Gestational Trophoblastic Disease: Clinical and Imaging Features

An Invasive Molar Pregnancy: A Case Report With Associated Imaging

Human chorionic gonadotropin is generally used as a biomarker to identify invasive molar pregnancy. The extent of the disease (e.g., its staging) has not, however, relied on its sonographic description. A case is presented that can illustrate some diagnostically useful sonographic features of three-dimensional transvaginal sonography for this condition. The clinical imaging of this case initially suggested it to be a benign hydatidiform mole but ultimately was diagnosed as an invasive molar pregnancy, with human chorionic gonadotropin monitoring. Clinical imaging was used to help manage this patient, with the demonstration of trophoblastic invasion of the uterine wall. Although two-dimensional sonography is commonly used to diagnose molar pregnancy, three-dimensional sonography may offer a clinical advantage for the management of invasive molar pregnancy, which can occur in 15% of benign hydatidiform molar pregnancies.

A case of unplanned pregnancy at 2 months after uterine curettage in a patient with a hydatidiform mole

Whether an unplanned pregnancy should be terminated during follow-up of a hydatidiform mole is controversial. We report a patient who had an unplanned pregnancy with a hydatidiform mole at 2 months after uterine curettage when the human chorionic gonadotropin level had decreased to a negative value. Hydatidiform mole was confirmed by histopathology. Uterine curettage was performed twice and regular follow-ups were performed after surgery. The patient achieved a full-term pregnancy. The Apgar score of the newborn was 10 at 1, 5, and 10 minutes, and the newborn had no malformations. We conclude that the pregnancy outcome might be good in an unplanned pregnancy when the human chorionic gonadotropin level is negative.

Demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma: a UK population study

OBJECTIVE

To investigate the demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma.

DESIGN

A retrospective national population-based study.

SETTING

UK 1995-2015.

POPULATION

A total of 234 women with a diagnosis of gestational choriocarcinoma, in the absence of a prior molar pregnancy, managed at the UKs two gestational trophoblast centres in London and Sheffield.

METHODS

Retrospective review of the patient's demographic and clinical data. Comparison with contemporary UK birth and pregnancy statistics.

MAIN OUTCOMES

Incidence statistics for non-molar choriocarcinoma across the maternal age groups. Cure rates for patients by FIGO prognostic score group.

RESULTS

Over the 21-year study period, there were 234 cases of non-molar gestational choriocarcinoma, giving an incidence of 1:66 775 relative to live births and 1:84 226 to viable pregnancies. For women aged under 20, the incidence relative to viable pregnancies was 1:223 494, for ages 30-34, 1:80 227, and for ages 40-45, 1:41 718. Treatment outcomes indicated an overall 94.4% cure rate. Divided by FIGO prognostic groups, the cure rates were low-risk group 100%, high-risk group 96% and ultra-high-risk group 80.5%.

CONCLUSIONS

Non-molar gestational choriocarcinoma is a very rare diagnosis with little prior detailed information on the demographics and natural history. The data in this study give age-related incidence data based on a large national population study. The results also demonstrated the widely varying natural history of this rare malignancy and the marked correlation of disease incidence with rising maternal age.

TWEETABLE ABSTRACT

National gestational choriocarcinoma database indicates a close association between increasing maternal age and incidence.

A review on management of gestational trophoblastic neoplasia

BACKGROUND

The rare presence of malignant cancerous cells afar any type of pregnancy is known as gestational trophoblastic neoplasia (GTN). GTN are benign lesions which mostly happen due to the activity of extravillous trophoblast cells and the placental villous tree development. These kinds of diseases would be occurring mainly due to the following clinicopathologic conditions: (I) existence of epithelioid trophoblastic tumor (ETT), (II) rare type of choriocarcinoma cancer, (III) gestational trophoblastic tumor of mole, and (IV) the rare malignant tumor of placental site trophoblastic tumor.

OBJECTIVE

This comprehensive study is trying to review the most recent approaches in comprehension of pathogenesis, more precise diagnosis, and also the most effective therapeutic procedures for patients who suffer from GTN disorders.

MATERIALS AND METHOD

A comprehensive research was carried out on scientific databases of Science Citation Index (SCI), MEDLINE, EMBASE, HMIC, PubMed, CINAHL, Google Scholar, Cochrane Database of Systematic Reviews (CDSR), and PsycINFO over the time period of 2005 to 2019. The keywords which applied for discovering more related records were including: Gestational trophoblastic diseases (GTD), Gestational trophoblastic neoplasia (GTN), molar pregnancy, choriocarcinoma, human chorionic gonadotropin (hCG), diagnosis, management and treatment.

CONCLUSION

In spite of the fact that GTN patients are treated with conventional surgical therapies or/and chemotherapy, in some patients with resistant disease, these therapies may not be effective and patients may die. Some novel remedial agents are required for decreasing the level of toxicity caused through administering conventional chemotherapy and also treating the patients who suffer from refractory or resistant disease. The newest issues are related to GTN diagnosis, process of progression of hydatidiform mole (HM) to GTN, and the issue of GTN drug resistance. In this regard, we should have a comprehensive knowledge on GTN genetics for answering all the available questions about this disorder.

Role of ultrasound in the evaluation of first-trimester pregnancies in the acute setting

In patients presenting for an evaluation of pregnancy in the first trimester, transvaginal ultrasound is the modality of choice for establishing the presence of an intrauterine pregnancy; evaluating pregnancy viability, gestational age, and multiplicity; detecting pregnancy-related complications; and diagnosing ectopic pregnancy. In this pictorial review article, the sonographic appearance of a normal intrauterine gestation and the most common complications of pregnancy in the first trimester in the acute setting are discussed.

Placental site trophoblastic disease

A case study of a 38-year-old woman with a diagnosis of placental site trophoblastic tumor is presented. The patient had a 22-month history of amenorrhea since her last pregnancy, and a dilation and curettage procedure was performed after a 3.1×2.4×2.8 cm endometrial echogenic lesion was visualized on a pelvic ultrasound. When the diagnosis of placental site trophoblastic tumor was made by histopathologic and immunohistochemical analysis, complementary examinations including including pelvic magnetic resonance imaging (MRI) and a chest computed tomography (CT) were done. There was no evidence of disease outside the uterus, and a laparoscopic hysterectomy with bilateral salpingectomy was performed. After a surveillance period of 12 months, no disease recurrence was identified. Best imaging studies, treatment options, and proper surveillance for these type of tumors are discussed alongside the case study.

Neuroimaging and radiation exposure in pregnancy

Physiologic changes occurring in pregnancy and postpartum can have secondary effects on the maternal nervous system. While most alterations to neurologic function during pregnancy are transient, there is an elevated risk for more serious complication in the peripartum period, such as cerebrovascular events or exacerbation of preexisting neurologic conditions. Due to the morbidity and mortality associated with these neurologic manifestations in some cases, timely diagnostic evaluation is essential. In the pregnant population, the use of diagnostic techniques such as computed tomography (CT) and magnetic resonance imaging (MRI), commonly employed to evaluate emergent neurologic abnormalities, requires special consideration of the potential risks associated with prenatal exposure. This review discusses several neurologic conditions affecting women during pregnancy for which diagnostic imaging may be warranted. Concerns relating to CT and MRI procedures, radiation exposure in utero, and exposure to intravenous contrast by placental transfer and breastfeeding are also reviewed.

Twin pregnancy with metastatic complete molar pregnancy and coexisting live fetus

We present a case of a 34-year old G1P0 female with twin-gestation and positive prenatal screening. Initial ultrasounds demonstrated a normal live fetus with an indeterminate but persistent placental lesion. The patient presented at 23 weeks of gestational age with vaginal bleeding. On examination, a 2 cm vaginal lesion was identified. Further cross-sectional imaging demonstrated a normal appearing fetus with a mixed solid and cystic placental lesion as well as an additional lesion in the vagina. Metastatic workup revealed diffuse pulmonary metastases. Intravascular embolization was carried out to minimize the bleeding from the vaginal lesion, followed by the delivery of the fetus with an urgent Caesarean section and treatment with chemotherapy. Pathology and genetics testing confirmed diagnosis of a complete molar pregnancy with a coexisting live fetus. This case highlights the importance of any unexpected findings within the placenta or the uterus in a pregnant patient. The radiologist should maintain a high index of suspicion for gestational trophoblastic disease in such cases, communicate clearly with the clinical team and suggest appropriate additional imaging.

Role of magnetic resonance imaging in pregnancy-associated obstetric and gynecological complications

Background

To study the role of MRI in diagnosing pregnancy-associated obstetric and gynecological complications. We prospectively studied 48 pregnant and postpartum women, aged between 20 and 45 years, who were referred for MRI between August 2016 and April 2018 with suspected pregnancy-associated obstetric and gynecological complication. MRI findings were confirmed by intra-operative or histological findings.

Results

Out of the 48 patients, there were 32 women with suspected placenta accreta, 5 pregnant women with 6 ectopic pregnancies (1 patient had two gestational sacs), 3 with ovarian pathologies, 3 with uterine pathologies, 3 with abruptio placenta, and 2 with miscellaneous pathologies. In our study, there was an accuracy of 81.6% with sensitivity of 100% and specificity of 50%. There was 100% accuracy in predicting abruptio placenta, ovarian, uterine, and miscellaneous pathologies by MRI. There was 83.4% and 75% accuracy in predicting ectopic pregnancy and placenta accreta, respectively, by MRI.

Conclusion

MRI is very useful to diagnose pregnancy-associated obstetric and gynecological complications. It will be an important complementary tool to sonography and thereby facilitate better patient management.

A Review on the Pathogenesis and Clinical Management of Placental Site Trophoblastic Tumors

Placental site trophoblastic tumor (PSTT) is a rare type of gestational trophoblastic disease originating from the intermediate trophoblast. Compared with hydatidiform mole, invasive hydatidiform mole and choriocarcinoma, the diagnosis of PSTT is more complicated and lacks specific and sensitive tumor markers. Most PSTT patients demonstrate malignant potential, and the primary treatment of PSTT is hysterectomy. However, metastasis occasionally occurs and even causes death in a small number of PSTT patients. Most PSTT patients are young women hence fertility preservation is an important consideration. The major obstacle for PSTT patient prognosis is chemotherapy resistance. However, the current understanding of the pathogenesis of PSTT and clinical treatment remains elusive. In this review, we summarized the research progress of PSTT in recent years from three aspects: mechanism, clinical presentation, and treatment and prognosis. Well-conducted multi-center studies with sufficient sample sizes are of great importance to better examine the pathological progress and evaluate the prognosis of PSTT patients, so as to develop prevention and early detection programs, as well as novel treatment strategies, and finally improve prognosis for PSTT patients.

[Epidemioclinical and ultrasonographic profile of hydatidiform moles in Abidjan]

Introduction

The purpose of our study was to describe the epidemioclinical and ultrasonographic features of hydatidiform moles (HM) in Abidjan.

Methods

We conducted a cross-sectional study in the Department of Radiology, University Teaching Hospital of Yopougon over a 6-year period (January 2011-December 2016). In this study we describe the epidemioclinical and ultrasonographic profile of patients with HM. Ultrasonographic exams were performed using a mixed-methods approach (intravaginal and subpubic) based on B-mode and Color Doppler by senior radiologists. Anatomopathological examination of uterine content was performed.

Results

Out of 12190 obstetric ultrasound performed, twenty-five cases of HM were diagnosed reflecting a radiological referral rate of 0.2%. The average age of patients was 33.4 years, ranging from 22 to 50 years. There was no dominant age class. The main clinical signs associated with amenorrhea (100%) included abdominal mass 36% and vaginal bleeding 28%. Ultrasound showed hypertrophic uterus in 100% of cases, homogeneous uterus in 96% of cases and myomatous uterus in 4% of cases. MH had an average thickness of 42.7 mm with vesicular appearance in 68% of cases, "honeycomb" appearance in 16%, multicystic appearance in 12% and snowstorm appearance in 4%. MHs were classified as partial in 4% of cases, complete in 92% of cases and invasive in 4% of cases. Hypertrophic ovaries were found in 44% of cases with macrofollicles in 32% of cases and cysts in 8% of cases. Ultrasonographic diagnosis of HM was confirmed by anatomopathological examination in 100% of cases.

Conclusion

HMs are rare in Abidjan and are dominated by the complete hydatidiform mole. Its occurrence at the extreme ages wasn't found.

Gestational Trophoblastic Neoplasia, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

Gestational trophoblastic neoplasia (GTN), a subset of gestational trophoblastic disease (GTD), occurs when tumors develop in the cells that would normally form the placenta during pregnancy. The NCCN Guidelines for Gestational Trophoblastic Neoplasia provides treatment recommendations for various types of GTD including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor.

More Than Just 2 Layers: A Comprehensive Multimodality Imaging Review of Endometrial Abnormalities

Endometrial abnormalities develop in female patients of all ages. Symptoms related to endometrial pathologies are among the most common causes of gynecologist office visits, with the radiologists playing an important role in endometrial evaluation. In some instances, the radiologist may be the first physician to note endometrial pathology. In this article, we will provide a comprehensive review of radiologic modalities utilized in the evaluation of the endometrium, as well as the imaging appearance of various endometrial disease processes.

Lidocine potentiates the cytotoxicity of 5-fluorouracil to choriocarcinoma cells by downregulating ABC transport proteins expression

Choriocarcinoma is a gestational trophoblastic cancer, which often occurs in the first 3 months of pregnancy. 5-Fluorouracil (5-Fu) is the widely used chemotherapeutic drug for choriocarcinoma but limited by drug resistance. Lidocaine, an aminamide-type anesthetic, shows potential anticancer and chemosensitization effects in recent years. Herein, we tested the possible chemosensitization activity of lidocaine on the cytotoxicity of 5-Fu in choriocarcinoma cells. Viabilities and apoptosis of choriocarcinoma JEG-3 and JAR cells after lidocaine and/or 5-Fu treatment were detected using Cell Counting Kit-8 assay, annexin V-FITC/PI (fluorescein isothiocyanate/propidium iodide) staining and Western blot analysis, respectively. Quantitative reverse transcription polymerase chain reaction was done to measure breast cancer resistance protein (ABCG2) messenger RNA level. Western blot analysis was carried out to detect ABCG2, P-glycoprotein (P-gp), MRP1, and MRP2 protein levels. pEX-ABCG2 was transfected to elevate ABCG2 level. Then, the influence of ABCG2 on lidocaine + 5-Fu-caused cell viability loss, apoptosis, and inactivation of PI3K/AKT pathway were analyzed. We found that lidocaine in low concentration had no significant cytotoxicity to JEG-3 and JAR cells, but stimulated cell apoptosis in high concentration. Moreover, lidocaine potentiated the cytotoxicity of 5-Fu to JEG-3 and JAR cells through decreasing viability and increasing apoptosis. Lidocaine treatment reduced the ABCG2, P-gp, MRP1, and MRP2 protein levels in cells. Overexpression of ABCG2 reversed the synergistic effects of lidocaine + 5-Fu on JEG-3 and JAR cell viability and apoptosis, as well as PI3K/AKT pathway. Our research verified that lidocaine potentiated the cytotoxicity of 5-Fu to choriocarcinoma cells by downregulating ATP-binding cassette (ABC) transport proteins expression.

Placental site trophoblastic tumor and epithelioid trophoblastic tumor: Clinical and pathological features, prognostic variables and treatment strategy

Placental site trophoblastic tumor [PSTT] and epithelioid trophoblastic tumor [ETT] are the rarest gestational trophoblastic neoplasias, developing from intermediate trophoblast of the implantation site and chorion leave, respectively. PSTT and ETT share some clinical-pathological features, such as slow growth rates, early stage at presentation, relatively low βhCG levels and poor response to chemotherapy. The mortality rate ranges from 6.5% to 27% for PSTT and from 10% to 24.2% for ETT. Advanced stage, long interval between antecedent pregnancy and diagnosis, and presence of clear cells are the independent prognostic variables for PSTT, and they may be similar for ETT. Hysterectomy can represent the only therapy for early disease, whereas adjuvant chemotherapy should be reserved to patients with poor risk factors, such as an interval from the antecedent pregnancy >4 years, deep myometrial invasion or serosal involvement. Few cases of fertility-sparing treatment in young women have been reported. An individualized multidisciplinary approach, including chemotherapy and debulking surgery with abdominal and/or extra-abdominal procedures, is warranted for advanced disease. EP/EMA and TP/TE are the preferred regimens in this setting. Immunohistochemistry has sometimes shown expression of EGFR, VEGF, MAPK, PDGF-R and PD-L1, and therefore investigational studies on biological agents targeting these molecules are strongly warranted for chemotherapy resistant-disease.

Ultrasound of the First Trimester

Ultrasound is the imaging study of choice for detection and full characterization of early pregnancies based on its accuracy, low cost, safety profile, and abundant availability. This article reviews the goals and utility of first-trimester ultrasound in gestation localization, viability determination, and abnormal pregnancies, including ectopic implantation, retained products, and molar pregnancy.

The potential value of red blood cell distribution width in patients with invasive hydatidiform mole

Background

Red blood cell distribution width (RDW) has attracted increasing attention in cancer. The aim of this study was to assess the changes of RDW in patients with invasive hydatidiform mole and analyze the relationship between RDW and invasive hydatidiform mole.

Methods

A retrospective analysis was performed on 102 patients diagnosed as invasive hydatidiform mole in the First Affiliated Hospital of Guangxi Medical University from January 2009 to March 2018. A total of 120 healthy subjects were used as a control group. The Mann‐Whitney U test was used for comparison between the invasive hydatidiform mole and control groups. Comparison of RDW with other blood parameters was performed using Spearman's. The area under the ROC curve (AUC) and 95% confidence interval (95% CI) were also determined.

Results

The RDW, platelet‐lymphocyte ratio (PLR), neutrophil‐lymphocyte ratio (NLR), and absolute lymphocyte count were significantly elevated in the invasive hydatidiform mole group compared with control group. The hemoglobin (Hb) concentration, mean red blood cell volume (MCV) and platelet count (PLT) were significantly lower in invasive hydatidiform mole group than control group. Grade III and above invasive hydatidiform mole patients had higher levels of RDW than grade I and II patients. Correlation analysis showed that RDW was negatively correlated with Hb, MCV, NLR, and neutrophil count, but positively correlated with PDW and different stages of invasive hydatidiform mole. The ROC curve showed that the AUC of the RDW was 0.660 (95% CI 0.581‐0.740; P < 0.01).

Conclusion

This study reveals the potential value of RDW in invasive hydatidiform mole.

Imaging in Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD) is a spectrum of disorders characterized by abnormal trophoblastic proliferation. GTD includes benign conditions such as hydatidiform moles and malignant diseases that are referred as gestational trophoblastic neoplasia (GTN). Ultrasound plays a central role in the diagnosis of patients with hydatidiform mole. Other imaging modalities are useful in molar pregnancy, mainly for evaluating pulmonary complications and atypical presentation of hydatidiform mole. GTN typically arises after 20% of molar pregnancies but can uncommonly occur after nonmolar gestations. After uterine evacuation, serial human chorionic gonadotropin levels are evaluated in patients for early detection of GTN. Once GTN is suspected, Doppler ultrasound is the primary tool to confirm the diagnosis; however, magnetic resonance imaging can also help in selected cases. Metastatic disease workup can involve various modalities, including ultrasound, X-ray, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. In this article, we review the main imaging modalities used to evaluate patients with GTD.

Abdominal and pelvic imaging findings associated with sex hormone abnormalities

Hormones are substances that serve as chemical communication between cells. They are unique biological molecules that affect multiple organ systems and play a key role in maintaining homoeostasis. In this role, they are usually produced from a single organ and have defined target organs. However, hormones can affect non-target organs as well. As such, biochemical and hormonal abnormalities can be associated with anatomic changes in multiple target as well as non-target organs. Hormone-related changes may take the form of an organ parenchymal abnormality, benign neoplasm, or even malignancy. Given the multifocal action of hormones, the observed imaging findings may be remote from the site of production, and may actually be multi-organ in nature. Anatomic findings related to hormone level abnormalities and/or laboratory biomarker changes may be identified with imaging. The purpose of this image-rich review is to sensitize radiologists to imaging findings in the abdomen and pelvis that may occur in the context of hormone abnormalities, focusing primarily on sex hormones and their influence on these organs.

The management of hydatidiform mole with lung nodule: a retrospective analysis in 53 patients

Objective

To investigate the significance of lung nodule in hydatidiform mole, we retrospectively compared the clinical outcomes of those patients treated with different strategies.

Methods

The patients were divided into three groups: chemotherapy immediately once lung nodule was detected (group 1, n=17), delayed chemotherapy until human chorionic gonadotrophin (hCG) level met the diagnostic criteria for gestational trophoblastic neoplasia (GTN) (group 2, n=18), and hCG surveillance alone until hCG level was normalized spontaneously (group 3, n=18). The clinical parameters of these patients were collected and analyzed.

Results

Totally 53 (4.0%) patients were included from 1,323 cases with molar pregnancy during past 16 years. Among them, the diameters of lung nodules were 0.3–2.5 cm. Chemotherapy cycles for achieving hCG normalization and the failure rate of first-line chemotherapy in group 1 were significantly increased than that in group 2 (5 vs. 3 cycles, p=0.000, 58.8% vs. 11.1%, p=0.005). The hCG level of all 18 cases in group 3 was normalized spontaneously within 6 months. Of those, lung nodules of 9 patients disappeared spontaneously, accounting for 25% (9/36) of patients who initially selected observation. The proportion of single nodule in group 3 was significantly higher than that in group 2 (10/18 vs. 2/18, p=0.012).

Conclusion

Our results suggest that lung nodule alone is not an adequate indication of chemotherapy in molar pregnancy. hCG surveillance is safe for patients with lung nodule, especially with single nodule, as long as their hCG levels do not meet International Federation of Gynecology and Obstetrics diagnostic criteria for GTN.

Magnetic resonance imaging of the placenta and gravid uterus: a pictorial essay

The placenta is commonly overlooked on magnetic resonance imaging of the pregnant patient, which is frequently performed for alternative reasons such as to characterize fetal or uterine anomalies or to investigate the etiology of acute pelvic pain in pregnancy. Placental disorders have potential for significant maternal and fetal morbidity and peripartum complications if not recognized and treated in a timely manner. The radiologist must be familiar with normal placental variants and the spectrum of benign to life-threatening conditions affecting the placenta so that the Obstetrician can be promptly notified and patient management altered, if necessary. In this pictorial essay, we will describe our MR protocol for placental imaging, provide an image-rich review of the normal placenta, placental variants, and a variety of pathological conditions affecting the placenta and gravid uterus.

The role of ultrasound in the evaluation of acute pelvic pain in pregnancy and postpartum period: a review

PURPOSE OF REVIEW

Acute pelvic pain in pregnant and postpartum patients presents diagnostic and therapeutic challenges. Ultrasound remains the primary imaging modality of choice for assessing pregnant and postpartum women. The purpose of this review is to help practitioners ensure a correct diagnosis of acute pelvic pain in pregnancy and the postpartum period.

RECENT FINDINGS

This review describes the various causes and highlights the sonographic features and characteristics of acute pelvic pain in pregnancy and the postpartum period.

SUMMARY

Evaluation of acute pelvic pain in pregnancy and the postpartum period is challenging. Knowledge of the clinical settings and sonographic features of acute pelvic pain in pregnancy and the postpartum period can lead to accurate diagnosis and appropriate management of the condition.

Controversies in family planning: persistently elevated serum human chorionic gonadotropin levels after aspiration abortion

Low but rising serum human chorionic gonadotropin (hCG) levels occur infrequently after an induced abortion. Because this scenario rarely occurs after suction aspiration, clinicians may have higher suspicion for an uncommon diagnosis. The differential diagnosis includes both common and uncommon diagnoses, such as incomplete abortion, heterotopic or ectopic pregnancy, a new intrauterine pregnancy and gestational trophoblastic neoplasia. The etiology of this presentation may be unclear, especially in the absence of abnormal bleeding or pain which would suggest incomplete abortion, or when significant time has passed since the procedure. We describe two cases of an uncommon presentation of retained products of conception after aspiration abortion in which hCG levels were low but rising.

Exploring the links between cancer and placenta development

The development of metastatic cancer is a multistage process, which often requires decades to complete. Impairments in DNA damage control and DNA repair in cancer cell precursors generate genetically heterogeneous cell populations. However, despite heterogeneity most solid cancers have stereotypical behaviours, including invasiveness and suppression of immune responses that can be unleashed with immunotherapy targeting lymphocyte checkpoints. The mechanisms leading to the acquisition of stereotypical properties remain poorly understood. Reactivation of embryonic development processes in cells with unstable genomes might contribute to tumour expansion and metastasis formation. However, it is unclear whether these events are linked to immune response modulation. Tumours and embryos have non-self-components and need to avoid immune responses in their microenvironment. In mammalian embryos, neo-antigens are of paternal origin, while in tumour cells DNA mismatch repair and replication defects generate them. Inactivation of the maternal immune response towards the embryo, which occurs at the placental-maternal interface, is key to ensuring embryonic development. This regulation is accomplished by the trophoblast, which mimics several malignant cell features, including the ability to invade normal tissues and to avoid host immune responses, often adopting the same cancer immunoediting strategies. A better understanding as to whether and how genotoxic stress promotes cancer development through reactivation of programmes occurring during early stages of mammalian placentation could help to clarify resistance to drugs targeting immune checkpoint and DNA damage responses and to develop new therapeutic strategies to eradicate cancer.

Imaging of Metastatic Epithelioid Trophoblastic Tumor With 18F-FDG PET/CT

Epithelioid trophoblastic tumors are exceptionally rare malignant forms of gestational trophoblastic neoplasia arising from the placenta. We present here a case of a 33-year-old woman with an epithelioid trophoblastic tumor with metastatic disease to the lungs that was initially thought to represent cervical carcinoma. After appropriate diagnosis and treatment, the tumor responded to therapy and was in remission. The cancer recurred 5 years later with new lung metastases. F-FDG PET/CT was used for initial tumor staging, to evaluate treatment response, and to help detect the recurrence.

The Usefulness of Ultrasound Imaging in Gynecologic Oncology

Pelvic ultrasound examination is the primary imaging modality for evaluating a wide range of female pelvic symptomatology, and is often the first imaging test to detect a gynecologic malignancy. Ultrasound imaging is particularly useful for evaluating the thickness and appearance of the endometrium in patients with abnormal bleeding, and in detecting and characterizing ovarian lesions. This article reviews the ultrasound appearance of gynecologic neoplasms grouped by anatomic site of origin, the ultrasound appearance of select benign pelvic pathology not to be misinterpreted as malignancy, as well as available ultrasound imaging-based guidelines for managing potential gynecologic neoplasms.