Gestational trophoblastic disease: a spectrum of radiologic diagnosis

Complete Hydatidiform Mole with Lung Metastasis and Coexisting Live Fetus: Unexpected Twin Pregnancy Mimicking Placenta Accreta

Twin pregnancy with a complete hydatidiform mole and coexisting fetus (CHMCF) is an exceedingly rare condition with an incidence of about 1 in 20,000-100,000 pregnancies. It can be detected by prenatal ultrasonography and an elevated maternal serum beta-human chorionic gonadotropin (BhCG) level. Herein, the author reports a case of CHMCF which was incidentally diagnosed through pathologic examination without preoperative knowledge. The 41-year-old woman, transferred due to preterm labor, delivered a female baby by cesarean section at 28 + 5 weeks of gestation. Clinically, the surgeon suspected placenta accreta on the surgical field, and the placental specimen was sent to the pathology department. On gross examination, focal vesicular and cystic lesions were identified separately from the normal-looking placental tissue. The pathologic diagnosis was CHMCF and considering the fact that placenta accreta was originally suspected, invasive hydatidiform mole was not ruled out. After radiologic work-up, metastatic lung lesions were detected, and methotrexate was administered in six cycles at intervals of every two weeks. The author presents the clinicopathological features of this unexpected CHMCF case accompanied by pulmonary metastasis, compares to literature review findings, and emphasizes the meticulous pathologic examination.

Invasive Mole Mimicking Abnormal Uterine Bleeding: A Case Report

Invasive mole (IM) is a very uncommon subtype of gestational trophoblastic disease (GTD), which is the invasion of molar tissue into the uterine or myometrial vasculature. However, this report presents a rare case of a 41-year-old female multiparous P7 with five full-term normal vaginal deliveries and two preterm normal vaginal deliveries. As the patient was not using contraception, her urine pregnancy test (UPT) was done, which demonstrated positive results. A speculum examination revealed a healthy cervix with just mild bleeding, whereas a vaginal examination revealed a firm cervix and an anteverted and mobile eight-week-old uterus along with a free fornix. Pelvic ultrasound and magnetic resonance imaging (MRI) demonstrated the diagnosis of GTD, for which consultation from an oncology physician was taken and the treatment proceeded with a total abdominal hysterectomy. Histological examination of the uterus showed a circumscribed nodule showing a large area of hemorrhage with few chorionic villi lined with trophoblastic cells and occasional villi invading the myometrium and endometrial cavity suggesting hydatidiform mole showing early invasion that confirmed the diagnosis of IM. In conclusion, reproductive-age women who experience abnormal uterine bleeding (AUB) should suspect pregnancy with several possible complications, for which a pregnancy test should be done to rule out complications.

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.

Gestational Trophoblastic Disease: Clinical and Imaging Features

Gestational trophoblastic disease (GTD) is a spectrum of both benign and malignant gestational tumors, including hydatidiform mole (complete and partial), invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. The latter four entities are referred to as gestational trophoblastic neoplasia (GTN). These conditions are aggressive with a propensity to widely metastasize. GTN can result in significant morbidity and mortality if left untreated. Early diagnosis of GTD is essential for prompt and successful management while preserving fertility. Initial diagnosis of GTD is based on a multifactorial approach consisting of clinical features, serial quantitative human chorionic gonadotropin (β-hCG) titers, and imaging findings. Ultrasonography (US) is the modality of choice for initial diagnosis of complete hydatidiform mole and can provide an invaluable means of local surveillance after treatment. The performance of US in diagnosing all molar pregnancies is surprisingly poor, predominantly due to the difficulty in differentiating partial hydatidiform mole from nonmolar abortion and retained products of conception. While GTN after a molar pregnancy is usually diagnosed with serial β-hCG titers, imaging plays an important role in evaluation of local extent of disease and systemic surveillance. Imaging also plays a crucial role in detection and management of complications, such as uterine and pulmonary arteriovenous fistulas. Familiarity with the pathogenesis, classification, imaging features, and treatment of these tumors can aid in radiologic diagnosis and guide appropriate management. ^©RSNA, 2017.

"Bunch of grapes" in complete hydatidiform mole

Complete hydatidiform mole is a common cause of gestational bleeding of the first trimester, commonly assessed by ultrasound. It represents an abnormal proliferation of trophoblastic tissue, with no fetal formation, just hydropic villi. These abnormal villi seen in ultrasound are compared to a "bunch of grapes," a classic description of this disease.

Qualitative and quantitative analysis of diffusion-weighted imaging of gestational trophoblastic disease: Can it predict progression of molar pregnancy to persistent form of disease?

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The incidence of GTD in Iran is significantly higher than America and Europe.

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ADC value of GTD is (1.96 ± 0.32 × 10⁻³ mm²/s).

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GTD in T1 and T2-weighted images shows heterogeneous “snow-storm” appearance.

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Focal intratumoral hemorrhage is bright in DWI and low signal in the ADC map.

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ADC value and DWI are not helpful to predict progression of HM to persistent disease.

Purpose

To describe the diffusion-weighted imaging (DWI) appearance of gestational trophoblastic disease (GTD) and to determine its apparent diffusion coefficient (ADC) values. To evaluate the feasibility of DWI to predict progression of hydatidiform mole (HM) to persistent disease.

Methods

During a period of 6 months, women with preliminary diagnosis of GTD, based on ultrasound and ßhCG levels, underwent 1.5T MRI (T2 high-resolution and DWI; b values 50, 400, 800; sagittal and perpendicular to the endometrium; and T1, T2 Turbo Spin Echo [TSE] axial images). Patients were followed for 6–12 months to monitor progression to persistent form of the disease. ADC values and image characteristics were compared between HM and persistent neoplasia and between GTD and non-molar pregnancy using Mann–Whitney U and Fisher’s exact tests, respectively.

Results

Among the 23 studied patients, 19 (83%) were classified as molar and 4 (17%) as non-molar, based on pathology reports. After 6–12 months of follow-up, 5 (26%) cases progressed to persistent disease and 14 (74%) cases were benign HM. There was no significant difference between ADC values for HM (1.93 ± 0.33 × 10⁻³ mm²/s) and persistent neoplasia (2.03 ± 0.28 × 10⁻³ mm²/s) (P = 0.69). The ADC of non-molar pregnancies was (0.96 ± 0.46 × 10⁻³ mm²/s), which was significantly different from GTD (1.96  ± 0.32 × 10⁻³ mm²/s) (P = 0.001). Heterogeneous snowstorm appearance, focal intratumoral hemorrhage, myometrial contraction, and prominent myometrial vascularity were more common in GTD compared to non-molar pregnancy (P < 0.05).

Conclusion

Heterogeneous snowstorm appearance, focal intratumoral hemorrhage, myometrial contraction, and prominent myometrial vascularity are among the imaging characteristics of GTD. We cannot use ADC values to predict progression to persistent disease.

Caesarean Scar Choriocarcinoma: Ultrasound and Magnetic Resonance Imaging Findings

Primary gestational choriocarcinoma in a uterine caesarean section scar (CSS) is an extremely rare entity, and its timely diagnosis and treatment is crucial in order to prevent related complications and metastatic disease. Herein, we report on a 33-year-old female who was referred to our department with an initial diagnosis of ectopic pregnancy. Transabdominal ultrasound and magnetic resonance imaging (MRI) demonstrated a nodular mass on CSS. The final histopathological diagnosis was CSS choriocarcinoma.

Imaging Features of Uncommon Gynecologic Cancers

OBJECTIVE

The role of imaging in patients with suspected gynecologic malignancies is to provide an accurate diagnosis to achieve the best and most tailored treatment plan. Uncommon cancers pose a distinct challenge, because current knowledge of these diseases is still limited. Our purpose is to highlight the role of cross-sectional imaging techniques, including ultrasound, CT, MRI, and PET/CT, in the diagnosis and pretreatment stratification of patients with rare gynecologic cancers.

CONCLUSION

This review shows the relevance of imaging findings for diagnosis, staging, and treatment planning in patients with uncommon uterine, cervical, vaginal, vulvar, and ovarian cancers.

Imaging features of thoracic metastases from gynecologic neoplasms

Gynecologic malignancies are a heterogeneous group of common neoplasms and represent the fourth most common malignancy in women. Thoracic metastases exhibit various imaging patterns and are usually associated with locally invasive primary neoplasms with intra-abdominal spread. However, thoracic involvement may also occur many months to years after initial diagnosis or as an isolated finding in patients without evidence of intra-abdominal neoplastic involvement. Thoracic metastases from endometrial carcinoma typically manifest as pulmonary nodules and lymphadenopathy. Thoracic metastases from ovarian cancer often manifest with small pleural effusions and subtle pleural nodules. Thoracic metastases to the lungs, lymph nodes, and pleura may also exhibit calcification and mimic granulomatous disease. Metastases from fallopian tube carcinomas exhibit imaging features identical to those of ovarian cancers. Most cervical cancers are of squamous histology, and while solid pulmonary metastases are more common, cavitary metastases occur with some frequency. Metastatic choriocarcinoma to the lung characteristically manifests with solid pulmonary nodules. Some pulmonary metastases from gynecologic malignancies exhibit characteristic features such as cavitation (in squamous cell cervical cancer) and the "halo" sign (in hemorrhagic metastatic choriocarcinoma) at computed tomography (CT). However, metastases from common gynecologic malignancies may be subtle and indolent and may mimic benign conditions such as intrapulmonary lymph nodes and remote granulomatous disease. Therefore, radiologists should consider the presence of locoregional disease as well as elevated tumor marker levels when interpreting imaging studies because subtle imaging findings may represent metastatic disease. Positron emission tomography/CT may be helpful in identifying early locoregional and distant tumor spread.

40-year-old female with menorrhagia and abdominal pain: A case of metastatic gestational trophoblastic neoplasia

Choriocarcinoma is part of a rare spectrum of placental abnormalities known as gestational trophoblastic disease (GTD). It is the most invasive form of GTD, with a mortality rate approaching 100% if left untreated. It spreads predominantly hematogenously to multiple target sites, most commonly the lungs. Due to its hypervascular nature, it is often complicated by bleeding. We describe a case of choriocarcinoma in a 40-year-old female with metastases to the lungs, brain, and bilateral kidneys resulting in large retroperitoneal hematomas.

Pelvic Ultrasound Simulation Training Models and Case Scenarios

Pelvic ultrasound simulation training using high-fidelity mannequins can provide a safe and controlled learning environment to foster the ultrasound education of medical students, residents and faculty. The instruction can be tailored to the specific needs of the learners. Topics for instruction range from teaching basic anatomy and ultrasound scanning techniques to common and advanced obstetrics and gynecology disease presentations and pathological processes. Simulation can closely approximate patient encounters using case based scenarios which will aid in developing knowledge and skills that can be transferred to the clinical environment. The goal of simulation is to help the learners to become more confident and competent to care for their patients.

How to cite this article

Sarmiento J, Stewart K, Aguila J, Bagherpour A, Kupesic Plavsic S. Pelvic Ultrasound Simulation Training Models and Case Scenarios. Donald School J Ultrasound Obstet Gynecol 2014;8(1):22-30.

Sonographic characteristics of placental site trophoblastic tumor

OBJECTIVE

To investigate clinical features and ultrasound findings in cases of placental site trophoblastic tumor (PSTT).

METHODS

Fourteen cases of PSTT treated at our institution between May 2004 and October 2010 were identified and the clinical features and findings on transvaginal sonography (TVS) were investigated. Pathological confirmation of PSTT was obtained in all cases.

RESULTS

The most frequent symptoms associated with PSTT were abnormal vaginal bleeding, which was present in 11 cases, and amenorrhea, which was present in five cases. The interval from antecedent pregnancy to diagnosis was 4-36 (median, 12.5) months. Blood serum was positive for beta-human chorionic gonadotropin (β-hCG) at the time of ultrasound examination, although the level was generally low, with a median of 166.2 IU/L (range, 4.5-3480.2). Sonographic presentation of PSTT was classified into one of three types according to the characteristics observed on TVS: Type I, heterogeneous solid mass in the uterine cavity (four cases), with minimal to a moderate degree of vascularization on color Doppler imaging; Type II, heterogeneous solid mass in the myometrium (six cases), with minimal to a high degree of vascularization (only one case was highly vascularized); and Type III, cystic lesions in the myometrium (four cases) with a high degree of vascularization (lacunar-type lesions).

CONCLUSIONS

Combined with clinical features, characteristics demonstrated by TVS provide evidence for the suspicion of PSTT and could contribute to clinical decision making.

Ultrasound and infections on the Tibetan Plateau()

INTRODUCTION

The authors report on an ultrasound (US) outreach program for the nomadic people living in Yushu, a remote area of Qinghai, Tibet, People's Republic of China (PRC) about 4800 m above sea level. The program was carried out in cooperation with ROKPA INTERNATIONAL, a non-profit organization (NGO) that aims at helping the poorest peoples living in remote regions of the world.

MATERIALS AND METHODS

A hand-held US scanner (Sonosite 180 Plus, Sonosite Inc., Bothell, WA, USA) equipped with a 3.5-5 MHz convex probe was used at a local clinic for 21 days in 2007 and for 32 days in 2009.

RESULTS

A total of 1128 US examinations were performed (578 in 2007 and 550 in 2009). The main diagnoses were: Echinococcal cysts (66 cases; 6.23%) - Biliary tract and intrahepatic gallstones (10% of patients examined) - Ascariasis - Acute and chronic hepatitis, liver cirrhosis, abdominal masses - Abdominal tuberculosis - Miscellaneous (trophoblastic tumor, megacalicosis, splenomegaly in acute leukemia). After the first experience in 2007, collaboration with the local hospital was established for the treatment of patients affected by active echinococcal cysts using albendazole and puncture, aspiration and injection of scolicidal agent and re-aspiration (PAIR) and subsequent follow-up.

DISCUSSION AND CONCLUSIONS

US scanning was well accepted by the local population and allowed diagnosis, classification and choice of treatment of the echinococcal cysts according to recent criteria based on a stage-specific approach. Percutaneous treatment was also introduced, but more training of local healthcare providers is needed to secure continuation of this practice. Further experience may help improve the standard of health care services offered to the nomadic populations in this remote area.

Gestatational trophoblastic disease: multimodality imaging assessment with special emphasis on spectrum of abnormalities and value of imaging in staging and management of disease

Gestational trophoblastic disease is a spectrum of disorders of varying malignant potential arising from trophoblastic cells and encompassing hydatidiform moles and persistent trophoblastic neoplasia. Ultrasound is the initial imaging investigation of choice when gestational trophoblastic disease is suspected. Complete hydatiform mole, the most common form of molar pregnancy, usually has a characteristic "cluster of grapes" appearance, especially on second-trimester ultrasounds. Persistent trophobastic neoplasia usually appears as a focal, hypervascular myometrial mass on pelvic ultrasound. Pelvic magnetic resonance imaging is often used as a problem-solving tool in equivocal or complicated cases of gestational trophoblastic disease to assess the degree of invasion into the myometrium and surrounding tissues. Chest x-ray, brain magnetic resonance imaging, and body computed tomography scans are primarily used for the evaluation of metastatic disease, which usually occurs in the context of choriocarcinomas. Choriocarcinoma metastases are usually hypervascular and have a tendency to bleed, features that are reflected in their imaging appearance.

Intratumoral blood flow analysis in epithelioid trophoblastic tumors

OBJECTIVE

The purpose of this series was to describe the transvaginal color pulsed Doppler sonographic features of epithelioid trophoblastic tumors (ETTs) and to evaluate whether there were specific sonographic criteria to accurately distinguish them from other lesions.

METHODS

Seven cases of ETTs treated in the Women's Hospital of Zhejiang University were retrospectively analyzed. Doppler indices, including the Pourcelot resistive index (RI), pulsatility index (PI), and peak systolic to diastolic velocity (S/D) ratio from blood flow signals within the tumors were calculated from each waveform sample by using the software of the ultrasound machines.

RESULTS

Patients with ETTs had heterogeneously echoic masses and highly abnormal flow patterns. The mean PI, RI, and S/D ratio for the patients were 0.57 (range, 0.22-1.09), 0.42 (range, 0.2-0.7), and 1.89 (range, 1.25-3.40), respectively.

CONCLUSIONS

The clinical usefulness of intratumoral blood flow assessment in ETTs is yet to be established. However, the multiparameter sonographic approach can help in diagnosis of an ETT.

Gynecologic pathology on multidetector CT: a pictorial review

The purpose of this pictorial essay is to review the imaging appearance of the spectrum of gynecologic pathology that may be visualized by multidetector computed tomography (CT). Although ultrasound and magnetic resonance imaging remain the primary imaging modalities for evaluating female patients with suspected obstetric and gynecologic pathology, CT is frequently performed as the initial imaging modality in the evaluation of abdominal and pelvic pain of unknown etiology. Pelvic pain in women due to a gynecologic condition may also mimic numerous other conditions such as appendicitis and diverticulitis, resulting in initial evaluation by CT-particularly in the emergency setting. The radiologist should, therefore, be familiar with the spectrum of gynecologic and obstetric pathology that may be present on a CT evaluation of the abdomen and pelvis regardless of the study indication, particularly because CT is often the most readily available imaging modality in the emergency setting on a 24/7 basis.

CT of pregnancy-related complications

During pregnancy, the risk of radiation exposure to the fetus is increased so that more than the usual benefit is necessary to justify computed tomography (CT; or other radiation exposure) than in non-pregnant patients. In the setting of a life-threatening illness, CT may be indicated to assess for potentially fatal complications such as hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. After delivery, patients rarely develop serious problems requiring radiologic evaluation. When indicated, however, CT may be invaluable in making the diagnosis or determining the severity of peri- and post-partum complications, including uterine perforation, hemorrhage, endometritis, thrombophlebitis, and abscess formation. At times, CT may be the first to uncover conditions, such as post-partum cardiomyopathy, and heart failure, which are usually diagnosed by other modalities but may explain the symptoms for which the study was ordered. In some centers, CT pulmonary angiography represents the standard of care to diagnose pulmonary thromboembolism. In this article, we illustrate the spectrum of peri-partum and post-partum complications on CT to familiarize the radiologist with the CT features of these potentially life-threatening pregnancy-related complications.

Sonographic diagnosis of gestational trophoblastic disease and comparison with retained products of conception

OBJECTIVE

Gestational trophoblastic disease (GTD) and retained products of conception (RPC) can be difficult to distinguish sonographically. The aim of this study was to determine whether there were any sonographic criteria that could prospectively distinguish one from the other.

METHODS

Institutional ethics approval was obtained, and acquisition of consent was waived by the Institutional Review Board. A retrospective review of gynecologic oncology and pathology databases identified 17 cases of GTD and 14 cases of RPC. Findings from the pre-evacuation transvaginal sonographic examinations were analyzed. The scans were independently reviewed by 2 senior radiologists with specific expertise in pelvic sonography using several predetermined sonographic features. The reviewers were blinded to the diagnosis. A consensus reading was obtained.

RESULTS

The sonographic features that predicted GTD were a myometrial epicenter (P = .0002; odds ratio [OR] = 28), depth of myometrial invasion of more than one third (P = .001; OR = 20), placental venous lakes (P = .04; OR = 9), maximum mass dimensions of more than 3.45 cm (P = .009), and maximum endometrial thickness of less than 12 mm (P = .02). The remaining criteria were not statistically significant and included the characteristics of the mass, ascites, a "snowstorm" appearance, mass vascularity (including resistive index and peak systolic velocity), and the presence of ovarian cysts.

CONCLUSIONS

There are specific transvaginal sonographic features that can accurately differentiate GTD and RPC.

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.

Gestational trophoblastic disease: pictorial review

Ultrasound is the modality of choice for evaluating normal or abnormal first trimester pregnancy. Sonography can usually provide a specific diagnosis in abnormal first trimester bleeding. When the sonographic appearance is correlated with the clinical presentation, accurate diagnosis is possible in most cases of gestational trophoblastic disease (GTD). Partial or complete hydatidiform moles can be diagnosed in early gestation. However certain cases will be missed if the curettage material is not sent for pathologic examination. Sometimes molar pregnancies have very unusual sonographic appearances. Sonography and Doppler imaging are helpful in diagnosing gestational trophoblastic disease, in determining whether invasive disease is present, in detecting recurrent disease, and in following the effectiveness of chemotherapy. This pictorial essay describes the pathogenesis, epidemiology, and sonographic spectrum of gestational trophoblastic disease.

Pathologies of the uterine endometrial cavity: usual and unusual manifestations and pitfalls on magnetic resonance imaging

The endometrial cavity may demonstrate various imaging manifestations such as normal, reactive, inflammatory, and benign and malignant neoplasms. We evaluated usual and unusual magnetic resonance imaging (MRI) findings of the uterine endometrial cavity, and described the diagnostic clues to differential diagnoses. Surgically proven pathologies of the uterine endometrial cavity were evaluated retrospectively with pathologic correlation. The pathologies included benign endometrial neoplasms such as endometrial hyperplasia and polyp, malignant endometrial neoplasms such as endometrial carcinoma and carcinosarcoma, endometrial-myometrial neoplasm such as endometrial stromal sarcoma, pregnancy-related lesions in the endometrial cavity such as gestational trophoblastic diseases (hydatidiform mole, invasive mole and choriocarcinoma) and placental polyp, myometrial lesions simulating endometrial lesions such as submucosal leiomyoma and some adenomyosis, endometrial neoplasms simulating myometrial lesions such as adenomyomatous polyp and endometrial lesions arising in the hemicavity of a septate/bicornate uterus, and fluid collections in the uterine cavity (hydro/hemato/pyometra). It is important to recognize various imaging findings in these diseases, in order to make a correct preoperative diagnosis.

Sonographic and Doppler imaging in the diagnosis and treatment of gestational trophoblastic disease: a 12-year experience

OBJECTIVE

To evaluate the clinical utility of sonography with Doppler examination in the diagnosis and treatment of gestational trophoblastic disease (GTD).

METHODS

A retrospective analysis of 355 cases of GTD seen over a 12-year period in 2 large university referral hospitals in China was performed. Clinical appearances, sonographic findings, Doppler waveforms, and patient outcomes were reviewed. Sonographic and Doppler examinations were performed to diagnose the presence of molar tissue, detect invasive disease, assess disease recurrence, and monitor the efficacy of chemotherapy. Doppler waveforms of 13 patients with normal early pregnancies were also examined for comparison.

RESULTS

Of the 355 patients with GTD, 106 had a classic hydatidiform mole (CHM), 33 had a partial hydatidiform mole (PHM), 184 had an invasive hydatidiform mole (IHM), and 32 had choriocarcinoma. Sonography showed abnormal molar tissue confined to the endometrial cavity in all cases of CHM. In cases of IHM and choriocarcinoma, soft tissue invasion and cystic vascular spaces within the myometrium were shown. Cases of PHM had a thickened, hydropic placenta with a concomitant fetus. Doppler waveforms showed resistive indices of 0.55 (SD, 0.06) for CHM, 0.56 (SD, 0.04) for PHM, 0.28 (SD, 0.06) for IHM, 0.25 (SD, 0.05) for choriocarcinoma, and 0.66 (SD, 0.04) for normal pregnancies. The abnormal sonographic and Doppler findings in invasive disease resolved when chemotherapy was successful.

CONCLUSIONS

Sonography and Doppler imaging were helpful in diagnosing GTD, in determining whether invasive disease was present, in detecting recurrence of disease, and in following the effectiveness of chemotherapy.

MR Imaging of Maternal Diseases of the Abdomen and Pelvis during Pregnancy and the Immediate Postpartum Period

Magnetic resonance (MR) imaging provides multiplanar large field-of-view images of the body with excellent soft-tissue contrast and without ionizing radiation. As a result, MR imaging is increasingly being used to image the maternal abdomen and pelvis during and immediately after pregnancy. Results of rapid T1- and T2-weighted imaging are often diagnostic, and blood vessels, ductal structures, and the urinary tract can frequently be visualized without intravenous administration of contrast material. Until more conclusive safety data become available, MR imaging should be reserved for cases in which results of ultrasonography are inconclusive and patient care depends on further imaging. In the setting of acute abdomen during pregnancy, MR imaging allows identification of areas of inflammation, abscess formation, hemorrhage, and bowel obstruction. MR imaging also helps determine the organ of origin, extent, and composition of maternal neoplasms and is useful in evaluation of müllerian duct anomalies and abnormalities of placental formation, position, and implantation. Many postpartum complications such as retained products of conception and uterine dehiscence may be diagnosed with MR imaging when results of other modalities are indeterminate.

Sonographic evaluation of first-trimester bleeding

Vaginal bleeding is a leading cause of presentation for emergency care during the first trimester of the pregnancy. Clinical assessment of the pregnancy outcome at this stage is less reliable. US examination is crucial in establishing IUP and early pregnancy failure and to exclude other causes of bleeding, such as ectopic pregnancy and molar pregnancy. Diagnosis of a normal IUP at this stage not only assists the physician in an expectant management, but also gives a psychologic boost to the patient. With recent advances in US technology and the availability of high-frequency transvaginal transducers, reliable diagnosis of early pregnancy failure can be made even before the embryo is visible.

Transient uterine myometrial contraction associated with moles

PURPOSE

To examine the incidence of transient distortion of uterine central tissue and myometrial hypointense areas observed on MR images in women with clinically suspicious moles.

MATERIALS AND METHODS

The study population consisted of six women aged 15-47 years with clinically suspicious moles (hydatidiform mole in four, invasive mole in one, and microscopic mole in one). The control study population was 105 reproductive-age women (18-52 years) without uterine malignancy, gestational trophoblastic disease, or pregnancy. MR images were analyzed to check for discrepancies of the uterine central tissue configuration. If a discrepancy was observed, the myometrial hypointense area, its diameter, and changes in its shape and location were analyzed.

RESULTS

Differences in uterine central tissue configuration and hypointense areas were observed in all six patients. In the control study, only seven cases showed uterine endometrial distortion, and five exhibited hypointense areas. These areas disappeared, changed in shape, or other hypointense areas appeared on subsequent MR images. Significant differences (P < 0.01) in the incidence of uterine central tissue distortion and hypointense areas, and in their maximum diameter between the study and the control groups were observed.

CONCLUSION

Uterine myometrial hypointense areas with central tissue distortion, most likely due to transient myometrial contraction, are frequently seen in women with clinically suspicious moles.

Fast MR imaging in obstetrics

Ultrasonography (US) is the initial imaging modality of choice for evaluation of patients in obstetrics. However, the results of US are not always sufficient. Magnetic resonance (MR) imaging, which uses no ionizing radiation, may be an ideal method for further evaluation. Although MR imaging is not recommended during the first trimester and use of contrast material is not recommended in pregnant patients, fast MR imaging is useful in various obstetric settings and can provide more specific information with excellent tissue contrast and multiplanar views. In pregnant patients with acute conditions, various diseases (eg, red degeneration of a uterine leiomyoma) may be diagnosed. MR imaging allows characterization of pelvic masses discovered during pregnancy and diagnosis of postpartum complications (eg, abscess, hematoma, ovarian vein thrombosis). In pregnant patients with hydronephrosis, MR urography can demonstrate the site of obstruction and the cause (eg, a ureteral stone). MR pelvimetry may be beneficial in cases of breech presentation. Contrast material-enhanced dynamic MR imaging allows one to evaluate the vascularity of a placental polyp, detect the viable component of a gestational trophoblastic tumor, and diagnose a uterine arteriovenous malformation. MR imaging enables diagnosis of rare forms of ectopic pregnancy and early diagnosis of ectopic pregnancy.

Magnetic resonance imaging of the adolescent female pelvis

MR imaging is well suited to evaluation of the pelvis. Ultrasonography remains the study of choice for the initial evaluation of a suspected gynecologic mass. MR imaging and computed tomography remain problem-solving tools that can help to characterize masses and stage gynecologic malignancies. MR imaging has the advantage of higher soft tissue contrast compared with computed tomography. This article reviews the MR findings of congenital anomalies and masses of the adnexa and uterus in adolescent girls.

[Gestational trophoblastic diseases. Apropos of 105 cases]

The authors report a retrospective study of 105 observations of gestational trophoblastic diseases managed at the university clinic of obstetric gynecology I (Pr Chaoui). Of this study, one listed 72 cases of complete mole hydatiforme with 5 cases of sacrofetal pregnancy. The invasive mole is found in 4 cases and the choriocarcinoma in 24 cases. The general frequency of this pathology is of 1/770 pregnancies. The age of our patients varies from 15 to 52 years with an average age 27 years and the multiparity is found in 50% of the cases. 103 patients (95.5%) consulted for metrorrhagia associated pelvic pains in 31 cases (30%). The toxic syndrome was present in 20 patients (12%) with a preeclampsy in 6 cases (5.71%). The physical examination showed a very increased uterus of size in 92 cases (87.5%) associated adnexal mass in 37 cases (35.2%). The diagnosis was especially echographic in the totality of the cases associated or not with a proportioning of plasmatic beta HCG or prolans urinary. The treatment of the trophoblastic disease varies simple endo-uterine aspiration (85%) until the chemotherapy treatment (32.4%), the hysterectomy was indicated in a third of the cases. The evolution of the non complicated mole hydatiforme was good in 100% of the cases, it quasi totality of the invasive moles presented a complete remission. Among the 24 choriocarcinoma, we deplore 4 deaths in a table of pulmonary, hepatic and cerebral metastases. In order to improve the forecast of these diseases, the diagnosis must be early with an adequate treatment and a rigorous monitoring.

Hepatic metastasis from choriocarcinoma: angiographic findings in two cases

We report two cases of hepatic metastases from choriocarcinoma in women of childbearing age in whom imaging studies performed at presentation revealed the presence of liver masses, and who had clinically progressive anemia or intraabdominal hemorrhage. CT demonstrated heterogeneously enhanced liver masses. Characteristic angiographic findings included hypervascular hepatic masses with aneurysmal dilatations of the peripheral hepatic arteries at the arterial phase and persistent vascular lakes at the venous phase.

Radiographic imaging in gynecologic oncology

Current radiographic techniques are useful for evaluating and managing patients with gynecologic malignancies. Lymphoscintigraphy may prove useful in limiting surgery in women with vulvar cancer who have negative sentinel groin nodes. Selected patients benefit from pretherapy MRI scanning to help determine treatment of cervical or endometrial malignancies. Sonographic techniques are helpful in discriminating benign from malignant adnexal or pelvic masses, and preoperative CT scans are helpful in determining the extent of advanced ovarian cancer. The FDG PET scans appear to help localize occult disease in patients with a variety of gynecologic malignancies. Further refinements of currently available techniques or newer techniques, however, are needed to increase the sensitivity for detection of subclinical or microscopic metastases in patients with gynecologic malignancies.

Fast MRI in obstetric diagnoses

This article describes the fast MRI of fetal abnormalities and placental anomalies in evaluation of the usefulness of fast MRI in obstetric diagnoses. Fast MRI provides excellent resolution for imaging fetal and maternal anatomies without the need for sedation. Fast MRI is therefore useful to clarify diagnoses suggested by equivocal ultrasonographic findings and to obtain additional information for prenatal counseling and management.

Sonographic appearance of first trimester complete hydatidiform moles

OBJECTIVE

Complete hydatidiform moles are now being diagnosed earlier in gestation, thus the clinical presentation and pathologic findings of complete molar pregnancy have changed. We studied the sonographic appearance of first trimester moles and the ability of ultrasound to detect them.

METHODS

We reviewed the sonographic interpretation and sonograms, when available, from all patients with first trimester complete moles diagnosed at our institution from January 1988 to March 1996.

RESULTS

Of the 24 patients in our study, the mean gestational age at time of the sonogram was 8.7 +/- 2.0 weeks (mean +/- SD) with a range of 5.7-12.3 weeks. The initial sonographic interpretation was a complete mole in 17 (71%) cases, partial mole versus failed pregnancy in two (8%), and failed pregnancy in five (21%) cases. Of the 22 patients with sonograms available for review, interpretation on review of the images was a complete mole in 18 (82%) cases, partial mole versus failed pregnancy in one (5%), and failed pregnancy in three (14%) cases. The typical sonographic appearance of a first trimester complete mole was a complex, echogenic, intra-uterine mass containing many small cystic spaces.

CONCLUSION

The majority of first trimester complete moles demonstrate a typical ultrasound appearance such that the diagnosis can be made with ultrasound in most cases.

Radiologically identified molar invasion into pelvic arteriovenous shunts

A case of radiologically identified molar invasion into extensive arteriovenous shunts (AVSs) is described. CT and MRI revealed a large uterine mass, accompanied by multiple AVSs. Dynamic MRI and pelvic angiography demonstrated multiple trophoblastic cysts invading into the AVSs. Resected specimen confirmed the diagnosis of invasive mole. Dynamic MRI was very useful in determining the etiology of AVS.