A multivariate analysis of prognostic indicators in complete hydatidiform moles (CHM)

OBJECTIVE: To analyse prognostic factors in complete hydatidiform moles using multiple logistic regression analysis. METHODS: Evaluation of host and tumour related parameters including (a) gestational age, patient age, parity, molar phenotype, grade of proliferation of the tumour and cytological atypia, (b) expression of beta-HCG, EGF, EGFR, TGF-alpha, TGF-beta, IL1-alpha, IL1-beta by immunohistochemistry, (c) serial monitoring of serum beta-HCG levels by ELISA, and (d) lectin binding using jack fruit lectin histochemistry as indices for persisting trophoblastic disease (PTD). RESULTS: Serum beta-HCG levels at 4 weeks, cellular atypia, lectin binding, expression of TGF-alpha and IL1-beta showed highly significant correlation with persistence of the tumour (P<0.001). The sensitivity and specificity at 4 weeks in combination with cytological atypia to identify spontaneously regressing lesions was 100% and those requiring chemotherapeutic intervention was 80%. CONCLUSION: The concentration of serum beta-HCG 4 weeks post evacuation(<300 mIU/ml) combined with cytological abnormalities could identify nearly 100% of the spontaneously regressing lesions (low risk) and 80% of those needing chemotherapeutic intervention (high risk), thereby suggesting that patients who have a serum beta-HCG at 4 weeks of evacuation <300 mIU/ml with no cytological atypia of the trophoblasts need only be followed up at long intervals, while those having a serum beta-HCG at 4 weeks of evacuation >300 mIU/ml accompanied with cytological atypia of the trophoblasts should be closely followed up.     

Expression of nm23-H1 protein in relation to myometrial invasion in complete hydatidiform moles

OBJECTIVE: Although nm23-H1 protein expression has been related to invasion in many cancers, its expression and prognostic significance in complete hydatidiform moles has not yet been investigated. The search for biologic parameters in molar placentas, which are useful for identifying patients who show myometrial invasion of the tumor, is crucial. We examined the clinical significance of nm23-H1 expression in complete hydatidiform mole. METHODS: Sections of 105 cases of complete hydatidiform moles (including 25 cases of invasive mole) and 95 cases of gestational age--matched normal placentas were immunohistochemically stained with anti-nm23-H1 antibody, which recognizes the nm23-H1/NDP kinase A gene product. RESULTS: Expression of nm23-H1 was detected in the cytotrophoblasts and syncytiotrophoblasts of molar placentas and normal placentas, whereas it was not detected in stromal tissue. Expression of nm23-H1 showed a negative relation to invasion, suggesting its use as a potential marker of myometrial invasion in complete hydatidiform moles. CONCLUSION: nm23-H1 expression could be used as a marker for accurate evaluation of myometrial invasion in complete hydatidiform mole.     

Demonstration of TGF-α–EGFR and EGF-EGFR autocrine loops and their relation to proliferation in complete hydatidiform moles (CHM)

Abstract. Balaram P, John M, Enose S, Symaladevi PK. TGF-α–EGFR and EGF-EGFR autocrine loops and their relation to proliferation in complete hydatidiform moles (CHM).
Complete hydatidiform moles (CHM) are the most common form of gestational trophoblastic disease. The prevalence rate is much higher in the state of Kerala, India, than in other parts of the world. The biology and role of growth factors are not fully understood in these tumors. In this study, we have immunohistochemically evaluated the expression of epidermal growth factor (EGF) and transforming growth factor alpha (TGF-α) along with their receptor, epidermal growth factor receptor (EGFR), and we have related them to the proliferative activity in normal placenta and CHM using the expression of proliferating cell nuclear antigen (PCNA) as the marker of proliferation. The results suggest activation of both EGF-EGFR and TGF-α–EGFR autocrine pathways in both types of tissues, with a predominance of the TGF-α–EGFR autocrine pathway in CHM. This is especially so in the more aggressive cases of CHM, the persisting group of diseases.     

Heterogeneity in the origin of recurrent complete hydatidiform moles: not all women with multiple molar pregnancies have biparental moles

Hydatidiform moles of two women, each with three molar pregnancies, were examined in order to study their origin. Multiple recurrences have previously been associated with women who have biparental complete hydatidiform moles (CHM). However, all the moles examined in this study were androgenetic CHM (AnCHM), indicating that recurrent (>2) moles, particularly in the absence of a positive family history, may be androgenetic rather than biparental. These data suggest that some women have a specific liability for having AnCHM. Making the distinction between a biparental or an androgenetic origin of recurrent moles is of relevance for counselling and when considering therapeutic options. Therefore, we propose that all recurrent moles should be investigated using molecular techniques.     

Risk factors for gestational trophoblastic disease: a separate analysis of complete and partial hydatidiform moles

Risk factors for complete and partial hydatidiform mole were analyzed in a case-control study conducted in the greater Milan area on 139 complete moles, 49 partial moles, and 410 obstetric control subjects. Patients tended to be more frequently nulliparous than controls, and the risk of complete mole and partial mole decreased with number of births, although the trend in risk was significant only for partial mole (chi 2(1) trend, P = .05). The risk for both histopathologic subgroups was greater in women reporting spontaneous miscarriages. Compared with women with no previous miscarriage, the estimated odds ratios (as estimators of relative risks) were 3.1 and 1.9, respectively, for complete mole and partial mole for two or more miscarriages. Infertility problems or difficulty in conception were associated with an odds ratio of 2.4 (95% confidence interval 1.3-4.3) and 3.2 (95% confidence interval 1.4-7.0), respectively, for complete mole and partial mole. No association emerged between mole and induced abortions and age at first pregnancy. A personal history of gestational trophoblastic disease increased the risk of both complete mole and partial mole: The odds ratios were 12.0 (95% confidence interval 3.0-38.9) and 18.1 (95% confidence interval 5.0-64.7), respectively. Similarly, a family history of gestational trophoblastic disease was more frequently reported in complete mole cases (five of 128) than in controls (one of 395) (odds ratio 16.0, 95% confidence interval 3.2-80.3). When the mating frequencies by patient/husband blood groups were considered, a nonsignificant increased risk was evident for women with group A married to men of group O in both histopathologic subgroups (odds ratio 1.5 compared with all other combinations).(ABSTRACT TRUNCATED AT 250 WORDS)     

Human chorionic gonadotropin and free subunits' serum levels in patients with partial and complete hydatidiform moles

Serum levels of hCG and its free subunits were measured in patients with partial and complete hydatidiform moles and in women with normal 10-week pregnancies. whereas complete moles had higher levels of percent-free beta-hCG than partial moles (2.4 versus 1.0; P less than or equal to .005), partial moles had higher levels of percent-free alpha-hCG than complete moles (0.85 versus 0.17; P less than or equal to .005). Normal 10-week pregnancies had lower levels of both percent-free beta-hCG and percent-free alpha-hCG than partial moles (0.40 versus 1.0, P less than or equal to .005 and 0.27 versus 0.85, P less than or equal to .005, respectively). Percent-free beta-hCG and beta-hCG levels did not distinguish which patients with complete mole were more likely to develop persistent post-molar tumor. The trophoblastic cells in complete and partial moles differ significantly in the manner in which they secrete the free subunits of hCG.     

Increased frequency of complete hydatidiform mole in women with repeated abortion

The association between spontaneous abortion and gestational trophoblastic disease (GTD) has been investigated in a study based on 93 women with 2 consecutive (repeated) spontaneous abortions and 82 control subjects who delivered normal babies. Nine molar pregnancies were observed among 7 of the 93 cases of repeated abortion while no control reported previous GTD. This difference was statistically significant and was not explained by allowance for age and number of pregnancies between cases and controls (chi 2(1) = 4.20; P = 0.04). When the observed number (9) of hydatidiform mole in the 385 pregnancies of the women with repeated abortion was compared with the expected one (0.28) based on the regional frequency data, the estimated relative risk was 32.1 with a 95% confidence interval from 13.9 to 63.3. The present findings confirm the association between GTD and spontaneous abortion and indicate that the risk is larger in women with repeated abortions.     

Expression of CD44, E-cadherin, and antimetastatic protein nm23-H1 in complete hydatidiform moles

INTRODUCTION: There is scant information about the expression of CD44 and E-cadherin, two cell adhesion molecules, and the antimetastatic protein nm23-H1, in complete hydatidiform moles. We measured the expression of these markers to determine their usefulness in predicting the development of invasive disease. MATERIALS AND METHODS: We performed a retrospective study of 27 patients with complete hydatidiform moles, collecting clinical information including the patient's age, pre-evacuation hCG level, pathology, hCG monitoring, and the development of gestational trophoblastic neoplasia. Immunohistochemical staining for CD44, E-cadherin, and nm23-H1 was performed. CD44 expression was classified as positive or negative. For E-cadherin and nm23-H1, the intensity of expression was graded on a 0 to 3 scale. Chi-square or Fisher's exact testing was used to evaluate the relationship between these markers and the development of invasive disease. RESULTS: CD44 was expressed in 26% of cases. E-cadherin expression was 1+, 2+, and 3+in 8%, 33%, and 59% of cases, respectively. Nm23-H1 expression was 1+, 2+, and 3+in 4%, 11%, and 85% of cases. The risk of developing invasive disease did not correlate with the expression of CD44, E-cadherin, or nm23-H1. CONCLUSION: In this preliminary study, there is no relationship between CD44, E-cadherin, and nm23-H1 expression in complete hydatidiform moles and the risk of invasive disease. Other molecular markers predictive of invasive disease should be sought to limit hCG surveillance to those at risk.     

Localization of leukocytes and cytokines in chorionic villi of normal placentas and complete hydatidiform moles

Monoclonal antibodies were used to localize and characterize leukocytes and cytokines in chorionic villi of normal placenta and complete mole. OKT4a reacted with Hofbauer cells in first-, second-, and third-trimester placentas. HLA-DR was expressed on second- and third-trimester placental Hofbauer cells but was not detected in the first trimester. The cytokines, gamma-interferon, granulocyte-macrophage colony-stimulating factor, interleukin-1 alpha, and tumor necrosis factor alpha, were all detectable on Hofbauer cells in first-, second-, and third-trimester placentas. None of the tested cytokine antibodies reacted with cellular constituents in complete molar chorionic villi. The absence of cytokine-positive cells in molar chorionic villi may be related to the hyperplastic and unregulated growth of molar villous trophoblast.     

A polymorphism of the interleukin-1 beta gene is associated with sperm pathology in humans

In a prospective case-control study of 127 normozoospermic and 435 non-normozoospermic Caucasian men, the genotype frequencies of a polymorphism of the interleukin-1 beta gene (IL-1beta Taq C-->T) were statistically significantly different between groups (homozygous wild-type C/C [57%], heterozygous C/T [42%], and homozygous mutant T/T [1%] vs. C/C [57%], C/T [36%], T/T [7%] for normozoospermic and non-normozoospermic men, respectively; odds ratio, 4.8; 95% confidence interval, 1.13 to 20.28). This association was restricted to men with the oligoasthenoteratozoospermia (OAT) syndrome. We conclude that the investigated polymorphism is associated with sperm pathology in Caucasians.     

Increased insulin resistance and C-reactive protein in women with complete hydatidiform mole

Objective.?To evaluate (i) insulin resistance and C-reactive protein (CRP) levels in women with complete hydatidiform mole (CHM) and (ii) whether there were any correlations between these parameters and CHM.

Methods.?Thirty-two women with CHM and 30 healthy pregnant women were enrolled in the study. Fasting serum glucose and insulin levels, low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol (TC), and triglyceride (TG) and C-reactive protein (CRP) were measured. Insulin resistance was calculated by the homeostasis model assessment ratio (HOMA-IR).

Results.?Fasting glucose, insulin, HOMA-IR, CRP, and TG levels were higher, and HDL was lower among patients with CHM compared with healthy pregnant group (p?<?0.05 for all). There were positive associations between CHM status and glucose, insulin, HOMA-IR, CRP, TG levels and had a negative correlation with HDL (p?<?0.05 for all). The receiver operating characteristic curve (ROC) analysis value for HOMA-IR in CHM was 0.96 (95% confidence interval (CI)?=?0.92–1.00), sensitivity?=?94%, and specificity?=?87%. The area under ROC curve value for CRP was 0.72 (95% confidence interval (CI)?=?0.58–0.84), sensitivity?=?82%, and specificity?=?60% in CHM.

Conclusions.?Insulin resistance and CRP were found to be higher among patients with CHM. These parameters were also closely associated with CHM. Further studies are needed to investigate the nature of this link in this group.     

Immunohistochemical characterization of cyclin E and p27KIP1 expression in early hydatidiform moles.

The aim of this study is to evaluate whether the expression of p27 (p27) and cyclin E (cE) is related to the development of hydatidiform moles and whether their expressions are associated with prognosis in these lesions. Ten diploid voluntary artificial abortions (ABs), 20 diploid hydropic abortions (HAs), 20 triploid partial moles (PMs), and 44 diploid complete moles (CMs) (including 4 with persistent disease), all of which were in the first trimester, were evaluated by immunohistochemistry of formalin-fixed tissues using monoclonal antibodies against p27 and cE protein. DNA ploidy in all cases was analyzed by flow cytometry. In ABs, nuclear cE was expressed at low (1+) to moderate (2+) levels in cytotrophoblast (CT), intermediate trophoblast (IT) and occasionally in syncytiotrophoblast (ST). In all CMs, cE-positive nuclei of CT were observed at high levels (3+), and (1+) to (2+) levels in clusters of IT. On the other hand, all HAs and PMs showed cE levels comparable to those observed in ABs. There was a significant difference in cyclin E expression in CT between CMs and non CMs, but there was no significant difference of cE levels between CMs with and without persistent disease. In 3 of 10 ABs, nuclear p27 was expressed at (1+) levels in ST. Similar expression was observed in 27 (including 2 invasive lesions) of 44 CMs, 10 of 20 PMs, and 8 of 20 HAs. CT and IT were rarely positive (1+) for p27 in the cases examined. Decidual stromal cells provided a reliable positive internal control for p27 expression. These findings support the hypothesis that trophoblast proliferation is related to the balance between the positive cell cycle factors, such as cE, and the negative cell cycle inhibitors, such as p27. The overexpression of cE in the trophoblastic elements suggests that cE protein expression may be dysregulated in early CMs. Neither cE nor p27 expression is a prognostic indicator in CMs.     

Flow cytometric and clinicopathologic study of complete hydatidiform moles with special reference to the significance of cytometric aneuploidy

OBJECTIVE: As complete hydatidiform moles (CMs) have been studied less with respect to aneuploidy and its clinical implications, the significance of cytometric aneuploidy in CMs was evaluated. METHODS: Two hundred thirty-nine CMs were studied clinicopathologically and analyzed by flow cytometry using formalin-fixed paraffin-embedded tissues. RESULTS: Of 239 CMs, 182 were diploid, 30 were tetraploid, and 27 were aneuploid (nontriploid/tetraploid aneuploid). There were no significant histologic differences among the diploid, tetraploid, and aneuploid CMs. Persistent disease developed in 20 of 114 CMs (17.6%) (16 of 77 diploid, 4 of 18 tetraploid, and none of 19 aneuploid CMs). Eight diploid and three tetraploid CMs were invasive, and one patient each with diploid CM and tetraploid CM developed choriocarcinoma and none of 19 patients with aneuploid CMs had sequelae. CONCLUSION: These results suggest that aneuploid CMs are associated with less risk for persistent disease than diploid or tetraploid CMs. DNA ploidy status may be an independent predictor of persistent disease.     

Comparison between vacuum aspiration and forceps plus blunt curettage for the evacuation of complete hydatidiform moles

ObjectiveSuction curettage is recommended for molar evacuation rather than sharp curettage because of its safety. However, the superiority of suction curettage with respect to the incidence of gestational trophoblastic neoplasia (GTN) has not been reported. This study aimed to compare the efficacy and safety of two evacuation procedures, vacuum aspiration and forceps/blunt curettage, for complete hydatidiform moles (CHMs) to determine the differences between them.Materials and methodsPatients with androgenetic CHM determined by multiplex short tandem repeat polymorphism analysis were included in this observational cohort study. Patients underwent evacuation with forceps and blunt curettage (forceps group) before March 2013 and with vacuum aspiration (vacuum group) thereafter. GTN was diagnosed based on the International Federation of Gynecology and Obstetrics 2000 criteria. The incidence of GTN and other clinical parameters were compared.ResultsNinety-two patients were diagnosed with androgenetic CHM. The number of patients in the forceps and vacuum groups was 41 and 51, respectively. The incidence of GTN was 12.2% (5/41) and 13.7% (7/51) in the forceps and vacuum groups, respectively, which was not significantly different (P = 1, Fisher's exact test). No major adverse events, such as uterine perforation and blood transfusion, were noted in either group. The median surgery time was shorter in the vacuum group (16 min) than in the forceps group (25 min) (P = 0.05, Mann–Whitney U test).ConclusionThere were no differences in the incidence of GTN between the forceps and vacuum groups for androgenetic CHM. However, vacuum aspiration could have the advantage of a shorter surgery period. The use of vacuum aspiration for molar pregnancy seems to be safer. Therefore, we recommend suction curettage for the first evacuation of hydatidiform moles.     

Interleukin-1 alpha but not interleukin-1 beta gene polymorphism is associated with polycystic ovary syndrome

Interleukin-1 (IL1) is a multifunctional cytokine and IL1-mediated inflammatory processes have been proposed to influence the processes of ovulation, fertilization and implantation. All these parameters are also affected in women with polycystic ovary syndrome (PCOS). This study investigated the association of common polymorphisms of the interleukin-1 genes (IL1A and IL1B) with the occurrence and clinical characteristics of PCOS. We evaluated one polymorphism of the IL1alpha gene (IL1A C[-889]T) and two of the IL1beta gene (IL1B promoter C[-511]T and IL1B exon 5 position +3953) in 105 Caucasian women with PCOS and 102 healthy Caucasian controls by polymerase chain reaction. For the mutated IL1A allele, allele frequencies in women with PCOS and controls were 60% and 46%, respectively, versus 40% and 54%, respectively, for the wild type allele. Allele frequencies in women with PCOS and controls were 59% (54%) and 61% (41%), respectively, for the mutated IL1B promoter (mutated IL1B exon 5) and 41% (46%) and 39% (59%), respectively, for the wild type alleles. Presence of a polymorphism in the interleukin-1alpha but not the interleukin-1beta gene was found to correlate with the occurrence of PCOS (p=0.04; odds ratio 1.8). The serum level of FSH and subsequent LH/FSH ratio correlated with the polymorphism of IL1A within the PCOS group (p=0.005 and 0.01, respectively). We have shown that a common polymorphism of the interleukin-1alpha but not interleukin-1beta gene is associated with the presence of PCOS and with clinical parameters of women affected by this condition.