Trophoblast:滋养层
Trophoblast
Protocol applies to all gestational
trophoblastic malignancies.
Protocol revision date: January 2004 thBased on AJCC/UICC TNM, 6 edition
Procedures
• Dilatation and Curettage
• Resection
Authors
Janice M. Lage, MD
Department of Pathology, Medical University of South Carolina, Charleston,
South Carolina
Saeid Movahedi-Lankarani, MD
Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland For the Members of the Cancer Committee, College of American Pathologists
Previous contributors: Janice M. Lage, MD; Donald E. Henson, MD;
Enrique Hernandez, MD; Maureen Killacky, MD; Beverly B. Kramer, MD; Rachelle Lanciano, MD; Stanley J. Robboy, MD; Steven G. Ruby, MD; Robert E. Scully, MD; Steven G. Silverberg, MD; Richard Zaino, MD
Trophoblast • Gynecologic CAP Approved
Surgical Pathology Cancer Case Summary
Protocol revision date: January 2004
Applies to invasive trophoblastic neoplasms only thBased on AJCC/UICC TNM, 6 edition
TROPHOBLAST: Dilation and Curettage/Resection
Patient name:
Surgical pathology number:
Note: Check 1 response unless otherwise indicated.
MACROSCOPIC
Specimen Type
___ Dilation and curettage
___ Hysterectomy
___ Radical hysterectomy
___ Pelvic exenteration
___ Other (specify): ____________________________
___ Not specified
Tumor Site
Specify, if known: ____________________________
___ Not specified
Fetal Anomalies
___ Cannot be determined
___ Absent
___ Present
*Specify type: ____________________________
Tumor Size
Greatest dimension: ___ cm
*Additional dimensions: ___ x ___ cm
___ Cannot be determined (See Comment)
Other Organs Involved by Tumor (check all that apply) ___ Not applicable
___ Specify organ(s) with direct extension: ____________________________ ___ Specify organ(s) with separate metastasis: ____________________________
* Data elements with asterisks are not required for accreditation purposes for 2
the Commission on Cancer. These elements may be clinically important,
but are not yet validated or regularly used in patient management.
Alternatively, the necessary data may not be available to the pathologist
at the time of pathologic assessment of this specimen.
CAP Approved Gynecologic • Trophoblast
MICROSCOPIC
Histologic Type
___ Hydatidiform mole, complete
___ Hydatidiform mole, partial
___ Hydatidiform mole, invasive
___ Choriocarcinoma
___ Placental site trophoblastic tumor
___ Epithelioid trophoblastic tumor
___ Other (specify type): ____________________________ ___ Malignant trophoblastic tumor, type cannot be determined
Pathologic Staging (pTNM [FIGO])
Primary Tumor (pT)
___ pTX [--]: Primary tumor cannot be assessed ___ pT0 [--]: No evidence of primary tumor
___ pT1 [I]: Tumor confined to uterus
___ pT2 [II]: Tumor extends outside of the uterus but is limited to the genital
structures (adnexa, vagina, broad ligament)
Distant Metastasis (pM)
___ pMX [--]: Metastasis cannot be assessed
___ pM1a [III]: Tumor extends to the lungs with or without genital tract involvement
___ pM1b [IV]: Tumor involves all other metastatic sites
*Specify site(s), if known: ____________________________
Margins
___ Cannot be assessed
___ Uninvolved by malignant tumor
Distance of malignant tumor from closest margin: ___ mm
Specify margin: ____________________________
___ Involved by malignant tumor
Specify margin(s): ____________________________
Venous/Lymphatic (Large/Small Vessel) Invasion (V/L) ___ Absent
___ Present
___ Indeterminate
* Data elements with asterisks are not required for accreditation purposes for 3
the Commission on Cancer. These elements may be clinically important, but are not yet validated or regularly used in patient management. Alternatively, the necessary data may not be available to the pathologist at the time of pathologic assessment of this specimen.
Trophoblast • Gynecologic CAP Approved
Fetal Tissue (Macroscopic or Microscopic)
___ Cannot be determined
___ Absent
___ Present
*Specify type: ____________________________
*Additional Pathologic Findings (check all that apply)
*___ None identified
*___ Implantation site
*___ Other (specify): ____________________________
*Comment(s)
* Data elements with asterisks are not required for accreditation purposes for 4
the Commission on Cancer. These elements may be clinically important,
but are not yet validated or regularly used in patient management.
Alternatively, the necessary data may not be available to the pathologist
at the time of pathologic assessment of this specimen.
For Information Only Gynecologic • Trophoblast
Background Documentation
Protocol revision date: January 2004
I. Dilatation and Curettage
A. Clinical Information
1. Patient identification
a. Name
b. Identification number
c. Age (birth date)
2. Responsible physician(s)
3. Date of procedure
4. Other clinical information
a. Relevant history (Note A)
(1) menstrual history
(2) week of pregnancy
(3) passage of tissue
(4) history of hydatidiform mole
b. Relevant findings (eg, size of uterus, ultrasound, human chorionic
gonadotropin [hCG] level)
c. Clinical diagnosis
d. Procedure (eg, endometrial biopsy, dilation and curettage, spontaneous
passage of tissue)
e. Anatomic site(s) of specimen(s) (eg, uterine corpus, cervix)
B. Macroscopic Examination
1. Specimen
a. Unfixed/fixed (specify fixative)
b. Size (aggregate dimensions if multiple, after separating tissue from blood)
c. Lesion/tumor
(1) dimensions
(2) descriptive features
(3) vesicles, with size of largest
(4) fetal tissue and anomaly
(5) firmness
(6) necrosis
d. Results of intraprocedural consultation 2. Tissue submitted for microscopic evaluation
a. Villous tissue
(1) representative samples, if abundant
(2) all, if sparse
b. Fetal tissue
c. Uterine tissue
3. Special studies (specify) (eg, immunohistochemistry, DNA analysis [specify type],
oncogene analysis, karyotype analysis)
C. Microscopic Evaluation
1. Adequacy of specimen (if inadequate for evaluation, specify reason)
2. Tumor
a. Histologic type (Note B)
b. Presence in sharp curettage specimen
c. Presence in suction curettage specimen
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Trophoblast • Gynecologic For Information Only
3. Additional tissues or pathologic findings, if present
a. Implantation site
b. Endometrium
c. Myometrium
d. Cervix
e. Fetal tissues (cord, amnion, chorion, yolk sac)
f. Fetal anomalies, if present
4. Results/status of special studies
5. Comments
a. Correlation with intraprocedural consultation, as appropriate
b. Correlation with other specimens, as appropriate
c. Correlation with clinical information, including hCG level, as appropriate
II. Resection
A. Clinical Information
1. Patient identification
a. Name
b. Identification number
c. Age (birth date)
2. Responsible physician(s)
3. Date of procedure
4. Other clinical information
a. Relevant history (Note A)
(1) menstrual history
(2) week of pregnancy
(3) passage of tissue
(4) history of hydatidiform mole
b. Relevant findings (eg, size of uterus, ultrasound, hCG level)
c. Clinical diagnosis
d. Procedure (eg, abdominal hysterectomy, radical hysterectomy with bilateral
salpingo-oophorectomy, staging laparotomy, pelvic exenteration, other)
e. Anatomic site(s) of specimen(s) (eg, uterine corpus, cervix)
B. Macroscopic Examination
1. Specimen
a. Organ(s)/tissue(s) included
b. Unfixed/fixed (specify fixative)
c. Number of pieces
d. Dimensions
e. Orientation, if indicated by surgeon
f. Areas indicated by surgeon for specific microscopic evaluation
g. Results of intraoperative consultation
2. Tumor
a. Location (eg, corpus, fundus, cornu, isthmus, cervix)
b. Size
c. Descriptive characteristics (eg, villous tissue, exophytic, color)
d. Extent of invasion (Note C)
(1) into myometrium/serosa/parametrium/cervix
(2) invasion of other organ(s)/tissue(s)
e. Distance from margins
3. Additional pathologic findings, if present
a. Evidence of prior sampling or treatment at apparent site of lesion
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For Information Only Gynecologic • Trophoblast
4. Uterine corpus
a. Dimensions
b. Descriptive features of endometrium, myometrium, and serosa
c. Tumor
(1) descriptive features, including size, location, and extent
(2) relation to main tumor
d. Resection margins if, appropriate
e. Additional findings, if present
5. Uterine cervix
a. Descriptive features, including appearance of ectocervix and endocervix
b. Tumor
(1) descriptive features, including size, location, and extent
(2) relation to main tumor
c. Resection margins, if appropriate
d. Additional findings, if present
6. Vagina
a. Size (length, circumference, thickness)
b. Descriptive features, including inner and outer surfaces, wall
c. Tumor
d. Descriptive features, including size, location, and relation to main tumor
e. Resection margins, if appropriate
f. Additional findings, if present
7. Fallopian tube(s)
a. Dimensions
b. Descriptive features, including dimensions
c. Tumor
(1) descriptive features, including size, location, and extent
(2) relation to main tumor
d. Resection margins, if appropriate
e. Additional findings
8. Ovary(ies)
a. Descriptive features, including measurements, outer surface, and sectioned
surface
b. Lesion/tumor
(1) descriptive features, including size, location, and extent
(2) relation to main tumor
c. Resection margins, if appropriate
d. Additional findings (eg, multiple luteinized follicle cysts) 9. Organ containing primary tumor (uninvolved component)
a. Dimensions
b. Descriptive features
c. Resection margins if appropriate
d. Additional findings, if present
10. Regional lymph nodes
a. Tumor
(1) size
(2) descriptive features
b. Additional findings, if present
11. Other organ(s) or tissue(s) removed (eg, omentum, staging biopsy specimens)
a. Type(s) or site(s)
b. Dimensions and other descriptive features
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Trophoblast • Gynecologic For Information Only
c. Tumor
(1) descriptive features, including size, location, and extent
(2) relation to main tumor
d. Resection margins if appropriate
12. Tissues submitted for microscopic evaluation
a. Primary tumor of uterus or other organ, adequate number to demonstrate the
following:
(1) deepest myometrial invasion or extent of involvement
(2) distance from serosa or resection margin
(3) cornual/isthmic/cervical/parametrial involvement, if present
b. Other lesions
c. Grossly uninvolved tissue, as appropriate
d. Staging and lymph node specimens (at least 1 section of each)
e. Omentum (multiple sections whether or not grossly involved)
f. Vaginal cuff
g. Frozen section tissue fragment(s) (unless saved for special studies)
h. Other organs/tissues, as appropriate for gross/clinical indications 13. Special studies (eg, DNA flow cytometry, genetic studies such as karyotype
analysis, image analysis, DNA polymorphism analysis)
C. Microscopic Evaluation
1. Organ primarily involved
a. Tumor
(1) histologic type (Note B)
(2) site
(3) extent of invasion (Note C)
(4) depth of invasion from endometrial junction/thickness of myometrium, or
extent of primary tumor in other organs
(5) closest distance to serosa
(6) venous/lymphatic vessel invasion
b. Resection margins
c. Status of inked areas or areas designated by surgeon 2. Additional pathologic findings, if present
a. Implantation site, if present (endometrium, myometrium, cervix)
b. Fetal tissues (chorion, amnion, yolk sac)
c. Fetal anomalies, if present
3. Regional lymph nodes
a. Total number
b. Number involved by tumor
c. Other findings (eg, decidua)
4. Other organ(s) and tissue(s)
a. Tumor
(1) location
(2) extent
(3) relation to primary tumor
b. Resection margins, if appropriate
c. Additional findings (eg, decidua, hyperreactio luteinalis of ovaries) 5. Results/status of special studies (specify)
6. Comments
a. Correlation with intraoperative consultation, as appropriate
b. Correlation with other specimens, as appropriate
c. Correlation with clinical information, as appropriate
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For Information Only Gynecologic • Trophoblast
Explanatory Notes
A. Previous History
Previous slides should be reviewed by the pathologist if it is deemed necessary by the gynecologist or pathologist for optimal evaluation of the specimen.
B. Histologic Type
A modified World Health Organization (WHO) classification of gestational trophoblastic 1-5lesions is as follows:
Histologic Classification of Gestational Trophoblastic Lesions
Hydatidiform mole # Complete ## Partial
Invasive hydatidiform mole
Choriocarcinoma ###Placental site trophoblastic tumor 6, ###Epithelioid trophoblastic tumor
Trophoblastic lesions, miscellaneous
Exaggerated placental site^
Placental site nodule^^
Unclassified trophoblastic lesions
# Usually diploid, 46 chromosomes; most commonly no fetal tissues unless with a twin gestation; villi markedly enlarged, hydropic, central cistern; prominent trophoblastic hyperplasia.
## Usually triploid, 69 chromosomes; fetal tissues present; villi scalloped, have stromal trophoblastic inclusions; focal trophoblastic hyperplasia, usually of syncytiotrophoblast.
### Malignant tumor of intermediate trophoblast.
^ Benign lesion composed of seemingly increased intermediate trophoblast at the implantation site, most commonly seen in uterine curettage specimens. These lesions are benign and do not require staging.
^^ Retention of nodule(s) of benign intermediate trophoblast. These lesions are benign and do not require staging.
C. TNM and Stage Groupings thThe 6 edition of the TNM staging system of the American Joint Committee on Cancer 3,4(AJCC) and the International Union Against Cancer (UICC), and the corresponding
updated 2001 edition of staging system of the International Federation of Gynecology 5and Obstetrics (FIGO), are recommended as follows. Both are based not only on the anatomic extent of the tumor but on additional factors, including clinical and laboratory findings.
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Trophoblast • Gynecologic For Information Only
By AJCC/UICC convention, the designation “T” refers to a primary tumor that has not been previously treated. The symbol “p” refers to the pathologic classification of the TNM, as opposed to the clinical classification, and is based on gross and microscopic examination. pT entails a resection of the primary tumor or biopsy adequate to evaluate the highest pT category and pM implies microscopic examination of distant lesions. Clinical classification (cTNM) is usually carried out by the referring physician before treatment during initial evaluation of the patient or when pathologic classification is not possible. Gestational trophoblastic tumors do not have an N classification (see below).
Pathologic staging is usually performed after surgical resection of the primary tumor. Pathologic staging depends on pathologic documentation of the anatomic extent of disease, whether or not the primary tumor has been completely removed. If a biopsied tumor is not resected for any reason (eg, when technically unfeasible) and if the highest T category or the M1 category of the tumor can be confirmed microscopically, the criteria for pathologic classification and staging have been satisfied without total removal of the primary cancer.
3,4 AJCC/UICC TNM Classification for Trophoblastic Tumors
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Tumor confined to uterus
T2 Tumor extends to other genital structures (vagina, ovary, broad ligament,
fallopian tube) by metastasis or direct extension
Regional Lymph Nodes (N)
There is no regional nodal designation (N classification) in the staging of gestational trophoblastic tumors. Nodal involvement in these tumors is rare but has an extremely poor prognosis. Nodal metastases should be classified as metastatic M1b disease.
Distant Metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis #M1a Metastasis to lung(s) #M1b Other distant metastasis (eg, brain) with or without lung metastasis
# Genital metastasis (vagina, broad ligament, ovary, fallopian tube) is classified as T2. Direct invasion or metastasis to any non-genital structure is classified using the M classification.
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For Information Only Gynecologic • Trophoblast
5 FIGO Staging for Gestational Trophoblastic Tumors (2001)
Stage I Tumor confined to the uterus
IA Tumor confined to the uterus with low risk prognostic score IB Tumor confined to the uterus with high-risk prognostic score Stage II Tumor extends outside of the uterus but is limited to the genital structures
(adnexa, vagina, broad ligament)
IIA Tumor involving genital structures with low risk prognostic score IIB Tumor extends outside of the uterus but limited to genital structures with
high-risk prognostic score
Stage III Tumor extends to the lungs with or without known genital tract
involvement
IIIA Tumor extends to the lungs with or without genital tract involvement and
with low risk prognostic score
IIIB Tumor extends to the lungs with or without genital tract involvement and
with high-risk prognostic score
Stage IV Tumor involves all other metastatic sites
IVA Tumor involves all other metastatic sites with low risk prognostic score IVB Tumor involves all other metastatic sites with high-risk prognostic score
Note: Stages I to IV are subdivided into A (low risk) and B (high risk) according to the prognostic score (see below).
3,4Prognostic Score
pTM Pathological Classification
The pT and pM categories correspond to the T and M categories.
Prognostic Score
Prognostic Factor 0 1 2 3
Age <40 >40
Antecedent pregnancy H. mole Abortion Term
pregnancy
<4 4 – <7 7 – 12 >12 Months from index
pregnancy
33 4455<10 10–<10 10 – <10 >10 Pretreatment serum hCG
(IU/ml)
<3 cm 3 – <5 cm >5 cm Largest tumor size
including uterus
Sites of metastasis Lung Spleen, Gastrointes-Liver,
kidney tinal tract brain
Number of metastasis 1 – 4 5 – 8 >8
Previous failed Single 2 or more
chemotherapy drug drugs
Risk Categories
Total prognostic score 7 or less is low risk (add “A” to FIGO Stage)
Total prognostic score 8 or more is high risk (add “B” to FIGO Stage)
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Trophoblast • Gynecologic For Information Only
#Stage Groupings
FIGO Stage TNM Classification Risk Factors
Stage I T1 M0 unknown
Stage IA T1 M0 low
Stage IB T1 M0 high
Stage II T2 M0 unknown
Stage IIA T2 M0 low
Stage IIB T2 M0 high
Stage III Any T M1a unknown
Stage IIIA Any T M1a low
Stage IIIB Any T M1a high
Stage IV Any T M1b unknown
Stage IVA Any T M1b low
Stage IVB Any T M1b high
# The T and M categories are defined to correspond to the FIGO Stages.
TNM Descriptors
For identification of special cases of TNM or pTNM classifications, the “m” suffix and “y,” “r,” and “a” prefixes are used. Although they do not affect the stage grouping, they indicate cases needing separate analysis.
The “m” suffix indicates the presence of multiple primary tumors in a single site and is recorded in parentheses: pT(m)NM.
The “y” prefix indicates those cases in which classification is performed during or following initial multimodality therapy (ie, neoadjuvant chemotherapy, radiation therapy, or both chemotherapy and radiation therapy). The cTNM or pTNM category is identified by a “y” prefix. The ycTNM or ypTNM categorizes the extent of tumor actually present at the time of that examination. The “y” categorization is not an estimate of tumor prior to multimodality therapy (ie, before initiation of neoadjuvant therapy).
The “r” prefix indicates a recurrent tumor when staged after a documented disease-free interval, and is identified by the “r” prefix: rTNM.
The “a” prefix designates the stage determined at autopsy: aTNM.
Additional Descriptors
Residual Tumor (R)
Tumor remaining in a patient after therapy with curative intent (eg, surgical resection for cure) is categorized by a system known as R classification, shown below.
RX Presence of residual tumor cannot be assessed
R0 No residual tumor
R1 Microscopic residual tumor
R2 Macroscopic residual tumor
For the surgeon, the R classification may be useful to indicate the known or assumed status of the completeness of a surgical excision. For the pathologist, the R classification
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For Information Only Gynecologic • Trophoblast
is relevant to the status of the margins of a surgical resection specimen. That is, tumor involving the resection margin on pathologic examination may be assumed to correspond to residual tumor in the patient and may be classified as macroscopic or microscopic according to the findings at the specimen margin(s).
Vessel Invasion
By AJCC/UICC convention, vessel invasion (lymphatic or venous) does not affect the T category indicating local extent of tumor unless specifically included in the definition of a T category. In all other cases, lymphatic and venous invasion by tumor are coded separately as follows.
Lymphatic Vessel Invasion (L)
LX Lymphatic vessel invasion cannot be assessed
L0 No lymphatic vessel invasion
L1 Lymphatic vessel invasion
Venous Invasion (V)
VX Venous invasion cannot be assessed
V0 No venous invasion
V1 Microscopic venous invasion
V2 Macroscopic venous invasion
In summary, the following factors should be considered and noted in reporting: 1. Prior chemotherapy for known gestational trophoblastic tumors. 2. Benign placental site tumors (exaggerated placental site and placental site nodule)
should be reported separately and are not staged.
3. Histological verification of disease is not required when the human chorionic
gonadotropin (hCG) is abnormally elevated.
4. TNM and FIGO staging applies to choriocarcinoma, invasive hydatidiform mole,
placental site trophoblastic tumor and epithelioid trophoblastic tumor. 5. In contrast to other sites, an N classification (regional lymph node status) does not
apply to gestational trophoblastic tumors.
References
1. Kurman RJ, ed. Blaustein’s Pathology of the Female Genital Tract. New York:
Springer-Verlag; 2002.
2. Scully RE, Bonfiglio TA, Kurman RJ, Silverberg SG, Wilkinson EJ. World Health
Organization International Histological Classification of Tumours. Histological
Typing of Female Genital Tract Tumours. New York: Springer-Verlag; 1994.
3. Greene FL, Page DL, Fleming ID, et al, eds. AJCC Cancer Staging Manual. 6th ed.
New York: Springer; 2002. th4. Sobin LH, Wittekind C. UICC TNM Classification of Malignant Tumours. 6 ed.
New York: Wiley-Liss; 2002.
5. Ngan HYS, Odicino F, Maisonneuve P, et al. Gestational trophoblastic tumours:
FIGO Annual Report. J Epidemiol Biostat. 2001;6:175-184.
6. Shih IM, Kurman RJ. Epithelioid trophoblastic tumor: a neoplasm distinct from
choriocarcinoma and placental site trophoblastic tumor simulating carcinoma. Am J
Surg Pathol. 1998;22:1393-1403.
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Trophoblast • Gynecologic For Information Only
Bibliography
Bagshawe KD, Lawler SD, Paradinas FJ, Dent J, Brown P, Boxer GM. Gestational
trophoblastic tumours following initial diagnosis of partial hydatidiform mole. Lancet.
1990;335:1074-1076.
Berkowitz RS, Im SS, Bernstein MR, Goldstein DP. Gestational trophoblastic disease:
subsequent pregnancy outcome, including repeat molar pregnancy. J Reprod Med.
1998;43:81-86.
Collins RJ, Ngan HYS, Wong LC. Placental site trophoblastic tumor: with features
between an exaggerated placental site reaction and a placental site trophoblastic
tumor. Int J Gynecol Pathol. 1990;9:170-177.
Chang YL, Chang TC, Hseuh S, et al. Prognostic factors and treatment for placental site
trophoblastic tumor: report of 3 cases and analysis of 88 cases. Gynecol Oncol.
1999;73:216-222.
Fukunaga M, Ushigome S, Fukunaga M, Sugishita M. Application of flow cytometry in
diagnosis of hydatidiform moles. Mod Pathol. 1993;6:353-359.
Fukunaga M, Ushigome S. Malignant trophoblastic tumors: immunohistochemical and
flow cytometric comparison of choriocarcinoma and placental site trophoblastic
tumors. Hum Pathol. 1993;24:1098-1106.
Huettner PC, Gersell DJ. Placental site nodule: a clinicopathologic study of 38 cases.
Int J Gynecol Pathol. 1994;13:191-198.
Hui P, Parkash V, Perkins AS, Carcangiu ML. Pathogenesis of placental site
trophoblastic tumor may require the presence of a paternally derived X
chromosome. Lab Invest. 2000;80:965-972.
Keep D, Zaragoza MV, Hassold T, Redline RW. Very early complete hydatidiform mole.
Hum Pathol. 1996;27:708-713.
Kurman RJ, Young RH, Main CA, et al. Immunohistochemical localization of placental
lactogen and chorionic gonadotropin in the normal placenta and trophoblastic
tumors with emphasis on intermediate trophoblast and the placental-site
trophoblastic tumor. Int J Gynecol Pathol. 1984;3:101-121.
Lage JM, Mark SD, Roberts DJ, et al. A flow cytometric study of 137 fresh hydropic
placentas: correlation between types of hydatidiform moles and nuclear DNA ploidy.
Obstet Gynecol. 1992;79:403-410.
Lawler SD, Fisher RA, Dent J. A prospective genetic study of complete and partial
hydatidiform moles. Am J Obstet Gynecol. 1991;164;1270-1277.
Miller D, Jackson R, Ehlen T, McMurtie E. Case report: complete hydatidiform mole
coexistent with a twin live fetus: clinical course of four cases with complete
cytogenetic analysis. Gynecol Oncol. 1993;50:119-123.
Paradinas FJ, Browne P, Fisher RA, et al. A clinical, histopathological, and flow
cytometric study of 149 complete moles, 146 partial moles and 107 non-molar
hydropic abortions. Histopathology (Oxf). 1996;28:101-110.
Qiao S, Nagasaka T, Nakashima N. Numerous vessels detected by CD 34 in the villous
stroma of complete hydatidiform moles. Int J Gynecol. 1997;16:233-238.
Redline RW, Hassold T, Zaragoza MV. Prevalence of the partial molar phenotypes in
triploidy of maternal and paternal origin. Hum Pathol. 1998;29:505-511.
Rotmensch S, Cole LA. False diagnosis and needless therapy of presumed malignant
disease in women with false-positive human chorionic gonadotropin concentrations.
Lancet. 2000;355:712-715.
Shih IM, Kurman RJ. Ki-67 labeling index in the differential diagnosis of exaggerated
placental site, placental site trophoblastic tumor, and choriocarcinoma: a double
immunohistochemical staining techniques using Ki-67 and MEL-CAM antibodies.
Hum Pathol. 1998;29:27-33.
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For Information Only Gynecologic • Trophoblast
Shih IM, Kurman RJ. Immunohistochemical localization of inhibin-alpha in the placenta
and gestational trophoblastic lesions. Int J Gynecol Pathol. 1999;18:144-150.
Silva E, Tornos C, Lage J, Ordonez M, Kavanagh J. Multiple nodules of intermediate
trophoblast: an unusual complication of hydatidiform motes. Int J Obstet Gynecol.
1993; 12:324-332.
Silverberg SG, Kurman RJ. Atlas of Tumor Pathology. Tumors of the Uterine Corpus and
Gestational Trophoblastic Disease. Third Series. Fascicle 3. Washington, DC:
Armed Forces Institute of Pathology; 1992.
Soper JT, Evans AC, Conoway RM, et al. Evaluation of prognostic factors and staging in
gestational trophoblastic tumor. Obstet Gynecol. 1994;84:969-973.
Stellar MA, Genest DR, Bernstein MR, Lage JM, Goldstein DP, Berkowitz RS. Natural
history of twin pregnancy with complete hydatidiform mole and coexisting fetus.
Obstet Gynecol. 1994;83:35-42.
Szulman AE, Surti U. The syndromes of hydatidiform mole, I: cytogenetic and
morphologic correlations. Am J Obstet Gynecol. 1978;131;665-671.
Szulman AE, Surti U. The syndromes of hydatidiform mole, II: morphologic evolution of
the complete and partial mole. Am J Obstet Gynecol. 1978;32:20-27.
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