induce widespread acceptance and positiveparticipation on the part of an enlightenedpublic.

James Scott, M.D.Streator, Illinois

GestationalTrophoblastic Neoplasia

To the EdItor:

I would like to compliment Hammond andassociates on their excellent and thoroughreview of “¿�GestationalTrophob!astic Neoplasia,―(Ca 31:322—332, 1981), but feelcompelled to make three comments.

First, it is unfortunate, in an article ofthis caliber, that the authors did not usegrey-scale ultrasound as their example.The accompanying photograph, which isgrey-scale. details the most common sonographic pattern of an enlarged uterus withsmall sonolucent and echogenic areas representing hydropic villi.'

Secondly, because of the difficulty ofvisualizing a total skeleton early in gestation and because of the presence of ionizing radiation, the use of radiographs isquestionable.

Thirdly, amniography is now rarely ifever used to diagnose gestational trophoblastic neoplasia.

Alan G. Dembner, M.D.Department of RadiologySt. Barnabas Medical CenterLivingston, New Jersey

Reference

@.) .‘-‘.‘

- @‘¿� .‘--.-,.@@‘¿�;-@ b

Sagittal sections of true pelvis with distendedurinary bladder (B) and hydatidiform mole (U)

ate ultrasonographic technique of choice.The details of the radiographic study arethe same, however, but it would have beenmore appropriate to utilize the more current technology. We would also agree withDr. Dembner that routine use of x-ray invisualizing the fetal skeleton is rarely indicated. However, in cases where confusion is present, either skeletal x-ray oramniography would be an appropriateconfirming study to the ultrasound study.

Charles B. Hammond, M.D.Professor and ChairmanDepartment of Obstetrics

and GynecologyDuke University Medical CenterDurham, North Carolina

1. F!eischer AC, James AE, Krause DA, et a!:Sonographic patterns in trophoblastic disease.Radiology 126:215—220,1978.

Author's Reply:

We agree with Dr. Dembner that greyscale ultrasound is currently the appropri

VOL 32, NO 3 MAYJUNE 1982 191

To the Editor:

Since I had never encountered a single caseof hydatidiform mole or choriocarcinoma,with their never-to-be-forgotten severebleedingproblems.duringtheyearsIhadpracticed medicine as an American physician in varying regions of the Orient before Pearl Harbor, I am particularly interested in the opposing statistics on this

topic, as posed by Hammond and his colleagues in the article, “¿�GestationalTrophoblastic Neoplasia.―

Quoting directly from their article: “¿�Insome areas of the Orient, the incidence ofhydatidiformmole isreportedtobeashighas one in 125 births, while the incidenceofchoriocarcinomaisone in625 pregnancies. These incidences vary in differentareas of the United States, but are generally reported as one in 1,000 to 2,000 andone in 20,000 to 40,000 pregnancies, respectively.―

I had never encountered a single benignormalignantmolartumorinsome 60,000native Filipino miners and their familieswhen I was in charge of a medical serviceand a complexofhospitalsrunand ownedby the largest American-owned gold minein the Orient; on the medical staff of amissionary medical school and hospital inMoukden, Manchuria (Manchukuo); anddirector of a medical service and hospitalof a somewhat smaller American-run goldmine in northern Korea, south of the Yaluriver.

While there must be sound epidemiological reasons for the great disparity inthe incidence of molar tumors in the various regions of the Orient, I am as yetunable to provide clues why this should beso.The pointis madethatpregnantnativewomen seldom if ever came to the westernrun hospitals where I had practiced medicine in the Orient unless they had seriousobstetrical problems of the greatest dimension, and the presence of gestational trophoblastic neoplasia would most certainlybe one of those problems.

Other experiences with molar tumorsin the Orient, which have not to date beenpublished in medical journals, would helpput this problem into proper perspective.I hope this will be done. Until I am convinced otherwise, rhetorical embellishment of statistics to make a point mayprove to be the logical explanation for thegreatly increased incidence of gestationaltrophoblastic neoplasia in selected regionsof the Orient.

Leonard B. Creentree, M.D.Columbus, Ohio

192 CA-A CANCER JOURNAL FOR CLINICIANS

Author's Reply:

Geographicvariationinthe incidenceofgestational trophoblastic disease has beensubstantially and repeatedly documented.Inparticular,Orientalethnicgroupshavehistorically displayed a two-fold to threefold enhancement of the incidence rateswitnessed in the West. Although this epidemiologic fact has been incontrovertiblyestablished, its relationship to the genesisof this disorder remains enigmatic.

General associations between variousmedical conditions such as malnutrition,prominent in low socioeconomic population strata, and trophoblastic disease arethought to exist. However, these observations cannot satisfactorily account forregional incidence variations, as the economic development of Japan has not resulted in a marked decline of incidencerates.6

We welcome Dr. Greentree'sinquirybut cannot explain why his experienceshould vary with that reported in the international medical literature addressingthis subject.

Charles B. Hammond, M.D.

References

I. Acosta-Sison H: Statistical study of chorionepithelioma in the Philippine General Hospital.Am I Obstet Gynecol 58:125, 1949.2. The Joint Project for Study of Choriocarcinoma and Hydatidiform Mole in Asia: Geographic variation in the occurrence of hydatidiform mole and choriocarcinoma. Ann NYAcadSci80:178—196,1959.3. Poen HI, Djojopranoto M: The possibleetiologic factor of hydatidiform mole and choriocarcinoma:preliminaryreport. Am J ObstetGynecol92:510—513,1965.4. Wei PY, Ouyang PC: Trophoblastic diseasein Taiwan: a review of 157 cases in a 10-yearperiod. Am J Obstet Gynecol 85:844—849,1963.5. Márquez-Monter H, de Ia Vega GA. RidauraC, et al: Gestational choriocarcinoma in theGeneral Hospital of Mexico: analysis of 40cases. Cancer 22: 91—98,1968.6. Ishikuza N: Studies on trophoblastic neoplasia. Gan 18:203, 1976.