Diagnostic Accuracy of H&E stained

Biopsy in Differentiation of

Hydatidiform Mole

Kywe Pyae Wai 1, Saw Wut Hmone 2 , Nyo Me May Thyn 3, Win Naing 4

12 ND Yr M.Med.Sc (Pathology) , Department of Pathology, UMMG

2 Department of Pathology, UM 1

3 Department of Pathology, UM 2

4 Department of Pathology, UMM

Presentation Outlines 1. INTRODUCTION

2. OBJECTIVES

3. MATERIALS AND METHODS

4. RESULTS

5. DICUSSION

6. CONCLUSION

7. RECOMMANDATION

8. REFERENCES

9. ACKNOWLEDGEMENT

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INTRODUCTION

Hydatidiform mole

Hydatidiform mole is an abnormal

gestational condition characterized by

significant hydropic enlargement and

variable trophoblastic proliferation

involving part or all of the chorionic villi

(Pirog and Ellenson, 2015).

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Histopathological diagnosis and

classification of hydatidiform mole has

become increasingly difficult because

hydatidiform moles are now commonly

evacuated at an earlier stage and do not

satisfy the well-established classic

morphological features (Romaguera et al.,

2004).

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Differentiating and classification of

complete mole and partial mole is

important for both clinical practice and

investigational studies because the risk of

choriocarcinoma is higher after complete

mole (Pirog and Ellenson, 2015).

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The differentiation between complete

mole and partial mole by this H&E

method alone is not sufficient for some

cases because of inter-observer variability

and suboptimal diagnostic reproducibility

(Romaguera et al., 2004).

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Immunohistochemistry is widely used for

confirmation of histological diagnosis

because it is effective, cheaper than other

advanced molecular techniques and with

high accuracy.

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Nowadays, the immunostaining of P57

becomes a recognized marker to adjunct the

classification of hydatidiform mole in the

absence of fascilities for genotyping.

P57 immunostaining is an in situ technique

performed on paraffin-embedded tissues and

the results are easy to interpret (Samadder

and Kar, 2015).

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The lack of P57 activity can lead to a loss

of cell cycle control, which results

abnormal proliferation and differentiation

of trophoblasts in complete mole.

Therefore, the P57 is not expressed in

complete mole and expressed in partial

mole (Luchini et al., 2016).

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The specificity of P57 is 97-100% in

complete hydatidiform mole and 93-95% in

partial hydatidiform mole (Luchini et al.,

2016).

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OBJECTIVES

General Objective

To study the diagnostic accuracy of H&E

stained biopsy in differentiation of

Hydatidiform mole

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Specific Objectives

1. To differentiate complete and partial hydatidiform mole by H&E-stained biopsy

2. To differentiate complete and partial hydatidiform mole by P57 immunohistochemical marker

3. To compare the diagnostic values of the two methods in differentiation of hydatidiform mole

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MATERIALS AND METHODS

Study Design - a cross-sectional, descriptive study.

From July, 2018 to June, 2019

Study Area

1.Gynaecological Units (MRH) and (MTH)

2. Department of Pathology, and (MTH)

3.Common Research Laboratory, UMMG

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The sample size was calculated by the

following formula

Sample size n = Z2α/2 p*(1-p*)/d2

(Daniel, 2008)

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Fifty-one cases of newly diagnosed cases

of Hydatidiform mole were included

explanation to the patients

taking informed consents

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The biopsied samples sent to the Pathology

Department were fixed in 10% buffered

formalin saline.

After adequate fixation, tissue processing

and proper paraffin wax embedding, all the

tissues sections were stained with

Hematoxylin and Eosin.

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Classification of hydatidiform mole was

done according to histological findings

under the ordinary light microscope.

Confirmed cases of hydatidiform mole

were selected and proceeded for

immunohistochemical method.

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Then paraffin wax embedded tissue blocks

were proceeded for IHC staining with P57

monoclonal antibody (Mouse monoclonal

antibody for human P57KIP2protein,

Thermoscientific Ltd) by using

Peroxidase-antiperoxidase technique.

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Dark brown to black nuclear staining of more

than 10% of villous mesenchyme and

cytotrophoblastic cells were regarded as

positive P57 immunoexpression.

Less than 10% as negative P57

immunoexpression.

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Positive control (placenta) and negative

control (without adding primary antibody)

were included in each run.

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After getting the results of H&E method

and P57 IHC method, comparison of the

diagnostic values of the two methods in

differentiation of hydatidiform mole were

done and found out the final diagnosis of

hydatidiform mole.

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Then the diagnostic accuracy of H&E

stained biopsy was determined in

comparison with P57 IHC method.

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RESULTS

0%

5%

10%

15%

20%

25%

30%

35%

under 20years 21-30years 31-40 years over 40 years

Age distribution of patients with hydatidiform mole

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H&E-stained

biopsy Number of

cases

Percentage

%

Complete mole

8 16%

Partial mole 43 84%

Total 51 100%

Distribution of H&E-stained biopsy in H mole

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Distribution of P57immunoexpression in the studied

cases

(44/51)86%

(7/51)14%

Positive expression

Negative expression

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Clinical

diagnosis

Final diagnosis

Complete mole

H&E

diagnosis

P57 IHC

Complete

mole

8 6

Partial

mole

- 2

Total 8 8

Comparison of the diagnostic values of H&E-stained biopsy and

P57 IHC marker in differentiation of hydatidiform mole

(for complete mole)

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Clinical

diagnosis

Final diagnosis

Partial mole

H&E

diagnosis

P57 IHC

Complete

mole

- 1

Partial mole 43 42

Total 43 43

Comparison of the diagnostic values of H&E-stained biopsy and

P57 IHC marker in differentiation of hydatidiform mole

(for partial mole)

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Complete Hydatidiform mole (H&E 40X)

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Complete Hydatidiform mole showing negative P57

immunoexpression 40X

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Partial Hydatidiform mole (H&E 40X)

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Partial Hydatidiform mole showing positive P57 immunoexpression

40X

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DICUSSION

Histological morphology yields an

accurate diagnosis in the majority of

hydatidiform mole by routine H&E

sections.

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However, sometimes making a diagnosis

can be problematic based on morphology alone, when distinguishing between complete mole and partial mole.

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P57 immunohistochemical detection of

nuclear staining of cytotrophoblasts and

villous mesenchymal cells was an effective

method for differentiation and accurate

diagnosis.

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In this study, among 51 cases of

hydatidiform mole, distribution of H&E-

stained biopsy shows 8 cases (16%) were

complete mole and 43 cases (84%) were

partial mole.

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Immunoexpression of P57 in complete

mole were 14% (7/51) and in partial mole

were 86% (44/51).

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Among 8 cases of complete mole

diagnosed by H&E staining, 6 cases were

confirmed by negative staining of P57

(75% (6/8)) but 2 cases were found to be

P57 positive, the final diagnosis became

partial mole.

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The study done by Diwa et al in 2016, P57

immunoexpression was observed in only 1

(2%) of the 54 cases diagnosed as partial

mole.

All 68 (100%) cases diagnosed as

complete mole were negative for P57

immunoexpression (Diwa et al., 2016).

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Out of 43 cases of partial mole diagnosed

by H&E staining, 42 cases were confirmed

by positive staining of P57 (98% (42/43))

but only 1 case showed P57 negative

staining and final diagnosis was found to

be a complete mole (p<0.0001).

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CONCLUSION

According to the findings in this study, P57

IHC is likely to be useful in differentiating

complete mole from partial mole.

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Therefore, P57 is a sensitive and specific

IHC marker which should be used to

differentiate complete mole and partial

mole in problematic cases.

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RECOMMANDATION

The results from the present study may

help for further studies, and prospective

study with longer study period and larger

population of patients are suggested to get

more clinically useful data.

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Furthermore, cytogenetic studies and

molecular studies on hydatidiform mole

should be introduced in Myanmar to get

better diagnosis and better management of

hydatidiform mole cases.

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REFERENCES

1. Diwa, M. H., Kim, M. A., Avila, J. M. C., Pedroza, D.G. and Michelle, A.

M. (2016) Utility of P57KIP2 and Her-2 Fluorescence in Situ

Hybridization in Differentiating Partial from CopleteHydatidiform Mole.

ACTA MEDICA PHILIPPINA.50(4), pp.318-325.

2. IHC World (2012) Introduction to IHC technique[online].Online

information Center For Immunohistochemistory. Available from

:http://www.ihcworld.com/ Introduction.hmt [Accessed on 9th June

2017].

3. Lee, C., Smith, H. O. and Kim, S. J. (2009). Epidemiology, In: Hancock,

B. W, Berkowitz, R. S, Seckl, M, Cole, L. A (eds). Gestational

trophoblastic disease 3rd ed. International Society for the study of

Trophoblastic Disease, Sheffield, pp.49-96.

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REFERENCES

4.Lelic, M., Fatusic, Z., Iijazovic, E., Ramic, S., Markovic, S.,

Alicelebic, S. (2017), Challenges in the Routine Praxis Diagnosis of

Hydatidiform Mole; a Tertiary Health Center Experience, MED

ARCH.2017 AUG; 71 (4) pp.256-260.

5. Madi, J. M, Braga, A. R., Paganella, M. P., Litvin, I. E., and

Wendland, E. M. D. R., (2016), Accuracy of p57 KIP2compared with

genotyping for the diagnosis of complete hydatidiform mole;

protocol for a systematic review and meta-analysis, Systematic

Reviews (2016) 5:169, pp 1-6.

6. Pirog, E. C. and Ellenson, L. H. (2015) Gestational Trophoblastic

Disease. In:Kumar,V., Abbas, A.K. and Aster, J.C. (eds.) Robbins

and Cotran Pathologic Basis of Disease. 9thedn. Philadelphia:

Elsevier, pp.1039-1042.

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REFERENCES

7. Romaguera, R. L, Maria, M., Rodriguez Jocelyn, H. Bruce, Zuluaga,

T.,Viciana, A., Manuel, A.Penalver and Nadji, M. (2004) Molar

Gestations and Hydropic Abortions Differentiated by P57

Immunostaining,Fetal and Pediatric Pathology, pp.1-11.

8. Rosai, J (2011) Female Reproductive System (pregnancy, trophoblastic

disease and placenta). Rosai and Ackerman’s Surgical Pathology,

10thedn. St. Louis: Mosby, pp.1639-1641.

9. Samadder, A. and Kar, R. (2015) Utility of P57 immunohistochemistry

in differentiating between complete mole, partial mole & non-molar

or hydropic abortus.Indian J Med Res 145, January 2017, pp.133-

137.

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REFERENCES

10. Su-Thandar-Han (2011) Outcome of Women who had Hydatidiform

Mole after Surgical Evacuation in Central Women's Hospital

(Yangon); M.Med.Sc (OG) Dissertaion, University of Medicine (1),

Yangon.

11. Toe-Toe-Win (2005) A study of Risk Factors for Hydatidiform Mole

in North Okkalapa General Hospital: M.Med.Sc (OG)

Dissertation,University of Medicine (2), Yangon.

12. Yi-Yi-Lwin (2014) Clinical Profile Of Hydatidiform Mole In

Teaching Hospitals Of University Of Medicine, Magway: M.Med.Sc

(OG) Dissertation,University Of Medicine, Magway.

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ACKNOWLEDGEMENT

Rector Prof Dr Htay Hla (Rector,

University of Medicine, Magway)

Prof Dr Nwe Mar Tun (Professor and

Head, Department of Obstetrics and

Gynaecology, UM1)

Department of Medical Research

(External Grant) for Financial Support

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THANK YOU VERY MUCH FOR YOUR KIND ATTENTION

? ? Any Questions

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