Trophoblastic Neoplasia in an African Urban Population Akin Agboola, MD, MRCOG Lagos, Nigeria
A clinical study of trophoblastic neoplasia in a Nigerian population in Lagos over a four-year period is reported. A high incidence of one in 379 deliveries for benign trophoblastic tumor and one in 846 deliveries for malignant tumor was found. Seventeen percent of benign trophoblastic tumors in this series progressed to the malignant type, but malignant trophoblastic tumor was preceded by the benign type (hydatidiform mole) in 46 percent of cases. The anterior vaginal wall is a common site for metastases of malignant trophoblastic neoplasia and, in one patient, the lesion progressed further to form a vesicovaginal fistula. While the management of benign disease was conservative, all cases of malignant trophoblastic neoplasia received
chemotherapy. Literature reports about trophoblastic neoplasia are numerous and different authors have described the tumor under various names such as hydatidiform mole, invasive mole, malignant mole, chorioadenoma destruens, and choriocarcinoma. Efforts, however, have been made in this paper to create a simpler understanding of the clinical study of this disease by classifying the tumors into two broad categories of benign and malignant. The benign tumor includes only hydatidiform mole, while all other trophoblastic tumors, choriocarcinoma inclusive, which do not exhibit benign characteristics clinically, biologically, or histologically, are referred to as malignant trophoblastic tumors. The incidence of benign trophoblastic tumor varies widely from one part of the world to another. A high incidence of one in 294 deliveries from Japan', one in 314 pregnancies from Iran,2 one in 205 pregnancies from Nigeria,: and one in 257 deliveries in native Alas-
All 42 patients described were seen at the Lagos University Teaching Hospital between January 1974 and December 1977 and were all supervised by the author. This hospital, which is situated on the mainland of Lagos, has
Requests for reprints should be addressed to Dr. Akin Agboola, Department of Obstetrics and Gynecology, Martin Luther King, Jr. General Hospital, 12021 South Wilmington Avenue, Los Angeles, CA 90059.
the largest gynecological unit in Lagos and also serves as a referral center for trophoblastic disease. During this four-year period, the hospital recorded a total delivery of 11,000. The diagnosis of trophoblastic neoplasia was based on
kans4 have been reported, contrasting with a much lower incidence of one in 1,500 to 2,000 in the United States,5 and one in 2,000 to 3,000 in other Western countries.6 There have been, however, conflicting reports about the incidence of malignant trophoblastic tumor and this has been partly due to the various nomenclatures that have been given to this particular disease which sometimes makes one wonder whether gynecologists all over the world are dealing with the same type of tumor. However, the incidence is believed to be high in Asia7'- and Africa.9"'
Materials and Patients
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 10, 1979
the clinical history and findings, histological findings, urinary human chorionic gonadotrophin (HCG) bioassay, chest radiography, and pelvic angiogram. Chemotherapeutic treatment was our method of choice in all cases of malignant trophoblastic disease. The cytotoxic drugs employed were a combination of Methotrexate 0.4 mg per kg body weight/day and 6mercaptopurine 10 mg per kg body weight/day both given in five divided doses. The duration of each course of treatment was five days and treatment was repeated every two to three weeks if there were no adverse reactions, until HCG levels fell to normal. All cases of benign trophoblastic tumors were, however, managed conservatively by evacuating the mole, and then followed for two years.
Results A total number of 29 diagnosed cases of benign trophoblastic tumor was seen during this period thus giving an institutional incidence of one in 379 deliveries. The number of patients with 935
Table 1. Sites of Metastases in Malignant Trophoblastic Neoplasia
Sites
Number of Cases 4 3 2 2 1 1
Lungs Anterior vaginal wall Brain Pelvic cellular tissue Bladder
Vagina (vesico-vaginal fistula)
Table 2. Antecedent Pregnancy to Malignant Trophoblastic Neoplasia
Antecedent Pregnancy Hydatidiform mole Term pregnancy Abortion
malignant trophoblastic tumor was 13, giving an institutional incidence of one in 846 deliveries. The age distribution in benign trophoblastic tumor was 13-38 years with most patients falling into the 21-30 age group. There was only one patient below the age of 20. In the malignant type, the age distribution was 21-40 years with the mode again in the 21-30 age group. The parity distribution in benign trophoblastic tumor was 0-4 and there was no association between the incidence of the disease and parity. There was also no definite relationship between the incidence of malignant trophoblastic tumor and gravidity although 23 percent of these patients were primigravida. The commonest presenting symptom was recurrent vaginal bleeding or brownish loss which was noted in 80 percent of patients with benign trophoblastic tumor. Recurrent or profuse bleeding after evacuation of a mole, abortion, or term delivery was also the most frequent symptom in malignant trophoblastic tumor and was recorded in 61 percent of our patients. Other clinical features which occurred 936
to the malignant type within six months while being followed up.
Number of Cases (Percentage) 6 (46) 5 (38) 2 (16)
with less frequency in patients with benign trophoblastic tumor included excessive vomiting (14 percent), undue enlargement of the uterus (55 percent), and pseudo-toxemia (7 percent). Cystic enlargement of one or both ovaries was also noted in about 10 percent of these women. In the malignant type, cystic enlargement of one or both ovaries was found in four cases (30 percent). In this group also, symptoms which were attributed to metastases included hemoptysis, hematuria, hemiplegia, and urinary incontinence. The sites of metastases are shown in Table 1. The nature of the pregnancy antecedent to malignant trophoblastic tumor in patients studied is shown in Table 2. Hydatidiform mole was recorded in 46 percent while term pregnancy and abortion accounted for 38 percent and 16 percent, respectively. There was no case of antecedent ectopic pregnancy in this series. The interval between termination of an antecedent pregnancy and time of occurrence of malignant trophoblastic disease varied from two weeks to five years. In 46 percent of cases, this interval was within six months. Seventeen percent of cases of benign trophoblastic tumor progressed
Discussion The incidence of trophoblastic tumor, both benign and malignant, varies from one part of the world to another, although it must be remembered that in most cases the institutional incidence is much higher than the true incidence representative of the population in any particular country. I The institutional incidence of one in 379 deliveries for the benign and one in 846 deliveries for the malignant tumors obtained in this study from Lagos should be regarded as high. This high incidence agrees with the findings of another Nigerian author.3 Nigeria could therefore claim an incidence comparable to that in the Asian countries. The age distribution of our patients with benign trophoblastic tumor was similar to that from other countries.2"2'13 This disease has not been found to be associated with age or parity in our series though association with parity has been observed by other authors.2 No relationship with gravidity has been noted in our cases of malignant trophoblastic tumor. Progression from benign to malignant trophoblastic tumor was recorded in 17 percent of our cases. This figure is higher than those reported by other authors2'3"14 but similar to the figures given by Curry et al.'5 This disparity could possibly be explained on the basis of our classification of trophoblastic tumors into two broad categories of benign and malignant. This classification has been adopted for clinical simplicity and therapeutic reasons in that any tumor that was not benign automatically qualified for chemotherapy. This practice may probably provide a solution to the usual argument between the clinicians on one side and the pathologists on the other about which mole is potentially malignant and thus needs to be placed in a high risk category which sooner or later might require chemotherapy, or be given prophylactic chemotherapy. It is also hoped that this practice may in the long run improve the survival rate. At present, our survival rate of 46 percent in malignant trophoblastic tumor is much lower than 81.5 percent quoted by Bagshawe. 16 Thsof course was due to the
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 10, 1979
fact that about 54 percent of our patients did not report in hospital early enough for diagnosis and treatment. This latter group commenced chemotherapy well after six months following the onset of symptoms. Malignant trophoblastic tumor was preceded by hydatidiform mole in about 46 percent of patients. A comparable figure of about 50 percent has also been reported from Uganda10 and Iran.2 Six patients (20 percent) who were being followed up after evacuation of a mole became pregnant within six months of follow-up contrary to a policy that pregnancy should be delayed for two years. Incidentally, all the pregnancies were uneventful, and the suggestion from this is probably that the present policy should be reexamined and a new concept introduced which would perhaps permit pregnancy once the HCG has fallen to normal level especially if the radioimmunoassay (RIA) method is employed. The incidence of theca lutein cyst in trophoblastic tumor in our series was not higher than 30 percent. Although cystic formation of the ovary in this condition is said to be due to excessive
stimulation of the ovaries by HCG, we have not been able to demonstrate a correlation between urinary HCG levels and ovarian cyst formation. Attempts have been made to associate the occurrence of trophoblastic tumors with some external factors like viral,17 chemical,'8 dietary,2"9 and genetic,20'21 but results are still rather inconclusive, and the best that can be said presently is that racial incidence makes trophoblastic tumor more common in Asia and Africa than in Europe and in the Western world. Literature Cited 1. Hasegawa T:,Trophoblastic NeoplasiaIts Basic and Clinical Aspects, ed 1. Baltimore, Williams and Wilkins, 1971, p 166 2. Javey H, Sajadi H: Hydatidiform mole in Southern Iran: A statistical survey of 113 cases. Int J Gynaecol Obstet 15:390-395, 1978 3. Ogunbode 0: Benign hydatidiform mole in Ibadan, Nigeria. Int J Gynaecol Obstet 15:387-390, 1978 4. Martin PM: High frequency of hydatidiform mole in native Alaskans. Int J Gynaecol Obstet 15:395-396, 1978 5. Goldstein DM: Worldwide controversies in gestational trophoblastic neoplasms. Int J Gynaecol Obstet 15:207-215, 1977 6. Dewhurst CJ: Integrated Obstetrics and Gynaecology for Postgraduates. Oxford, Blackwell Scientific, 1972, pp 237-238 7. Joint project for study of choriocarcinoma and hydatidiform mole in Asia (1959): Geographic variation in the occurrence of
hydatidiform mole and choriocarcinoma. Ann NY Acad Sci 80:178-196, 1959 8. Pai KN: A study of choriocarcinoma: Its incidence in India and its aetiopathogenesis. In Holland JF, Hreshchyshyn MM (eds): Choriocarcinoma: Transactions of a Conference of the International Union Against Cancer. Berlin, Springer-Verlag, 1967, pp 54-57 9. de V Hendrickse JP, Cockshott WP, Evans KTE, et al:Pelvic angiography in the management of malignant trophoblastic disease. N Engl J Med 271:859-866, 1964 10. Leighton PC: Trophoblastic disease in Uganda. Am J Obstet Gynecol 117:341-344, 1973 11. Rolon PA, de Lopez BH: Epidemiological aspects of hydatidiform mole in the republic of Paraguay (South America). BrJ Obstet Gynaecol 84:862-864, 1977 12. MacGregor C, Ontiveros E, Vargas E, et al: Hydatidiform mole: Analysis of 145 patients. Obstet Gynecol 33:343-351, 1969 13. Westerhout FC, Morel ES, Slate WG: Observations on 138 molar pregnancies. Am J Obstet Gynecol 103:56-59, 1969 14. Acosta-Sisson H: Changing attitudes in the management of hydatidiform mole. Am J Obstet Gynecol 88:634-636, 1964 15. Curry SL, Hammond CB, Tyrey L, et al: Hydatidiform mole: Diagnosis, management, and long-term follow-up of 347 patients. Obstet Gynecol 45:1-8, 1975 16. Bagshawe KD: Monitoring of choriocarcinoma. Br J Radiol 49:291-292, 1976 17. Barr S J: More hydatidiform mole?, letters. Br Med J 2:707-708, 1977 18. Calvert, JP: More hydatidiform mole?, letters. Br Med J 2:578-579, 1977 19. Novak ER, Woodruff JD: Gynecologic and Obstetric Pathology, ed 7. Philadelphia, WB Saunders, 1974, p 599 20. lliya FA, Williamson S, Azar HA: Choriocarcinoma in the Near East: Consanguinity as a possible etiologic factor. Cancer 20:144149, 1967 21. Bagshawe KD: ABO blood groups in trophoblastic neoplasia. Lancet 1:553-556,1971
Surgical Operations in Short.Stay Hospitals, United States, 1975 In 1975 there were an estimated 34 million inpatients discharged from the nation's non-federal short-stay hospitals. An estimated 14.2 million inpatients, or about two out of every five inpatients, underwent at least one surgical operation. By number of operations per patient, about 9.7 million inpatients, or 68.1 percent, underwent one surgical operation; approximately
3.2 million, 22.5 percent, had two operations; and 1.3 million, 9.4 percent, had three operations. About 5.4 million patients with surgery were male, and 8.8 million were female. The corresponding rates per 1,000 population were 53.5 for males and 81.2 for females. The rate of surgically treated patients increased consistently with age: from 31.6 for
those under 15 years of age to 110.9 for those 65 years and over. The rate of male patients with surgery also increased with age, but for females the rate of discharges with surgery was highest for age group 15-44 years, the childbearing years.
from Vital and Health Statistics Public Health Service, DHEW
Meharry Leads In NHSC Scholarship Awards With 198 students receiving scholarships, Meharry Medical College School of Medicine led US medical and osteopathic schools in the number of par-* ticipants in the Public Health/National Health service Corps Scholarship Program from 1973-1977. Other schools with a large number of participants in the first five years of
the program administered by the Division of Manpower Training Support, Bureau of Health Manpower, were: Georgetown University School of Medicine, 189; Kansas City College of Osteopathic Medicine, 170; and Howard University School of Medicine, 134. Also, Loma Linda University
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 10, 1979
School of Medicine, 131; George Washington University, School of Medicine, 127; Medical College of Thomas Jefferson University, 105; and the College of Osteopathic Medicine and Surgery (Iowa), 102. from Health Resources News August 1978
A clinical study of trophoblastic neoplasia in a Nigerian population in Lagos over a four-year period is reported. A high incidence of one in 379 deliveries for benign trophoblastic tumor and one in 846 deliveries for malignant tumor was found. Seventeen percent of benign trophoblastic tumors in this series progressed to the malignant type, but malignant trophoblastic tumor was preceded by the benign type (hydatidiform mole) in 46 percent of cases. The anterior vaginal wall is a common site for metastases of malignant trophoblastic neoplasia and, in one patient, the lesion progressed further to form a vesicovaginal fistula. While the management of benign disease was conservative, all cases of malignant trophoblastic neoplasia received
chemotherapy. Literature reports about trophoblastic neoplasia are numerous and different authors have described the tumor under various names such as hydatidiform mole, invasive mole, malignant mole, chorioadenoma destruens, and choriocarcinoma. Efforts, however, have been made in this paper to create a simpler understanding of the clinical study of this disease by classifying the tumors into two broad categories of benign and malignant. The benign tumor includes only hydatidiform mole, while all other trophoblastic tumors, choriocarcinoma inclusive, which do not exhibit benign characteristics clinically, biologically, or histologically, are referred to as malignant trophoblastic tumors. The incidence of benign trophoblastic tumor varies widely from one part of the world to another. A high incidence of one in 294 deliveries from Japan', one in 314 pregnancies from Iran,2 one in 205 pregnancies from Nigeria,: and one in 257 deliveries in native Alas-
All 42 patients described were seen at the Lagos University Teaching Hospital between January 1974 and December 1977 and were all supervised by the author. This hospital, which is situated on the mainland of Lagos, has
Requests for reprints should be addressed to Dr. Akin Agboola, Department of Obstetrics and Gynecology, Martin Luther King, Jr. General Hospital, 12021 South Wilmington Avenue, Los Angeles, CA 90059.
the largest gynecological unit in Lagos and also serves as a referral center for trophoblastic disease. During this four-year period, the hospital recorded a total delivery of 11,000. The diagnosis of trophoblastic neoplasia was based on
kans4 have been reported, contrasting with a much lower incidence of one in 1,500 to 2,000 in the United States,5 and one in 2,000 to 3,000 in other Western countries.6 There have been, however, conflicting reports about the incidence of malignant trophoblastic tumor and this has been partly due to the various nomenclatures that have been given to this particular disease which sometimes makes one wonder whether gynecologists all over the world are dealing with the same type of tumor. However, the incidence is believed to be high in Asia7'- and Africa.9"'
Materials and Patients
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 10, 1979
the clinical history and findings, histological findings, urinary human chorionic gonadotrophin (HCG) bioassay, chest radiography, and pelvic angiogram. Chemotherapeutic treatment was our method of choice in all cases of malignant trophoblastic disease. The cytotoxic drugs employed were a combination of Methotrexate 0.4 mg per kg body weight/day and 6mercaptopurine 10 mg per kg body weight/day both given in five divided doses. The duration of each course of treatment was five days and treatment was repeated every two to three weeks if there were no adverse reactions, until HCG levels fell to normal. All cases of benign trophoblastic tumors were, however, managed conservatively by evacuating the mole, and then followed for two years.
Results A total number of 29 diagnosed cases of benign trophoblastic tumor was seen during this period thus giving an institutional incidence of one in 379 deliveries. The number of patients with 935
Table 1. Sites of Metastases in Malignant Trophoblastic Neoplasia
Sites
Number of Cases 4 3 2 2 1 1
Lungs Anterior vaginal wall Brain Pelvic cellular tissue Bladder
Vagina (vesico-vaginal fistula)
Table 2. Antecedent Pregnancy to Malignant Trophoblastic Neoplasia
Antecedent Pregnancy Hydatidiform mole Term pregnancy Abortion
malignant trophoblastic tumor was 13, giving an institutional incidence of one in 846 deliveries. The age distribution in benign trophoblastic tumor was 13-38 years with most patients falling into the 21-30 age group. There was only one patient below the age of 20. In the malignant type, the age distribution was 21-40 years with the mode again in the 21-30 age group. The parity distribution in benign trophoblastic tumor was 0-4 and there was no association between the incidence of the disease and parity. There was also no definite relationship between the incidence of malignant trophoblastic tumor and gravidity although 23 percent of these patients were primigravida. The commonest presenting symptom was recurrent vaginal bleeding or brownish loss which was noted in 80 percent of patients with benign trophoblastic tumor. Recurrent or profuse bleeding after evacuation of a mole, abortion, or term delivery was also the most frequent symptom in malignant trophoblastic tumor and was recorded in 61 percent of our patients. Other clinical features which occurred 936
to the malignant type within six months while being followed up.
Number of Cases (Percentage) 6 (46) 5 (38) 2 (16)
with less frequency in patients with benign trophoblastic tumor included excessive vomiting (14 percent), undue enlargement of the uterus (55 percent), and pseudo-toxemia (7 percent). Cystic enlargement of one or both ovaries was also noted in about 10 percent of these women. In the malignant type, cystic enlargement of one or both ovaries was found in four cases (30 percent). In this group also, symptoms which were attributed to metastases included hemoptysis, hematuria, hemiplegia, and urinary incontinence. The sites of metastases are shown in Table 1. The nature of the pregnancy antecedent to malignant trophoblastic tumor in patients studied is shown in Table 2. Hydatidiform mole was recorded in 46 percent while term pregnancy and abortion accounted for 38 percent and 16 percent, respectively. There was no case of antecedent ectopic pregnancy in this series. The interval between termination of an antecedent pregnancy and time of occurrence of malignant trophoblastic disease varied from two weeks to five years. In 46 percent of cases, this interval was within six months. Seventeen percent of cases of benign trophoblastic tumor progressed
Discussion The incidence of trophoblastic tumor, both benign and malignant, varies from one part of the world to another, although it must be remembered that in most cases the institutional incidence is much higher than the true incidence representative of the population in any particular country. I The institutional incidence of one in 379 deliveries for the benign and one in 846 deliveries for the malignant tumors obtained in this study from Lagos should be regarded as high. This high incidence agrees with the findings of another Nigerian author.3 Nigeria could therefore claim an incidence comparable to that in the Asian countries. The age distribution of our patients with benign trophoblastic tumor was similar to that from other countries.2"2'13 This disease has not been found to be associated with age or parity in our series though association with parity has been observed by other authors.2 No relationship with gravidity has been noted in our cases of malignant trophoblastic tumor. Progression from benign to malignant trophoblastic tumor was recorded in 17 percent of our cases. This figure is higher than those reported by other authors2'3"14 but similar to the figures given by Curry et al.'5 This disparity could possibly be explained on the basis of our classification of trophoblastic tumors into two broad categories of benign and malignant. This classification has been adopted for clinical simplicity and therapeutic reasons in that any tumor that was not benign automatically qualified for chemotherapy. This practice may probably provide a solution to the usual argument between the clinicians on one side and the pathologists on the other about which mole is potentially malignant and thus needs to be placed in a high risk category which sooner or later might require chemotherapy, or be given prophylactic chemotherapy. It is also hoped that this practice may in the long run improve the survival rate. At present, our survival rate of 46 percent in malignant trophoblastic tumor is much lower than 81.5 percent quoted by Bagshawe. 16 Thsof course was due to the
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 10, 1979
fact that about 54 percent of our patients did not report in hospital early enough for diagnosis and treatment. This latter group commenced chemotherapy well after six months following the onset of symptoms. Malignant trophoblastic tumor was preceded by hydatidiform mole in about 46 percent of patients. A comparable figure of about 50 percent has also been reported from Uganda10 and Iran.2 Six patients (20 percent) who were being followed up after evacuation of a mole became pregnant within six months of follow-up contrary to a policy that pregnancy should be delayed for two years. Incidentally, all the pregnancies were uneventful, and the suggestion from this is probably that the present policy should be reexamined and a new concept introduced which would perhaps permit pregnancy once the HCG has fallen to normal level especially if the radioimmunoassay (RIA) method is employed. The incidence of theca lutein cyst in trophoblastic tumor in our series was not higher than 30 percent. Although cystic formation of the ovary in this condition is said to be due to excessive
stimulation of the ovaries by HCG, we have not been able to demonstrate a correlation between urinary HCG levels and ovarian cyst formation. Attempts have been made to associate the occurrence of trophoblastic tumors with some external factors like viral,17 chemical,'8 dietary,2"9 and genetic,20'21 but results are still rather inconclusive, and the best that can be said presently is that racial incidence makes trophoblastic tumor more common in Asia and Africa than in Europe and in the Western world. Literature Cited 1. Hasegawa T:,Trophoblastic NeoplasiaIts Basic and Clinical Aspects, ed 1. Baltimore, Williams and Wilkins, 1971, p 166 2. Javey H, Sajadi H: Hydatidiform mole in Southern Iran: A statistical survey of 113 cases. Int J Gynaecol Obstet 15:390-395, 1978 3. Ogunbode 0: Benign hydatidiform mole in Ibadan, Nigeria. Int J Gynaecol Obstet 15:387-390, 1978 4. Martin PM: High frequency of hydatidiform mole in native Alaskans. Int J Gynaecol Obstet 15:395-396, 1978 5. Goldstein DM: Worldwide controversies in gestational trophoblastic neoplasms. Int J Gynaecol Obstet 15:207-215, 1977 6. Dewhurst CJ: Integrated Obstetrics and Gynaecology for Postgraduates. Oxford, Blackwell Scientific, 1972, pp 237-238 7. Joint project for study of choriocarcinoma and hydatidiform mole in Asia (1959): Geographic variation in the occurrence of
hydatidiform mole and choriocarcinoma. Ann NY Acad Sci 80:178-196, 1959 8. Pai KN: A study of choriocarcinoma: Its incidence in India and its aetiopathogenesis. In Holland JF, Hreshchyshyn MM (eds): Choriocarcinoma: Transactions of a Conference of the International Union Against Cancer. Berlin, Springer-Verlag, 1967, pp 54-57 9. de V Hendrickse JP, Cockshott WP, Evans KTE, et al:Pelvic angiography in the management of malignant trophoblastic disease. N Engl J Med 271:859-866, 1964 10. Leighton PC: Trophoblastic disease in Uganda. Am J Obstet Gynecol 117:341-344, 1973 11. Rolon PA, de Lopez BH: Epidemiological aspects of hydatidiform mole in the republic of Paraguay (South America). BrJ Obstet Gynaecol 84:862-864, 1977 12. MacGregor C, Ontiveros E, Vargas E, et al: Hydatidiform mole: Analysis of 145 patients. Obstet Gynecol 33:343-351, 1969 13. Westerhout FC, Morel ES, Slate WG: Observations on 138 molar pregnancies. Am J Obstet Gynecol 103:56-59, 1969 14. Acosta-Sisson H: Changing attitudes in the management of hydatidiform mole. Am J Obstet Gynecol 88:634-636, 1964 15. Curry SL, Hammond CB, Tyrey L, et al: Hydatidiform mole: Diagnosis, management, and long-term follow-up of 347 patients. Obstet Gynecol 45:1-8, 1975 16. Bagshawe KD: Monitoring of choriocarcinoma. Br J Radiol 49:291-292, 1976 17. Barr S J: More hydatidiform mole?, letters. Br Med J 2:707-708, 1977 18. Calvert, JP: More hydatidiform mole?, letters. Br Med J 2:578-579, 1977 19. Novak ER, Woodruff JD: Gynecologic and Obstetric Pathology, ed 7. Philadelphia, WB Saunders, 1974, p 599 20. lliya FA, Williamson S, Azar HA: Choriocarcinoma in the Near East: Consanguinity as a possible etiologic factor. Cancer 20:144149, 1967 21. Bagshawe KD: ABO blood groups in trophoblastic neoplasia. Lancet 1:553-556,1971
Surgical Operations in Short.Stay Hospitals, United States, 1975 In 1975 there were an estimated 34 million inpatients discharged from the nation's non-federal short-stay hospitals. An estimated 14.2 million inpatients, or about two out of every five inpatients, underwent at least one surgical operation. By number of operations per patient, about 9.7 million inpatients, or 68.1 percent, underwent one surgical operation; approximately
3.2 million, 22.5 percent, had two operations; and 1.3 million, 9.4 percent, had three operations. About 5.4 million patients with surgery were male, and 8.8 million were female. The corresponding rates per 1,000 population were 53.5 for males and 81.2 for females. The rate of surgically treated patients increased consistently with age: from 31.6 for
those under 15 years of age to 110.9 for those 65 years and over. The rate of male patients with surgery also increased with age, but for females the rate of discharges with surgery was highest for age group 15-44 years, the childbearing years.
from Vital and Health Statistics Public Health Service, DHEW
Meharry Leads In NHSC Scholarship Awards With 198 students receiving scholarships, Meharry Medical College School of Medicine led US medical and osteopathic schools in the number of par-* ticipants in the Public Health/National Health service Corps Scholarship Program from 1973-1977. Other schools with a large number of participants in the first five years of
the program administered by the Division of Manpower Training Support, Bureau of Health Manpower, were: Georgetown University School of Medicine, 189; Kansas City College of Osteopathic Medicine, 170; and Howard University School of Medicine, 134. Also, Loma Linda University
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 10, 1979
School of Medicine, 131; George Washington University, School of Medicine, 127; Medical College of Thomas Jefferson University, 105; and the College of Osteopathic Medicine and Surgery (Iowa), 102. from Health Resources News August 1978
