Difference between revisions of "Gestational trophoblastic disease"

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'''Gestational trophoblastic disease''' (GTD) includes [[choriocarcinoma]] and hydatidiform moles.
'''Gestational trophoblastic disease''' (abbreviated '''GTD'''), also '''gestational trophoblastic neoplasia''' (abbreviated '''GTN'''), includes [[choriocarcinoma]] and hydatidiform moles.


==Overview==
=Overview=
===Most common===
===Most common===
Overview of gestational trophoblastic disease:
Overview of gestational trophoblastic disease:
{| class="wikitable"
{| class="wikitable sortable"
|
! Type of mole
| '''Gross'''
! Gross
| '''Nuclear atypia'''
! [[Nuclear atypia]]
| '''Villi'''
! [[Chorionic villi]]
| '''[[IHC]]'''
! [[IHC]]
| '''DNA content'''
! DNA content
| '''Images'''
! Micrographs
|-
|-
| Complete mole
| Complete mole
| "snowstorm"
| "snowstorm"
| +/- ?
| +/- ?
| yes, all abnormal <ref>[http://pathologyoutlines.com/placenta.html#completemole http://pathologyoutlines.com/placenta.html#completemole]</ref>
| yes, all abnormal  
| p57(KIP2) -ve
| p57(KIP2) -ve
| Paternal, diploid
| Paternal, diploid
| [http://www.pathconsultddx.com/pathCon/largeImage?pii=S1559-8675%2806%2970167-X&figureId=fig1 Complete mole (pathconsultddx.com)]
| [http://commons.wikimedia.org/wiki/File:Intermediate_trophoblast_3_-_low_mag.jpg complete mole + intermed. trophoblast (WC)], [http://en.wikipedia.org/wiki/File:Hydatidiform_mole_%281%29_complete_type.jpg complete mole (WC)]  
|-
|-
| Partial mole
| Partial mole
Line 27: Line 27:
| p57(KIP2) +ve
| p57(KIP2) +ve
| Maternal & paternal, tripoid
| Maternal & paternal, tripoid
| [http://library.med.utah.edu/WebPath/PLACHTML/PLAC064.html Partial mole (utah.edu)]
| [http://library.med.utah.edu/WebPath/PLACHTML/PLAC064.html partial mole (utah.edu)]
|-
|-
| Choriocarcinoma
| Choriocarcinoma
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| beta-hCG +ve
| beta-hCG +ve
| ?
| ?
| [http://www.webpathology.com/image.asp?case=36&n=1 Choriocarcinoma - testicular (webpathology.com)]
| [[Image:Choriocarcinoma_-2-_very_high_mag.jpg|thumb|center|120px|Choriocarcinoma. (WC)]]
|-
|-
|}
|}
Line 41: Line 41:
===More comprehensive overview===
===More comprehensive overview===
Benign abnormal looking placenta:
Benign abnormal looking placenta:
*Placental site nodule (PSN).
*[[Placental site nodule]] (PSN).
*Exaggerated placental site (EPS).
*[[Exaggerated placental site]] (EPS).


Abnormal fertilization:
Abnormal fertilization:
*Hydatidiform mole.
*[[Hydatidiform mole]].


Tumours:
Tumours:
*Invasive mole.
*Invasive mole.
*Choriocarcinoma.
*[[Choriocarcinoma]].
*Placental site trophoblastic tumour (PSTT).
*[[Placental site trophoblastic tumour]] (PSTT).
*Epithelioid trophoblastic tumour (ETT).
*[[Epithelioid trophoblastic tumour]] (ETT).


=Entities=
==Choriocarcinoma==
==Choriocarcinoma==
===General===
{{Main|Choriocarcinoma}}
*Classified as a [[germ cell tumour]].
*Usually a mixed tumour, i.e. pure choriocarcinoma is rare, e.g. [[dysgerminoma]] + choriocarcinoma.
 
===Clinical/Epidemiology===
*High beta-hCG.
*May be preceded by a complete hydatidiform mole.<ref name=Ref_PBoD1110-1>{{Ref PBoD|1110-1111}}</ref>
*More common in the far east.
*More common at extremes of fertile age (teens and 40-50 years).
 
===Microscopic===
Features:
*[[Nuclear pleomorphism]] - usually marked.
*Often haemorrhage.
*Syncytiotrophoblast surrounds nests of cytotrophoblast.
 
Image:
*[http://www.webpathology.com/image.asp?case=36&n=1 Choriocarcinoma (webpathology.com)].
*[http://oac.med.jhmi.edu/Pathology/Repro/Placenta/279B_Full.html Choriocarcinoma - testicular (med.jhmi.edu)].
 
Notes:
*Its usually ''NOT'' choriocarcinoma if there are villi.<ref>Notebook P.180. 21 September 2009.</ref>
 
===IHC===
*beta-hCG +ve.<ref name=pmid19145204>{{cite journal |author=Kalhor N, Ramirez PT, Deavers MT, Malpica A, Silva EG |title=Immunohistochemical studies of trophoblastic tumors |journal=Am. J. Surg. Pathol. |volume=33 |issue=4 |pages=633–8 |year=2009 |month=April |pmid=19145204 |doi=10.1097/PAS.0b013e318191f2eb |url=}}</ref>


==Hydatidiform moles==
==Hydatidiform moles==
===General===
===General===
*Significance: increased risk for choriocarcinoma (in complete moles).
*Non-neoplastic proliferation.
*Non-neoplastic proliferation.
*Significance: increased risk for choriocarcinoma (in complete moles).


Etymology:
Etymology:
Line 89: Line 66:


====Types====
====Types====
*Partial mole.
#Partial mole - see [[partial mole]].
**Triploid.
#Complete mole - see [[complete mole]].
**Choriocarcinoma extremely rare.
 
*Complete mole.
Extent:
**Diploid or tetraploid.
*Invasive mole - '''not''' a subtype.
**"Empty" egg fertilized, ergo paternal DNA.
**Within uterine muscle +/- vessels.
**Risk for choriocarcinoma; memory device '''c'''omplete -> '''c'''horiocarcinoma.


===Microscopic===
===Microscopic===
====Partial====
Hydropic changes:
Features:
{| class="wikitable sortable"
*Scant trophoblastic proliferation.
! Entity
**May form finger-like projections.
! [[Chorionic villi]] (outline)
*Fetal tissue.
! Cisterns
**Nucleated RBCs common.
! [[Blood vessel]]s
! Nucleated RBCs
! p57 / Ki-67<ref>URL: [http://www.ihcworld.com/_newsletter/2003/focus_mar_2003.pdf http://www.ihcworld.com/_newsletter/2003/focus_mar_2003.pdf]. Accessed on: 28 May 2011.</ref> staining ‡
! Ploidy
! Micrograph
|-
| Complete mole
| bizarre; often not ovoid; fissures/slit-like gaps
| well-developed
| canalicular (thin walled) / few (???)
| rare
| -ve / ~70%
| diploid / tetraploid
| [http://commons.wikimedia.org/wiki/File:Hydatidiform_mole_%281%29_complete_type.jpg], [http://commons.wikimedia.org/wiki/File:Hydatidiform_mole_%282%29_complete_type.jpg], [http://commons.wikimedia.org/wiki/File:Hydatidiform_mole_%283%29_complete_type.jpg], [http://commons.wikimedia.org/wiki/File:Hydatidiform_mole_%284%29_complete_type.jpg]
|-
| Partial mole
| jagged, still quasi ovoid
| poorly developed / small
| present
| common
| +ve / ~70%
| triploid
| [http://www.flickr.com/photos/78147607@N00/571279403], [http://www.flickr.com/photos/78147607@N00/570796738]
|-
| Hydropic abortus
| smooth
| poorly developed / small
| common
| common
| +ve / ~20%
| diploid
| [http://www.ipath-network.com/ipath/object/view/181344]
|}
Note:
* ‡ The amount of [[Ki-67]] staining varies considerably based on what one reads. Chen ''at al.''<ref>{{Cite journal  | last1 = Chen | first1 = Y. | last2 = Shen | first2 = D. | last3 = Gu | first3 = Y. | last4 = Zhong | first4 = P. | last5 = Xie | first5 = J. | last6 = Song | first6 = Q. | title = The diagnostic value of Ki-67, P53 and P63 in distinguishing partial Hydatidiform mole from hydropic abortion. | journal = Wien Klin Wochenschr | volume = 124 | issue = 5-6 | pages = 184-7 | month = Mar | year = 2012 | doi = 10.1007/s00508-011-0119-4 | PMID = 22218717 }}</ref> suggest 25% versus 5% for partial mole versus hydropic abortus.


====Complete====
====Mole versus normal====
Features:
*Moles have large [[chorionic villi]] with edema and abnormal blood vessels.<ref>URL: [http://pathologyoutlines.com/placenta.html#hydatgeneral http://pathologyoutlines.com/placenta.html#hydatgeneral].</ref>
*Cisterns usu. well-developed.
**Large empty areas within trophoblastic tissue.
*Rarely nucleated [[RBC]]s.
*Canalicular (thin) blood vessels.


====Mole vs. normal====
====Non-molar versus partial versus complete - short version====
*Moles have large [[chorionic villi]] with edema and abnormal blood vessels.<ref>URL: [http://pathologyoutlines.com/placenta.html#hydatgeneral http://pathologyoutlines.com/placenta.html#hydatgeneral].</ref>
Features:<ref name=pmid8157742>{{Cite journal  | last1 = Howat | first1 = AJ. | last2 = Beck | first2 = S. | last3 = Fox | first3 = H. | last4 = Harris | first4 = SC. | last5 = Hill | first5 = AS. | last6 = Nicholson | first6 = CM. | last7 = Williams | first7 = RA. | title = Can histopathologists reliably diagnose molar pregnancy? | journal = J Clin Pathol | volume = 46 | issue = 7 | pages = 599-602 | month = Jul | year = 1993 | doi =  | PMID = 8157742 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC501384/?page=3 }}</ref>
*Non-molar pregnancy: polar proliferation of trophoblastic tissue.
*Partial mole: Norwegian fjord periphery, circumferential or multifocal trophoblastic proliferation, fetal parts.
*Complete mole: grapes grossly, large villi with round borders.


===IHC===
===IHC===
*p57(KIP2) - the gene is strongly paternally imprinted and the paternal copy is inactived; its expression is from the maternal gene.
*p57(KIP2) - the gene is strongly paternally imprinted and the paternal copy is inactived; its expression is from the maternal gene.
**Complete moles lacks the maternal genome; thus, p57(KIP2) immunostaining is absent.<ref name=pmid15754295>{{cite journal |author=Merchant SH, Amin MB, Viswanatha DS, Malhotra RK, Moehlenkamp C, Joste NE |title=p57KIP2 immunohistochemistry in early molar pregnancies: emphasis on its complementary role in the differential diagnosis of hydropic abortuses |journal=Hum. Pathol. |volume=36 |issue=2 |pages=180–6 |year=2005 |month=February |pmid=15754295 |doi=10.1016/j.humpath.2004.12.007 |url=}}</ref>
**Complete moles lack the maternal genome; thus, p57(KIP2) immunostaining (in the cytotrophoblasts and villous stromal cells) is absent.<ref name=pmid15754295>{{cite journal |author=Merchant SH, Amin MB, Viswanatha DS, Malhotra RK, Moehlenkamp C, Joste NE |title=p57KIP2 immunohistochemistry in early molar pregnancies: emphasis on its complementary role in the differential diagnosis of hydropic abortuses |journal=Hum. Pathol. |volume=36 |issue=2 |pages=180–6 |year=2005 |month=February |pmid=15754295 |doi=10.1016/j.humpath.2004.12.007 |url=}}</ref><ref name=pmid12514787>{{Cite journal  | last1 = Fukunaga | first1 = M. | title = Immunohistochemical characterization of p57(KIP2) expression in early hydatidiform moles. | journal = Hum Pathol | volume = 33 | issue = 12 | pages = 1188-92 | month = Dec | year = 2002 | doi = 10.1053/hupa.2002.129421 | PMID = 12514787 }}</ref>
***Intermediate trophoblasts and maternal tissue are positive controls.<ref name=pmid12514787/>  
**Memory device:  
**Memory device:  
***'''''p'''57 is '''p'''ositive in '''p'''artial moles''.
***'''''p'''57 is '''p'''ositive in '''p'''artial moles''.
Line 125: Line 135:
*The type of mole can be determined by [[cytogenetics]].<ref>[http://jcp.bmjjournals.com/cgi/reprint/51/6/438.pdf http://jcp.bmjjournals.com/cgi/reprint/51/6/438.pdf]</ref>
*The type of mole can be determined by [[cytogenetics]].<ref>[http://jcp.bmjjournals.com/cgi/reprint/51/6/438.pdf http://jcp.bmjjournals.com/cgi/reprint/51/6/438.pdf]</ref>


==Partial Mole==
==Hydropic abortus==
*Formal name: ''partial hydatidiform mole''.
===General===
*May be seen in the context of a previously detected fetal heart beat.
 
===Microsopic===
Features:
*Enlarged chorionic villi with some cisterns.
 
DDx:<ref>{{cite journal |authors=Rios-Doria E, Pennington KP, Reiter DJ, Parker EU |title=Diagnostic challenges in differentiating between hydropic abortus, and complete and partial hydatidiform molar pregnancies in early gestation |journal=Int J Gynecol Cancer |volume=33 |issue=9 |pages=1482–1484 |date=September 2023 |pmid=37268312 |doi=10.1136/ijgc-2022-004104 |url=}}</ref>
*Molar pregnancy.
 
===Sign out===
<pre>
Submitted as "Retained Products of Conception":
- Small and large chorionic villi with cisterns, suggestive of hydropic abortus, see comment.
- Benign decidual tissue present.
- Negative for evidence of fetal tissue in sampled tissue, see comment.
 
Comment:
Imaging previously described a gestational sac and a fetal heart beat. 
</pre>
 
==Partial hydatidiform mole==
*[[AKA]] ''partial mole''.


===Genetics===
===General===
*Polypoid - usually triploid (e.g. 69XXY).
Genetics:
Images: [http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=12&cat2=86&cat3=795&cat4=3&stype=n]
*Usually triploid (e.g. 69XXY).


===Histology===
===Microscopic===
Features:
*Abnormal chorionic villi.
*Abnormal chorionic villi.
**Villi too large (>0.1 mm ?).
**Villi too large (>0.1 mm ?).
Line 138: Line 171:
***Contain fluid in the centre, i.e. are "hydropic".
***Contain fluid in the centre, i.e. are "hydropic".
**Villi with cytotrophoblastic inclusions.
**Villi with cytotrophoblastic inclusions.
***Cytotrophoblast in the core of a villus (normally it is only at the surface of the villus).
***[[Cytotrophoblast]] in the core of a villus (normally it is only at the surface of the villus).
*May have fetal parts, such as nucleated RBCs.
*May have fetal parts, such as nucleated RBCs.
*Trophoblastic proliferation - [http://library.med.utah.edu/WebPath/PLACHTML/PLAC065.html image - med.utah.edu].
*Trophoblastic proliferation.
**Without atypia.<ref>[http://pathologyoutlines.com/placenta.html#incompletemole http://pathologyoutlines.com/placenta.html#incompletemole]</ref>
**Without atypia.<ref>URL: [http://pathologyoutlines.com/placenta.html#incompletemole http://pathologyoutlines.com/placenta.html#incompletemole]. Accessed on: 9 August 2011.</ref>
*"Norwegian fjord periphery"<ref name=pmid8157742>{{Cite journal  | last1 = Howat | first1 = AJ. | last2 = Beck | first2 = S. | last3 = Fox | first3 = H. | last4 = Harris | first4 = SC. | last5 = Hill | first5 = AS. | last6 = Nicholson | first6 = CM. | last7 = Williams | first7 = RA. | title = Can histopathologists reliably diagnose molar pregnancy? | journal = J Clin Pathol | volume = 46 | issue = 7 | pages = 599-602 | month = Jul | year = 1993 | doi =  | PMID = 8157742 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC501384/?page=3 }}</ref> - jagged border / irregular sawtooth-like periphery.
**Complete moles tend to have a smooth border
 
DDx:
*[[Complete hydatidiform mole]].
*[[Placental mesenchymal dysplasia]].
*Hydropic abortus - see [[products of conception]] and [[chorionic villi]].


Images:  
Images:  
*[http://www-medlib.med.utah.edu/WebPath/PLACHTML/PLAC067.html partial mole] - med.utah.edu.
*[http://www-medlib.med.utah.edu/WebPath/PLACHTML/PLAC067.html Partial mole (med.utah.edu)].
*[http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=12&cat2=86&cat3=795&cat4=3&stype=n partial mole (several images)] - gfmer.ch.
*[http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=12&cat2=86&cat3=795&cat4=3&stype=n Partial mole - several images (gfmer.ch)].


==Complete Mole==
===IHC===
*Formal name: ''complete hydatidiform mole''.
Features:<ref name=pmid22218717>{{Cite journal  | last1 = Chen | first1 = Y. | last2 = Shen | first2 = D. | last3 = Gu | first3 = Y. | last4 = Zhong | first4 = P. | last5 = Xie | first5 = J. | last6 = Song | first6 = Q. | title = The diagnostic value of Ki-67, P53 and P63 in distinguishing partial Hydatidiform mole from hydropic abortion. | journal = Wien Klin Wochenschr | volume = 124 | issue = 5-6 | pages = 184-7 | month = Mar | year = 2012 | doi = 10.1007/s00508-011-0119-4 | PMID = 22218717 }}</ref>
*Also known as ''classic mole''.
*Ki-67 ~ 25+/-5% of cytotrophoblasts and intermediate trophoblasts.
**Hydropic abortus ~ 5+/-1%.
*p53 ~ 22+/-12% of cytotrophoblasts and intermediate trophoblasts.
**Hydropic abortus ~ 5+/-3%.


===Epidemiology===
==Complete hydatidiform mole==
*May precede [[choriocarcinoma]].<ref name=Ref_PBoD1111>{{Ref PBoD|1111}}</ref>
*[[AKA]] ''complete mole'', [[AKA]] ''classic mole''.


===Genetics===
===General===
Epidemiology:
*May precede [[choriocarcinoma]]<ref name=Ref_PBoD1111>{{Ref PBoD|1111}}</ref> ~ 1-2% risk.
 
Genetics:
*Diploid - most are 46XX.
*Diploid - most are 46XX.
*All male dervived, i.e. arise from DNA in sperm.
*Male derived, i.e. arise from DNA in sperm; empty egg fertilized.  
 
===Gross/Radiology===
*"Snowstorm" appearance on ultrasound.<ref>URL:[http://www.jultrasoundmed.org/cgi/content/abstract/18/9/589 http://www.jultrasoundmed.org/cgi/content/abstract/18/9/589]. Accessed on: 27 July 2010.</ref>
*May be described as "grape-like" on gross exam.<ref name=pmid18162339>{{Cite journal  | last1 = Abike | first1 = F. | last2 = Temizkan | first2 = O. | last3 = Payasli | first3 = A. | last4 = Avsar | first4 = F. | last5 = Karahan | first5 = N. | last6 = Baspinar | first6 = S. | title = Postmenopausal complete hydatidiform mole: a case report. | journal = Maturitas | volume = 59 | issue = 1 | pages = 95-8 | month = Jan | year = 2008 | doi = 10.1016/j.maturitas.2007.10.005 | PMID = 18162339 }}</ref>


===Microscopy===
Image:
*[http://library.med.utah.edu/WebPath/PLACHTML/PLAC063.html Complete mole (utah.edu)].
 
===Microscopic===
Features:
*No normal villi.
*No normal villi.
*No fetal parts seen.
*No fetal parts seen.
**Very rarely nucleated [[RBC]]s.
====Images====
<gallery>
Image:Intermediate_trophoblast_3_-_low_mag.jpg | Complete mole and intermediate trophoblast - intermed. mag. (WC)
Image:Hydatidiform_mole_%281%29_complete_type.jpg | Complete mole - low mag. (WC)
Image:Hydatidiform_mole_%282%29_complete_type.jpg | Complete mole - high mag. (WC)
</gallery>
==Invasive hydatidiform mole==
*[[AKA]] ''invasive mole''.
*[[AKA]] ''chorioadenoma destruens''.<ref name=pmid6300738>{{Cite journal  | last1 = McDonald | first1 = TW. | last2 = Ruffolo | first2 = EH. | title = Modern management of gestational trophoblastic disease. | journal = Obstet Gynecol Surv | volume = 38 | issue = 2 | pages = 67-83 | month = Feb | year = 1983 | doi =  | PMID = 6300738 }}</ref>
===General===
*This is not a distinct subtype - see ''[[hydatidiform mole]]''.
===Microscopic===
Features:
*[[Chorionic villi]] - abnormal +/- normal.
*Trophoblastic cells within uterine muscle +/- vessels - '''key feature'''.
DDx:
*[[Choriocarcinoma]] - lack [[chorionic villi]], usu. hemorrhagic.
====Images====
<gallery>
Image:Invasive hydatidiform mole - very low mag.jpg | Invasive mole - very low mag. (WC)
Image:Invasive_hydatidiform_mole_-_low_mag.jpg | Invasive mole - low mag. (WC)
Image:Invasive_hydatidiform_mole_-_intermed_mag.jpg | Invasive mole - intermed. mag. (WC)
Image:Invasive_hydatidiform_mole_-_high_mag.jpg | Invasive mole - high mag. (WC)
Image:Invasive hydatidiform mole - very high mag.jpg | Invasive mole - very high mag. (WC)
</gallery>
=Entities - intermediate trophoblast=
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Entity
! Key feature
! Other histologic features
! IHC
! DDx
! Other
! Image
|-
| [[Placental site nodule]] (PSN)
| paucicellular, hyaline material
| no mitotic activity
| p16 -ve, MIB1 low
| [[EPS]], [[squamous carcinoma]]
| post-partum
| [[Image:Placental_site_nodule_-_intermed_mag.jpg |thumb| center| 80px|PSN. (WC)]] [http://www.ijpmonline.org/viewimage.asp?img=IndianJPatholMicrobiol_2009_52_2_240_48931_u4.jpg (ijpmonline.org)]
|-
| [[Exaggerated placental site]] (EPS)
| abundant [[intermediate trophoblast]]s - between muscle
| no mitotic activity
| MIB1 ~0%
| [[PSTT]], [[PSN]]
| post-partum
| Image?
|-
| [[Placental site trophoblastic tumour]] (PSTT)
| abundant cytoplasm - not clear, dyscohesive
| +/-multinucleation
| MIB1 high, p63 -ve, CD146 +ve
| [[EPS]], [[choriocarcinoma]]
| Other?
| [http://www.webpathology.com/case.asp?case=588 (webpathology.com)]
|-
| [[Epithelioid trophoblastic tumour]] (ETT)
| nests of cells in hyaline stroma
| eosinophilic cytoplasm, central nucleus
| MIB1 low, p63 +ve, CD146 -ve
| [[squamous carcinoma]]
| Other?
| [http://www.webpathology.com/image.asp?case=589&n=2 (webpathology.com)]
|-
| [[Choriocarcinoma]]
| polygonal cells with clear cytoplasm ([[cytotrophoblast]]s)
| multinucleated cells with smudged nuclei ([[syncytiotrophoblast]]s), '''no''' [[chorionic villi]]
| beta-hCG +ve, p63 +ve
| [[invasive hydatidiform mole]], [[PSTT]]
| elevated beta-hCG (serum); '''not''' intermediate trophoblast derived.
| [[Image:Choriocarcinoma_-2-_very_high_mag.jpg|thumb|center|120px|Choriocarcinoma. (WC)]] [http://www.webpathology.com/image.asp?case=36&n=1 (webpathology.com)]
|- <!--
| Entity?
| Key feature?
| Other histologic features?
| IHC?
| DDx?
| Other?
| Image? -->
|}


Image:
==Placental site nodule==
*[http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675(06)70167-X Complete mole (pathconsultddx.com)].
*Abbreviated ''PSN''.
{{Main|Placental site nodule}}


===Radiology===
==Exaggerated placental site==
*"Snowstorm" appearance on ultrasound.<ref>URL:[http://www.jultrasoundmed.org/cgi/content/abstract/18/9/589 http://www.jultrasoundmed.org/cgi/content/abstract/18/9/589]. Accessed on: 27 July 2010.</ref>
*Abbreviated ''EPS''.
*Previously known as ''syncytial endometritis''.<ref>URL: [http://www.webpathology.com/image.asp?case=565&n=7 http://www.webpathology.com/image.asp?case=565&n=7]. Accessed on: 22 May 2014.</ref>
{{Main|Exaggerated placental site}}


==Placental site trophoblastic tumour==
==Placental site trophoblastic tumour==
*Abbreviated ''PSTT''.
*Abbreviated ''PSTT''.
*Malignant counterpart of ''exaggerated placental site'' or ''EPS''.
*Malignant counterpart of ''exaggerated placental site'' (abbreviated ''EPS'').
===General===
*Derived from ''intermediate trophoblast''.
*Follows pregnancy.
*May be associated with [[nephrotic syndrome]]<ref name=pmid15457847>{{Cite journal  | last1 = Bonazzi | first1 = C. | last2 = Urso | first2 = M. | last3 = Dell'Anna | first3 = T. | last4 = Sacco | first4 = S. | last5 = Buda | first5 = A. | last6 = Cantú | first6 = MG. | title = Placental site trophoblastic tumor: an overview. | journal = J Reprod Med | volume = 49 | issue = 8 | pages = 585-8 | month = Aug | year = 2004 | doi =  | PMID = 15457847 }}</ref> with granular IgM staining.<ref>{{Cite journal  | last1 = Komatsuda | first1 = A. | last2 = Nakamoto | first2 = Y. | last3 = Asakura | first3 = K. | last4 = Yasuda | first4 = T. | last5 = Imai | first5 = H. | last6 = Miura | first6 = AB. | title = Case report: nephrotic syndrome associated with a total hydatidiform mole. | journal = Am J Med Sci | volume = 303 | issue = 5 | pages = 309-12 | month = May | year = 1992 | doi =  | PMID = 1580319 }}</ref>


===Clinical===
Clinical:
*Raised beta-hCG - but usually not has high as in choriocarcinoma.<ref name=pstt_pc>URL: [http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675(06)70463-6 http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675(06)70463-6]. Accessed on: 23 September 2009.</ref>
*Raised (serum) beta-hCG - but usually not has high as in [[choriocarcinoma]].
*Derived from ''trophoblast'' - the stuff that forms the chorionic villi - remember: ''syncytiotrophoblasts'' (outer layer) and ''cytotrophoblasts'' (inner layer).
**In ~70% < 1000 IU/L.<ref name=pmid19552948>{{Cite journal  | last1 = Schmid | first1 = P. | last2 = Nagai | first2 = Y. | last3 = Agarwal | first3 = R. | last4 = Hancock | first4 = B. | last5 = Savage | first5 = PM. | last6 = Sebire | first6 = NJ. | last7 = Lindsay | first7 = I. | last8 = Wells | first8 = M. | last9 = Fisher | first9 = RA. | title = Prognostic markers and long-term outcome of placental-site trophoblastic tumours: a retrospective observational study. | journal = Lancet | volume = 374 | issue = 9683 | pages = 48-55 | month = Jul | year = 2009 | doi = 10.1016/S0140-6736(09)60618-8 | PMID = 19552948 }}</ref>
 
**In a series of 55 cases the average beta-hCG was ~700 IU/L.<ref name=pmid16246400>{{Cite journal  | last1 = Baergen | first1 = RN. | last2 = Rutgers | first2 = JL. | last3 = Young | first3 = RH. | last4 = Osann | first4 = K. | last5 = Scully | first5 = RE. | title = Placental site trophoblastic tumor: A study of 55 cases and review of the literature emphasizing factors of prognostic significance. | journal = Gynecol Oncol | volume = 100 | issue = 3 | pages = 511-20 | month = Mar | year = 2006 | doi = 10.1016/j.ygyno.2005.08.058 | PMID = 16246400 }}</ref>
===Epidemiology===
*Prognosis dependent on time of diagnosis from last pregnancy.
*Usually follows a normal pregnancy ~ 75% of cases.<ref name=pstt_pc>URL: [http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675(06)70463-6 http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675(06)70463-6]. Accessed on: 23 September 2009.</ref>
**<48 months = good prognosis.<ref name=pmid19552948/>


===Microscopic===
===Microscopic===
Features:
Features:
*Large cells.
*Large cells:
*Nuclear atypia.
**Nuclear pleomorphism.
*Cytoplasm - cytoplasmic.
**Cytoplasm:
*NC ratio ~ normal.
***Abundant.
***Solid, i.e. not vesicular.
***Light basophilic, not clear - '''key feature'''.
**[[NC ratio]] ~ normal.
*+/-Multinucleated cells.
*Ectatic blood vessels.
 
Note:
*'''No''' chorionic villi.
**If villi are present... it is probably a [[hydatidiform mole]].
 
DDx:
*[[Exaggerated placental site]] - EPS has near zero Ki-67.
*[[Choriocarcinoma]] - choriocarcinoma biphasic.<ref>URL: [http://www.webpathology.com/image.asp?n=3&Case=588 http://www.webpathology.com/image.asp?n=3&Case=588]. Accessed on: 1 January 2012.</ref>


EPS vs. PSTT:
Images:
*EPS has a low MIB-1 (Ki-67).
*[http://www.webpathology.com/case.asp?case=588 Collection of PSTT images (webpathology.com)].
 
===IHC===
Features:<ref>{{Cite journal  | last1 = Shih | first1 = IM. | last2 = Kurman | first2 = RJ. | title = Ki-67 labeling index in the differential diagnosis of exaggerated placental site, placental site trophoblastic tumor, and choriocarcinoma: a double immunohistochemical staining technique using Ki-67 and Mel-CAM antibodies. | journal = Hum Pathol | volume = 29 | issue = 1 | pages = 27-33 | month = Jan | year = 1998 | doi =  | PMID = 9445130 }}</ref>
*CD146 +ve.
*p63 -ve.
*Ki-67 ~14+/-7%.
**Choriocarcinoma ~69+/-20%.


==Epithelioid trophoblastic tumour==
==Epithelioid trophoblastic tumour==
*Abbreviated ''ETT''.
*Abbreviated ''ETT''.
===General===
*Often in endocervix.
*Often in endocervix.
*Malignant counterpart of ''placental site nodule'' or ''PSN''.
*Malignant counterpart of ''placental site nodule'' or ''PSN''.


Images:
Clinical:
*[http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=12&cat3=861&stype=d ETT (gfmer.ch)].
*Vaginal bleeding.
*Elevated beta-hCG.
 
===Gross===
Features:<ref name=pmid16258513>{{Cite journal  | last1 = Fadare | first1 = O. | last2 = Parkash | first2 = V. | last3 = Carcangiu | first3 = ML. | last4 = Hui | first4 = P. | title = Epithelioid trophoblastic tumor: clinicopathological features with an emphasis on uterine cervical involvement. | journal = Mod Pathol | volume = 19 | issue = 1 | pages = 75-82 | month = Jan | year = 2006 | doi = 10.1038/modpathol.3800485 | PMID = 16258513 }}</ref>
*Solid mass.
*Flesh-like appearance.
 
Image:
 
===Microscopic===
Features:<ref name=webp_ett>URL: [http://www.webpathology.com/image.asp?case=589&n=2 http://www.webpathology.com/image.asp?case=589&n=2]. Accessed on: 15 August 2011.</ref>
*Architecture: nests in hyaline matrix.
*Cytoplasm: abundant, eosinophilic.


DDx:
DDx:
*Invasive [[squamous cell carcinoma]].
*Invasive [[squamous cell carcinoma]].


==Placental site nodule==
Images:
===General===
*[http://www.webpathology.com/image.asp?case=589&n=2 ETT (webpathology.com)].<ref name=webp_ett/>
*Benign.


===Microscopic===
===IHC===
Features:
Features:<ref name=pmid16931955>{{Cite journal  | last1 = Mao | first1 = TL. | last2 = Seidman | first2 = JD. | last3 = Kurman | first3 = RJ. | last4 = Shih | first4 = IeM. | title = Cyclin E and p16 immunoreactivity in epithelioid trophoblastic tumor--an aid in differential diagnosis. | journal = Am J Surg Pathol | volume = 30 | issue = 9 | pages = 1105-10 | month = Sep | year = 2006 | doi = 10.1097/01.pas.0000209854.28282.87 | PMID = 16931955 }}</ref>
*Small collection of cells that look similar to decidua (mnemonic ''NEW''):
*Cyclin E +ve (nuclear).
**Nucleus, central location.
*p16 -ve.  
**Eosinophilic cytoplasm.
**+ve (nuclear) in squamous cell carcinoma of the cervix.
**Well-defined cell borders.


Images:
Others:
*[http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=12&cat3=1256&stype=d PSN (gfmer.ch)].
*HMCK -ve.
**SCC +ve.


DDx:
Note:
*Invasive [[squamous cell carcinoma]].
*p63 not useful... +ve in both SCC and ETT.
**Can be sorted-out with IHC (SCC will typically be: p16 +ve, MIB-1 +ve).


==See also==
=See also=
*[[Hydatid disease]] - due to Echinoccus spp. such as E. granulosus.
*[[Hydatid disease]] - due to Echinoccus spp. such as E. granulosus.
*[[Chorionic villi]].
*[[Chorionic villi]].
*[[Ectopic pregnancy]].
*[[Ectopic pregnancy]].
*[[Placenta]].
*[[Placenta]].
*[[Arias-Stella reaction]] - benign atypical changes of the endometrium associated with trophoblastic tissue.


==References==
=References=
{{reflist|2}}
{{reflist|2}}


[[Category:Gynecologic pathology]]
[[Category:Gynecologic pathology]]
[[Category:Gestational trophoblastic disease]]

Latest revision as of 22:07, 7 December 2023

Gestational trophoblastic disease (abbreviated GTD), also gestational trophoblastic neoplasia (abbreviated GTN), includes choriocarcinoma and hydatidiform moles.

Overview

Most common

Overview of gestational trophoblastic disease:

Type of mole Gross Nuclear atypia Chorionic villi IHC DNA content Micrographs
Complete mole "snowstorm" +/- ? yes, all abnormal p57(KIP2) -ve Paternal, diploid complete mole + intermed. trophoblast (WC), complete mole (WC)
Partial mole grape-like
clusters 		+/- large villi, villi with cisterns,
villi with cytotrophoblastic inclusions 		p57(KIP2) +ve Maternal & paternal, tripoid partial mole (utah.edu)
Choriocarcinoma haemorrahagic, necrotic marked none beta-hCG +ve ?
Choriocarcinoma. (WC)

More comprehensive overview

Benign abnormal looking placenta:

Abnormal fertilization:

Tumours:

Entities

Choriocarcinoma

Main article: Choriocarcinoma

Hydatidiform moles

General

  • Significance: increased risk for choriocarcinoma (in complete moles).
  • Non-neoplastic proliferation.

Etymology:

  • Hydatid is literally watery vesicle.[1]

Types

  1. Partial mole - see partial mole.
  2. Complete mole - see complete mole.

Extent:

  • Invasive mole - not a subtype.
    • Within uterine muscle +/- vessels.

Microscopic

Hydropic changes:

Entity Chorionic villi (outline) Cisterns Blood vessels Nucleated RBCs p57 / Ki-67[2] staining ‡ Ploidy Micrograph
Complete mole bizarre; often not ovoid; fissures/slit-like gaps well-developed canalicular (thin walled) / few (???) rare -ve / ~70% diploid / tetraploid [1], [2], [3], [4]
Partial mole jagged, still quasi ovoid poorly developed / small present common +ve / ~70% triploid [5], [6]
Hydropic abortus smooth poorly developed / small common common +ve / ~20% diploid [7]

Note:

  • ‡ The amount of Ki-67 staining varies considerably based on what one reads. Chen at al.[3] suggest 25% versus 5% for partial mole versus hydropic abortus.

Mole versus normal

Non-molar versus partial versus complete - short version

Features:[5]

  • Non-molar pregnancy: polar proliferation of trophoblastic tissue.
  • Partial mole: Norwegian fjord periphery, circumferential or multifocal trophoblastic proliferation, fetal parts.
  • Complete mole: grapes grossly, large villi with round borders.

IHC

  • p57(KIP2) - the gene is strongly paternally imprinted and the paternal copy is inactived; its expression is from the maternal gene.
    • Complete moles lack the maternal genome; thus, p57(KIP2) immunostaining (in the cytotrophoblasts and villous stromal cells) is absent.[6][7]
      • Intermediate trophoblasts and maternal tissue are positive controls.[7]
    • Memory device:
      • p57 is positive in partial moles.
      • 3 Ps - partial moles are triploid.

Molecular

Hydropic abortus

General

  • May be seen in the context of a previously detected fetal heart beat.

Microsopic

Features:

  • Enlarged chorionic villi with some cisterns.

DDx:[9]

  • Molar pregnancy.

Sign out

Submitted as "Retained Products of Conception":
- Small and large chorionic villi with cisterns, suggestive of hydropic abortus, see comment.
- Benign decidual tissue present.
- Negative for evidence of fetal tissue in sampled tissue, see comment.
 
Comment:
Imaging previously described a gestational sac and a fetal heart beat.

Partial hydatidiform mole

  • AKA partial mole.

General

Genetics:

  • Usually triploid (e.g. 69XXY).

Microscopic

Features:

  • Abnormal chorionic villi.
    • Villi too large (>0.1 mm ?).
    • Villi with cisterns.
      • Contain fluid in the centre, i.e. are "hydropic".
    • Villi with cytotrophoblastic inclusions.
      • Cytotrophoblast in the core of a villus (normally it is only at the surface of the villus).
  • May have fetal parts, such as nucleated RBCs.
  • Trophoblastic proliferation.
  • "Norwegian fjord periphery"[5] - jagged border / irregular sawtooth-like periphery.
    • Complete moles tend to have a smooth border

DDx:

Images:

IHC

Features:[11]

  • Ki-67 ~ 25+/-5% of cytotrophoblasts and intermediate trophoblasts.
    • Hydropic abortus ~ 5+/-1%.
  • p53 ~ 22+/-12% of cytotrophoblasts and intermediate trophoblasts.
    • Hydropic abortus ~ 5+/-3%.

Complete hydatidiform mole

  • AKA complete mole, AKA classic mole.

General

Epidemiology:

Genetics:

  • Diploid - most are 46XX.
  • Male derived, i.e. arise from DNA in sperm; empty egg fertilized.

Gross/Radiology

  • "Snowstorm" appearance on ultrasound.[13]
  • May be described as "grape-like" on gross exam.[14]

Image:

Microscopic

Features:

  • No normal villi.
  • No fetal parts seen.
    • Very rarely nucleated RBCs.

Images

  • Complete mole and intermediate trophoblast - intermed. mag. (WC)

  • Complete mole - low mag. (WC)

  • Complete mole - high mag. (WC)

Invasive hydatidiform mole

  • AKA invasive mole.
  • AKA chorioadenoma destruens.[15]

General

Microscopic

Features:

  • Chorionic villi - abnormal +/- normal.
  • Trophoblastic cells within uterine muscle +/- vessels - key feature.

DDx:

Images

  • Invasive mole - very low mag. (WC)

  • Invasive mole - low mag. (WC)

  • Invasive mole - intermed. mag. (WC)

  • Invasive mole - high mag. (WC)

  • Invasive mole - very high mag. (WC)

Entities - intermediate trophoblast

Entity Key feature Other histologic features IHC DDx Other Image
Placental site nodule (PSN) paucicellular, hyaline material no mitotic activity p16 -ve, MIB1 low EPS, squamous carcinoma post-partum
PSN. (WC)
(ijpmonline.org)
Exaggerated placental site (EPS) abundant intermediate trophoblasts - between muscle no mitotic activity MIB1 ~0% PSTT, PSN post-partum Image?
Placental site trophoblastic tumour (PSTT) abundant cytoplasm - not clear, dyscohesive +/-multinucleation MIB1 high, p63 -ve, CD146 +ve EPS, choriocarcinoma Other? (webpathology.com)
Epithelioid trophoblastic tumour (ETT) nests of cells in hyaline stroma eosinophilic cytoplasm, central nucleus MIB1 low, p63 +ve, CD146 -ve squamous carcinoma Other? (webpathology.com)
Choriocarcinoma polygonal cells with clear cytoplasm (cytotrophoblasts) multinucleated cells with smudged nuclei (syncytiotrophoblasts), no chorionic villi beta-hCG +ve, p63 +ve invasive hydatidiform mole, PSTT elevated beta-hCG (serum); not intermediate trophoblast derived.
Choriocarcinoma. (WC)
(webpathology.com)

Placental site nodule

  • Abbreviated PSN.
Main article: Placental site nodule

Exaggerated placental site

  • Abbreviated EPS.
  • Previously known as syncytial endometritis.[16]
Main article: Exaggerated placental site

Placental site trophoblastic tumour

  • Abbreviated PSTT.
  • Malignant counterpart of exaggerated placental site (abbreviated EPS).

General

  • Derived from intermediate trophoblast.
  • Follows pregnancy.
  • May be associated with nephrotic syndrome[17] with granular IgM staining.[18]

Clinical:

  • Raised (serum) beta-hCG - but usually not has high as in choriocarcinoma.
    • In ~70% < 1000 IU/L.[19]
    • In a series of 55 cases the average beta-hCG was ~700 IU/L.[20]
  • Prognosis dependent on time of diagnosis from last pregnancy.
    • <48 months = good prognosis.[19]

Microscopic

Features:

  • Large cells:
    • Nuclear pleomorphism.
    • Cytoplasm:
      • Abundant.
      • Solid, i.e. not vesicular.
      • Light basophilic, not clear - key feature.
    • NC ratio ~ normal.
  • +/-Multinucleated cells.
  • Ectatic blood vessels.

Note:

DDx:

Images:

IHC

Features:[22]

  • CD146 +ve.
  • p63 -ve.
  • Ki-67 ~14+/-7%.
    • Choriocarcinoma ~69+/-20%.

Epithelioid trophoblastic tumour

  • Abbreviated ETT.

General

  • Often in endocervix.
  • Malignant counterpart of placental site nodule or PSN.

Clinical:

  • Vaginal bleeding.
  • Elevated beta-hCG.

Gross

Features:[23]

  • Solid mass.
  • Flesh-like appearance.

Image:

Microscopic

Features:[24]

  • Architecture: nests in hyaline matrix.
  • Cytoplasm: abundant, eosinophilic.

DDx:

Images:

IHC

Features:[25]

  • Cyclin E +ve (nuclear).
  • p16 -ve.
    • +ve (nuclear) in squamous cell carcinoma of the cervix.

Others:

  • HMCK -ve.
    • SCC +ve.

Note:

  • p63 not useful... +ve in both SCC and ETT.

See also

References

  1. ↑ URL: http://dictionary.reference.com/browse/hydatid.
  2. ↑ URL: http://www.ihcworld.com/_newsletter/2003/focus_mar_2003.pdf. Accessed on: 28 May 2011.
  3. ↑ Chen, Y.; Shen, D.; Gu, Y.; Zhong, P.; Xie, J.; Song, Q. (Mar 2012). "The diagnostic value of Ki-67, P53 and P63 in distinguishing partial Hydatidiform mole from hydropic abortion.". Wien Klin Wochenschr 124 (5-6): 184-7. doi:10.1007/s00508-011-0119-4. PMID 22218717.
  4. ↑ URL: http://pathologyoutlines.com/placenta.html#hydatgeneral.
  5. ↑ 5.0 5.1 Howat, AJ.; Beck, S.; Fox, H.; Harris, SC.; Hill, AS.; Nicholson, CM.; Williams, RA. (Jul 1993). "Can histopathologists reliably diagnose molar pregnancy?". J Clin Pathol 46 (7): 599-602. PMID 8157742. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC501384/?page=3.
  6. ↑ Merchant SH, Amin MB, Viswanatha DS, Malhotra RK, Moehlenkamp C, Joste NE (February 2005). "p57KIP2 immunohistochemistry in early molar pregnancies: emphasis on its complementary role in the differential diagnosis of hydropic abortuses". Hum. Pathol. 36 (2): 180–6. doi:10.1016/j.humpath.2004.12.007. PMID 15754295.
  7. ↑ 7.0 7.1 Fukunaga, M. (Dec 2002). "Immunohistochemical characterization of p57(KIP2) expression in early hydatidiform moles.". Hum Pathol 33 (12): 1188-92. doi:10.1053/hupa.2002.129421. PMID 12514787.
  8. ↑ http://jcp.bmjjournals.com/cgi/reprint/51/6/438.pdf
  9. ↑ Rios-Doria E, Pennington KP, Reiter DJ, Parker EU (September 2023). "Diagnostic challenges in differentiating between hydropic abortus, and complete and partial hydatidiform molar pregnancies in early gestation". Int J Gynecol Cancer 33 (9): 1482–1484. doi:10.1136/ijgc-2022-004104. PMID 37268312.
  10. ↑ URL: http://pathologyoutlines.com/placenta.html#incompletemole. Accessed on: 9 August 2011.
  11. ↑ Chen, Y.; Shen, D.; Gu, Y.; Zhong, P.; Xie, J.; Song, Q. (Mar 2012). "The diagnostic value of Ki-67, P53 and P63 in distinguishing partial Hydatidiform mole from hydropic abortion.". Wien Klin Wochenschr 124 (5-6): 184-7. doi:10.1007/s00508-011-0119-4. PMID 22218717.
  12. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1111. ISBN 0-7216-0187-1.
  13. ↑ URL:http://www.jultrasoundmed.org/cgi/content/abstract/18/9/589. Accessed on: 27 July 2010.
  14. ↑ Abike, F.; Temizkan, O.; Payasli, A.; Avsar, F.; Karahan, N.; Baspinar, S. (Jan 2008). "Postmenopausal complete hydatidiform mole: a case report.". Maturitas 59 (1): 95-8. doi:10.1016/j.maturitas.2007.10.005. PMID 18162339.
  15. ↑ McDonald, TW.; Ruffolo, EH. (Feb 1983). "Modern management of gestational trophoblastic disease.". Obstet Gynecol Surv 38 (2): 67-83. PMID 6300738.
  16. ↑ URL: http://www.webpathology.com/image.asp?case=565&n=7. Accessed on: 22 May 2014.
  17. ↑ Bonazzi, C.; Urso, M.; Dell'Anna, T.; Sacco, S.; Buda, A.; Cantú, MG. (Aug 2004). "Placental site trophoblastic tumor: an overview.". J Reprod Med 49 (8): 585-8. PMID 15457847.
  18. ↑ Komatsuda, A.; Nakamoto, Y.; Asakura, K.; Yasuda, T.; Imai, H.; Miura, AB. (May 1992). "Case report: nephrotic syndrome associated with a total hydatidiform mole.". Am J Med Sci 303 (5): 309-12. PMID 1580319.
  19. ↑ 19.0 19.1 Schmid, P.; Nagai, Y.; Agarwal, R.; Hancock, B.; Savage, PM.; Sebire, NJ.; Lindsay, I.; Wells, M. et al. (Jul 2009). "Prognostic markers and long-term outcome of placental-site trophoblastic tumours: a retrospective observational study.". Lancet 374 (9683): 48-55. doi:10.1016/S0140-6736(09)60618-8. PMID 19552948.
  20. ↑ Baergen, RN.; Rutgers, JL.; Young, RH.; Osann, K.; Scully, RE. (Mar 2006). "Placental site trophoblastic tumor: A study of 55 cases and review of the literature emphasizing factors of prognostic significance.". Gynecol Oncol 100 (3): 511-20. doi:10.1016/j.ygyno.2005.08.058. PMID 16246400.
  21. ↑ URL: http://www.webpathology.com/image.asp?n=3&Case=588. Accessed on: 1 January 2012.
  22. ↑ Shih, IM.; Kurman, RJ. (Jan 1998). "Ki-67 labeling index in the differential diagnosis of exaggerated placental site, placental site trophoblastic tumor, and choriocarcinoma: a double immunohistochemical staining technique using Ki-67 and Mel-CAM antibodies.". Hum Pathol 29 (1): 27-33. PMID 9445130.
  23. ↑ Fadare, O.; Parkash, V.; Carcangiu, ML.; Hui, P. (Jan 2006). "Epithelioid trophoblastic tumor: clinicopathological features with an emphasis on uterine cervical involvement.". Mod Pathol 19 (1): 75-82. doi:10.1038/modpathol.3800485. PMID 16258513.
  24. ↑ 24.0 24.1 URL: http://www.webpathology.com/image.asp?case=589&n=2. Accessed on: 15 August 2011.
  25. ↑ Mao, TL.; Seidman, JD.; Kurman, RJ.; Shih, IeM. (Sep 2006). "Cyclin E and p16 immunoreactivity in epithelioid trophoblastic tumor--an aid in differential diagnosis.". Am J Surg Pathol 30 (9): 1105-10. doi:10.1097/01.pas.0000209854.28282.87. PMID 16931955.
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