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A Case of Products of Conception

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... Analysis on POC Use of p57 Immunohistochemistry PowerPoint Presentation Our patient Cytogenetics of Complete Mole Cytogenetics of Partial Mole FISH ... – PowerPoint PPT presentation

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Title: A Case of Products of Conception


1
A Case of Products of Conception
  • Nora K Frisch M.D.
  • 4.19.12

2
Definition
  • The human fetus, placenta and other such products
    which occur with a miscarriage or abortion

3
Our patient
  • 38yo G4P3 woman
  • Positive home pregnancy test at 6 weeks and
    office test 4 days later.
  • Bleeding beginning at 8 weeks. Enlarged uterus
    with no fetus/heart tones seen on ultrasound.
  • D/C performed

4
Surgical Pathology Gross
  • No fetal parts identified
  • Edematous appearing villi/placental tissue
  • Clotted blood

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Microscopic Findings
  • Villi with marked edema
  • Cellular, myxoid villous stroma
  • Circumferential trophoblastic hyperplasia
  • Irregular and scalloped borders of villi
  • Occasional central cisterns

10
Differential Diagnosis
  • Complete mole vs partial mole vs hydropic
    degeneration of spontaneous abortion

11
Quick review
  • A complete mole is caused by a single (90) or
    two (10) sperm combining with an egg which has
    lost its DNA (the sperm then reduplicates forming
    a "complete" 46 chromsome set) The genotype is
    typically 46,XX (10 are 46XY)
  • A partial mole occurs when an egg is fertilized
    by two sperm or by one sperm which reduplicates
    itself yielding the genotypes of 69,XXY
    (triploid) or 92,XXXY (quadraploid)

12
Ancillary Test to Aid in the Diagnosis of Molar
Pregnancy
  • Cytogenetics
  • P57 immunoshistochemistry
  • FISH analysis
  • Flow cytometry

13
Cytogenetics
  • Not sent. hmmmmmm

14
Indications for Cytogenetic Analysis on POC
  • history of more than two miscarriages
  • abnormalities on ultrasound prior to pregnancy
    loss
  • confirmation of abnormal prenatal results
  • pregnancy loss after IVF

15
Use of p57 Immunohistochemistry
  • p57kip2 (p57) is the protein product of the
    maternally expressed gene CDKN1C located on
    chromosome 11p15.5 --- thus is absent in complete
    molar pregnancies (paternal only contribution)
  • Helpful in differentiating complete mole from
    partial or complete from hydropic degeneration.
  • Cannot distinguish partial mole from hydropic
    degeneration (both will be positive)

16
Photo from RMLonline.com
17
Our patient
  • Diagnosis confirmed with immunohistochemisty
  • complete hydatidiform mole

18
Cytogenetics of Complete Mole
19
Cytogenetics of Partial Mole
20
FISH Testing
  • Why? Differentiating hydropic degeneration,
    partial and complete moles can be very difficult
    in early pregnancy loss with evacuation.
  • Low clinical suspicion OFTEN leads to no fresh
    tissue being sent for cytogenetics.
  • Diagnosis has important clinical considerations

21
Procedure
  • Test is performed on formalin fixed, paraffin
    embedded tissue
  • In one study, centromeric probes for chromosomes
    9 and 18 are used. In another, Her2 probe was
    used.
  • Simple anaylsis count the signals!

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Prognosis
  • After D C women are followed with serial
  • B-HCG measurements until they return to 0
  • Persisent gestational trophoblastic disease
    occurs
  • 0.5-4 incomplete mole
  • 10-30 complete mole
  • Progression to invasive molar disease or more
    rarely choriocarcinoma can occur

24
Back to our patient
  • Her B-HCG levels were followed. They dropped
    slowly to 175 mIU/ml but then plateaued and then
    rose to 320 mIU/ml
  • Patient reported abdominal pain worsening since
    initial procedure
  • U/S was concerning for retained products with
    possible myometrial involvement of invasive
    disease
  • Patient desired hysterectomy

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PGTD
  • Persistent gestational trophoblastic disease is a
    term used to describe GTD that is not cured by
    initial surgery. Persistent GTD occurs when the
    hydatiform mole has grown from the surface layer
    of the uterus into the deeper uterine tissues
  • The most common type of PGTD is invasive mole
  • More rarely choriocarcinoma, placental site
    trophoblastic tumor or epithelioid trophoblastic
    tumor

30
Invasive Mole
  • Formerly known as chorioadenoma destruens
  • Molar villi grow into the myometrium or blood
    vessels of the uterus.
  • May rarely spontanteously regress
  • May grow through uterine wall and cause
    hemorrhage
  • May metastasize to lungs, vagina, and other sites
  • Primary treatment is chemotherapy and continuing
    to follow B-HCG levels
  • Hysterectomy if perforation or other complications

31
Invasive Mole vs. Choriocarcinoma
  • Differs from choriocarcinoma by the presence of
    villi in the invasive component
  • Although it can metastasize, has slightly better
    prognosis than choriocarcinoma
  • Metastatic choriocarcinoma has cure rates ranging
    from 75 to near 100
  • Metastatic invasive mole has cure rates near 100

32
Thank you
  • Dr. Richard Lieberman

33
References
  • -Benirschke, Kurt et al. Pathology of the Human
    Placenta. Fifth Edition. Springer (2006)
  • -Catrillon, DH, et al. Discrimination of
    complete hydatidiform mole from its mimics by
    immunohistochemistry of the paternally
    imprinted gene product p57KIP2. Am J Surg
    Pathol. 2001 Oct25(10)1225-30.
  • -Ronnett, Brigitte et al. Hydatiform Moles
    Ancillary Techniques to Refine Diagnosis.
    International Journal of Gynecologic Pathology.
    2011 (30) 101-116.
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