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Arborizing amniotic polyps in triploid conceptuses: A diagnostic anatomic lesion?
Arborizing amniotic polyps in triploid conceptuses: A diagnostic anatomic lesion? ROBERT J. SCHLEGEL, M.D.
(MAJOR, MC, USA)*
RICHARD NEU, M.S. JOSE CARNEIRO LEAO, M.D. ELVIRA FARiAS, M.D. PATRICIA LEWCZAK, B.S. LYTT I. GARDNER, M.D. Syracuse. New York
other sources. Cultures and chromosome preparations were made according to the technique of Aspillaga, Curtis, and Gardner.7 Small samples of the specimen were taken from areas between explants and sectioned by standard histologic technique to confirm the identity of the tissue. Portions
A B N oR M A L chromosome complements have bem found in a large proportion of spontaneously aborted human conceptuses. 1 -'' Many differing types of chromosomal aberration have been described in fetal membranes and in the embryo proper following abortion. Some of these cytogenetic abnormalities have not been described in living patients, and there is little published information on the anatomical appearance of the conceptuses bearing such chromosomal abnormalities. vVe would like to present observations on the microscopic and gross morphology of 3 triploid conceptuses.
of amnion vvere stretched, mounted over
glass slides and were stained with cresyl violet or by the Feulgen reaction." Portions of the remaining embryo and membrane were imbedded in paraffin blocks, sectioned, and stained with hematoxylin and f'osin or by the Feulgen technique. Results Specimen No. 1 was obtained by curettage. It was composed of an amnion, a chorion, and endometrial tissue. Curettage had been performed hPr,.mP nf vagina! hemorrhage at an estimated gestation of +! days (calculated as number of days elapsing between the end of the last normal menstrual period and the delivery date, minus 14 days). An identifiable embryo was not recovered. Chromosome counts on the amnion demonstrated a major chromosome number of 69 and a minor one of 46 (Table I). Karyotypes of meta phases having 69 chromosomes each showed all autosomes
Methods Amnions, chorions, and embryos were rinsed with T.C. 199 nutrient medium to remove adherent contaminating cells from Department of Pediatrics, State University of New York, Upstate Medical Center. This study was supported by grants TI-AM 5277 and AM 02504 from the National Institutes of Health, United States Public Health Service. *Dr. Schlegel was on assignment from the Office of the Sur[{eon General, United States Army Medical Corps. *Present addre>s: Pediatric Service, Walter Reed General Hospital, Washington, D. C. 20012.
357
358
Schlegel et a/.
{.)ctobt·l·
.f ( )!tsl.
\111.
l.
& ( ·~·
!qh(1 II•''
Table I
1- _______ ____ Sp ecimen
No. of chromosomes_l.!_'!___<:_!l!.__
! 45 I 46 si-6R ' li9 ~ -------------'-------- -;\;-~~~~ cells e~~mined 5
7
1.'!8
1\. aryotype
Ill
')
I~
1I
triplica ted and an XXY sex chromosome complement. Karyotypcs of metaphascs having --i-6 chromosomes reyealcd 22 normal autosome pairs and an XY sex chromosome complement. Specimen N o. 2 was a spontaneously aborted amnion, chorion, and embryo ( 19 mm. crown-rump length). The estimated gestation by dates was 13--i- days, although uterine size ( estin1ated at :) \\'Cf'k intervals
during the final 12 weeks of this period) never exceeded that expected for 8 weeks' gestation. A chromosome number of 6<1 was established both on cultured amnion cells and cells from the embryo proper !,Table II. Karyotypes demonstrated an XXX sex chromosome set. Specimen No. 3 was obtained by curettage performed because of vaginal h emorrhage. It consisted of amnion, chorion, embryo ( 16 mm. crown-rump length I and endometrium.
XXYiHA XXX XYY
tifiA titi:\ fifi.\
h
J
XY
The kngt l1 of gestation was Bb d ays . est imated by dates 1 . althou.!.!)l li!t ·riue ~iz•· :It .r ttl<' tmw 01 curenage o1o not •·xnTo 1na 1 t'xpcctt-cl for 8 weeks' gestation. Chromosnnw counts on cultured anmiou cdls \\Trt· in th e trip loid range ('fable 1 . a nd karvutvpt·s of these cells demonstrated X\'Y st.·x .1
. •
,.
..
I '
1
_
_
1
C flrOil10SO!llCS.
The :; arnmons had a characteristic anato1uical ahnortnality (:Fig. I\ u1nerou~polyps 'ATre growing on the hhrous surfau· of the membrane, facing tO\\·;u·d the cndnnwtrium and away from tlH' entbryo. Tlwn· \\·en:. on the average, 13 of thest' structures per squarl' centimeter of nwtubrane. Th<·; \aried in length from 0.1 to 2 CIJI .. and WI'J'<.· atlached to the membrane IJy thin stt'ill' about n.l llltl1. in clianwtel. Longer stcJIIS formed branches 0.1 to l Jrllll . in length, and tfH· longer branches often arborized furtht·l into t\H> subdivisions. Stems. branches anti
Fig. 1. Cystic polyps on the surface of a triploid XYY amnion. ( - I:). :
Volume ~)ti Xl!lnlwr 3
Fig-. 2. a . Membrane epithelium in a triploid XYY amnion. b, Loose conn ective tissue la yer in the same speci men. c. Giant ce ll nu cleus in th e l'pithclium of a pt>lyp (same specimen). ( Cresyl ,·iolct. lfiO .)
Triploid conceptuses
359
twigs formed club-shaped expansions, the sizes of which were directly related to the length of supporting structures ( 1 to 7 mm . in length, 0.2 to 1 mm. in diameter in th e case of stems; 0.5 to 2 mrn. in length, 0.5 t(l I nm1. in diameter in the case of branche~: 0.2 to 0.5 mm. in length, 0.2 to 0.5 mn1. in diameter m the case of twigs). Stem.'. branches, twigs, and polypoid terminations were hollow. The epithelial surface of tht· utemb ranc was intact beneath these structures. Histologic studies on stretched mounts of amn ion dnnonstratcd a layer of cuboidal epithelium on the inner surface facing the embr)'O (Fig. 2, a l . This was sepa rated front a zone of loose connec tive tissue by a basement membrane (Fig. 2, b). A layer of dense connective tissue faced outward toward tht· endometrium. The epithelial cel ls aud fibroblasts were largrr than comparable cell types from diploid am nions of the same gestati ona l age. Sheets of giant Ct'l ls having ;t single nucleus were found at the bases of sonw polyps, and similar cells were occasionally present in the stems a nd terminal ends (Fig. 2, c) . The vegeta tions had an outer covering of cuboidal epithdium which was separated from an inner layer of connective tissu e by a basement membrane. Detailed cytologic studies will be reported :lt a later date. There were multiple cysts of the chorionic villi (maximum diameter 1.5 em. ·1 in speci-
Fig. 3. Chorionic cyst and hyd at idiform mole- like villi from a triploid XYY conceptus. (Hematoxylin and eosin . x9.)
360 Schlegel et al.
mens No. 1 and No. 3 (Fig. 3). The cyst walls consisted of an outer layer of syncytial cells, a layer of Langhans cells, and an inner layer of dense connective tissue. In some portions of the cyst wall there was a cellular latticework between the Langhans cell layer and the inner lining of dense connective tissue. The syncytium of the chorionic villi was hydropic and avascular in each of tlw :) specimens. None of the specimens showed hyperplasia of the Langhans cells. The embryo was without gross abnormality in specimens No. 2 and 1'\o. ~{. Serial sections of specimen No. 3 demonstrated organ development and tissue differentiation compatible with a gestational age late in the sixth week. Comment
We have been unable to find a description of amnion lesions similar to those seen in the present cases. \Vhether they arc invariably associated with a triploid chromosome constitution must await the study of additional triploid conceptuses. The hydatidiform mole-like villi m our 3 cases resemble those reported by Makino, Sasaki, and Fukuschima9 in 3 triploid chorions. In addition, there were thick-walled cysts of the chorion in 2 of our 3 triploid specimens. Triploidy has been described in early 1mman conceptuses by others. 1 • "· 5 • "· Jn, 11 Survival beyond embryonic life might not be possible if a high proportion of cells in the conceptus are triploid. There have been 3 cases reported of living children exhibiting diploid/triploid mosaicism/ 2 - 15 but a purely triploid individual has not yet been described. Clinical features present in diploid/triploid patients have been body asymmetry, mental retardation, porencephaly, syndactylism, and cutaneous lipomatosis. Similar findings were not apparent in the triploid Pmbryos studied by us. Extensive lesions were present in the fetal membranes and placenta in our 3 cases. On the other hand, there was no detectable
: iclt,hl·~ \Ill.
L ( lh~t
J. ! 'tht,
& L\fl"
anomaly of the embryo. Death and ulttrnate abortion of triploid ernbrvo,; tni~ltt n·,idt from abnormalities in the placenta and membranes rather than from a kthal def1TI in the embryo proper. Kerr and Rashad •· have also sug-gested this possibilitv with 11·spect to triploidy and placental ahnormali t\'. The 2 triploid embryos reco\Tred hv ih appeared to be at the de\·elopmental age ,·xpected late in the sixth we1'k of gestation. The triploid/diploid mosaic spt·cinwn, which did not contain an embryo. was obtained h\ curettage after an Pstima ted g1'stati11tl Ill slightly more than 6 weeks. Lterirw silt' did not Pxct:'t'cl that expt·ctt•d fot B week•;' ,t.;t·statinn in the 3 cast•s pn·st'ntt"d lwn· although retPntion of the concept1ts fl\ tlw mother continued for an estimated 1B wcPks in one instance and 11 weeks Jtl another i. Triploidy would apJJl'ar to lw a'sociatecl with loss of viability in tlw human t'Jnbryo during the sixth wed nf intrauterim· t·xistcnct·. Further morphologic studies on the hmnan conceptus might prove of \·al11e iu instann·;, m which there is an establish!·d ahnonnalitv of chromosome coustitu tion. Summary
Characteristic structural abnormalities W!'t'l' found in an aborted human triploid/diploid conceptus and in 2 triploid human conceptuses. Arborizing amniotic polyps were present in each of the :1 specimens. The cell constitution of the polyps was found to tw partially composed of mononuclear g·iant cells. Tlwre was hydatidiform degeneration of the chorionic villi in each specimen, ;md. in the triploid/diploid mosaic specimen and one of the triploid specimens. thick-walled chorionic cysts were present. ~ o anomaly could be detected in either of the 2 triploid embryos which were n·cm·en~d. Dt.•ath and ul timatc abortion of triploid crubn·os might result from abnormalities of the placenta ami fetal nwmhrancs ratlwr than frotn a l!·thal defect in the embryo propPr.
Volume 9fi ":\umber 3
REFERENCES
1. Carr, D. H.: Lancet 2: 603, 1963. :!. Naujoks, H.: Acta cytol. 7: 300, 1963. :l. Thiede, H. A., and Sa1m, S. B.: AM. J. OnsT. & GYNEC. 90: 205, 1964. ·L Hall, B., and Kallen, F.: Lancet 1: 110, 1964. 5. Szulman, A. E.: New England J. Med. 272: B11, 1965. 6. Inhorn, S. M.: Personal communication. 7. Aspillaga, M. ]., Curtis, E. H., and Gardner, L. I.: Hum. Chromosome Newsletter 12: 15, 1964. B. Stowell, R. E.: Stain Techno!. 20: 45, 1945. 9. Makino, S., Sasaki, M. S., and Fukuschima, T.: Lancet 2: 1273, 1964. 10. Penrose, L. S., and Delhanty, J.D. A.: Lancet 1: 1261, 1961.
Triploid conceptuses
361
11. Delhanty, J. D. A., Ellis, J. R., and Rowlry. P. T.: Lancet 1: 1286, 1961. 12. Book, ]. A., and Santesson, B.: Lancet 1: 858, 1960. 13. Book, J_ A., and Santesson, B.: Lanct't 2: 318, 1961. 14. Ellis, ]. R., Marshall, R., Normand, I. C. S .. and Penrose, L. S.: ;"\;ature (Lond.) 198: ·lll, 1963. 15. Ferrier, P., Stalder, G., Bamatter, R., Ferrier, S., Buhler, E. and Klein, D.; Lancet 1: 80. 1964. 16. Kerr, M., and Rashad, M. N.: AM. J. OnsT. & GYNEC. 94: 322, 1966. 750 East Adams Street Syracuse, New York 13210
(MAJOR, MC, USA)*
RICHARD NEU, M.S. JOSE CARNEIRO LEAO, M.D. ELVIRA FARiAS, M.D. PATRICIA LEWCZAK, B.S. LYTT I. GARDNER, M.D. Syracuse. New York
other sources. Cultures and chromosome preparations were made according to the technique of Aspillaga, Curtis, and Gardner.7 Small samples of the specimen were taken from areas between explants and sectioned by standard histologic technique to confirm the identity of the tissue. Portions
A B N oR M A L chromosome complements have bem found in a large proportion of spontaneously aborted human conceptuses. 1 -'' Many differing types of chromosomal aberration have been described in fetal membranes and in the embryo proper following abortion. Some of these cytogenetic abnormalities have not been described in living patients, and there is little published information on the anatomical appearance of the conceptuses bearing such chromosomal abnormalities. vVe would like to present observations on the microscopic and gross morphology of 3 triploid conceptuses.
of amnion vvere stretched, mounted over
glass slides and were stained with cresyl violet or by the Feulgen reaction." Portions of the remaining embryo and membrane were imbedded in paraffin blocks, sectioned, and stained with hematoxylin and f'osin or by the Feulgen technique. Results Specimen No. 1 was obtained by curettage. It was composed of an amnion, a chorion, and endometrial tissue. Curettage had been performed hPr,.mP nf vagina! hemorrhage at an estimated gestation of +! days (calculated as number of days elapsing between the end of the last normal menstrual period and the delivery date, minus 14 days). An identifiable embryo was not recovered. Chromosome counts on the amnion demonstrated a major chromosome number of 69 and a minor one of 46 (Table I). Karyotypes of meta phases having 69 chromosomes each showed all autosomes
Methods Amnions, chorions, and embryos were rinsed with T.C. 199 nutrient medium to remove adherent contaminating cells from Department of Pediatrics, State University of New York, Upstate Medical Center. This study was supported by grants TI-AM 5277 and AM 02504 from the National Institutes of Health, United States Public Health Service. *Dr. Schlegel was on assignment from the Office of the Sur[{eon General, United States Army Medical Corps. *Present addre>s: Pediatric Service, Walter Reed General Hospital, Washington, D. C. 20012.
357
358
Schlegel et a/.
{.)ctobt·l·
.f ( )!tsl.
\111.
l.
& ( ·~·
!qh(1 II•''
Table I
1- _______ ____ Sp ecimen
No. of chromosomes_l.!_'!___<:_!l!.__
! 45 I 46 si-6R ' li9 ~ -------------'-------- -;\;-~~~~ cells e~~mined 5
7
1.'!8
1\. aryotype
Ill
')
I~
1I
triplica ted and an XXY sex chromosome complement. Karyotypcs of metaphascs having --i-6 chromosomes reyealcd 22 normal autosome pairs and an XY sex chromosome complement. Specimen N o. 2 was a spontaneously aborted amnion, chorion, and embryo ( 19 mm. crown-rump length). The estimated gestation by dates was 13--i- days, although uterine size ( estin1ated at :) \\'Cf'k intervals
during the final 12 weeks of this period) never exceeded that expected for 8 weeks' gestation. A chromosome number of 6<1 was established both on cultured amnion cells and cells from the embryo proper !,Table II. Karyotypes demonstrated an XXX sex chromosome set. Specimen No. 3 was obtained by curettage performed because of vaginal h emorrhage. It consisted of amnion, chorion, embryo ( 16 mm. crown-rump length I and endometrium.
XXYiHA XXX XYY
tifiA titi:\ fifi.\
h
J
XY
The kngt l1 of gestation was Bb d ays . est imated by dates 1 . althou.!.!)l li!t ·riue ~iz•· :It .r ttl<' tmw 01 curenage o1o not •·xnTo 1na 1 t'xpcctt-cl for 8 weeks' gestation. Chromosnnw counts on cultured anmiou cdls \\Trt· in th e trip loid range ('fable 1 . a nd karvutvpt·s of these cells demonstrated X\'Y st.·x .1
. •
,.
..
I '
1
_
_
1
C flrOil10SO!llCS.
The :; arnmons had a characteristic anato1uical ahnortnality (:Fig. I\ u1nerou~polyps 'ATre growing on the hhrous surfau· of the membrane, facing tO\\·;u·d the cndnnwtrium and away from tlH' entbryo. Tlwn· \\·en:. on the average, 13 of thest' structures per squarl' centimeter of nwtubrane. Th<·; \aried in length from 0.1 to 2 CIJI .. and WI'J'<.· atlached to the membrane IJy thin stt'ill' about n.l llltl1. in clianwtel. Longer stcJIIS formed branches 0.1 to l Jrllll . in length, and tfH· longer branches often arborized furtht·l into t\H> subdivisions. Stems. branches anti
Fig. 1. Cystic polyps on the surface of a triploid XYY amnion. ( - I:). :
Volume ~)ti Xl!lnlwr 3
Fig-. 2. a . Membrane epithelium in a triploid XYY amnion. b, Loose conn ective tissue la yer in the same speci men. c. Giant ce ll nu cleus in th e l'pithclium of a pt>lyp (same specimen). ( Cresyl ,·iolct. lfiO .)
Triploid conceptuses
359
twigs formed club-shaped expansions, the sizes of which were directly related to the length of supporting structures ( 1 to 7 mm . in length, 0.2 to 1 mm. in diameter in th e case of stems; 0.5 to 2 mrn. in length, 0.5 t(l I nm1. in diameter in the case of branche~: 0.2 to 0.5 mm. in length, 0.2 to 0.5 mn1. in diameter m the case of twigs). Stem.'. branches, twigs, and polypoid terminations were hollow. The epithelial surface of tht· utemb ranc was intact beneath these structures. Histologic studies on stretched mounts of amn ion dnnonstratcd a layer of cuboidal epithelium on the inner surface facing the embr)'O (Fig. 2, a l . This was sepa rated front a zone of loose connec tive tissue by a basement membrane (Fig. 2, b). A layer of dense connective tissue faced outward toward tht· endometrium. The epithelial cel ls aud fibroblasts were largrr than comparable cell types from diploid am nions of the same gestati ona l age. Sheets of giant Ct'l ls having ;t single nucleus were found at the bases of sonw polyps, and similar cells were occasionally present in the stems a nd terminal ends (Fig. 2, c) . The vegeta tions had an outer covering of cuboidal epithdium which was separated from an inner layer of connective tissu e by a basement membrane. Detailed cytologic studies will be reported :lt a later date. There were multiple cysts of the chorionic villi (maximum diameter 1.5 em. ·1 in speci-
Fig. 3. Chorionic cyst and hyd at idiform mole- like villi from a triploid XYY conceptus. (Hematoxylin and eosin . x9.)
360 Schlegel et al.
mens No. 1 and No. 3 (Fig. 3). The cyst walls consisted of an outer layer of syncytial cells, a layer of Langhans cells, and an inner layer of dense connective tissue. In some portions of the cyst wall there was a cellular latticework between the Langhans cell layer and the inner lining of dense connective tissue. The syncytium of the chorionic villi was hydropic and avascular in each of tlw :) specimens. None of the specimens showed hyperplasia of the Langhans cells. The embryo was without gross abnormality in specimens No. 2 and 1'\o. ~{. Serial sections of specimen No. 3 demonstrated organ development and tissue differentiation compatible with a gestational age late in the sixth week. Comment
We have been unable to find a description of amnion lesions similar to those seen in the present cases. \Vhether they arc invariably associated with a triploid chromosome constitution must await the study of additional triploid conceptuses. The hydatidiform mole-like villi m our 3 cases resemble those reported by Makino, Sasaki, and Fukuschima9 in 3 triploid chorions. In addition, there were thick-walled cysts of the chorion in 2 of our 3 triploid specimens. Triploidy has been described in early 1mman conceptuses by others. 1 • "· 5 • "· Jn, 11 Survival beyond embryonic life might not be possible if a high proportion of cells in the conceptus are triploid. There have been 3 cases reported of living children exhibiting diploid/triploid mosaicism/ 2 - 15 but a purely triploid individual has not yet been described. Clinical features present in diploid/triploid patients have been body asymmetry, mental retardation, porencephaly, syndactylism, and cutaneous lipomatosis. Similar findings were not apparent in the triploid Pmbryos studied by us. Extensive lesions were present in the fetal membranes and placenta in our 3 cases. On the other hand, there was no detectable
: iclt,hl·~ \Ill.
L ( lh~t
J. ! 'tht,
& L\fl"
anomaly of the embryo. Death and ulttrnate abortion of triploid ernbrvo,; tni~ltt n·,idt from abnormalities in the placenta and membranes rather than from a kthal def1TI in the embryo proper. Kerr and Rashad •· have also sug-gested this possibilitv with 11·spect to triploidy and placental ahnormali t\'. The 2 triploid embryos reco\Tred hv ih appeared to be at the de\·elopmental age ,·xpected late in the sixth we1'k of gestation. The triploid/diploid mosaic spt·cinwn, which did not contain an embryo. was obtained h\ curettage after an Pstima ted g1'stati11tl Ill slightly more than 6 weeks. Lterirw silt' did not Pxct:'t'cl that expt·ctt•d fot B week•;' ,t.;t·statinn in the 3 cast•s pn·st'ntt"d lwn· although retPntion of the concept1ts fl\ tlw mother continued for an estimated 1B wcPks in one instance and 11 weeks Jtl another i. Triploidy would apJJl'ar to lw a'sociatecl with loss of viability in tlw human t'Jnbryo during the sixth wed nf intrauterim· t·xistcnct·. Further morphologic studies on the hmnan conceptus might prove of \·al11e iu instann·;, m which there is an establish!·d ahnonnalitv of chromosome coustitu tion. Summary
Characteristic structural abnormalities W!'t'l' found in an aborted human triploid/diploid conceptus and in 2 triploid human conceptuses. Arborizing amniotic polyps were present in each of the :1 specimens. The cell constitution of the polyps was found to tw partially composed of mononuclear g·iant cells. Tlwre was hydatidiform degeneration of the chorionic villi in each specimen, ;md. in the triploid/diploid mosaic specimen and one of the triploid specimens. thick-walled chorionic cysts were present. ~ o anomaly could be detected in either of the 2 triploid embryos which were n·cm·en~d. Dt.•ath and ul timatc abortion of triploid crubn·os might result from abnormalities of the placenta ami fetal nwmhrancs ratlwr than frotn a l!·thal defect in the embryo propPr.
Volume 9fi ":\umber 3
REFERENCES
1. Carr, D. H.: Lancet 2: 603, 1963. :!. Naujoks, H.: Acta cytol. 7: 300, 1963. :l. Thiede, H. A., and Sa1m, S. B.: AM. J. OnsT. & GYNEC. 90: 205, 1964. ·L Hall, B., and Kallen, F.: Lancet 1: 110, 1964. 5. Szulman, A. E.: New England J. Med. 272: B11, 1965. 6. Inhorn, S. M.: Personal communication. 7. Aspillaga, M. ]., Curtis, E. H., and Gardner, L. I.: Hum. Chromosome Newsletter 12: 15, 1964. B. Stowell, R. E.: Stain Techno!. 20: 45, 1945. 9. Makino, S., Sasaki, M. S., and Fukuschima, T.: Lancet 2: 1273, 1964. 10. Penrose, L. S., and Delhanty, J.D. A.: Lancet 1: 1261, 1961.
Triploid conceptuses
361
11. Delhanty, J. D. A., Ellis, J. R., and Rowlry. P. T.: Lancet 1: 1286, 1961. 12. Book, ]. A., and Santesson, B.: Lancet 1: 858, 1960. 13. Book, J_ A., and Santesson, B.: Lanct't 2: 318, 1961. 14. Ellis, ]. R., Marshall, R., Normand, I. C. S .. and Penrose, L. S.: ;"\;ature (Lond.) 198: ·lll, 1963. 15. Ferrier, P., Stalder, G., Bamatter, R., Ferrier, S., Buhler, E. and Klein, D.; Lancet 1: 80. 1964. 16. Kerr, M., and Rashad, M. N.: AM. J. OnsT. & GYNEC. 94: 322, 1966. 750 East Adams Street Syracuse, New York 13210