Postevacuation hCG levels and risk of gestational trophoblastic neoplasia among women with partial molar pregnancies.

OBJECTIVE: To develop human chorionic gonadotropin (hCG) criteria that determine a patient's risk of developing persistent gestational trophoblastic neoplasia (GTN) or achieving remission after partial mole evacuation. STUDY DESIGN: We used a database from the New England Trophoblastic Disease Center to analyze hCG levels from 284 women with partial molar pregnancies diagnosed between 1973 and 2003. RESULTS: An hCG level >199 mIU/mL in the third through eighth week following molar evacuation was associated with at least a 35% risk of GTN. CONCLUSION: Women with partial mole who have elevated hCG levels within the first few weeks after molar evacuation are at increased risk for developing GTN.

Clinical characteristics of persistent gestational trophoblastic neoplasia after partial hydatidiform molar pregnancy.

OBJECTIVE: To identify clinical characteristics associated with developing persistent gestational trophoblastic neoplasia (GTN) after partial hydatidiform molar pregnancy (PHM). STUDY DESIGN: Utilizing the Donald P. Goldstein in patients who developed persistence between 1973 and 1989. CONCLUSION: Older age at diagnosis and history of prior mole were significantly more common in women who developed persistence after partial molar pregnancy in referral of patients the earlier cohort but not in idefined clinical the recent cohort. In recent years no clinical factor was at increase their risk significantly associated with rsistence. database at the New England Trophoblastic Disease Center, 284 women with partial molar pregnancy diagnosed between 1973 and 2003 were characteristics identified. Clinical charac- for pe teristics, such as gravidity, parity, age, uterine size, gestational age at diagnosis, human chorionic gonadotropin levels at presentation and time to development of persistence (GTN) were analyzed. Data were also divided into 2 cohorts, an earlier one (1973-1989) and a later one (1990-2003), in order to look at potential changes over time. RESULTS: GTN developed in 5.6% of partial molar pregnancies. Older maternal age was significantly associated with development of persistent GTN in the earlier cohort but not in the recent cohort. Previous molar pregnancy was also statistically significantly more common the development of +/-after PHM.

Low risk of relapse after achieving undetectable HCG levels in women with partial molar pregnancy.

OBJECTIVE: We evaluated the risk of gestational trophoblastic neoplasia (GTN) for women with partial molar pregnancy whose human chorionic gonadotropin (hCG) levels fall spontaneously to undetectable levels using a sensitive hCG assay. METHODS: We analyzed data from the New England Trophoblastic Disease Center to estimate the risk of GTN among 284 women with partial molar pregnancy and at least 6 months of gonadotropin follow-up. RESULTS: None of the 238 women with complete gonadotropin follow-up and a spontaneous decline in serum hCG levels to undetectable levels subsequently developed GTN (95% confidence interval 0-1.6%). CONCLUSION: If these results are replicated at other institutions with longstanding experience managing partial molar pregnancies, it may be reasonable to abbreviate clinical follow-up for women with partial molar pregnancy whose serum hCG levels spontaneously decline to an undetectable level.

The clinical significance of benign-appearing endometrial cells on a Papanicolaou test in women 40 years or older.

The 2001 Bethesda System revision recommends reporting benign-appearing endometrial cells (BAEMC) in all women 40 years or older, not just in postmenopausal women. We studied the influence of this change on clinical practice and the detection of endometrial neoplasia. Women 40 years or older were selected for study if BAEMC were reported on a cervical cytologic specimen. Cases were stratified by implementation of the 2001 guidelines. Results of endometrial biopsies within 18 months, with special attention to the frequency of adenocarcinoma and hyperplasia, were assessed. In the preimplementation group, BAEMC were reported as an epithelial cell abnormality in 154 postmenopausal women and as an incidental finding in 636 premenopausal women (total = 790). In the postimplementation group, BAEMC were reported in 836 women. The proportion of endometrial biopsies in these cohorts was significantly increased (P < .05). After implementation of the 2001 guidelines, the detection of endometrial cancer increased (6 vs 3 cases, not significant). Of the women with cancer, 3 were premenopausal, 5 were asymptomatic, and 2 were premenopausal and asymptomatic. All cancers were identified in women older than 45 years, suggesting that the Bethesda cutoff of 40 years is safe and conservative.

Immunohistochemistry for the imprinted gene product IPL/PHLDA2 for facilitating the differential diagnosis of complete hydatidiform mole.

OBJECTIVE: To determine if immunohistochemistry for PHLDA2 (also known as IPL and TSSC3), the product of a paternally imprinted, maternally expressed gene, can be used as a tool in the differential diagnosis of molar gestations. STUDY DESIGN: Twenty-five cases (15 complete moles, 5 partial moles and five hydropic abortions) were stained by immunohistochemistry for PHLDA2 and scored (without knowledge of the diagnosis) for positivity in the villous cytotrophoblast and then compared to adjacent sections stained by p57KIP2 immunohistochemistry. RESULTS: All partial moles and hydropic abortions were positive for PHLDA2 and p57KIP2. There was strong PHLDA2 staining of the cytoplasm in virtually all cells of the villous cytotrophoblast, while p57KIP2 was localized to the nucleus in a subset of those cells. All complete moles were negative for both markers in the villous cytotrophoblast. CONCLUSION: Immunohistochemistry for PHLDA2 serves as a practical and reliable diagnostic marker for the discrimination of complete mole from partial mole and hydropic abortion. Since the immunohistochemical diagnosis of complete mole is based on a negative result, absence of staining, the use of both markers (PHLDA2 and p57KIP2) together could increase the level of confidence when making this prognostically important distinction.

Complete hydatidiform mole retaining a chromosome 11 of maternal origin: molecular genetic analysis of a case.

Hydatidiform moles are pregnancies characterized by abnormal development of both embryonic and extraembryonic tissues and are associated with the misexpression of imprinted genes. The vast majority of complete hydatidiform moles are diploid and androgenetic, whereas partial hydatidiform moles are triploid, with an extra set of chromosomes of paternal origin. Here, we present an unusual complete mole that showed strong expression of two imprinted, maternally transcribed genes, CDKN1C (encoding p57(KIP2)) and PHLDA2 (TSSC3/IPL), both part of a large imprinted gene domain on chromosome 11. Using microsatellite genotyping and fluorescent in situ hybridization, we show that this paradoxical gene expression was due to retention of a maternal copy of chromosome 11 in addition to the two paternal copies normally present in complete moles. These findings demonstrate that, despite being predominantly androgenetic, some complete moles contain small amounts of DNA of maternal origin. Furthermore, these results provide an explanation for rare false negatives that can arise when p57(KIP2) is used as a diagnostic marker for complete moles.

Unilateral transverse arm defect with subterminal digital nubbins.

We present a case of unilateral terminal transverse forearm deficiency with subterminal digit-like nubbins, identified in a fetus from a pregnancy terminated electively in the second trimester because the distal right arm and hand could not be seen by ultrasound and were presumed to be absent. Pathologic evaluation showed distal transverse shortening, tapering to a point in the mid-forearm. Five primitive digital nubbins were present, located just proximal to the tapered point. The arm vessels appeared normal histologically, and the amnion showed no evidence of intrauterine disruption. Histologic examination of the nubbins revealed osteocartilaginous tissue, never described previously within digital nubbins. This fetus has the rare phenotype of terminal transverse limb defects with residual nubbins, but differs in that the nubbins are not at the tip of the terminal transverse limb defect.

Osteopontin is down-regulated in hydatidiform mole.

OBJECTIVE: Osteopontin (OPN) is a glycoprotein of the extracellular matrix that can bind to different types of receptors including integrins and CD44 receptors. Multiple binding affinity enables OPN to play a role in many physiological and pathological processes. OPN contributes to tumorigenesis in several types of cancers. OPN is also expressed by the endometrium and by trophoblast cells of the chorionic villus in human placenta, where OPN may regulate implantation and placentation in early pregnancies by promoting cell-cell interactions, adhesion, spreading, and migration of trophoblast. Our purpose was to determine the expression of OPN mRNA and protein in hydatidiform mole and in normal placenta of comparable gestational age. METHODS: A total of 13 fresh tissues from complete hydatidiform moles, 2 from partial hydatidiform moles, and 9 from normal placentas were analyzed by performing quantitative real-time PCR on microdissected trophoblast cells and immunohistochemistry on frozen sections of tissue. RESULTS: Our results showed significantly lower expression of OPN mRNA and protein in hydatidiform mole, and in particular complete mole (P = 0.001 by real-time PCR and P < 0.001 by immunohistochemistry) as compared to nermal placenta. CONCLUSION: Although precise molecular mechanisms of gestational trophoblastic diseases have not yet been determined, down-regulation of osteopontin may play an important role in the pathogenesis of molar pregnancy.

Type 3 iodothyronine deiodinase is highly expressed in the human uteroplacental unit and in fetal epithelium.

Type 3 iodothyronine deiodinase (D3) is the major physiologic inactivator of thyroid hormone. This selenoenzyme, previously identified in human placenta and brain, catalyzes the inner-ring deiodination of T(4) to reverse T(3) and T(3) to 3, 3'-diiodothyronine, both of which are biologically inactive. We analyzed D3 expression in several human adult and fetal tissues by immunohistochemistry and correlated the results with D3 activity assays where possible. High D3 expression was present in the placental syncytiotrophoblasts and cytotrophoblasts, endothelium of fetal vessels, and maternal decidua. D3 was also present at other sites of maternal-fetal interface, including the umbilical arteries and vein and the fetal respiratory, digestive, and urinary tract epithelium. Surprisingly, D3 was also present in the endometrial glands of nonpregnant human uteri, and endometrial activity approximated that of term placenta. The presence of D3 at maternal-fetal interfaces is consistent with its role in modulating the thyroid status of the human fetus and its expression in endometrium suggests that local regulation of thyroid status is important in implantation.

Antenatal mycoplasma infection, the fetal inflammatory response and cerebral white matter damage in very-low-birthweight infants.

We address the question as to whether Ureaplasma urealyticum or Mycoplasma hominis, cultured from the placenta of very-low-birthweight (VLBW) infants, are associated with an increased risk of (a) fetal vasculitis and (b) ultrasonographic cerebral white matter echolucency. The sample consisted of 464 VLBW infants for whom (i) the surface of the chorion was cultured for U. urealyticum and M. hominis; (ii) the placenta was examined histologically; and (iii) a cranial ultrasound scan was obtained close to days 1, 7 or 21. Infants with echolucency were compared with controls in univariable and stratified analyses and in multivariable logistic regressions. Fifty-three per cent of placentas from infants with fetal vasculitis harboured U. urealyticum compared with 18% of controls (P

Biomarkers in diagnostic obstetric and gynecologic pathology: a review.

Until recently, the histologic diagnosis of obstetrical and gynecologic neoplasia was based principally on morphologic criteria. However, interobserver reproducibility for entities such as squamous intraepithelial, endometrial, and trophoblastic disease varies widely between observers. This inherent variability in interpretation between individuals has led to wide ranges in diagnostic precision between practices, and in many cases, between recognized experts. The advent of immunohistochemistry, and the more recent accelerated discovery of new genes and their functions has resulted in the discovery of cellular proteins or nucleic acids that are differentially expressed in tumors. When applied in conjunction with existing histologic criteria, these "biomarkers" have the potential to enhance diagnostic consistency and reproducibility. The gains expected are to practicing diagnostic pathologists (who will enjoy greater diagnostic consistency) and to academics (for whom biomarkers may uncover new pathways unappreciated by histologic diagnosis alone). However, fundamental to the success in both arenas will be critical analysis of the potential pitfalls in immunohistochemistry, strict validation of new markers as they arrive in the field, and a realistic view of their value in the laboratory management of obstetrical and gynecologic diseases.

The maternally transcribed gene p57(KIP2) (CDNK1C) is abnormally expressed in both androgenetic and biparental complete hydatidiform moles.

Hydatidiform mole (HM) is an abnormal gestation characterized by trophoblast hyperplasia and overgrowth of placental villi. The genetic basis in the vast majority of cases is an excess of paternal to maternal genomes, suggesting that global misexpression of imprinted genes is the common molecular mechanism underlying the genesis of this condition. Although most complete HM are androgenetic in origin, a rare, frequently familial, biparental variant has been described. Here we evaluate the expression of p57(KIP2), the product of CDKN1C, an imprinted, maternally expressed gene in a series of these rare, biparental complete HM (BiCHM). We observed dramatic underexpression of p57(KIP2) in BiCHM, identical to that seen in complete HM of androgenetic origin (AnCHM). The series included two sisters, both of whom had BiCHM. Genotyping of this family identified a 15 cM region of homozygosity for 19q13.3-13.4 similar to that found in three other families with recurrent BiCHM. These results demonstrate that BiCHM, like AnCHM, result from abnormal expression of imprinted genes. In addition we provide further evidence for a major control gene on 19q13.3-13.4 which regulates expression of imprinted genes on other chromosomes.

Placental surface cysts detected on sonography: histologic and clinical correlation.

OBJECTIVE: To evaluate the clinical outcome and histologic findings of pregnancies in which placental surface cysts were detected on prenatal sonography. METHODS: A computerized search of our obstetric sonographic database from 1988 through 2000 identified 34 cases. Results of pathologic examinations, when performed, were obtained. Sonographic features were correlated with histologic findings and clinical parameters. RESULTS: On review of available microscopic slides, in all cases in which the cyst was seen at pathologic examination, there was subchorionic fibrin with central cyst formation. All pregnancies resulted in live births, although intrauterine growth restriction occurred in 4 (12%) of 34. Three (11%) of 28 cases with placental pathologic findings had maternal floor infarction. Only 2 significant associations between sonographic features and postnatal findings were found. In all cases of intrauterine growth restriction, average cyst size was larger than 4.5 cm. Of 12 cysts larger than 4.5 cm, 4 (33%) had intrauterine growth restriction. Of 22 cysts smaller than 4.5 cm, there were no instances of intrauterine growth restriction (P = .01). Of 32 cases with 3 or fewer cysts, only 2 had intrauterine growth restriction, whereas in 2 cases with more than 3 cysts, both had intrauterine growth restriction (P = .01). CONCLUSIONS: Most placental surface cysts are associated with a normal pregnancy outcome. Most such cysts are related to cystic change in an area of subchorionic fibrin. Cysts larger than 4.5 cm or more than 3 in number are more frequently associated with intrauterine growth restriction.

Advances in the understanding of placental site trophoblastic tumor.

Placental site trophoblastic tumor (PSTT) is the least common form of gestational trophoblastic disease. The tumor represents a neoplastic transformation of intermediate trophoblastic cells that normally play a critical role in implantation. PSTT can occur after a normal pregnancy, spontaneous abortion, termination of pregnancy, ectopic pregnancy or molar pregnancy. It displays a wide spectrum of behavior, and when metastatic, can be difficult to control even with surgery and chemotherapy. Because of PSTT's rarity, limited information is known about its natural history. Several recent studies have indicated that mitotic index is an important prognostic indicator. Advances in chemotherapeutic regimens have also improved clinical response in metastatic disease.

Ploidy and imprinting in hydatidiform moles. Complementary use of flow cytometry and immunohistochemistry of the imprinted gene product p57KIP2 to assist molar classification.

OBJECTIVE: To determine whether the combination of flow cytometry and immunohistochemistry for p57 expression is useful for the pathologic classification of diagnostically challenging hydatidiform moles. STUDY DESIGN: Six probable hydatidiform moles that were difficult to classify pathologically were reevaluated by histology, flow cytometry and immunohistochemistry for p57. RESULTS: In all cases, the pathologic diagnoses were easily resolved: two cases were partial moles (triploid, p57 positive), two cases were early complete moles (diploid, p57 negative), and two cases were twin gestations with normal villi (diploid, p57 positive) admixed with villi from a complete hydatidiform mole (diploid, p57 negative). CONCLUSION: Immunostaining for the paternally imprinted, maternally expressed p57 gene product is a practical and accurate adjunct to flow cytometry in the pathologic classification of hydatidiform moles.

Do nontriploid partial hydatidiform moles exist? A histologic and flow cytometric reevaluation of nontriploid specimens.

OBJECTIVE: To study whether nontriploid partial hydatidiform moles truly exist. STUDY DESIGN: We conducted a reevaluation of pathology and ploidy in 19 putative nontriploid partial hydatidiform moles using standardized histologic diagnostic criteria and repeat flow cytometric testing by the Hedley technique. RESULTS: On review of the 19 moles, 53% (10/19) were diploid nonpartial moles (initially pathologically misclassified), and 37% (7/19) were triploid partial moles (initial ploidy misclassifications). One additional case (5%) was a diploid early complete mole (initially pathologically misclassified). CONCLUSION: Nontriploid partial moles probably do not exist: careful reevaluation of putative specimens will probably uncover pathologic or ploid errors in almost all cases.

Managing atypical squamous cells of undetermined significance (ASCUS): human papillomavirus testing, ASCUS subtyping,or follow-up cytology?

OBJECTIVE: This study related morphologic subtype, human papillomavirus status, and a second cytologic examination to the follow-up biopsy-proven high-grade squamous intraepithelial lesion (HSIL; grade II or III cervical intraepithelial neoplasia) after a cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS). STUDY DESIGN: Seven hundred four liquid-based cervical cytology specimens were classified as normal, "ASCUS, favor reactive" (AFR), "ASCUS, not otherwise specified," "ASCUS, favor low-grade squamous intraepithelial lesion," "ASCUS, favor HSIL" (AFHS), low-grade squamous intraepithelial lesion, and HSIL. Human papillomavirus typing used polymerase chain reaction-restriction fragment length polymorphism analysis. A longitudinal review of the cytologic and histologic records of ASCUS cases with > or =1 follow-up test or biopsy ascertained the frequency of a follow-up diagnosis of biopsy-proven HSIL (grade II or III cervical intraepithelial neoplasia). RESULTS: Three hundred eighty-six cases (208 ASCUS, 68 normal, 86 with low-grade squamous intraepithelial lesions, and 24 with HSIL) were evaluated. High-risk human papillomavirus (HRHPV positive) was lowest with normal cytology (13%), highest with HSIL (71%), and was present in 29.8% of ASCUS cases, ranging from 22.2% (AFR) to 75% (AFHS). Most ASCUS tests (64%) were followed by a negative cytologic or histologic examination. Overall, 3.8% and 11% of ASCUS and HRHPV-positive ASCUS had histologic outcomes of HSIL. AFHS had the highest (25%) and AFR had the lowest (1.1%) proportion of HSIL outcomes. Sensitivity, specificity, and positive predictive values of human papillomavirus testing for biopsy-proven HSIL were 87.5%, 72.5%, and 11.3%, respectively. CONCLUSION: HSIL and AFHS are distinguished by the highest frequency of HRHPV types and higher rates of HSIL outcome. The remaining categories of ASCUS are heterogeneous with respect to human papillomavirus type and HSIL risk, and the value of subclassification of these entities is dependent on the practice. A human papillomavirus detection system based on polymerase chain reaction-restriction fragment length polymorphism identifies a smaller percentage of high-risk human papillomaviruses than mixed probe-based methods, probably because of the more precise exclusion of cross-reacting low-risk human papillomavirus. Negative HRHPV findings by either system show a markedly reduced risk of an HSIL outcome. However, the relative advantage of human papillomavirus testing over follow-up cytology will be influenced by the frequency of negative follow-up cytologic examination and sensitivity of liquid-based preparations in a given practice.

Maternal floor infarction and massive perivillous fibrin deposition: histological definitions, association with intrauterine fetal growth restriction, and risk of recurrence.

Maternal floor infarction (MFI) is a poorly understood placental lesion reportedly associated with intrauterine growth restriction (IUGR) and recurrence. In this study of MFI and the related placental disorder, massive perivillous fibrin deposition (MFD), semiquantitative histologic criteria for these diagnoses are defined and rates of IUGR and recurrence are assessed. Pathologic slides of 80 placentas diagnosed as MFI or MFD at the Brigham and Women's Hospital (1989-99) were reviewed and reclassified as classic MFI, transmural MFD, borderline MFD, or neither MFI or MFD. The prevalence of IUGR was determined, and placental slides from additional pregnancies were reviewed to evaluate recurrence. Among 25 cases originally diagnosed as MFI, 5 (20%) were reclassified by study criteria as classic MFI, 9 (36%) as transmural or borderline MFD, and 11 (44%) as neither lesion. Among 55 cases originally diagnosed as MFD, 27 (49%) were reclassified as transmural or borderline MFD, 4 (7%) as classic MFI, and 24 (44%) as neither lesion. IUGR was identified in no case with classic MFI, in 31% of cases with transmural or borderline MFD (P = 0.02), and in 11% of cases with neither lesion. Recurrence was documented in 1 of 7 (14%) second- or third-trimester placentas. Possible recurrence was suggested in 3 of 6 (50%) first-trimester spontaneous abortion specimens. Classification of intraplacental fibrin is subjective and problematic; almost half of potential cases of MFI or MFD did not fulfill our study's diagnostic criteria. MFD may be more common and more strongly associated with IUGR than classic MFI. Recurrence of these lesions appears to be infrequent among second- and third-trimester placentas, but may be relatively common in first-trimester spontaneous abortions.