Diagnosis Of Gestational Trophoblastic Disease Research Articles

B-312 Overcoming Challenges in Reporting High ß-hCG Results In Cancer Patients: A Tertiary Cancer Institute Experience

Abstract Background Serum ß-hCG is levels are a useful marker for diagnosis of Gestational Trophoblastic Disease as well as germ cell tumours of the ovary and testicle. However, values ranging from 50,000 - 1,00,000 mIU/ml are commonly seen in malignancies which are beyond the linearity of the most methods used in routine practice. This poses a great challenge to laboratory professionals while reporting for this test as serial monitoring of ß-hCG values is essential for ascertaining the effectiveness of treatment and progression of disease in oncology patients. The aim of this study was to develop a protocol for reporting beyond linearity values of serum ß-hCG in our laboratory with comparison of the same on two analysers with different linearity. Methods One hundred and fifty serum samples for ß-hCG received from patients with trophoblastic as well as germ cell tumours over a period of three months from October 2023 to December 2023 were processed by Chemiluminescence Immunoassay (CLIA) method on Atellica IM (Siemens Healthineers) and Alinity-i (Abbott Healthcare) immunoassay analysers simultaneously. The linearity for Atellica IM is 0 -1000mIU/ml and same for Alinity-i is 0- 15,000 mIU/ml as reported by the manufacturer. The protocol followed for samples processed on Atellica IM was as follows with 50 samples in each group. For values of ß-hCG less than 500 mIU/ml, we repeat tested samples with 1:10 dilution in case any instrument flags were observed in the report. For values between 500-1000 mIU/ml, samples were repeat tested with 1:50 dilution. For values reported as >1000 mIU/ml, samples were repeat tested with 1:5000 dilutions. For Alinity-i, samples with values higher than 15,000 mIU/ml were processed with a dilution of 1:10. For all results with instrument flags, the dilution protocol was followed. Diluent provided by the manufacturer was used for all sample dilution processes. The values obtained on both analysers were compared statistically for correlation using linear regression analysis and coefficient of correlation (R) was calculated. Results The serum ß-hCG values observed ranged from 102 mIU/ml to 187,000 mIU/ml. Linear regression analysis for all groups showed good correlation. For serum ß-hCG values < 500 mIU/ml; between 500-1000 mIU/ml and >1000 mIU/ml coefficient of correlation was observed as R=0.9987, 0.9936 and 0.9713 respectively. Conclusions Good correlation was observed between values of serum ß-hCG obtained by dilution protocol on Atellica IM and Alinity-i analysers. The protocol developed by our laboratory to report beyond linearity sample results on Atellica IM can be a very useful tool in oncology patients where high values of beta HCG are expected and serial monitoring of values is essential.

High HIV prevalence in gestational trophoblastic neoplasia patients.

To assess the HIV prevalence in patients diagnosed with gestational trophoblastic neoplasia (GTN). A retrospective single centre cohort study. A database from the Sheffield Trophoblastic Disease Centre (STDC), Sheffield, UK was searched between 1st January 2015 and 31st December 2021. A total of 3,591 patients were referred to STDC with a diagnosis of gestational trophoblastic disease (GTD), of which 221 (6.2%) were treated for GTN. The prevalence of HIV-positive tests in GTN patients was assessed. HIV testing was performed in 93% GTN patients ( n = 205/221). Overall, 1.3% of GTN patients ( n = 3/221) were HIV-positive, involving two known HIV-positive patients and one new diagnosis. This equates to a HIV prevalence of 14 : 1000, which is ∼7 to 9× higher than the HIV prevalence in Sheffield (1.9 per 1000) and Yorkshire and Humber (1.5 per 1000). Given the extremely high HIV prevalence in our population, 'opt out' HIV testing is recommended within our specialist trophoblastic centre for all referred GTD and GTN patients. There is little reason to suspect that the prevalence of HIV-positive patients is any lower in the cohort of GTD patients referred to specialist trophoblastic centres for hCG screening alone, without requiring chemotherapy, particularly considering that most GTN arises from GTD.

Development of radioimmunoassay system for determination of human chorionic gonadotropin in human sera

The main objective of this study was the preparation and evaluation of the primary reagents for the liquid phase human chorionic gonadotropin-radioimmunoassay (HCG-RIA) kit. Polyclonal antibody is specific and valid; monoclonal antibodies are more specific. In HCG-RIA technique, polyclonal antibodies for βHCG subunits with high binding and displacement % were used. 125I-HCG radioactive tracer was prepared with high yield 71.58 ± 0.92%, purity 99.2 ± 0.05%, and specific activity 170.42 ± 1.65 µCi/µg using chloramine T method, βHCG polyclonal antisera and HCG standards in assay buffer matrix were locally prepared. In-house HCG-RIA was developed with high sensitivity 0.5 mIU/ml, specificity (99%), precision (CV% < 6.4 and < 8.3 for intra-and inter-assay, respectively), and accuracy (recovery range 96.4–104.3%) could be used for quantitative estimation of HCG in human sera for monitoring pregnancy and diagnosis of gestational trophoblastic diseases.

How Could One Sperm and One Oocyte Proceed To Molar Pregnancy? Prevalence of Molar Pregnancy during ICSI Procedure in Over 25,000 Fresh Embryo Transfers: A Retrospective Cross-Sectional Study.

Gestational trophoblastic disease (GTD) is a heterogeneous group of diseases characterized by excessive proliferating trophoblastic tissue. The prevalence of GTD has a varied geographical distribution. However, its frequency following intracytoplasmic sperm injection (ICSI) cycles has not yet been reported. This study aimed to estimate GTD frequency and prevalence after ICSI cycles. This retrospective cross-sectional study included all patients diagnosed with GTD subsequent to ICSI and segmental embryo transfer procedure during 2011-2019 at Royan Institute. GTD diagnosis was established for patients who met all three criteria: beta-human chorionic gonadotropin (β-hCG) levels greater than 100,000 mIU/mL, vesicular ultrasonographic pattern, and presence of pathologic features of hydatidiform mole. Although we assessed the GTD frequency in all ICSI cycles, GTD cases were only observed following fresh embryo transfer ICSI procedures. We evaluated 25,667 fresh embryo transfer ICSI procedures out of 41,540 ICSI cycles. This study identified a total of 10 GTDs confirmed by all criteria which were mentioned previously. Of these 10 GTDs, nine cases had hydatidiform mole, and one had gestational trophoblastic neoplasia. The frequency of GTD was calculated 10 cases in 41,540 (0.240 per 1000) ICSI procedures and 10 in 25,667 (0.389 per 1000) fresh embryo transfers following ICSI cycles. Also, we detected 10 GTD cases in 8,196 (1.220 per 1000) clinical pregnancies. We discuss that the possibility of GTD after ICSI procedure is not as low as expected. Thus, the previous theses are insufficient to explain all aspects of molar pregnancy, and more research is required.

A Histopathological Profile of Gestational Trophoblastic Disease in the Madinah Region of Saudi Arabia

Gestational trophoblastic disease (GTD) is a rare and often curable group of diseases that has a large range of morphological features, sometimes making the diagnosis difficult. The objectives of this study were to evaluate the pathological frequency and histopathological profile of GTD diagnoses in the Madinah region of Saudi Arabia (KSA). The computerized record of the pathology department of the Maternity and Children's Hospital (MCH) in Madinah, KSA, was reviewed from July 2015 to June 2021. During the study period, all the pathology reports with diagnosis of GTD were included in the study for the following parameters: age, nationality, year of diagnosis, type of GTD, and total annual number of pregnancies. Simple statistical analysis was performed, utilizing the SPSS-19 software. A total of 289 cases of GTD were diagnosed during the study period. The mean age was 33.47 ± 9.3, and most of the patients (n = 106, 36.2%) were in the fourth decade [31-40 age group]. Histologically, the most common type diagnosed was Hydatidiform mole [HM] (n = 284, 98.6%), followed by three cases of trophoblastic neoplasm (1.0%) and one case of tumor-like condition called exaggerated placental site (0.3%). Complete HM (n = 53, 50%) was common in the fourth decade, whereas partial HM (n = 50, 53.8%) was common in the third decade. In the Al Madinah region of KSA, the most common type of GTD in women was HM. Most GTD cases were found in women between the ages of 31 to 40 years. The frequency of GTD, its histopathological subtypes are consistent with most of the studies on GTD; however, larger studies involving multiple centers are recommended, for confirmation of present study's findings.

Trophoblastic Disease: Review of the Literature

The purpose of this literature review is to discuss the most effective gestational trophoblastic disease diagnostic and treatment methods. Also, to introduce some of the novel treatment options currently being explored. A comprehensive research was carried out on scientific databases of MEDLINE and PubMed over the time period of 2014 to 2021. According to literature sources initial gestational trophoblastic disease diagnosis is multimodal: encompassing clinical features, quantitative human chorionic gonadotropin titers and pelvic ultrasonography. Pelvic magnetic resonance imaging, body computed tomography, chest radiography and angiography are the methods usually used for overall disease staging and metastases detection. The best treatment method is designated with reference to individual features of the patient and the disease. Conventional treatment consists of hysterectomy and chemotherapy; however, the use of new methods, such as directed enzyme prodrug therapy is also being attempted to cure metastasized and/or resistant gestational trophoblastic neoplasias. Most women with gestational trophoblastic disease can be successfully managed with preservation of reproductive function due to early diagnosis in the first trimester of pregnancy. It is important to identify gestational trophoblastic disease promptly and adjust specific treatment for every patient properly to minimize various complications.

Angiogenin and MMP-2 as potential biomarkers in the differential diagnosis of gestational trophoblastic diseases.

Background:Gestational trophoblastic diseases (GTDs) are characterized by vascular abnormalities of the trophoblast, but their pathogenesis is unknown. Angiogenin (ANG) and matrix metalloproteinase (MMP)-2, which are molecules implicated in the angiogenic process, may play some role in this process.Material and methods:We determined ANG and MMP-2 in the placental tissues of 26 patients who had a benign mole (BM), 12 patients with gestational trophoblast neoplasia (GTN) (1 invasive hydatidiform mole, 10 choriocarcinomas, and 1 placental-site trophoblastic tumor), and 28 normal chorionic villi (NCV) subjects using immunohistochemistry staining. We obtained the serum samples from 20 patients with GTDs and 20 early pregnant women and evaluated them by the enzyme linked immunosorbent assay.Results:ANG expression in GTN (66.7%) and BM (100%) samples were both significantly higher (strong/intermediate staining) than in NCV (60.7%) samples (P < .001). Similarly, the immunoreactivities of MMP-2 in the GTN (66.7%) and BM (80.8%) samples were significantly elevated compared to that of the NCV (57.1%) samples (P < .001). The levels of ANG and MMP-2 in the maternal serum of the GTN group were both significantly higher than those of the control group (P < .001). ANG and MMP-2 expressions were associated with gestation age, clinical stage, and FIGO stage. A positive correlation between ANG and MMP-2 expression was observed (rs = 0.725; P < .01).Conclusion:ANG and MMP-2 levels were significantly elevated in the placental tissues and maternal serum from patients with GTDs. Further studies with more patients may clarify the vascular abnormalities in GTDs and determine potential biomarkers in the differential diagnosis of GTDs.

The current state of pathology and immunohistochemistry in gestational trophoblastic disease therapeutic management: A tertiary center experience

Gestational trophoblastic disease (GTD) is derived from the abnormal development of trophoblastic tissue and covers a broad range of benign and malignant disorders. The histological diagnosis of GTD continues to be a challenge, even among expert pathologists. The present study evaluates the roles of pathology and immunohistochemistry in GTD diagnostic and therapeutic approaches. A retrospective study was conducted in Filantropia Clinical Hospital, Bucharest, Romania, involving cases of GTD between 2010 and 2020. We reported 19 clinically diagnosed and histologically confirmed cases of GTD, 15 moles (complete and partial), along with 4 cases of gestational trophoblastic neoplasia (GTN). The mean age of the patients studied was 31.3±7.5 years. The percentage of cases diagnosed after the sonographic evaluation was 94.7%. The rate of progression of GTD to GTN was 5.2%. Seven patients with low-risk GTD (risk score six or less) were treated with first-line chemotherapy (CT), and two cases required second-line CT. Twelve patients with highrisk GTD (risk score seven or more) were treated with first-line CT (n = 4), first-line CT followed by second-line CT (n = 4), first-line CT with adjuvant surgery (n = 3), and first-line surgery (one case). No causal relationship has been established between the forms of gestational trophoblastic disease regarding hCG level, the rate of normalization of hCG, and the rate of progression to GTN. After chemotherapy for GTD, only 42.1% of patients who wanted a future pregnancy could conceive. Underutilized in the current practice (5.2%), the immunohistochemical markers for trophoblasts and DNA genotyping are particularly useful tools in the fast and accurate diagnosis and prognosis of GTD.

Histopathological examination of the curettage material in nonviable pregnancies and evaluation of the frequency of hydatidiform mole.

The study aimed to determine the frequency of possible missed diagnosis of gestational trophoblastic disease in nonviable pregnancies and to evaluate the importance of histopathological examination. In this retrospective study, the results of the histopathological assessment of patients undergoing uterine surgery with a diagnosis of nonviable pregnancy were analyzed before 14 weeks of gestation. Nonviable pregnancy was defined as anembryonic pregnancy and intrauterine exitus (IU-ex) based on ultrasound findings. The frequency and sonographic characteristics of molar pregnancy in nonviable pregnancy were analyzed. Molar pregnancy was detected in 24 (1.62%) of 1481 patients diagnosed with nonviable pregnancy on ultrasound. One thousand one hundred and twenty-one of the cases were IU-ex (75.69%) and the remaining were anembryonic pregnancy (24.31%). The mean crown-rump length of pregnancies in the IU-ex group was 16.7 mm and the mean gestational age was 8 weeks. The average gestational sac diameter was found to be 26 mm in anembryonic pregnancy patients. The hydatidiform mole ratio was significantly higher in anembryonic pregnancy patients (3.06%) than in IU-ex patients (1.16%) (p=0.013). The appearance of early molar pregnancy on ultrasound evaluation may mimic anembryonic pregnancies. Therefore, histopathological examination of anembryonic pregnancies may be useful in early diagnosis and for the treatment of gestational trophoblastic neoplasia.

The potential of serum fetal DNA for early diagnosis of gestational trophoblastic disease.

Objective:To study cell-free DNA (cfDNA) levels in patients with gestational trophoblastic disease (GTD) in order to test the hypothesis that cfDNA circulating in maternal plasma could provide early detection of GTD.Materials and Methods:This study included 32 patients with GTD (complete mole and partial mole) and 30 non-GTD patients in the first trimester of pregnancy with no other medical problems. cfDNA levels in maternal serum were measured using polymerase chain reaction analysis on Y-chromosome–specific sequences.Results:cfDNA was found as 327±367 pg on average in the control group and 600±535 pg in the GTD group. Within the GTD group, the partial mole group had an cfDNA average of 636±549 pg, and the complete mole group had an cfDNA average of 563±536 pg. Although there was a statistically significant difference between the GTD group and the control group in terms of cfDNA (p=0.02), there was no statistically significant difference between the complete mole group and the partial mole group (p=0.76).Conclusion:Non-parametric analysis of covariance in terms of cfDNA in GTD was performed, thereby increasing its power and revealing a significant difference compared with the control group. This indicates that maternal peripheral bloodstream cfDNA monitoring might be significant in the early diagnosis of GTD.

Correlation of ultrasound imaging with histopathological findings in gestational trophoblastic disease

Introduction: Gestational trophoblastic diseases include a spectrum of pregnancy-related diseases caused by abnormal proliferation of the placenta. The main aim of this study was to correlate ultrasound imaging with histopathological findings.&#x0D; Method: This is the retrospective chart review of findings of transabdominal ultrasonography in clinically suspected gestational trophoblastic diseases which were confirmed by histopathology after the evacuation of a product of conception during 3 years from 2016 to 2019 at Patan Hospital, Patan Academy of Health Sciences Nepal. The accuracy of sonography was correlated with histopathological findings and analyzed by Fisher’s Exact or Pearson’s Chi-square tests. The study was approved ethically.&#x0D; Result: Among 155 clinically suspected gestational trophoblastic diseases, ultrasonography was accurate in 141(91.0%) and confirmed by histopathology; 14(9.0%) were non-molar miscarriages. In 141 histologically confirmed trophoblastic disease, 110(71.0 %) were partial mole, 15(9.7%) complete mole, 12(7.7%) invasive mole and 3(1.9 %) persistent mole, and 1(0.6%) choriocarcinoma. Snowstorm appearance and absence of fetus were statistically significant ultrasonography findings.&#x0D; Conclusion: The ultrasound is a reliable non-invasive first-line imaging modality for the diagnosis of gestational trophoblastic diseases and had an accuracy of 91% as confirmed by histopathology in this study.

Clinical presentation and diagnosis of Gestational Trophoblastic Disease.

Gestational trophoblastic disease (GTD) is a heterogeneous group of pregnancy-related disorders characterized by abnormal proliferation of trophoblastic tissue. It encompasses the premalignant partial and complete hydatidiform mole but also the malignant invasive mole, choriocarcinoma, placental-site trophoblastic tumor, and epithelioid trophoblastic tumor. The clinical presentation changed to earlier detection after the introduction of first trimester ultrasounds. Patients are often asymptomatic, but vaginal bleeding continues to be the most common presenting symptom. Other symptoms can develop in the case of metastatic disease. Ultrasound, serum human chorionic gonadotrophin, and sometimes additional imaging such as CT, MRI, or PET can confirm the diagnosis and stage of disease. Familiarity with the pathogenesis, classification, imaging features, and treatment of GTD facilitates diagnosis and appropriate management.

Update on the Diagnosis of Gestational Trophoblastic Disease

Penyakit trofoblas gestasional (PTG)/Gestational trophoblastic disease (GTD) terdiri dari kelompok mola hidatidosa yang terbagi menjadi komplit dan parsial, hingga kelompok Tumor trofoblas gestasional (TTG)/Gestational trophoblastic neoplasia (GTN) yang terdiri dari mola invasif, koriokarsinoma, dan placental site trophoblastic tumour/epithelioid trophoblastic tumour (PSTT/ETT). TTG dikategorikan menjadi dua yaitu yang tidak bermetastasis (hanya terbatas di uterus) dan yang bermetastasis (telah menyebar ke vagina, paru-paru atau otak). Penegakan diagnosis inisial PTG melalui pendekatan multimodalitas mencakup gejala klinis, kadar hCG dan pemeriksaan USG pelvis. Doppler membantu menilai angiogenesis dan karakterisitik neovaskularisasi PTG. Gambaran yang tampak pada USG akan menjelaskan gambaran pada histopatologinya. Pemeriksaan penunjang lain untuk PTG adalah rontgen thoraks, CT Scan dan MRI. Saat ini pemeriksaan imunohistokimia (IHK) dan polymerase chain reaction (PCR) sudah mulai digunakan untuk menentukan diagnosis PTG. Pemantauan hCG mempunyai peran penting dalam penatalaksanaan PTG. Tetapi karena terdapat beberapa pedoman yang menyatakan protokol berbeda-beda dalam pemantauan hCG, hal ini membuat para dokter spesialis obgin mempertanyakan mengenai pemantauan hCG pasca evakuasi. Himpunan Onkologi Ginekologi Indonesia mengeluarkan suatu Pedoman Nasional Pelayanan Kedokteran (PNPK) Tumor Trofoblas Gestasional yang didalamnya terkait diagnosis dan penatalaksaan TTG.

Morts maternelles par maladies trophoblastiques gestationnelles. Résultats de l’enquête confidentielle française sur la mortalité maternelle, 2010–2012

Gestational trophoblastic diseases (GTD) correspond to several entities which all have a common pattern: hypersecretion of human chorionic gondotrophin by trophoblastic hyperplasia. Between 2010 and 2012, there were 4 maternal deaths due to GTD (choriocarcinoma). The ratio of maternal death caused by GTD was 0,16/100,000 living births which was similar to the rate from the 2007–2009 period. These deaths represented 1.6% from the whole maternal mortality and 3.3% of the direct maternal mortality. These four deaths occurred after delivery and the diagnosis of GTD was made between 60 and 180 days in the postpartum period. Two cases seemed to be potentially avoidable. The main causes of suboptimal management were linked to delay either in diagnosis of GTD or in initiating the appropriate treatment. The analysis of these maternal deaths gave the opportunity to stress some major lessons to optimize medical management of GTD. Therefore, a patient presenting with persistent bleedings more than six weeks after delivery needs some specific exams such as plasma human chorionic gondotrophin measurement and histopathologic examination to affirm GTD and start early specific treatments generally leading to complete recovery.

A review of gestational trophoblastic diseases in a tertiary hospital

BACKGROUND: Gestational trophoblastic diseases (GTD) result from abnormal proliferation of trophoblastic tissue and although rare, are a recognizable cause of maternal morbidity and mortality worldwide. However, prognosis is good when diagnosed and treated early. OBJECTIVES: To describe the prevalence, pattern of presentation, management practices and outcome of Gestational Trophoblastic Diseases at the University of Abuja Teaching Hospital, Abuja, Nigeria. MATERIALS AND METHODS: Case notes of women with a diagnosis of Gestational Trophoblastic Disease from 1st January 2009 and 31st December 2016 were retrospectively reviewed. Relevant information was extracted and entered into structured proformas. The data processing and analysis was done with the aid of SPSS for windows version 20.0. Results were expressed as percentages, means and range. RESULTS: A total of 51 cases of Gestational Trophoblastic Diseases were reviewed, giving a prevalence rate of 4.4/1000 deliveries. The prevalence of molar pregnancy and choriocarcinoma were 2.4 and 1.6 per thousand deliveries respectively. The age group with the highest frequency of occurrence was the 25-29 years {18(35.3%)} and 25(49%) were para 1-4. The commonest antecedent pregnancy event was a miscarriage in 74.5% of cases while the commonest symptoms were amenorrhoea 46(90.2%) and vaginal bleeding 45(88.2%). These were complicated by anaemia in 18(35.5%) of cases. Thirty (58.8%) women had suction evacuation, 16(31.4%) had chemotherapy and 3(5.9%) had hysterectomy. Loss to follow up was 33(64.7%) and case fatality rate was 19.6%. CONCLUSION: Morbidity and mortality resulting from Gestational Trophoblastic Diseases is still high in University of Abuja Teaching Hospital, Abuja. Significant contributing factors were late presentation and poor compliance. Efforts have to be made to reeducate patients and health workers so as to address challenges related to early diagnosis and compliance.

Morts maternelles par maladies trophoblastiques gestationnelles. Résultats de l’enquête confidentielle française sur la mortalité maternelle, 2010–2012

Gestational trophoblastic diseases (GTD) correspond to several entities which all have a common pattern: hypersecretion of human chorionic gondotrophin by trophoblastic hyperplasia. Between 2010 and 2012, there were 4 maternal deaths due to GTD (choriocarcinoma). The ratio of maternal death caused by GTD was 0,16/100,000 living births which was similar to the rate from the 2007–2009 period. These deaths represented 1.6% from the whole maternal mortality and 3.3% of the direct maternal mortality. These four deaths occurred after delivery and the diagnosis of GTD was made between 60 and 180 days in the postpartum period. Two cases seemed to be potentially avoidable. The main causes of suboptimal management were linked to delay either in diagnosis of GTD or in initiating the appropriate treatment. The analysis of these maternal deaths gave the opportunity to stress some major lessons to optimize medical management of GTD. Therefore, a patient presenting with persistent bleedings more than six weeks after delivery needs some specific exams such as plasma human chorionic gondotrophin measurement and histopathologic examination to affirm GTD and start early specific treatments generally leading to complete recovery.

Analysis of p53 expression in partial hydatidiform mole and hydropic abortion

Gestational trophoblastic disease (GTD) is a heterogeneous group of disorders characterized by abnormal trophoblast tissue. Molar and non-molar hydropic placental changes are the most common forms of GTD. Differential diagnosis of GTD is sometimes problematic. Recently, p53 expression was identified as a good marker for distinguishing GTD types. Comparison of p53 expression in partial hydatidiform mole (PHM) and hydropic abortion. In this prospective cross-sectional study, molar and non-molar hydropic pregnancy specimens were collected. Immunohistochemical staining, based on the Labeled Streptavidin Biotin (LSAB) technique, was carried out on multiple 4 mm paraffin block sections prepared from formalin-fixed trophoblastic tissues. Polymer-based Envision was used to assess p53 tumor suppressor protein immunoreactivity. p53 expression was then compared between both groups. In the study, 40 patients were included: 20 with confirmed PHM and 20 with hydropic pregnancy. p53 protein was positive in 60% of patients with PHM and 25% of patients with hydropic pregnancy. The p53 positive rate was significantly higher in patients with PHM (p = 0.027). Moreover, patients with PHM had a significantly high grade of staining (p<0.001). Our findings indicate that immunohistochemical analysis of p53 protein can be used to distinguish PHM and hydropic pregnancy.

OP27.11: HDlive, HDliveFlow and HDliveFlow silhouette mode for the diagnosis of gestational trophoblastic disease

We present our experience of using HDlive, HDliveFlow, and the HDliveFlow silhouette mode for the diagnosis of gestational trophoblastic disease. Five patients with complete hydatidiform mole and one with clinical invasive mole were evaluated using HDlive, HDliveFlow, and the HDliveFlow silhouette mode. In the case of an early-stage nonhydropic complete hydatidiform mole, smooth, lobulated masses were clearly recognised using HDlive, and small, irregular, cystic spaces inside the mass were also evident. In the case of a complete mole, colour Doppler showed numerous vesicles without blood vessels, while HDliveFlow with the HDlive silhouette mode clearly depicted these vesicles forming a mass with the clear demarcation of its edges, and demonstrated no blood flow inside the mass. The HDlive silhouette inversion mode clearly depicted the number, size, and spatial position of molar vesicles, compared with conventional two-dimensional(2D) sonography or the HDlive inversion mode. Moreover, spatial relationships among molar vesicles, intrauterine anechoic fluid collection, and the uterine wall enabled the clear localisation of the lesion. The HDliveFlow silhouette mode showed new visualisation of numerous small vesicles in the uterine cavity surrounded by silky vitreous-like clarity of the uterine blood flows. In the case of clinical invasive mole, abundant blood flows were clearly recognised in the posterior uterine wall using with HDliveFlow and the HDliveFlow silhouette mode. These novel techniques provide new insights, and have the potential to supplement conventional 2D sonography and colour/power Doppler ultrasound in the diagnosis of gestational trophoblastic disease.

Obstetric ultrasound aids prompt referral of gestational trophoblastic disease in marginalized populations on the Thailand–Myanmar border

ABSTRACT Background: The use of obstetric ultrasound in the diagnosis of gestational trophoblastic disease (GTD) in high-income settings is well established, leading to prompt management and high survival rates. Evidence from low-income settings suggests ultrasound is essential in identifying complicated pregnancies, but with limited studies reviewing specific conditions including GTD. Objective: The aim of this study is to review the role of ultrasound in diagnosis and management of GTD in a marginalized population on the Thailand–Myanmar border. Antenatal ultrasound became available in this rural setting in 2001 and care for women with GTD has been provided by Thailand public hospitals for 20 years. Design: Retrospective record review. Results: The incidence of GTD was 103 of 57,004 pregnancies in Karen and Burmese women on the Thailand–Myanmar border from 1993–2013. This equates to a rate of 1.8 (95% CI 1.5–2.2) per 1000 or 1 in 553 pregnancies. Of the 102 women with known outcomes, one (1.0%) died of haemorrhage at home. The median number of days between first antenatal clinic attendance and referral to hospital was reduced from 20 (IQR 5–35; range 1–155) to 2 (IQR 2–6; range 1–179) days (p = 0.002) after the introduction of ultrasound. The proportion of severe outcomes (death and total abdominal hysterectomy) was 25% (3/12) before ultrasound compared to 8.9% (8/90) with ultrasound (p = 0.119). A recurrence rate of 2.5% (2/80) was observed in the assessable population. The presence of malaria parasites in maternal blood was not associated with GTD. Conclusions: The rate of GTD in pregnancy in this population is comparable to rates previously reported within South-East Asia. Referral time for uterine evacuation was significantly shorter for those women who had an ultrasound. Ultrasound is an effective method to improve diagnosis of GTD in low-income settings and an effort to increase availability in marginalized populations is required.

Gestasyonel Trofoblastik Hastalıkların Ayırıcı Tanısında İmmünohistokimyasal p57 Ekspresyonunun Rolü

Amaç: Gestasyonel trofoblastik hastalıkların (GTH) ayırıcı tanısında, immünohistokimyasal p57 ekspresyonunun komplet molü parsiyel molden, parsiyel molü hidropik abortus ve normal gebelikten ayırmadaki rolünü incelemektir. Gereç ve Yöntemler: Hastanemizde 2010-2016 yılları arasında, başlangıçta GTH şüphesiyle değerlendirilmiş, sonrasında ise klinik, patolojik ve laboratuar bulgularıyla kesin tanısı konulmuş komplet mol, parsiyel mol, normal gebelik kalıntısı veya hidropik abortus hastalarının parafin bloklarından yeni kesitler alınarak immünohistokimyasal p57 boyaması yapılmıştır. Hidropik abortus ve normal gebelik kalıntısı olanlar kontrol grubunu oluşturmuştur. Kesitleri inceleyen patologlar, hastaların kesin tanılarını bilmeden değerlendirme yapmıştır. Bulgular: Kesin tanıları konulmuş toplam 87 hastanın boyanma paternleri şu şekilde saptanmıştır: Komplet mol olan 26 hastada 22 negatif, 4 pozitif boyanma (%84,6 negatif boyanma, %15,4 pozitif boyanma); parsiyel mol olan 14 hastada 12 pozitif, 2 negatif boyanma (%85,7 pozitif boyanma, %14,3 negatif boyanma); hidropik abortus veya gebelik kalıntısı olan 47 hastada 35 pozitif, 12 negatif boyanma (%74,4 pozitif boyanma, %25,6 negatif boyanma) görülmüştür. Sonuç: Gestasyonel trofoblastik hastalıkların ayırıcı tanısında immünohistokimyasal p57 boyama yöntemi, komplet molü parsiyel molden ayırmada oldukça duyarlı bir yöntemdir. Ancak, bu yöntemin parsiyel molü hidropik abortus ve normal gebelikten ayırmada kullanılabilmesi için yeni çalışma ve deneyimlere ihtiyaç olduğu düşünülmektedir. Objective: To investigate the role of immunohistochemical p57 expression to distinguish complete mole from partial mole and partial mole from hydropic abortion and normal pregnancy remnant in the differential diagnosis of gestational trophoblastic diseases (GTH). Material and Methods: p57 immunohistochemical staining was performed with new slides provided from paraffin blocks of the cases of complete mole, partial mole, normal pregnancy remnant and hydrophic abortions whose were evaluated for GTD in the beginning but definitive diagnosis were later made by clinical, laboratory and pathological findings in our hospital between the years 2010-2016. The cases of hydropic abortion and normal pregnancy remnants were also used as control group. The pathologists performed investigations without knowing the diagnosis of the cases. Results: The staining patterns of overall 87 cases with definitive diagnosis are as follows. Of the 26 complete mole cases, 22 cases revealed negative staining and 4 cases revealed positive staining (84,6% negative staining, 15.4% positive staining). Of the 14 partial mole cases, 12 cases revealed positive staining and 2 cases revealed negative staining (85.7% positive staining, 14.3% negative staining). Of the 47 hydropic abortion or pregnancy remnant cases, 35 revealed positive staining and 12 revealed negative staining (74.4% positive staining, 25.6% negative staining). Conclusion: In the differential diagnosis of gestational trophoblastic diseases, immunohistochemical p57 staining is a quite sensitive method to distinguish complete mole from partial mole. However in our opinion, in order to use this method to distinguish partial mole from hydropic abortion and normal pregnancy, further studies and experience are needed.