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Pediatric and Developmental Pathology 6, 69–77, 2002 DOI: 10.1007/s10024-002-0079-9 © 2002 Society for Pediatric Pathology

REVIEW

Histopathological Diagnosis of Partial and Complete Hydatidiform Mole in the First Trimester of Pregnancy

NEIL J. SEBIRE, * ROSEMARY A. FISHER, AND HELENE C. REES

Department of Histopathology, Trophoblastic Disease Unit, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK

Received July 31, 2002; accepted October 10, 2002; published online December 10, 2002.

ABSTRACT

The diagnosis of molar pregnancy is a continuing diagnos- tic problem for many practicing histopathologists who are required to examine specimens of products of conception, particularly since changes in gynecological management in recent years have resulted in uterine evacuation at earlier gestations. The aim of this review is to provide practical, up-to-date, diagnostically useful information regarding the histological diagnosis of molar disease in early pregnancy. Pathophysiological issues relevant to molar pregnancies, such as genetic abnormalities, will be briefly summarized, but nonhistopathological aspects of molar disease will not be covered in detail in this review.

Key words: complete mole, hydatidiform mole, partial mole, trophoblastic disease

INTRODUCTION

Hydatidiform moles (HM) are abnormal conceptions, which occur in about 1 in 500–1000 pregnancies [1]. Pathological and cytogenetic studies have demonstrated that molar pregnancies may be either of two distinct subtypes, complete and partial hydatidiform mole. Com- plete moles (CM) are usually diploid and androgenetic, pathologically demonstrating minimal embryonal devel- opment with hydropic chorionic villi and trophoblastic hyperplasia, while partial moles (PM) are usually pater-

*Corresponding author, e-mail: njsebire@hotmail.com

nally derived triploid conceptions in which embryonal development occurs in association with trophoblastic hyperplasia [2,3]. The conceptus in molar pregnancies is almost always nonviable and, following diagnosis, molar tissue is evacuated from the uterus by surgical curettage and the patient followed up with serial serum and/or urine human chorionic gonadotropin (hCG) estimations [4]. In the United Kingdom, all cases of hydatidiform mole since 1973 must be registered in a system jointly set up by the Royal College of Obstetricians and Gyne- cologists and the Department of Health [5]. The aims of registration are to facilitate monitoring of hCG levels following surgical evacuation, to provide optimal man- agement of persistent trophoblastic disease and to pro- vide information for patients and medical staff. Around 1200 patients are registered annually at three centers in London, Sheffield, and Dundee. Following registration, patients undergo hCG monitoring for either 6 months or 2 years depending on their hCG levels at 56 days poste- vacuation, and all women are requested to notify the center in all subsequent pregnancies for further hCG monitoring, since women with a history of hydatidiform mole are at increased risk of a molar pregnancy in future pregnancies [1].

Clinical importance of accurate diagnosis of partial and complete HM

Persistent gestational trophoblastic disease (pGTD), in- cluding overt malignancy such as choriocarcinoma, may

occur following any conception but the risk is signi- cantly higher following a pregnancy affected by PM or CM. Genetic analysis has now clearly conrmed that choriocarcinoma may arise from either a previous PM or CM, the risk being signicantly greater for CM [6,7]. pGTD in this scenario is usually recognized by either failure of the maternal serum hCG concentration (MShCG) to fall to normal levels, or a rising MShCG. In such cases, chemotherapeutic treatment, usually with methotrexate-based protocols, will lead to complete res- olution of disease with hCG levels returning to normal in most cases. In the United Kingdom, about 15% of preg- nancies complicated by CM, and 1% of pregnancies complicated by PM, will be affected by pGTD and re- quire chemotherapy [6]. In cases of pGTD in which the index pregnancy was either an unrecognized HM, or following an apparently normal pregnancy, presentation may either be with persistent vaginal bleeding or symp- toms/signs of metastatic choriocarcinoma, such as neu- rological abnormality [6]. Although the majority of cases of such advanced disease also respond well to chemo- therapy, the mortality rate is increased compared to pGTD detected at an earlier stage through MShCG screening.

Genetic studies in HM

CM have been shown to have a diploid 46,XX or 46,XY

karyotype while PM are usually triploid [8 10]. The ma- jority of CM are androgenetic in origin [11,12], all 46

chromosomes in the molar tissue being paternally de-

rived. Most CM are also monospermic and arise follow-

ing fertilization of an anucleate egg by a haploid sperm

which undergoes endoreduplication [1315], while ap-

proximately 20% are dispermic [16,17], arising by fertil- ization of an anucleate egg by two sperm [18]. Despite

the fact that the nuclear genome is androgenetic, the

mitochondrial DNA in CM, as in a normal conceptus, is maternally derived [19,20]. CM which are diploid but biparental, rather than androgenetic, in origin, although

rare, are now well recognized [17,2124]. These unusual

CM tend to be associated with recurrent HM or families

with several affected individuals [2224] and are thought to represent a familial form of CM. PM, which are trip- loid, usually arise as a result of fertilization of an ovum by two sperm [25,26] although fertilization of an egg by

a single diploid sperm cannot be excluded [27]. Occa- sional triploid or tetraploid CM have been reported as have tetraploid PM [28]. Again, these usually have an excess of paternal contributions, polyploid CM being androgenetic [28] while tetraploid PM have one mater-

nal and three paternal contributions to the genome

[29,30].

A small number of genes are transcribed only from the maternally or paternally inherited allele, the allele inher-

ited from the other parent being imprintedor silent

[31]. This phenomenon of genomic imprinting underlies

70 D. RAKHEJA ET AL.

the pathophysiology of HM. The characteristic tropho- blastic features of both androgenetic CM and PM are due to the presence of two paternal genomes. Digynic trip- loids, which have two maternal contributions to the nuclear genome, are not generally associated with molar pathology but instead have an abnormally small pla- centa and growth-retarded fetus [32]. In conceptions which have no maternal contribution to the nuclear genome, a CM develops, with trophoblastic hyperplasia

and little or no fetal development. In PM, the presence of

a maternal genome is associated with less trophoblastic

hyperplasia and a greater degree of fetal development. Thus overexpression of paternally transcribed genes is likely to play a role in the development of PM, while CM reect both overexpression of paternally transcribed and loss of maternally transcribed genes.

GENETIC DIAGNOSIS OF HM

Although diagnosis of molar pregnancy is usually possi- ble based on morphology alone, poor sampling, necrosis, and earlier uterine evacuations can make a pathological diagnosis difcult [33,34]. In such cases, other tech- niques may be required to make a rm diagnosis. Par- ticularly useful are those techniques that can be applied to xed material. Assessment of ploidy using in situ hybridization or, more usually, ow cytometry, may be used for distinguishing diploid CM from triploid PM [34 38]. However, examination of ploidy will not distin- guish between CM and diploid nonmolar products of conception. More recently, the products of imprinted genes have shown useful in the differential diagnosis of PM and CM. For example p57 KIP2 , the product of the cyclin dependent kinase inhibitor CDKN1C, shows high levels of expression in normal human placenta [39] but is repressed in the cytotrophoblast of CM [40]. Immu- nohistochemical staining with antibody to p57 KIP2 has been shown to be a reliable discriminator between CM and PM [41]. Since CM are the only type of conceptus to show repression of p57 KIP2 , this technique also permits

a distinction between CM and nonmolar products of

conception. However, none of these techniques distinguishes be- tween molar and nonmolar triploids, monospermic and dispermic CM, or androgenetic and biparental CM. To distinguish between these entities, the parental origin of the nuclear chromosomes needs to be determined. DNA polymorphisms, in particular microsatellite polymor- phisms [42,43], are highly informative genetic markers and, when used in conjunction with the polymerase chain reaction (PCR), can provide useful information regarding the parental origin of a sample even from small amounts of xed tissue from parafn blocks [44 48]. These types of genetic studies have been used to conrm a diagnosis of CM or PM, and to differentiate between a twin pregnancy with CM and coexistent nor- mal fetus from a PM. Analysis of DNA polymorphisms

can be used to differentiate between monospermic (ho-

mozygous) CM and dispermic (heterozygous), although

the clinical signicance of this distinction has yet to be

established. Most recently, molecular genetic diagnosis

has

been used to differentiate the rare diploid, biparental

CM

from the more usual androgenetic CM [2224]. It is

potentially clinically important to identify diploid, bipa-

rental CM, because patients with these have a particu- larly high risk of subsequent CM; in vitro fertilization techniques, used to avoid subsequent PM or androge- netic CM in patients with recurrent molar pregnancies [49], may not be successful for this group of patients.

Changes in clinical presentation in relation to diagnostic pathological features

Classically, HM presented as second trimester vaginal

bleeding, large for datesuterus, and spontaneous abor- tion with passage of vesicles per vaginum. Such preg- nancies may also be complicated by early onset pre- eclampsia and features of hyperthyroidism [50,51]. With changes in gynecological investigation and manage- ment, this classical presentation of pregnancies affected by HM is now highly unusual [52,53]. In Europe, the majority of clinically recognized pregnancies undergo a routine rst-trimester ultrasound examination at which time fetal number and viability are conrmed. Further- more, almost all pregnancies presenting with rst-tri- mester vaginal bleeding are investigated using transvag-

inal ultrasound examination. These changes in practice

have resulted in the majority of molar pregnancies being evacuated in the late rst trimester, either suspected as molar disease sonographically or, more commonly, sim- ply diagnosed sonographically as a nonviable pregnancy (missed abortion) [54]. In a study of 194 consecutive cases of suspected PM or CM referred to the Charing Cross Trophoblastic Disease Centre, the sonographic di- agnosis was that of a missed abortion/anembryonic pregnancy with no prenatal suspicion of molar preg- nancy in 131 (67%), referral being purely on the basis of routine histological examination of products of concep- tion. In 63 cases, however, ultrasound examination did suggest molar pregnancy; in 84% of these, the diagnosis of molar pregnancy was correct, the remainder being nonmolar hydropic abortions (HA), sonographically mimicking HM [55]. Overall, 58% of CM had a sono- graphic diagnosis of molar pregnancy compared to only 17% of partial moles, conrming that the majority of

HM now present as missed abortion/anembryonic preg-

nancy, highlighting the importance of routine histolog-

ical examination of products of conception to diagnose

gestational trophoblastic disease (GTD). Furthermore, since diagnosis/evacuation is now usually in the rst trimester of pregnancy, the classic pathological features previously described in cases persisting to the second trimester are no longer appropriate [52], and updated

pathological criteria are necessary, the discussion of which is the aim of this article.

Histopathological diagnostic features

There are several important questions which the his- topathologist must address when examining products of conception in the context of possible molar disease. The rst is to decide whether the chorionic villi show any morphological abnormalities other than those associ- ated with fetal demise. If there are abnormal villous features, do these indicate molar change or other non- molar abnormal conception such as fetal aneuploidy or mesenchymal dysplasia? Finally, if the features are those of HM, do they indicate CM or PM? Even the rst of these questions may sometimes be difcult to answer in clinical practice since the tissue examined may be lim- ited, either only a single block being submitted or pos- sibly several blocks which contain primarily decidua with only a few scattered chorionic villi present. In such circumstances, although only scanty villi may occasion- ally be adequate for the diagnosis of CM or PM, it must be accepted that it may be impossible to exclude a PM on histopathological grounds alone on the basis of limited material. It is not possible to be dogmatic regarding the number of chorionic villi required for a sample to be adequate,because in some cases, particularly those affected by CM, a condent diagnosis may be made on the basis of only a small number of villi, whereas in other cases, greater number of villi may be present but these may show much more subtle changes, the interpretation of which requires a more global assessment of the preg- nancy. In order to minimize such problems, any case of suspected molar disease, either clinically, sonographi- cally, or on the basis of routine histopathological exam- ination of products of conception, should have all tissue submitted for histopathological examination; if referral to a tertiary center is required, all such blocks/slides should be examined. Once appropriate criteria are used for the diagnosis of HM, even in products from the early rst trimester, the majority of cases of CM or PM in which adequate tissue is submitted for examination will be correctly identied. Some cases of possible PM, particularly those in whom there is limited material available, may require ancillary investigations such as karyotyping or ow cytometry in order to reach a denitive diagnosis. In the United King- dom, since this number represents only a small propor- tion of all cases referred for suspected CM or PM ( 4%) [56], in such cases a report may be issued stating the reasons for uncertainty and the most likely diagnosis, following which the patient is registered for MShCG follow up. In cases of nonmolar HA, the MShCG falls rapidly and, once normal levels are achieved, follow-up is curtailed. This policy will result in a small number of nonmolar cases receiving a short MShCG follow-up but minimizes the number of cases of PM which are not

CHIARI I MALFORMATION AND CYSTIC FIBROSIS

71

followed, and limits the workload and cost for laboratories performing ancillary molecular diagnostic techniques.

COMPLETE HYDATIDIFORM MOLE (CM)

Classical histopathological features

The entire specimen consists of large, vesicular chori- onic villi with extensive central cistern formation and marked circumferential trophoblastic hyperplasia. No fetal parts, fetal blood vessels, or nucleated fetal red blood cells (RBCs) are present.

First-trimester histopathological features

Numerous chorionic villi are usually present and may show an overall variation in size consistent with im- mature intermediate villi from early gestation. Scat-

tered larger, hydropic villi may be present but hydrops

is usually not marked in early pregnancy [56]. Simi-

larly, scattered villi with central cistern formation may

be seen but this also is not a constant feature, partic- ularly in cases with limited material. The villi show a highly characteristic buddingarchitecture (Figs. 1, 2), with focally marked mucoid/myxoid degeneration of the villous stroma, which may be enhanced using periodic acid-Schiff (PAS) staining. Within the stroma

of well-preserved villi, abundant nuclear karyorrhectic

debris is present; note that such debris may often be present within fetal vessels in nonmolar failed preg- nancies, only stromal debris is signicant for the di- agnosis of CM. Villi from cases of CM may often contain blood vessels in early pregnancy, usually col- lapsed, but very occasionally containing RBCs (Fig. 3). With advancing gestation, the frequency of identi- able vessels decreases [56]. Similarly, microscopic fragments of amnion may also be present in some rare cases of CM [57]. Presence of identiable fetal parts,

signicant amounts of amnion or large numbers of nucleated RBCs essentially excludes the diagnosis of CM, although the possibility of a twin pregnancy with

a CM and coexisting nonmolar conception must al-

ways be considered since such pregnancies require MShCG follow-up in the same manner as singleton CM. Finally, and most importantly, the diagnosis of molar disease requires the presence of abnormal tro- phoblast proliferation, recognized as more than two layers of trophoblast, often with nuclear pleomor- phism, forming circumferential masses. Even in early CM, there are usually areas of denite circumferential trophoblast hyperplasia (Fig. 4), and sheets of pleo- morphic extravillous trophoblast may also be present.

These fragments do not indicate the presence of cho- riocarcinoma and appear to have little prognostic sig- nicance other than aiding the diagnosis of CM [3]. Extravillous trophoblast invasion also appears disor- ganized in pregnancies affected by CM, many showing

a prominent implantation site with absence of the normal endovascular trophoblast population but

72 D. RAKHEJA ET AL.

orid interstitial extravillus trophoblast invasion, sometimes resulting in interstitial hemorrhage [58] (Fig. 5). Immunohistochemical staining may aid the diagnosis in some difcult cases (see section below).

PARTIAL HYDATIDIFORM MOLE (PM)

Classic histopathological features

Specimen comprises a mixture of two distinct popula- tions of villi, some morphologically normal, others dem- onstrating an irregular outline, villous edema, cistern formation, and trophoblast hyperplasia. Amnion and fe- tal parts can be present.

First-trimester histopathological features

Villi of varying sizes are usually present but these are of variable size and often demonstrate a spectrum rather than two distinct populations. Similar to the ndings with CM in the rst trimester, villous hydrops may be patchy and mild with only occasional scattered cisterns. The larger, hydropic villi may demonstrate an abnormal, irregular dentateoutline with cleft formation, and round or oval pseudoinclusions are often present in some villous cross-sections (Fig. 6). Amnion or fetal parts may be present and the chorionic villi usually demonstrate blood vessels often containing nucleated fetal red blood cells. In some cases, especially with ad- vancing gestation, angiomatoid change may be seen fo- cally, manifest as dilated thin-walled vessels within en- larged villi [56] (Fig. 7). Abnormal, nonpolar trophoblast hyperplasia is present, but this is almost always focal and less marked than in CM at this gestation, usually being multifocal rather than truly circumferential and sometimes demonstrating a lace-likeor vacuolated pattern. The villous stroma will show a mixture of hy- dropic change and stromal brosis in different villi, which is a useful feature since CM rarely exhibit signif- icant stromal brosis. The stroma of PM in well-pre- served villi does not exhibit signicant stromal karyor- rhectic debris (Fig. 8). The implantation site in cases of PM is usually unremarkable with endovascular tropho- blast population identiable.

NONMOLAR CONCEPTIONS (HYDROPIC ABORTIONS [HA])

First-trimester histopathological features

Villi of varying sizes may be present but there are usually no villi with marked enlargement. The majority of villi usually show hydropic change but with no well-formed cistern formation, and some smaller villi may be brotic. Most villi are hypovascular, some may show empty, col- lapsed vessels, others appear avascular. Occasional tro- phoblastic pseudoinclusions may be identied, includ- ing single cell inclusions, and scattered villi may show an irregular outline, particularly in cases of fetal nonmolar aneuploidy. Some villi may show normal polar cytotro-

Figure 1. First trimester complete mole (CM), demon- strating characteristic “ budding ” appearance of

Figure 1. First trimester complete mole (CM), demon- strating characteristic buddingappearance of the villi. Much of the trophoblast has been displaced from this villus.

Figure 2.

istic buddingappearance of the villi and mild tropho- blast hyperplasia.

Figure 3. First trimester CM, demonstrating presence of collapsed villous vessels. In products of conception from CM obtained in the first trimester, villous vessels are often identified.

Figure 4.

istic abnormal circumferential trophoblast hyperplasia.

Figure 5. Implantation site fragments from a pregnancy affected by CM, at 8 wk gestation, demonstrating presence of florid interstitial extravillous trophoblast invasion but lack of normal endovascular trophoblast “plugging,” with resultant interstitial hemorrhage.

First trimester CM, demonstrating character-

First trimester CM, demonstrating character-

Figure 6. First trimester partial mole (PM), demonstrat- ing chorionic villi with an irregular “dentate” outline and in which trophoblastic pseudoinclusions are present.

phoblastic cell column formation and occasionally small trophoblast budsare present, but there is no abnormal trophoblast hyperplasia (Fig. 9). The implantation site is

Figure 7. First trimester PM, demonstrating chorionic villi with villous vessels exhibiting “angiomatoid” change. This appearance is more common with advanc- ing gestational age.

Figure 8.

served chorionic villus with a prominent villous vessel but no stromal karyorrhectic debris.

First trimester PM, demonstrating a well-pre-

Figure 9. First trimester nonmolar hydropic abortion, demonstrating chorionic villi with polar trophoblastic cell columns but no abnormal trophoblast hyperplasia.

Figure 10. Products of conception from a first trimester failed pregnancy demonstrating presence of folded ges- tation sac which should not be confused with cistern formation.

Figure 11. First trimester chorionic villi from a PM, demonstrating positive nuclear immunostaining with p57 KIP2 , an imprinted gene product. Such cytotropho- blast and villus stromal staining is absent in cases of com- plete hydatidiform mole.

usually unremarkable, although in some cases may show features related to an underlying condition predisposing to the pregnancy loss.

CHIARI I MALFORMATION AND CYSTIC FIBROSIS

73

Table 1.

partial mole, and nonmolar hydropic abortion, in products of conception evacuated in the first trimester a

Main diagnostic histopathological features and differences between complete mole,

 

CM

PM

HA

Villous size

Varied

Varied

Uniform

Villous outline

Budding

Irregular

Smooth b

Villous stroma

Mucoid/myxoid

Fibrotic

Hydropic

Villous hydrops

Varied

Varied

Present

Cistern formation

Varied

Varied

None

Stromal karyorrhectic debris

Present

Absent

Absent

Villous vessels

Absent/collapsed

Present

Absent/collapsed

Nucleated red blood cells

Very rare

Present

Present

Trophoblast pseudoinclusions

Present

Present

Rare b

Trophoblast hyperplasia

Present

Present c

Polar

Extravillous trophoblast

Pleomorphic

Present

Absent

Implantation site

Florid d

Normal

Normal

Fetal parts/amnion

Absent

Present

Present

CM, complete mole; PM, partial mole; HA, nonmolar hydropic abortion. a The features are oversimplied in order to act as a guide only; please refer to the text for further discussion of individual features. b Cases of nonmolar fetal aneuploidy may demonstrate irregular, hydropic villi with pseudoinclusions, but no abnormal trophoblast hyperplasia is present. c Abnormal trophoblast hyperplasia may be focal and demonstrate a lace-likepattern around the villus. d Extravillous interstitial trophoblast invasion may appear orid but there is reduced normal endovascular trophoblast pluggingand interstitial hemorrhage may be seen.

The main diagnostic histopathological features and differences between CM, PM, and HA in products of conception evacuated in the rst trimester are summa- rized in Table 1.

PRACTICAL ISSUES IN HISTOPATHOLOGI- CAL EVALUATION OF PRODUCTS OF CONCEPTION

Limited material

As with all aspects of histopathology, sampling adequacy is of signicant importance with regard to diagnostic accuracy. In many cases of molar pregnancy, there may have been partial spontaneous uterine evacuation prior to curettage, or the diagnosis was not suspected by the referring clinician, therefore only limited material may be submitted for examination. In most cases, all material should be processed and examined, and all villi evalu- ated. It must be recognized that in cases with only few villi present, it may be impossible on histopathological grounds alone to reach a rm diagnosis; management must be pragmatic in such cases, if denitive ancillary investigations are not available.

Fetal vessels and nucleated red blood cells

The dogma that presence of fetal nucleated red blood cells or fetal vessels within villi excludes the possibility

74 D. RAKHEJA ET AL.

of a CM is now known to be incorrect when examining products of conception in the rst trimester [56], al- though this is a rare nding; it remains true that large numbers of nucleated red cells in villous vessels should make the diagnosis of CM questioned. In a previous study involving histological examination of 3180 molar conceptions, there were 60 cases (1.8%) with clear his- tological features of CM and a diploid chromosomal complement on ow cytometry, in which either fetal nucleated red cells or fragments of amnion were present in the sample [59]. In some of the cases, further exami- nation revealed the presence of a CM with possible twin, but in the remaining cases, there was no evidence of a twin and nucleated fetal red blood cells were present within the vessels of the molar villi. Therefore, it should be remembered that the nding of apparent fetal tissue with molar villi or nucleated red cells in fetal vessels is not sufcient to classify the case as PM, since it may represent either a twin pregnancy with CM, or abortive fetal development in CM. Such rare diploid moles with amnion or nucleated red cells present have histological appearances and prognosis otherwise similar to those of classicearly CM.

Trophoblast hyperplasia

Abnormal trophoblast hyperplasia is a requirement for the diagnosis of molar pregnancy. In most cases of CM,

the degree of hyperplasia is more marked compared to PM, although this in itself should not be used as a dis- tinguishing criterion, especially since villous trophoblast may be dislodged during evacuation and observed as extravilloustrophoblast sheets. The character of the proliferating trophoblast may vary from fairly mono- morphic sheets of apparent cytotrophoblast to a delicate lace-likebranching pattern of vacuolated trophoblast, particularly seen in some cases of PM. Furthermore, following surgical evacuation of retained products of conception (ERPC), particularly with PM, excessive tro- phoblast may be stripped from the villi resulting in only scanty villi remaining in which circumferential tropho- blast hyperplasia can be identied. Similarly, although not diagnostic per se, the presence of large amounts of extravillous trophoblast fragments should alert the pa- thologist to the possible presence of molar change, par- ticularly if marked trophoblast nuclear pleomorphism is present. A mimic of trophoblast hyperplasia may be seen where there is perivillous brin deposition present. This can result in separation of the syncytiotrophoblast from the villous core with secondary cytotrophoblast prolifer- ation. For the purposes of diagnosis of molar disease, trophoblastic hyperplasia should not be based solely on villi in which perivillous brin deposition is present.

Villous hydrops

In the older literature, villous hydrops was the most striking feature of products of conception affected by molar disease. As previously stated, in rst trimester specimens, the degree of villous hydrops may be much less marked and patchy, with both CM and PM. En- larged hydropic villi in molar pregnancies usually show an irregular outline and other features of GTD, whereas in cases of HA, the enlarged villi are usually more circu- lar in cross section with hypocellular villous cores and trophoblast attenuation. Occasionally, fragments of ges- tation sac may become folded with the appearance of a central cell-free area, which may be misinterpreted as a villous cistern. Gestation sac demonstrates a denser col- lagenous stroma, and no trophoblast hyperplasia is usu- ally present (Fig. 10).

Trophoblast pseudoinclusions

Cases of both CM and PM usually demonstrate villous trophoblastic pseudoinclusions from an early gestation. In CM the inclusions are irregular in shape and scat- tered, whereas in PM, they are often more regular, round or oval in shape, and more widespread. The presence of villous pseudoinclusions should raise the possibility of molar disease but may indicate other pregnancy pathol- ogies, particularly nonmolar fetal aneuploidy. Both gy- negenetic triploidy and a range of fetal trisomies may be associated with the presence of villous pseudoinclusions, irregular and abnormally shaped villi, and mild hydropic

change. Therefore, in cases with sufcient material for assessment in which some features of possible PM are identied but where there is no nonpolar trophoblast hyperplasia, the presence of nonandrogenetic triploid, fetal aneuploidy should be considered.

Pseudopartial mole/stem villous hydrops

A relatively recently described condition, known as pla- cental mesenchymal dysplasia (PMD), pseudopartial mole or stem villous hydrops, may be diagnostically confused with PM since there may be marked villous hydropic change in association with a raised MShCG during the pregnancy [60]. However, in cases of PMD, the fetus is usually normally formed and the pregnancy progresses to the third trimester. Histologically, there is marked stem villous hydrops, often with associated pe- ripheral chorioangiomatoid change, but no trophoblas- tic hyperplasia is present [61]. The fetus and placenta demonstrate a diploid karyotype and, in most cases, it appears that the infant is phenotypically normal, al- though there is an association between PMD and Beck- with-Wiedemann syndrome. Suspicion of this condition should be raised in any case of apparent PM associated with a phenotypically normal fetus in the third trimes- ter.

Immunohistochemistry

The basis for the diagnosis of CM and PM remains detailed examination of tissue morphology on routine hematoxylin and eosin (H&E) stained sections. Addi- tional special stains may be carried out to highlight certain aspects of the microanatomy, such as trichrome stains for collagen, but these have not been shown to provide useful additional diagnostic information. Immu- nohistochemical methods may be used to identify tro- phoblast and dene the hormonal prole of the tissue but, in contrast to the case with gestational trophoblastic tumors, in molar pregnancy this does not provide clues to the differential diagnoses [52]. Immunomarkers of cell proliferation, such as PCNA and Ki67, have also been examined in this context, and similarly have been reported to be of little practical use in differentiating between HA, CM, and PM [62,63]. Recently, the expres- sion of cell cycle control proteins has been examined, and E2F-1 and cyclin E reported to be upregulated in molar tissue [64]. The most useful immunohistochemi- cal marker, however, appears to be related to the fact that molar pregnancies are associated with imprinting abnormalities. p57 KIP2 is a gene expressed predomi- nantly from the maternal allele in most tissues; p57 KIP2 expression in cytotrophoblast and villous mesenchyme is markedly reduced or absent in CM compared with strong expression in both PM and HA [41] and may, therefore, be useful in the rare cases in which the main differential diagnosis is between CM and PM, rather than PM and HA (Fig. 11). At present, immunohisto-

CHIARI I MALFORMATION AND CYSTIC FIBROSIS

75

chemical techniques remain potentially useful adjuncts to morphological diagnosis in molar disease.

CONCLUSIONS

Changing clinical management of early pregnancy com- plications has resulted in the majority of complete and partial hydatidiform moles being evacuated in the rst or early second trimester, at which time the histopatho- logical diagnostic criteria may be different from those classically described at later gestations. Recognition of these specic features allows a condent histopatholog- ical diagnosis to be made in most cases. The use of ancillary techniques, such as ow cytometry, immuno- histochemistry, and molecular studies, will usually facil- itate the diagnosis in cases where the morphological features are inconclusive.

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