Choriocarcinoma - postdisease ultrasonographic findings

Gestational trophoblastic disease: Literature review

Gestational trophoblastic disease is characterized by abnormal proliferation of pregnancy-associated trophoblastic tissue with malignant potential. Gestational trophoblastic disease covers a spectrum of conditions including hydatidiform mole, invasive mole, choriocarcinoma and placental site trophoblastic tumour. It is very important to understand the pathophysiology and natural history of the disease in order to achieve faster recognition and effective treatment. The presence and course of the disease can be monitored with quantitative levels of human chorionic gonadotrophin in all cases. Clinical signs and symptoms are usually insufficient to diagnose and predict the extent of disease. Nowadays, gestational trophoblastic diseases are the best treated gynaecological malignancy thanks to modern technology. This review covers various aspects of gestational trophoblastic disease: its development, epidemiology, aetiology and pathogenesis, as well as its classification, clinical manifestations and diagnostic methods.

[Review of potentials of Doppler ultrasonographic findings in patients with confirmed gestational trophoblastic neoplasms]

<zakljucak> Transvaginalna dopler ultrazvucna dijagnostika, kao neinvazivna i neskodljiva dijagnosticka metoda, ima respektabilno mesto u ranoj dijagnostici gestacijskih trofoblastnih neoplazmi. Uz odredjivanje serumske vrednosti humanog horionskog gonadotropina i pracenje dinamike njegovih promena, histoloski nalaz i promene u ultrazvucnoj slici, moguce je rano dijagnostikovati GTN, pa cak i maligne oblike, sto se pokazalo vaznim u donosenju pravovremene odluke o nacinu lecenja bolesnica i ocuvanja reproduktivnog zdravlja.

Radiology of gestational trophoblastic neoplasia

Gestational trophoblastic neoplasia (GTN) encompasses a broad spectrum of placental lesions from the pre-malignant hydatidiform mole (complete and partial) through to the malignant invasive mole, choriocarcinoma and rare placental site trophoblastic tumour (PSTT). Ultrasound remains the radiological investigation of choice for initial diagnosis, and it can also predict invasive and recurrent disease. Magnetic resonance imaging is of invaluable use in assessing extra-uterine tumour spread, tumour vascularity, and overall staging. Positron emission tomography and computed tomography undoubtedly have a role in recurrent and metastatic disease, while angiography has a place in disease and complication management. This review will describe the relevant pathophysiology and natural history of GTN, and the use of imaging techniques in the diagnosis and management of these conditions.

Routine pre-evacuation ultrasound diagnosis of hydatidiform mole: experience of more than 1000 cases from a regional referral center

OBJECTIVES

To examine the accuracy of sonographic findings of routine ultrasound examinations in patients with a proven histological diagnosis of complete or partial hydatidiform mole referred to a supra-regional referral center, and to examine the relationship of sonographic findings to gestational age across the first and early second trimesters.

METHODS

Review of consecutive cases referred to a trophoblastic disease unit from June 2002 to January 2005 with a diagnosis of possible or probable hydatidiform mole in whom results of a pre-evacuation ultrasound examination were documented. Ultrasound detection rates for partial and complete hydatidiform moles were calculated and comparison of detection rates between complete and partial mole, and gestational age groups carried out.

RESULTS

1053 consecutive cases were examined. The median maternal age was 31 (range, 15-54) years and the median gestational age was 10 (range, 5-27) weeks. 859 had a final review diagnosis of partial or complete hydatidiform mole (82%), including 253 (29%) complete moles and 606 (71%) partial moles. Non-molar hydropic miscarriage was diagnosed following histological review in 194 (18%). Overall, 378 (44%) cases with a final diagnosis of complete or partial hydatidiform mole had a pre-evacuation ultrasound diagnosis suggesting hydatidiform mole, including 200 complete moles and 178 partial moles, representing 79% and 29%, respectively, of those with complete (253) or partial (606) moles in the final review diagnosis. The ultrasound detection rate was significantly better for complete versus partial hydatidiform moles (Z = 13.4, P < 0.001). There was a non-significant trend towards improved ultrasound detection rate with increasing gestational age, with an overall detection rate of 35-40% before 14 weeks' gestation compared to around 60% after this gestation. The sensitivity, specificity, positive predictive value and negative predictive value for routine pre-evacuation ultrasound examination for detection of hydatidiform mole of any type were 44%, 74%, 88% and 23%, respectively.

CONCLUSIONS

Routine pre-evacuation ultrasound examination identifies less than 50% of hydatidiform moles, the majority sonographically appearing as missed or incomplete miscarriage. Detection rates are, however, higher for complete compared to partial moles, and improve after 14 weeks' gestation. Histopathological examination of products of conception remains the current gold standard for the identification of gestational trophoblastic neoplasia.

[Significance of transvaginal Doppler ultrasonography for detection of malignant gestational trophoblastic disease]

Transvaginal Doppler ultrasonography has an important role in detecting and confirming the gestational trophoblastic disease (GTD). It can also be helpful in early detection of the malignant cases of GTD such as the invasion and protrusion of trophoblastic tissue into the uterine wall. Ultrasonographic picture of the malignant GTD is also specific for the presence of prominent zones of vasculavization in the peritrophoblastic tissue, as well as in the uterine tissue in which malignant GTD is developed. Resistance Index (RI) values were measured at the level of blood vessels of peritrophoblastic tissue and of suspected zones in the uterine tissue to detect neovascularization, which followed the malignant process. Theca luteal cysts were often detected by Transvaginal Doppler ultrasonography.