeding in 69 per cent of women. Although triploidy was the most frequent karyotype (68 per cent), normal 46,XY or XX karyotypes were present, and phenotypically normal infants were delivered of mothers with a coexisting molar pregnancy. Malignant trophoblastic disease occurred in 14.5 per cent of the women. All of them achieved remission with adjuvant therapy. Partial moles are considered a less virulent form of molar pregnancy. The clinical characteristics and natural history are not entirely dissimilar from the complete mole. Malignant sequelae can occur after the evacuation of a partial mole. These women should be followed with serial serum beta-HCG.

Hydatidiform mole in southern Iran: a statistical survey of 113 cases.

A statistical review of 113 cases of hydatidiform mole (HM) seen at Pahlavi University Hospital from January 1970 to December 1975 is presented. The incidence of the disease was found to be 1:314 pregnancies. In this study, 73.5% of the patients presumably had acceptable socioeconomic circumstances. The highest incidence of the disease was found in patients 15-25 years old, and it increased with parity. All patients presented with a period of amenorrhea and vaginal spotting. More than 50% of the patients sought treatment after 1-2 weeks of uterine bleeding. Signs and symptoms of the disease are discussed. The management of patients with HM and coexisting difficulties are presented.

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.

Radiologically identified molar invasion into pelvic arteriovenous shunts.

A case of radiologically identified molar invasion into extensive arteriovenous shunts (AVSs) is described. CT and MRI revealed a large uterine mass, accompanied by multiple AVSs. Dynamic MRI and pelvic angiography demonstrated multiple trophoblastic cysts invading into the AVSs. Resected specimen confirmed the diagnosis of invasive mole. Dynamic MRI was very useful in determining the etiology of AVS.