Dear folks,
Thank you very much for your responses. Your suggestions and the papers you recommended are very helpful. Now I have some updated info. THe patient had a sex on Jan. 1 and had some bloody discharge in the middle of Jan. Her serum beta-hCG today (Feb. 7) is 45 UI/L and 27 UI/L (positive) in Urine, not as we expected back to normal.
I read a paper written by Dr. William M. Rich, Clinical professor of Obstetrics and Gynaecology, University of California. It is indicated that "After a mole pregnancy, B-HCG may be in the millions and has to be fall to less than 2. Usually the blood test is normal within 12weeks. then it is repeated every month for 3 months and then every other month until it has been normal for 6 months". With respect to the above statement, I agree with most colleagues opinion that it is a case of persistent gestational trophoblastic disease, especially when Dr. David Alter mentioned beta-hCG can be in this lower range, even though it is commonly greater than 100 UI/L. If this is the case, I think it is a great idea, as Dr. Joel Lavoie's from Montreal mentioned, that a gray zone for beta-hCG (6-25UI/L) should be established and the clinician calls the lab before a costly investigation starts.
Weekly Beta-hCG will be followed up for the patient. Are there any other suggestions or comments please? I will keep you all informed If anything exciting is coming up.
Amy Lou
> Subject: FW: Canadian ?ectopic
> Date: Tue, 5 Feb 2008 18:17:10 +0000
> From: [log in to unmask]
> To: [log in to unmask]
> CC: [log in to unmask]
>
> Dear Dr Lou,
>
> Hugh Mitchell has forwarded your email to me for comment together with a
> graph which he has put together of the hCG results against time. It is
> difficult to be sure exactly what has happened here, but you are right
> in thinking that this is real hCG as you have measured on two separate
> hCG assays and I am not surprised that it is normal in urine as the
> serum levels are now so low. So what is going on? Out of the several
> possibilities, the nicest one would be a further failing pregnancy or
> spontaneously resolving episode of GTD ie a molar pregnancy.
> Pragmatically, in the face of a falling hCG, we would simply monitor her
> until the hCG is normal assuming that there is nothing to see on Doppler
> ultrasound of the pelvis and/or MRI pelvis. If the latter shows an
> obvious lesion and/or the hCG remains elevated then further
> investigation would seem reasonable to exclude an underlying malignancy
> or failing pregnancy. You may find our paper published in Gynae Oncol
> last year to be helpful as it sets out a plan of investigation for women
> with unexplained elevated hCG. I have attached it to this email. Could
> you let us know what happens?
>
> With kind regards,
>
> Michael Seckl
>
> Professor Michael Seckl PhD FRCP
> Director of the Charing Cross GTD Centre
> Charing Cross Campus of Imperial College Hospitals NHS Trust
> Fulham Palace Rd London W68RF, UK
> Tel: 44-20-8846-1421 (PA Carol Sammut)
> Email: [log in to unmask]
>
>
>
> -----Original Message-----
> From: Hugh Mitchell [mailto:[log in to unmask]]
> Sent: 05 February 2008 12:29
> To: Seckl, Michael
> Cc: [log in to unmask]
> Subject: Canadian ?ectopic
>
> FIRST EMAIL SENT TO ACB MAILBASE
> Dear colleagues,
> Here is an interesting case. Any suggestions please?
>
> 21-yrs old patient was diagnosed with ectopic pregnancy and got
> surgery done on Oct.25. Pathological examination indicated a small
> focus of unremarkable implantation site to fallopian tube and no
> chorionic villi. beta-hCG level has been monitored and shown as
> following:
>
> Nov. 1/07 32 IU/L
> Nov.13/07 2
> Jan.10/08 14
> Jan.14/08 19
> Jan.20/08 16
> Jan.31/08 8
>
> The reference range of beta-hCG for non-pregnancy women is <5 IU/L.
> To rule out false positive hCG, The serum specimen of Jan.31 was done
> on both Architect and Roche analyzers and the result was 8.16 and
> 8.79 respectively. Random urine hCG on Jan 31was also performed and
> the result was <1.2 IU/L (undetectable).
>
> How do we interpret these hCG results? Are these hCG results false
> positive (Jan10-Jan 31)? Is tumor considered for this patient? Are
> there any suggestions for further investigation?
>
> Dr. Amy Lou
> Clinical Chemist
> Department of Laboratory Medicine
> Queen Elizabeth Hospital
> Charllottetown, PE. Canada
>
> REPLY #1
> Ask the clinician to consider the entity
> Persistent Gestational Trophoblastic Disease.
> It has persistent elevated levels of beta hCG in this range.
> I have seen two cases and can refer literature.
>
> David Alter, MD
> Clinical/ Chemical Pathologist
> Pathology and Laboratory Medicine
> Spectrum Health - Blodgett
> 1840 Wealthy ST SE
> Grand Rapids, MI 49506
>
> 616 774 5123
>
>
> REPLY #2
> Amy,
> False positivity due to heterophile and other interfering
> antibodies can vary over time, but, usually not as quickly as in this
> patient. I don't think the negative urine hCG is helpful in this
> case because urine hCG is typically negative unless the true serum
> hCG is greater than 20-25 U/L. The good agreement between the Roche
> and Abbott assays argues for this being true hCG. It is rare that an
> interfering antibody affects more than one assay, but it is possible.
> I think the most likely explanation is that she got pregnant early in
> January and it spontaneously aborted. hCG should continue to be
> monitored for a while.
> Was her hCG considerably higher before her surgery in October?
> -Jim
> James J Miller, Ph.D., DABCC, FACB
> Professor, Pathology & Laboratory Medicine
> University of Louisville, Louisville, KY 40292
>
> Director of Clinical Chemistry & Toxicology
> University of Louisville Hospital Laboratory
>
> [log in to unmask]
> Office: 502-852-1179
>
> REPLY #3
> Amy,
> I would certainly agree with the suggestions of Drs Miller & Alter.
> The hCG is likely not false positive.
> Short lived persistent gestational trophoblastic disease is very common.
> This should sort itself out pretty soon. (within a month or two.)
> Weekly hCGs are pretty anxiety generating at this point.
> Michael
>
> Michael P Metz
> BS, MD, FAAP, MAACB, FRCPA
> Chemical Pathologist
> Division of Laboratory Medicine
> Women's & Children's Hospital
> 72 King William Road
> North Adelaide, South Australia
> 5008
>
> phone: 08 8161 7483
> mobile: 0421 098 430
> e-mail: [log in to unmask]
>
> MY REPLY
> Dear Dr Lou
> Is is possible to send us some of her serum + urine? Here at Charing
> Cross Hospital in London, we are the largest of the 3 UK centres for
> follow-up and Rx of hydatidiform mole and choriocarcinoma. We use an
> in in-house RIA which doesn't suffer from the false positives
> reported for other assay systems, particularly sandwich assays and
> which may be the case here. The samples can be sent unfrozen.
> Hugh Mitchell
> Consultant Biochemist
>
> Dr LOU's reply giving more details
>
> Hi Colleagues,
>
> To give you a full picture of the story, all beta-hCG results before
> the surgery are shown as following:
>
> Sep. 5, /07 58
> Sep.7/07 93
> Sep.10 162
> Sep.15 317
> Sep.17 389
> Oct.19 776
> Oct.22 944
> Oct.24 1076
> Nov.1(post-surgery) 32
> Nov.13/07 2
> Jan.10/08 14
> Jan.14/08 19
> Jan.20/08 16
> Jan.31/08 8
>
> Thank you for the response. beta hCG will be monitored closely for
> the patient and the investigation is still ongoing as collegures
> suggested. I will keep you all informed. Thanks
>
> Amy
>
> I then put all the data into PDM and displayed it as a ppt, which I
> haven't sent yet.
> I think a clinical picture letter from you would go a long way to
> impressing these ACB generalists that there's a reason for having
> specialists. Your response could be sent to
> [log in to unmask]
> BW
> Hugh
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