Prognostic significance of the new placental proteins in trophoblastic disease

Summary. Circulating levels of four specific placental proteins, human chorionic gonadotrophin (hCG), Schwangerschafts protein 1 (SP₁), placental protein 5 (PP5) and pregnancy-associated plasma protein A (PAPP-A), were measured in 31 patients with hydatidiform mole before treatment. Seven patients subsequently developed clinical chorio-carcinoma and three of them had pulmonary metastases. The estimations of hCG, PP5 and PAPP-A levels were found to be of no value in the prediction of malignant sequelae. Levels of SP₁≥ 16.5 i.u./l were associated with a higher incidence of subsequent malignant disease ( P < 0.05), the risk being at least nine times greater in these patients. The predictive value of high levels of SP₁ was 35%, the specificity 45.8% and sensitivity 100%.     

Serum SP1 and hCG beta-subunit (hCG beta) levels in choriocarcinoma, invasive mole, and hydatidiform mole--clinical significance of SP1/hCG beta ratio

Serum SP₁ (pregnancy-specific β₁, glycoprotein) levels in patients with choriocarcinoma, invasive mole, and hydatidiform mole were radioimmunoassayed and compared with simultaneously measured serum hCGβ-subunit (hCGβ) levels in order to evaluate the clinical significance of SP₁ determination. Serum SP₁ levels at the time of admission ranged from 6.4 to 1660 ng/ml in choriocarcinoma patients, 16.3 to 540 ng/ml in invasive mole, and 720 to 58,000 ng/ml in hydatidiform mole. $\text{SP}{}_1\text{hCGβ}$ ratios were under 1.0 in choriocarcinoma (0.3 ± 0.2, mean ± SD), over 1.0 in hydatidiform mole (10.9 ± 8.3), and intermediate in invasive mole (1.5 ± 0.3). In normal pregnancy, the ratio increases as pregnancy progresses, that is, from 15.25 in 7-week gestation to 14,090.90 in 40-week gestation. The mean $\text{SP}{}_1\text{hCGβ}$ ratio differs significantly among choriocarcinoma, invasive mole, and hydatidiform mole. $\text{SP}{}_1\text{hCGβ}$ ratio is likely to represent the degree of differentiation of trophoblastic cells. The $\text{SP}{}_1\text{hCGβ}$ ratio may be useful in differentiating between choriocarcinoma and invasive mole.     

Value of Schwangerschaftsprotein 1 (SP1) and pregnancy-associated plasma protein-A (PAPP-A) in the clinical management of threatened abortion

Summary. Pregnancy-associated plasma protein-A (PAPP-A) and Schwangerschaftsprotein 1 (SP₁) levels were measured in single serum samples from 60 patients admitted with vaginal bleeding in the first 14 weeks of pregnancy. When based on ultrasound diagnoses the prediction of non-viability (the predictive value) was 97% for SP₁ and 84% for PAPP-A. Whereas the prediction of viability (above –2SD of the normal range) with SP₁ was 88% the value with PAPP-A was only 57%; the poorer result obtained with PAPP-A probably reflects its longer half-life. Pregnancy outcome is not related to the duration of bleeding.     

Levels of placenta-specific tissue protein 12 (PP12) in serum during normal pregnancy and in patients with trophoblastic tumour

A sensitive radioimmunoassay method has been developed to measure soluble placental protein 12. Using this method trace amounts of PP12 have also been detected in the sera of healthy non-pregnant subjects (24.0 +/- 6.15 micrograms/l). During normal pregnancy serum PP12 levels rose rapidly reaching a peak value of 139.90 +/- 40.26 micrograms/l at 18 weeks. Serial determinations of PP12 have been made in 31 patients with trophoblastic tumours (16 hydatidiform moles, 10 invasive moles and five choriocarcinomas). It has been found that in patients with hydatidiform and invasive moles its initial values are extremely high (342.9 +/- 257.9 micrograms/l and 279.3 +/- 103.1 micrograms/l, respectively), much exceeding the non-pregnant and normal pregnant values. After evacuation of hydatidiform moles serum-PP12 rapidly fell to the upper limit of normal at 21-28 days, and to normal values at 8-12 weeks after operation. In patients with invasive mole requiring chemotherapy the rate of fall of PP12 level was slower. In patients with choriocarcinoma serum-PP12 levels were moderately raised (59-132 micrograms/l) and followed the clinical course of the disease. Serum-PP12 levels would seem to be of less value in monitoring patients with trophoblastic tumours than other tumour-markers (hCG, and SP1).     

Molecular weight and fragmentation of human chorionic gonadotropin in urine in patients with trophoblastic diseases

Molecular weights (MW) of urinary human chorionic gonadotropin (hCG) from trophoblastic diseases were analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), followed by Western blotting using specific antibodies. Although the MW of hCG beta from hydatidiform mole and invasive mole were identical to that of standard hCG beta, those from choriocarcinoma were individually different. These results indicate that the structural changes of carbohydrates, which may be induced by malignant transformation of trophoblast, can be reflected as differences in MW. In SDS-PAGE under nonreducing conditions. Western blotting using anti-hCG beta-carboxy-terminal peptides (CTP) revealed a single band corresponding to hCG beta. Under reducing conditions with dithiothreitol (DTT), however, a second low MW material (CTP') could be observed with anti-hCG beta-CTP. All hCG samples from invasive mole and choriocarcinoma were much more susceptible than standard hCG to release of CTP' by DTT. Estimation of MW and susceptibility to DTT reducing of urinary hCG by Western blotting are useful in the diagnosis of invasive mole and choriocarcinoma.     

Complex formation of pregnancy-specific α2–glycoprotein (SP1α) and heparin

Summary. The Schwangerschaftsprotein 1 (SP₁,)α values in blood measured by rocket immunoelectrophoresis are affected by the addition of anticoagulants. When compared with values in serum, those in heparin plasma were much higher, while those in sequestrene ethylenediaminetetra acetic acid), sodium citrate and fluoride oxalate were lower. On the other hand, SP₁ and SP₁β concentrations were not significantly affected in heparin or sequestrene and were only slightly depressed in sodium citrate and flouride oxalate. The effect of heparin on SP₁α in serum was dosedependent. We surmise that SP₁α forms a complex with heparin and that it may be involved in the coagulation system in pregnancy.     

Serum SP1 and hCGβ-subunit (hCGβ) levels in choriocarcinoma, invasive mole, and hydatidiform mole—Clinical significance of ratio

Serum SP₁ (pregnancy-specific β₁, glycoprotein) levels in patients with choriocarcinoma, invasive mole, and hydatidiform mole were radioimmunoassayed and compared with simultaneously measured serum hCGβ-subunit (hCGβ) levels in order to evaluate the clinical significance of SP₁ determination. Serum SP₁ levels at the time of admission ranged from 6.4 to 1660 ng/ml in choriocarcinoma patients, 16.3 to 540 ng/ml in invasive mole, and 720 to 58,000 ng/ml in hydatidiform mole. ratios were under 1.0 in choriocarcinoma (0.3 ± 0.2, mean ± SD), over 1.0 in hydatidiform mole (10.9 ± 8.3), and intermediate in invasive mole (1.5 ± 0.3). In normal pregnancy, the ratio increases as pregnancy progresses, that is, from 15.25 in 7-week gestation to 14,090.90 in 40-week gestation. The mean ratio differs significantly among choriocarcinoma, invasive mole, and hydatidiform mole. ratio is likely to represent the degree of differentiation of trophoblastic cells. The ratio may be useful in differentiating between choriocarcinoma and invasive mole.     

On the results of hydatidiform mole managed by Niigata method

We have managed 518 cases of total mole patients in our Ob-Gyn clinic in the past 13 years by the Niigata postmole management method. Serial urinary hCG determination by sensitive assay (Higonavis and RIA) is the key examination in it. There are two critical points of urinary hCG determination: 1,000iu/L at the 5th week and 100iu/L at the 8th week after the termination of hydatidiform mole. The urinary hCG patterns are classified into type I if the hCG regression curve falls below both of them, and into type II if it follows curves other than type I. Among 89 cases of postmole patients who were administered no anti-cancer chemotherapy, 73 cases (82%) showed a type I hCG regression pattern, eight cases of which (11%) were complicated mole such as metastatic mole and invasive mole. Sixteen cases (18%) showed type II, but 8 of them (50%) were diagnosed as uncomplicated mole. The rate of complication among 118 cases of hydatidiform mole who had a molar pregnancy terminated and were followed up totally in our clinic was 24.6% and that of referral cases after molar evacuation was 21.3%, which is significantly higher than others reported in literature. There occurred no postmolar choriocarcinoma from uncomplicated mole patients who had their LH level confirmed in their urinary hCG determination, but 1 case (2.7%) did occur from LH level confirmed metastatic mole, and 3 cases (3.9%) from LH level confirmed metastatic invasive mole. It was shown that lung shadows on chest roentgenogram mostly take about 40 days to appear after D & C of hydatidiform mole and after surgery for uterine invasive mole.(ABSTRACT TRUNCATED AT 250 WORDS)     

Measurement of CA-125 in trophoblastic disease

OBJECTIVES: Physicians treating hydatidiform mole are still seeking means of identifying those patients who will require chemotherapy. The standard accepted method is to follow human chorionic gonadotropin levels but CA-125 measurement has been suggested as a supplement that may be clinically useful. This study was undertaken to validate or refute the one previous study that addresses this issue. CA-125 was measured at the time of hydatidiform mole evacuation to determine (1) whether it would predict the need for chemotherapy and (2) whether it correlated with human chorionic gonadotropin and tumor load in following patients with hydatidiform mole and metastatic gestational trophoblastic disease. PATIENTS AND METHODS: CA-125 was measured in serial weekly samples selected from diagnostic groups of patients with trophoblastic disease. Sixteen patients had hydatidiform mole with spontaneous resolution, fourteen had nonmetastatic gestational trophoblastic tumor, and four had low-risk metastatic disease. Six patients had high-risk metastatic disease. Ten patients had partial hydatidiform mole and one of these required chemotherapy. One patient had primary ovarian choriocarcinoma and three had placental site tumor. RESULTS: The mean preevacuation CA-125 among the 15 patients with complete hydatidiform mole was 40.9 U/ml: 52.5 U/ml for 5 patients who required chemotherapy and 36.2 U/ml for 10 patients who did not require chemotherapy. There was no statistical difference between these values. There was no correlation of CA-125 with hCG. Frequently CA-125 became negative when hCG was still elevated. Among six patients with high-risk disease, CA-125 was elevated in four but in all six patients hCG remained elevated when CA-125 became negative. In nine patients with partial hydatidiform mole CA-125 was elevated prior to mole evacuation and then became negative. The patient with a tetraploid conceptus who required chemotherapy had negative CA-125. With placental site tumor CA-125 was negative, but it was elevated with ovarian choriocarcinoma. CONCLUSION: CA-125 levels do not provide reliable information in the management of patients with gestational trophoblastic disease.     

Comparison of pregnancy-specific β1-glycoprotein (SP1) and ultrasound in predicting the date of delivery

Summary. The accuracy of ultrasound measurements (crown-rump length and gestational sac diameter) and the serum concentration of pregnancy-specific β₁-glycoprotein (SP₁) in the prediction of the date of birth was analysed in a study population of 94 patients. When measured before 8 weeks after the last menstrual period (LMP) the serum concentration of SP₁, was found to be a good predictor of the expected date of delivery and a good alternative to ultrasound, but it was of limited use when determined at a later gestation.     

Differential production of human chorionic gonadotropin and free subunits in gestational trophoblastic disease

Serum levels of human chorionic gonadotropin (hCG) and its free subunits (alpha hCG and beta hCG) were determined by means of highly sensitive and specific monoclonal and antipeptide-based monoclonal immunoradiometric assays. During normal pregnancy, the beta hCG to hCG ratio appears constant at approximately 0.5% after 5 weeks of gestation. In contrast, gestational choriocarcinoma was characterized by absolute serum beta hCG levels varying from three to 280 times greater than the maximum values observed during pregnancy and by exceedingly high beta hCG to hCG ratios. In complete hydatidiform mole, this ratio was intermediate between normal pregnancy and choriocarcinoma. The ratios of free beta hCG to hCG will distinguish normal from complete molar pregnancy (p less than 10(-8)), hydatidiform mole from choriocarcinoma (p less than 10(-4)), and choriocarcinoma from normal pregnancy (p less than 10(-8)) with high probability. Finally, it was found by means of the high sensitivity hCG immunoradiometric assays (less than 0.02 ng/ml) that this assay predicted very early tumor recurrence in patients with gestational choriocarcinoma.     

Prognostic significance of the new placental proteins in trophoblastic disease

Circulating levels of four specific placental proteins, human chorionic gonadotrophin (hCG), Schwangerschafts protein 1 (SP1), placental protein 5 (PP5) and pregnancy-associated plasma protein A (PAPP-A), were measured in 31 patients with hydatidiform mole before treatment. Seven patients subsequently developed clinical choriocarcinoma and three of them had pulmonary metastases. The estimations of hCG, PP5 and PAPP-A levels were found to be of no value in the prediction of malignant sequelae. Levels of SP1 greater than or equal to 16.5 i.u./l were associated with a higher incidence of subsequent malignant disease (P less than 0.05), the risk being at least nine times greater in these patients. The predictive value of high levels of SP1 was 35%, the specificity 45.8% and sensitivity 100%.     

Gestational trophoblastic disease in women aged 50 or more

Twenty cases of gestational trophoblastic disease in women aged 50 or more are reported. The lesions were 7 hydatidiform mole (35%), 8 invasive mole (40%), and 5 choriocarcinoma (25%). The most common presenting symptom was abnormal vaginal bleeding. Three choriocarcinoma patients were postmenopausal and all of them had choriocarcinoma. None of the patients with hydatidiform mole or invasive mole died of the disease, but 4 of 5 choriocarcinoma patients died of the disease. Because of the high rate (56.3%) of malignant sequelae after molar evacuation, a primary hysterectomy for the treatment of hydatidiform mole in this age group is recommended. It is important to maintain a high level of suspicion for the diagnosis of gestational trophoblastic disease in the elderly women.     

Human chorionic gonadotropin and its subunits in hydatidiform mole and choriocarcinoma.

Serum human chorionic gonadotropin (hCG) was measured by a radioreceptorassay (RRA) and radioimmunoassay (RIA) and serum hCG-beta and hCG-alpha by RIA in 10 patients with intact mole, 3 patients with choriocarcinoma, and 4 patients with hydatidiform mole during treatment. hCG levels by RRA were higher in 5 of 10 molar pregnancies and ranged from 20,900 to 100,000 ng/ml and from 30,000 to 100,000 ng/ml by RIA. hCG levels by RRA and RIA paralleled one another closely during treatment of hydatidiform mole. hCG-alpha was higher than hCG by RRA and RIA and hCG-beta in molar pregnancies, in the uterine venous blood draining a uterine choriocarcinoma, and during chemotherapy of choriocarcinoma. In 2 of 3 choriocarcinoma patients who eventually developed cerebral metastases, hCG-alpha increased while hCG and hCG-beta were declining or negative. hCG-beta was usually lower than hCG or hCG-alpha in all the cases studied. These results demonstrate the production of free alpha and beta subunits in trophoblastic disease. Further, due to the biospecificity, simplicity, and rapidity, the RRA of hCG is a sueful diagnostic aid during treatment of trophoblastic neoplasia until the levels fall to within the sensitivity range of the assay. Finally, the RIA of hCG, hCG-beta, and hCG-alpha, which requires several days, should be performed until they become negative or fall within normal range.     

Gestational trophoblastic diseases: the ratio of choriogonadotropin to specific pregnancy protein, hCG/SP1, provides useful diagnostic and prognostic evidence

Serum levels of human chorionic gonadotropin (hCG), specific pregnancy protein (SP1), and hPL were measured in 675 samples from women with uneventful pregnancy, and serially from the time of presentation in 125 patients with hydatidiform mole (HM), 43 with invasive mole (IM), and 34 with choriocarcinoma (CC). In HM serum levels of hCG and SP1 declined steadily from presentation to remission; when gestational age at the time of molar evacuation was shorter than 11 weeks, hCG declined to the normal range later than SP1 (57% patients), and when the age was longer--at the same rate as SP1 (26% patients) or earlier (17% patients). Serum levels of either marker were higher in IM than in HM and tended to increase, and in CC were either lower or higher than in IM. Treatment was followed by parallel decline of either marker, although SP1 declined to the normal range later than hCG in 12% of patients with IM and in 10% with CC. The hCG/SP1 ratios in normal pregnancy declined exponentially between the beginning and 23rd week of gestation and stayed level thereafter. The ratios calculated for the gestational age at the time of initial evacuation of the uterus or delivery were close to those of normal pregnancy in 80%, slightly increased in 20% of patients with spontaneously regressing HM, and markedly increased in 70% of patients with IM and in 74% of patients with CC. The ratios tended to increase during chemotherapy. An increase in the hCG/SP1 ratio seemed to be a characteristic sign of malignant change when compared with this ratio in normal pregnancy and hydatidiform mole. Determination of SP1 for monitoring therapy seemed redundant, and hPL assay was useful for discrimination between relapse and pregnancy.     

Molecular heterogeneity of hCG in urine of the patients with trophoblastic diseases]

In addition to whole hCG, hCG beta-related molecular species are also present in the serum and urine of patients with trophoblastic diseases. We simultaneously measured whole hCG, free hCG beta and beta-core fragment in the serum and urine of patients with hydatidiform mole and choriocarcinoma by the highly specific and sensitive sandwich enzyme-immunoassay (EIA) systems using two kinds of antibodies. During the clinical courses of patients, although the whole hCG levels in serum and urine were closely correlated, the concentrations in the serum were almost twice as high as those in the urine. The free hCG beta levels were also closely correlated in serum and urine, but the concentrations of free hCG beta were extremely low as compared with those of whole hCG. Furthermore, free hCG beta/whole hCG ratios were significantly higher in choriocarcinoma patients than in hydatidiform mole patients. While whole hCG and free hCG beta were contained in both serum and urine, the beta-core fragment could be detected only in the urine of the patients. The relative contribution of the beta-core fragment to the total urinary hCG beta-immunoactivity accounted for about 40% in hydatidiform mole and about 70% in choriocarcinoma. We conclude that whole hCG should be measured in the serum rather than in the urine as a tumor marker for trophoblastic diseases, and suggest that the ratios of whole hCG, free hCG beta and beta-core fragment to each other may be useful indices to employ in the differential diagnosis of trophoblastic diseases.     

Studies on the viability of trophoblast after termination of various kinds of pregnancies (author's transl)

Although normal value of hCG (LH level) does not necessarily indicate eradication of viable trophoblast, its confirmation has been demonstrated as a clinically useful guide for the probable prevention of choriocarcinoma after hydatidiform mole by Takeuchi et al. Choriocarcinoma preceded by other pregnancies than hydatidiform mole which has the highest risk for choriocarcinoma has drawn more attention than before in connection with the decrease of postmolar choriocarcinoma. So that I have studied the regression rate of urinary gonadotropin (hCG) after the termination of various kinds of pregnancies. In 2,433 cases of induced abortion, 695 cases of spontaneous abortion, 1,724 cases of term delivery and 43 cases of hydatidiform mole, their urinary hCG were determined to the level of physiological range of LH. The rate of hCG regression was in the order of term delivery, spontaneous abortion, induced abortion and hydatidiform mole. The younger was the gestational age of trophoblast, the slower was the regression of hCG. At one month after the termination of pregnancy, 80.1%, 11%, 0.3%, 8% and 4.1%, and at two month 55.8%, 1.6%, 0.5%, 4% and 0.5% for hydatidiform mole, induced abortion of less than 12 week of gestation, spontaneous abortion of less than 12 week of gestation, spontaneous abortion of between 13 and 20 week of gestation respectively still showed abnormal hCG value. One percent of induced abortion at 5 month, 4% of spontaneous abortion at 3 month, 0.3% of term delivery at 4 month still maintained abnormal titer. No malignant sequelae in patients under the investigation have ever been observed in the follow up period between 3 and 8 years.     

妊娠滋养细胞疾病组织中HIF-1α、VEGF的表达及临床意义

目的：检测缺氧诱导因子1α（HIF-1α）和血管内皮生长因子（VEGF）在正常早孕绒毛、葡萄胎和妊娠滋养细胞肿瘤（GTN）组织中的表达情况,并探究其临床意义。方法：收集正常早孕绒毛组织20例（正常早孕绒毛组）、葡萄胎组织35例（葡萄胎组）和GTN组织28例[包括侵蚀性葡萄胎组织14例（侵蚀性葡萄胎组）,绒毛膜癌组织14例（绒毛膜癌组）]。采用免疫组化法检测各组织样本中HIF-1α和VEGF的蛋白表达情况。分析GTN患者不同年龄及FIGO分期组织中HIF-1α和VEGF表达的情况。分析GTN组织样本中HIF-1α和VEGF表达的关系。结果：正常早孕绒毛组与葡萄胎组HIF-1α和VEGF蛋白表达的阳性率比较,差异无统计学意义（均P＞0.05）;正常早孕绒毛组HIF-1α和VEGF蛋白表达的阳性率低于侵蚀性葡萄胎组和绒毛膜癌组,差异有统计学意义（均P＜0.05）;侵蚀性葡萄胎组和绒毛膜癌组HIF-1α和VEGF蛋白表达的阳性率比较,差异无统计学意义（均P＞0.05）。GTN患者FIGO Ⅲ+Ⅳ期组HIF-1α和VEGF蛋白表达的阳性率高于Ⅰ+Ⅱ期组,差异有统计学意义（均P＜0.05）;而不同年龄GTN患者HIF-1α和VEGF蛋白表达的阳性率比较,差异无统计学意义（均P＞0.05）。HIF-1α与VEGF在GTN组织中的表达呈正相关（rs=0.995,P=0.000）。结论：HIF-1α及VEGF可能在GTN发生和恶性进展过程中发挥协同作用。     

Molecular biological analysis of the DNA in trophoblastic disease--with special reference to genetic information of hPL and hCG(alpha, beta)

Genomic DNAs extracted from normal placenta, while blood cells, hydatidiform mole and choriocarcinoma were examined to see if they had the same coding structure for hPL, hCG alpha and hCG beta using each of the complementary DNAs. The restriction analysis of these genomic DNAs showed the same pattern even for the DNA of choriocarcinoma that transcribed no hPL mRNA but a relatively high level of hCG(alpha,beta)mRNA. We considered that during trophoblastic malignant transformation, neither the gene deletion for hPL nor the gene amplification for hCG occurred. Moreover, the genomic DNA sequence in hCG alpha gene has polymorphic restriction sites designated as R+/- and H+/-. Using these polymorphisms, we confirmed the hypothesis that a hydatidiform mole develops from an androgenetic origin. We also observed that it is possible that a hydatidiform mole having R- and H+ homozygous DNA may develop into a choriocarcinoma. These observation suggested that some intervening sequence between these polymorphic sites is related to the tumorigenesis of choriocarcinoma.     

Change in human chorionic gonadotropin in gestational trophoblastic disease observed during the course of chemotherapy.

This study investigates the physicochemical characteristics of human chorionic gonadotropin (hCG) in gestational trophoblastic disease (GTD), with special reference to the clinical course of chemotherapy and prognosis. In gel high performance liquid chromatography (HPLC), the hCG molecules from normal pregnancy and from the hydatidiform mole had the same molecular form as standard purified hCG, whereas hCG from choriocarcinoma was inconsistent in molecular form, containing molecules which are smaller, the same or larger than those of standard purified hCG. In two fatal choriocarcinoma patients, large hCG and large hCG alpha were found in the urine samples collected within one month prior to death. In a chromatofocusing study, the chromatofocusing pattern of hCG from GTD was acidic and similar to that of early pregnancy. The chromatofocusing patterns did not alter or were altered only slightly during the course of chemotherapy. In a Concanavalin A-Sepharose (Con A) chromatography study, the Con A binding shifted from low to high binding in patients with GTD who were responsive to chemotherapy. In summary, the molecular form, electric charge and Con A binding of hydatidiform mole hCG are similar to those of early pregnancy hCG and standard purified hCG, whereas the molecular form and Con A binding of choriocarcinoma are different from those of early pregnancy hCG and standard purified hCG. The presence of smaller or larger molecular forms of hCG may be an ominous sign, whereas the presence of high Con A binding may be a favorable sign. The chromatofocusing pattern seems to be unrelated to the clinical course of chemotherapy.