Intact Chorionic Vesicle in Very Early Products of Conception Specimens

Abstract

Among the morphologic mimics of hydatidiform moles, the chorionic vesicle of early first-trimester pregnancy has received scant attention. The chorionic vesicle is the stage of the implanted blastocyst in which the cytotrophoblastic shell is circumferentially lined by primary and secondary villi and envelops the notochord stage embryo, yolk sac, and amniotic sac, ∼5 to 6 weeks since the last menstrual period. Miscarriage specimens at this early gestational age that contain an intact chorionic vesicle may be misinterpreted as a complete hydatidiform mole because of its large size, cistern-like cavity, and circumferentially radiating villi and trophoblast, particularly so when embryonic tissue is absent. We present the clinicopathologic features of 26 products of conception specimens containing a chorionic vesicle, some of which were submitted for consultation as a possible complete mole. The median gestational age was 6 weeks. The majority were free-floating in the specimen, unattached to endometrium. The median diameter was 6.3 mm and ranged up to 11.3 mm. The embryo was absent in 81% of cases, leaving an empty cavity resembling the cistern of a complete mole in all but 2 cases. Most cases exhibited circumferential villi and variable degrees of proliferating polarized villous trophoblast and extravillous trophoblast but trophoblast atypia was absent. Villous stromal karyorrhexis and blue-gray myxoid extracellular stromal matrix were observed in the majority of cases. A minority exhibited focal abnormal villous morphology concerning for early molar pregnancy, including irregular projections (27%), invaginations (12%), or bulbous shapes (4%) of the villous contours and trophoblast pseudoinclusions (15%). In contrast, orderly hierarchical branching of the secondary villi occurred in 31%. p57 immunoexpression was intact in all 25 cases tested. Short tandem repeat genotype testing confirmed a biparental diploid genotype in both of 2 cases tested. Although uncommonly observed in early first-trimester products of conception specimens, the normal chorionic vesicle merits awareness as a potential diagnostic pitfall. While some morphologic features resemble those of a well-developed complete mole, at this early gestational age such features are not expected in a very early complete mole. Attention to the reported gestational age, if available, and presence of embryonic tissues will mitigate against misclassification as complete mole. As with the workup of any potential gestational trophoblastic disease, partnering the clinical and morphologic evaluation with molecular evaluation (intact p57 immunoexpression and lack of any of the characteristic molar genotypes) offers the most precise classification.