HLA-G immunoreactivity is specific for intermediate trophoblast in gestational trophoblastic disease and can serve as a useful marker in differential diagnosis.

HLA-G is a nonclassical MHC class I antigen that has been shown to be a specific marker for normal intermediate trophoblast (IT). In this study HLA-G immunoreactivity assessed with an HLA-G specific antibody (4H84) was detected in all 14 cases of choriocarcinoma, 14 placental site trophoblastic tumors, 13 epithelioid trophoblastic tumors, 16 placental site nodules, and nine exaggerated placental sites. In contrast, HLA-G immunoreactivity was not detected in 34 nontrophoblastic uterine neoplasms. HLA-G immunoreactivity was present in all the IT cells of exaggerated placental sites and placental site trophoblastic tumors and in 70-100% of IT cells in placental site nodules and epithelioid trophoblastic tumors. The pattern of distribution of HLA-G in different subpopulations of IT confirms the relationship of various trophoblastic lesions to different types of IT (exaggerated placental site and placental site trophoblastic tumor to implantation site IT and placental site nodule and epithelioid trophoblastic tumor to chorionic-type IT) and suggests that choriocarcinoma is related to villous-type IT because the majority of mononucleate cells in this neoplasm were HLA-G immunoreactive. In conclusion, HLA-G immunoreactivity appears to be specific for IT in gestational trophoblastic disease and can serve as a useful marker in the differential diagnosis of these lesions.

Cytokines of the placenta and extra-placental membranes: biosynthesis, secretion and roles in establishment of pregnancy in women.

Virtually all known cytokines have been demonstrated to be expressed in the placenta and associated fetal and maternal membranes during normal gestation. In addition to playing their traditional roles as modulators of immunological function, cytokines derived from the placenta and extraplacental membranes, together with other locally-derived growth factors, appear to be implicated in various aspects of implantation and placental development. Imbalances in the intrauterine cytokine milieu around the time of implantation and invasion may play a causative role in disorders associated with early pregnancy failure, and are also associated with the abnormal trophoblast development seen in gestational trophoblastic disease. Cytokines thus appear to be an important component of a paracrine/autocrine communication network operating within the feto-maternal interface to ensure the successful establishment of pregnancy.

[The beta-hCG subunit, CA 125 and CA 19-9 antigen in the women with non-trophoblastic malignancy of genital tract]. / Podjenostka beta-HCG, antygen CA 125 i antygen CA 19-9 w nie-trofoblastycznych nowotworach narzadu rodnego kobiet. 3. Guzy jajnika.

OBJECTIVES: The aim of this study was preoperative estimation of serum level glicoprotein--CA 125, CA 19-9 and beta-hCG in ovarian tumors and comparison obtained values in groups divided according to postoperative pathologic examination. MATERIALS AND METHODS: In every patients with ovarian tumors before surgery the level above mentioned antigens was evaluated and compared in following groups: malignant, non-malignant and controls. In control group cut-off values was estimated. RESULTS: The levels of all investigated glycoproteins were significantly higher in malignant group comparing to benign and controls. The test differentiating non-malignant from malignant tumors was accepted as positive if at least one from markers level was elevated. Specificity of the test was 70%, sensitivity--94%, positive prognostic value--74%, negative prognostic value--94%. In the selected subgroups from non-malignant tumors the serum level of all glycoproteins was surprisingly high. CONCLUSIONS: Preoperative estimation of CA 125, CA 19-9 and beta-hCG subunit in ovarian tumors permits--at negative result--with probability 93% to qualify tumor as non-malignant and sensitivity of test is 94%.

[The c-erbB-related oncoproteins in normal placenta and in gestational trophoblastic diseases (in vitro study)]. / A c-erbB családba tartozó onkofehérjék normális lepényben és terhességi trophoblast-betegségekben (in vitro vizsgálatok).

In this study the expression of epidermal growth factor receptor (EGFR) and c-erbB-2, c-erbB-3 and c-erbB-4 oncogenes were investigated in gestational trophoblastic diseases and normal first trimester placenta. Furthermore, the possibility that macrophage (IL-1 alpha, IL-1 beta, TNF) and lymphocyte (IL-2, gamma-IFN, GM-CSF) cytokines effects are mediated by changes in EGFR expression were studied. Paraffin sections of 16 cases of partial mole, 25 cases of complete mole, 10 cases of gestational choriocarcinoma and 11 cases of therapeutic abortion were studied immunohistochemically for EGFR, c-erbB-2, c-erbB-3 and c-erbB-4 proteins. The presence of EGFR mRNA was studied using in situ hybridization. JEG-3 human choriocarcinoma cells were incubated with varying concentrations of interleukin 1-alpha, interleukin 1-beta, interleukin 2, gamma-interferon, granulocyte-macrophage colony stimulating factor and tumor necrosis factor-alpha, and the expression of EGFR was measured by radioimmunoassay using a murine monoclonal antibody with specificity for EGFR. Staining for EGFR was detected immunohistochemically in all cell type in gestational trophoblastic diseases and normal placenta. The levels of expression of EGFR in choriocarcinoma and syncytiotrophoblasts and cytotrophoblasts in complete mole were significantly greater than those in syncytiotrophoblasts and cytotrophoblasts in both normal placenta and partial mole (p < 0.01, p < 0.01). The immunoreactivity of c-erbB-2 was significantly stronger in choriocarcinoma and extravillous trophoblast in complete mole than that in extravillous trophoblast in partial mole and normal placenta (p < 0.02, p < 0.01, respectively). Strong immunostaining for EGFR (p = 0.02) and c-erbB-3 (p < 0.01) in extravillous trophoblasts of complete mole was found to be significantly correlated with the development of persistent postmolar gestational trophoblastic tumor. Macrophage-derived cytokines IL-1 alpha, IL-1 beta and TNF significantly suppressed cell growth; this was associated with a significant increase in EGFR expression. The lymphocyte (IL-2, gamma-IFN, GM-CSF) cytokines had no significant effect on either EGFR expression or cell growth. These findings support the concept that cytokines may act as paracrine mediators of autocrine processes involved in choriocarcinoma cell growth regulation by modulating growth factor receptor expression. The EGFR-related family of oncogenes may be important in the pathogenesis and prognosis of gestational trophoblastic diseases.

Recent advances in gestational trophoblastic disease.

Important advances continue to occur in both our understanding and management of gestational trophoblastic disease. Complete molar pregnancy is being diagnosed earlier in pregnancy which affects its clinical and pathological presentation. The use of chemotherapy in persistent gestational trophoblastic tumors continues to be refined and our understanding of the immunobiology of these tumors has substantially advanced.

Review: analogies between trophoblastic and malignant cells.

PROBLEM: The question of how trophoblastic and malignant cells evade immunologic recognition and rejection by their host was studied. METHOD OF STUDY: A literature review was conducted. RESULTS: Trophoblastic and malignant cells share a number of similarities. These include a lack of major histocompatibility complex antigen expression, resistance to lysis by natural killer cells, T-helper cell-2 (TH2)-biased response, prostaglandin E production, and response to transforming growth factor beta. In addition, the analogies between trophoblastic and malignant cells extend into immunotherapy in which anti-idiotype therapy has a viable role in the prevention of pregnancy loss and the treatment of cancer. CONCLUSIONS: Trophoblastic and malignant cells use a number of similar mechanisms to resist rejection by their host. By using similar strategies these cells are able to successfully co-exist in an immunologically hostile environment.

HLA antigen sharing in Italian couples in which women were affected by gestational trophoblastic tumors.

PROBLEM: The development of gestational trophoblastic tumors (GTT), in which genetic factors are strongly involved, is a rare event. To test the possibility that gene(s) linked to the Major histocompatibility Complex (MHC) may have a role in both embryo growth and tumor development, the HLA typing was performed on patients affected by GTT and on their partners. METHOD: The study group of sixteen couples, in which the women were affected by an invasive mole or choriocarcinoma, and the control group of thirty normal fertile couples without history of spontaneous abortion or GTT were typed for class I and class II HLA antigen. RESULTS: The results showed no differences in single HLA-A and B antigen frequency between GTT couples and controls. In HLA-DR, locus an increased frequency of DR-6 antigen was observed (p < 0.05). No differences were observed in the frequency of number of antigens shared. When considering the single locus no differences were found in the sharing of the antigens of the A and B locus, while the frequency of antigenic sharing for DR locus was significantly higher in GTT couples with respect to controls (p < 0.025). Furthermore a higher frequency of Bw35-DR5 antigenic combination was found in GTT partners than in controls (P < 0.02). CONCLUSIONS: These data represent a confirmation of the existence of a MHC linked gene(s) influencing the GTT development.

Serum interleukin-2 and soluble interleukin-2 receptor in gestational trophoblastic diseases.

OBJECTIVE: To investigate serum interleukin-2 (IL-2) and soluble interleukin-2 receptor (SIL-2) levels in gestational trophoblastic diseases (GTD). METHODS: Sixty-six patients with GTDs and 23 first-trimester healthy pregnant women (controls) participated in this study. According to the World Health Organization scoring system, GTDs were subgrouped into the following groups: 30 hydatidiform mole spontaneous regression (HMSR), 12 postmolar gestational trophoblastic tumors of high risk (PMHR), 14 low-risk choriocarcinomas, and ten high-risk choriocarcinomas. Before treatment, a blood sample from each case was assayed for beta-hCG by radioimmunoassay, IL-2 by IRMA, and SIL-2R by enzyme-linked immunosorbent assay. Follow-up beta-hCG assays were carried out at weekly intervals after treatment for 3 months, then monthly for 1 year. RESULTS: Serum IL-2 levels in all subgroups of GTD were significantly lower than that of controls. Meanwhile, there were concomitant significant elevations of serum SIL-2R, showing mean rises of 3.86-fold, 3.9-fold, twofold, and 6.1-fold for cases of HMSR, PMHR, low-risk choriocarcinoma, and high-risk carcinoma, respectively. All cases of high-risk choriocarcinoma revealed abnormally high SIL-2R values. There was a significant positive correlation between serum beta-hCG and SIL-2R concentrations. CONCLUSION: The possible causes of IL-2 decreases and SIL-2R increases may indicate a defective immune response in GTDs. The high correlation between SIL-2R level and tumor burden suggests the use of serum SIL-2R assay for disease monitoring: SIL-2R is indirect marker of tumor activity, and it is useful in the differential diagnosis of GTD because a normal value of serum SIL-2R excludes high-risk cases of choriocarcinoma.

Serum cytokines in gestational trophoblastic diseases.

Interleukin 1 beta (IL-1 beta), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) were assayed by 125I immunoradiometric assay in sera of 42 cases of vesicular mole (VM), 24 cases of choriocarcinoma and 23 normal pregnant women at their first trimester (controls). According to pathologic diagnosis and serial serum hCG beta assays, the cases with VM and choriocarcinoma were subdivided into remission and progressive tumor groups. The progressive tumor groups--both VM and choriocarcinoma--showed marked elevations of serum IL-1 beta, IL-6 and TNF alpha. For choriocarcinoma in remission this elevation was considerably less pronounced. The VM cases in remission had only a slight increase of the mean serum IL-6 value and none of the cases had elevated IL-1 beta or TNF values. These results may indicate that serum IL-1 beta and TNF-alpha assays are valuable biomarkers in the differential diagnosis of gestational trophoblastic disease (GTD). Moreover, normal values of these cytokines may rule out high-risk GTD, whereas markedly elevated values may indicate poor prognosis.

The significance of proliferating cell nuclear antigen in human trophoblastic disease: an immunohistochemical study.

The expression of proliferating cell nuclear antigen (PCNA) in human trophoblastic disease was assessed immunohistochemically in tissue from 29 spontaneous abortions, 33 partial moles, 40 complete moles and 23 choriocarcinomas using the monoclonal antibody PC10. PCNA immunoreactivity occurred predominantly in the cytotrophoblasts in each of the four types of tissues. Quantitative analysis showed that the choriocarcinoma group gave a statistically significant higher PCNA index than the other three. There was no significant difference between the groups of spontaneous abortion, partial or complete mole. Sixteen of the 73 patients with partial and complete moles developed persistent gestational trophoblastic disease and there was no significant difference between the patients requiring chemotherapy and those who did not. We conclude that choriocarcinoma has a significantly higher PCNA proliferative index whilst hydatidiform moles cannot be distinguished from abortions by such analysis. The PCNA index does not appear to be useful in predicting the progression of molar pregnancies to persistent trophoblastic diseases.

CA-125: a marker for persistent gestational trophoblastic disease?

The objective was to determine whether CA-125 levels have any clinical utility in gestational trophoblastic disease. Fifty-one patients with a pathologically confirmed diagnosis of complete hydatidiform mole had a CA-125 level obtained prior to suction molar evacuation. Data were analyzed using chi 2 and Mann-Whitney U test. CA-125 levels were twice as high in persistent gestational trophoblastic disease than those in complete hydatidiform molar patients (85.9 vs 48.3 U/ml; P = 0.004). CA-125 levels were independent of age, gravidity, weeks of amenorrhea, or presence of thecal-luteal cysts. CA-125 levels appear to be of value in predicting which molar patients will develop persistent disease.

Diagnosis and management of gestational trophoblastic disease.

Gestational trophoblastic disease is a term that describes a group of tumors that share several characteristics as follows: (1) they arise in fetal chorion, (2) they produce human chorionic gonadotropin (hCG), and (3) they respond extremely well to chemotherapy. Although rare, they have received a disproportionate amount of attention because they were the first metastatic solid tumor to be cured using chemotherapy. Also, hCG was the first reliable tumor marker. Finally, because they arise in fetal tissue, they have the potential for a strong immune response against paternal antigens in the tumor. This potential for immunologic rejection was thought initially to explain the success of chemotherapy in this disease. The early detection of gestational trophoblastic disease is successful in patients who have had a hydatidiform mole as the pregnancy event that begins the process but unsuccessful in the early detection of the development of choriocarcinoma after a normal term delivery, abortion (spontaneous or elective), or ectopic pregnancy. Surveillance after evacuation of a molar pregnancy (whether complete or a partial mole) consists of regular evaluation of hCG production and the detection of metastatic disease. However, the development of gestational choriocarcinoma after term pregnancy or an abortion (no molar tissue can develop as a consequence of these pregnancies) is detectable only by signs or symptoms of metastatic disease in any of the many organs to which this tissue can spread. Unlike most staging classifications in gynecologic cancers, which are based on histologic findings and tumor location, the classification used in gestational trophoblastic disease stresses other features that are more useful for treatment selection. Both the National Institutes of Health and the World Health Organization classifications emphasize the importance of recognizing factors that predict the likelihood of a tumor responding to chemotherapy. Currently available treatment can cure all patients except those who are in the very high-risk group, which usually is characterized by metastasis to the brain or liver or a history of prior chemotherapy. Even in this category, approximately 80% of patients are curable.

Studies on some trace elements and cell-mediated immunity in patients with gestational trophoblastic disease.

Cu, Zn, Mn, Se were determined in erythrocytes in 43 patients with gestational trophoblastic disease (GTD), and T cell subsets were also monitored in peripheral blood in 37 cases. The results revealed that the contents of Cu and Se in erythrocytes in patients with GTD were significantly higher than those in normal females, the contents of Zn in patients with hydatidiform mole (HM) and Mn in patients with GTD were significantly lower than those in normal females, and so were the absolutes of lymphocytes, T cell and T subsets in peripheral blood in patients with GTD, the T4+/T8+ ratio in patients with HM and high risk gestational trophoblastic tumor (GTT) was obviously lower than that in normal controls. The above findings led us to hold that the alteration of trace elements (TE) in patients with GTD affects their immunologic function and is closely related to the occurrence and development of GTD.

Malignant placental site trophoblastic tumor associated with placental abruption, fetal distress, and elevated CA-125.

The second pregnancy of 27-year-old woman, gravida 2, para 2 was complicated by a low alpha-fetoprotein and symptoms of chronic placental abruption. She delivered by cesarean section at 35 weeks for fetal distress at which time a biopsy of the uterus revealed a placental site trophoblastic tumor (PSTT). She rapidly developed intraabdominal spread of the neoplasm which did not respond to chemotherapy and she died 10 weeks later. Her CA-125 was elevated to 5360 mu/ml and this decreased after hysterectomy. This patient is reported to highlight a very malignant course of PSTT that was associated with a live-born male infant.

Immune aspects of pathology of the placental bed contributing to pregnancy pathology.

Interest has recently focused on the role of the placental bed in the pathogenesis of a variety of pregnancy disorders. Considerable advances have been made in the understanding of the complex relationships between maternal and fetal trophoblast in the placental bed in normal pregnancy. Invasion of uterine spiral arteries by extravillous trophoblast effects the physiological changes required to accommodate increased blood flow to the fetoplacental unit. Control of trophoblast invasion may depend on intrinsic properties, such as production of proteolytic enzymes and expression of a non-classical class I MHC antigen, but maternal cells within decidua may also play a role. Leukocytes form a major component of human decidualized endometrium and in the first trimester consist of granulated lymphocytes, macrophages and T lymphocytes. Suggested roles for decidualized leukocytes include natural killer cell activity, cytokine secretion, antigen presentation and immunosuppression. Several pregnancy disorders, including pre-eclampsia and intrauterine growth retardation, may be due to abnormal maternofetal cellular relationships within the placental bed causing inadequate invasion of spiral arteries and acute atherosis. However, the role of immunological factors in the pathogenesis of these disorders is uncertain since deposition of immunoglobulins and complement has also been detected in spiral arteries in normal pregnancy. Placenta accreta may reflect undue invasiveness of trophoblast and immunohistochemical studies of subinvolution of uteroplacental arteries also suggest an abnormal maternofetal relationship in the placental bed. Although the in vivo role of decidual leukocytes is not known, studies of infertile endometrium have reported a deficiency of granulated lymphocytes, suggesting a possible role in early implantation and placentation. Granulated lymphocytes may also play a role in pregnancy loss. There have been considerable advances in understanding of the abnormal maternofetal relationships in the placental bed which can lead to pregnancy disorders. However, the aetiology and pathogenesis of the various clinical conditions is unlikely to be fully established until regulatory mechanisms in normal pregnancy are elucidated.

The immune system in disease: gestational trophoblastic tumours.

Trophoblastic tumours form a spectrum of disease from the borderline malignancy of HM to highly aggressive choriocarcinoma. Their management requires the integration of the information derived from serial hCG estimations, the clinical history and pattern of spread of the disease, so that our understanding of the prognostic variables can be applied appropriately. This maximizes the patient's chances of complete remission from her disease with the minimum of toxicity. Given our knowledge of this group of diseases and an integrated approach to management, it should be uncommon for any woman to die from her trophoblastic tumour.

Proliferating cell nuclear antigen in human placenta and trophoblastic disease.

Expression of proliferating cell nuclear antigen (PCNA), an auxiliary factor for the DNA polymerase delta, is closely related to cell proliferation. Using the monoclonal anti-PCNA antibody 19F4, we examined the distribution of PCNA in formalin-fixed, paraffin-embedded sections of mature and first-trimester placentas, 8 hydatidiform moles, and 7 choriocarcinomas. In normal placentas there was strong expression of PCNA in cytotrophoblastic nuclei, while the syncytium and the amnionic epithelium were PCNA unreactive. Staining of stromal cells was variable. These results are in complete agreement with the autoradiographic localization of [3H]thymidine incorporation and demonstrate that immunoreactivity for PCNA accurately defines areas of proliferative activity in routinely processed placental tissues. In choriocarcinomas and hydatidiform moles PCNA was predominantly expressed in the cytotrophoblast and intermediate trophoblast. Again, the syncytium was largely unreactive for PCNA. These findings indicate that even after neoplastic transformation the syncytium has comparatively little proliferative activity whereas the mononuclear trophoblastic cells divide actively.

Sharing of human leukocyte antigens in primary and secondary recurrent spontaneous abortions.

The prevalence of recurrent fetal loss and its relationship to sharing of human leukocyte antigens within couples was examined in a large, ethnically homogeneous Chinese population in Taiwan: 91 couples with primary recurrent spontaneous abortion, 32 couples with secondary recurrent spontaneous abortion, and 51 normal fertile couples. There was an excess of human leukocyte antigen sharing in both types of recurrent aborters. The primary aborters shared human leukocyte A and DQ antigens and three or more of the human leukocyte A, B, DR, and DQ antigens. The secondary aborters did not have an excess of sharing at any one locus but they did share three or more of the human leukocyte A, B, DR, and DQ antigens. There was no excess of antipaternal cytotoxic antibodies in any group of aborters, and the primary aborters had a lower level of mixed lymphocyte reaction blocking factor than normal couples or secondary aborters. Previous studies showed that couples in whom a gestational trophoblastic tumor developed in the woman shared human leukocyte B and DQ antigens and three or more of the human leukocyte A, B, DR, and DQ antigens. These studies provide substantial support for the role of recessive genes linked to the major histocompatibility complex in the pathogenesis of recurrent spontaneous abortions and of gestational trophoblastic tumors.