Gestational Trophoblastic Disease: Clinical and Imaging Features

Secondary Postpregnancy Hemorrhage: Guide for Diagnosis and Management

Secondary postpregnancy hemorrhage (PPH) is increasing in incidence, especially in developed countries such as the United States. PPH occurs after 24 hours and up to 12 weeks in the postpregnancy period and may be associated with significant maternal morbidity. Common causes of secondary PPH are subinvolution of the placental site (SIPS) and retained or residual products of conception (RPOC). Other less common and rare causes include bleeding diathesis, endo(myo)metritis, gestational trophoblastic disease, and vascular anomalies such as congenital arteriovenous malformation (AVM), iatrogenic arteriovenous fistula, or pseudoaneurysm. A common finding encountered during imaging evaluation of secondary PPH is increased vascularity in the myometrium deep to an implantation site, termed enhanced myometrial vascularity (EMV). EMV typically represents the physiologic reversion of the uterus back to its prepregnancy state. The appearance of EMV varies from mild to marked and is also associated with SIPS and RPOC. Interpretation or reporting of EMV as an AVM or other rare uterine vascular anomaly may lead to unnecessary testing and overtreatment. The authors review placental physiology, describe the causes of secondary PPH and their imaging appearances, and present an algorithm to assist the radiologist in diagnosis of this important condition and management options. ©RSNA, 2025 Supplemental material is available for this article. See the invited commentary by Gomez in this issue.

Rare Pathologic Placenta Ultrasound Findings

Rare ultrasound placenta findings, such as avascular cystic lesions, hyperechogenic and thick placenta, and enlarged placenta, are associated with infarcts, perivillous fibrin deposition, and mesenchymal dysplasia. These lesions can be present in 20% of normal pregnancies but are more frequent in pregnant women with pre-eclampsia (PE) and/or fetal growth restriction, autoimmune diseases, and infections, and can increase the risk of perinatal complications, including fetal death. Evaluation of the placental surface may also identify cases with circumvallate placenta and chorioangiomas. These rare placental findings require close clinical follow-up and serial fetal evaluations to identify those at a higher risk of abnormal perinatal outcomes.

Lessons Learned in Emergency Pelvic and First-Trimester US: Focus on Cognitive Biases

Nonpregnant and pregnant women who present with acute pelvic pain can pose a diagnostic challenge in the emergency setting. The clinical presentation is often nonspecific, and the differential diagnosis may be very broad. These symptoms are often indications for pelvic US, which is the primary imaging modality when an obstetric or gynecologic cause is suspected. Interpretation of pelvic US may be challenging and a source of confusion and misinterpretation for radiologists. Additionally, cognitive biases in imaging interpretation can contribute to diagnostic errors. Cognitive biases represent systematic errors due to failure of the mental shortcuts that the brain subconsciously uses to produce quicker judgments. There are multiple different types of cognitive biases, all of which may lead to perceptual and interpretive errors. Familiarity with common and uncommon pelvic US findings in the setting of pelvic pain is imperative to assist with prompt and accurate diagnosis. Awareness of potential biases when interpreting pelvic US findings further helps hone the interpretation. The authors illustrate the imaging findings in several peer learning cases of nonpregnant and first-trimester pregnant patients who presented with acute pelvic pain in the emergency setting. Several nonobstetric and nongynecologic causes of acute pelvic pain are included for which pelvic US was the first imaging modality used in diagnosis. Diagnostic errors and cognitive biases in interpretation related to these cases are highlighted. The radiologist's awareness of potential cognitive biases in image interpretation may help to refine the differential diagnosis and mitigate errors. ©RSNA, 2025 Supplemental material is available for this article.

Metastatic choriocarcinoma presenting as upper gastrointestinal bleeding: A case report

Choriocarcinoma is a type of gestational trophoblastic disease that occurs as a complication of pregnancy-related events. The gestational trophoblastic disease includes both benign and malignant conditions including complete and partial mole, invasive mole, choriocarcinoma, and placental site trophoblastic disease. Choriocarcinoma generally presents with pervaginal bleeding, symptoms of anemia, and symptoms of its metastatic lesion. The common sites of metastasis are the lung, vagina, brain, and liver. The gastrointestinal (GI) tract is an uncommon site of metastasis occurring in <5% of patients. Upper GI bleeding as presenting complaints without pervaginal bleeding is also very rare with only a few reported cases. Here we present a case of 29 years young female who presented in our emergency department with complaints of hematemesis and altered sensorium where clinical suspicion was peptic ulcer disease but imaging modality with computed tomography showed hypervascular lesions in the brain with suspicion of choriocarcinoma. With further imaging and laboratory tests, confirmatory diagnosis of choriocarcinoma was made. This case highlights the importance of imaging in the diagnosis of choriocarcinoma where the history of the patient is misleading.

Common and Uncommon Gestational Complications in Radiological Practice: An Overview

Gestational complications are common in radiological practice and can be identified and evaluated using various imaging methods. Each complication typically presents with specific imaging features; however, there is a lack of comprehensive literature that consolidates this information to facilitate a diagnostic algorithm and focused study. In this context, this review aims to revisit the theoretical basis of differentials in pregnancy-related complications, discussing classic imaging features and providing examples of key features for each diagnosis. The focus is on essential information for accurate diagnosis, emphasizing the role of radiologists in contributing to better outcomes.

Ruptured large ectopic hydatidiform mole: an infrequent presentation of gestational trophoblastic disease

Gestational trophoblastic disease (GTD) comprises hydatidiform mole, invasive mole, epithelioid trophoblastic tumor, placental site trophoblastic tumor, and choriocarcinoma. Ectopic molar gestation (EMG) is exceedingly rare with similar malignant potential like that of an intrauterine molar pregnancy. We report an uncommon case of EMG diagnosed by ultrasonography (USG) with a brief literature review. A 36-year-multipara presented at 8-weeks gestational age with severe abdominal pain and spotting. She underwent a spontaneous abortion 4 months back. Current transabdominal USG revealed a large right adnexal hydatidiform mole with moderate hemoperitoneum. Right ovary could not be discerned separately. Emergency laparotomy with hysterectomy and right adnexal clearance was done. Histopathology showed complete ectopic hydatidiform mole. USG remains the modality of choice for initial assessment of suspected GTD and it allows reliable evaluation of residual or recurrent disease. This report emphasizes the role of USG in the diagnosis of EMG and also, the importance of including EMG in the differential diagnosis of suspected ectopic pregnancy.

Equol exerts anti-tumor effects on choriocarcinoma cells by promoting TRIM21-mediated ubiquitination of ANXA2

Choriocarcinoma is a malignant cancer that belongs to gestational trophoblastic neoplasia (GTN). Herein, serum metabolomic analysis was performed on 29 GTN patients and 30 healthy individuals to characterize the metabolic variations during GTN progression. Ultimately 24 differential metabolites (DMs) were identified, of which, Equol was down-regulated in GTN patients, whose VIP score is the 3rd highest among the 24 DMs. As an intestinal metabolite of daidzein, the anticancer potential of Equol has been demonstrated in multiple cancers, but not choriocarcinoma. Hence, human choriocarcinoma cell lines JEG-3 and Bewo were used and JEG-3-derived subcutaneous xenograft models were developed to assess the effect of Equol on choriocarcinoma. The results suggested that Equol treatment effectively suppressed choriocarcinoma cell proliferation, induced cell apoptosis, and reduced tumorigenesis. Label-free quantitative proteomics showed that 136 proteins were significantly affected by Equol and 20 proteins were enriched in Gene Ontology terms linked to protein degradation. Tripartite motif containing 21 (TRIM21), a E3 ubiquitin ligase, was up-regulated by Equol. Equol-induced effects on choriocarcinoma cells could be reversed by TRIM21 inhibition. Annexin A2 (ANXA2) interacted with TRIM21 and its ubiquitination was modulated by TRIM21. We found that TRIM21 was responsible for proteasome-mediated degradation of ANXA2 induced by Equol, and the inhibitory effects of Equol on the malignant behaviors of choriocarcinoma cells were realized by TRIM21-mediated down-regulation of ANXA2. Moreover, β-catenin activation was inhibited by Equol, which also depended on TRIM21-mediated down-regulation of ANXA2. Taken together, Equol may be a novel candidate for the treatment for choriocarcinoma.

Multimodality Imaging for Rare Presentation of Placenta Increta in the First Trimester in a Patient with Previous Cesarean Section and Asherman Syndrome

We report multi-modality imaging (Ultrasound and Magnetic Resonance Imaging) findings of a rare complication in a multi-gravida patient with history of Asherman syndrome presenting with placenta increta in a cesarean scar ectopic pregnancy. The appropriate diagnosis was established with imaging and patient was managed surgically with total abdominal hysterectomy and bilateral salpingectomy. Asherman syndrome and its management of hysteroscopic adhesiolysis are associated with increased odds of placenta accreta spectrum and postpartum hemorrhage. Patients with Asherman syndrome are considered high risk in pregnancy and should be closely monitored for placental site abnormalities during current and subsequent pregnancies.

Giant complete hydatidiform mole: a case report and review of the literature

BACKGROUND

This case describes the youngest patient documented in the literature who presented with a giant hydatidiform mole, effectively addressed through conservative treatment.

CASE PRESENTATION

Our department received a 20-year-old Caucasian patient who was admitted due to significant metrorrhagia in an undisclosed pregnancy. During examination, we identified a massive, highly vascularized hydatidiform mole measuring 22 cm (cm). We performed a surgical dilatation and curettage. The anatomopathological findings confirmed the presence of a complete hydatidiform mole (CHM). Following the established guidelines, we conducted weekly monitoring of human chorionic gonadotropin (hCG). Unfortunately, the patient discontinued the follow-up and became pregnant again before achieving hCG negativation.

CONCLUSION

This case suggests that conservative treatment is a viable option regardless of the size of gestational trophoblastic disease (GTD), especially when the preservation of fertility is a crucial consideration, as effectively demonstrated in our case.

The Rare of the Rarest: Placental Site Trophoblastic Tumor, Epithelioid Trophoblastic Tumor, Atypical Placental Site Nodule

BACKGROUND

Epithelioid Trophoblastic Tumor (ETT) and Placental Site Trophoblastic Tumor (PSTT) are two of the rarest GTNs that share certain features at diagnosis and management. Atypical Placental Site Nodule (APSN) is a relatively new entity considered as a premalignant lesion.

OBJECTIVES AND METHODS

The aim of this review was to summarize the main characteristics of each of these entities, their diagnostic features, and their treatment's standard of care including fertility-sparing treatments.

OUTCOME

This study provides a thorough review of ETT, PSTT, and APSN.

CONCLUSIONS

The reader will gain an insight view of these rare tumors arising from the intermediate trophoblast.

US, MRI, CT Performance and Interpretation of Uterine Masses

Uterine masses are commonly encountered as incidental findings during cross-sectional imaging or when individuals present with symptoms such as pain and bleeding. The World Health Organization categorizes tumors of the uterine corpus into 5 distinct groups: endometrial epithelial tumors and their precursors, tumor-like growths, mesenchymal uterine tumors, tumors with a combination of epithelial and mesenchymal elements, and various other types of tumors. The primary imaging method for assessing uterine abnormalities is transvaginal ultrasound. However, magnetic resonance imaging (MRI) can be employed to enhance the visualization of soft tissues, enabling a more detailed characterization of uterine masses. This article aims to outline the imaging features of both benign and malignant uterine masses using ultrasound, MRI, and computed tomography.

A rare case of pulmonary artery embolism with choriocarcinoma: A case report and literature review

Pulmonary embolism (PE) caused by malignant tumor is not uncommon, but pulmonary artery with choriocarcinoma is rare and difficult to timely diagnose and effectively treat. To the best of our knowledge, there are only 15 cases reported at present in the literature that present variable clinical characteristics and prognosis. In the current study reports a 21-year-old female with a history of chest pain and slight fever for 4 months who was treated as a case of pneumonia. Owing to the recurrence of the symptoms, a contrast-enhanced chest computer tomography scan was performed on the patient, which revealed complete occlusion of the right pulmonary artery. The patient was diagnosed to have pulmonary embolism (PE). However, no abnormalities were observed in D-dimer value, tumor antigen testing or ultrasonography. Positron emission tomography/computed tomography (PET/CT) was performed, which revealed the abnormal hypermetabolic lesion of the right pulmonary artery. Following the laboratory report of a significantly elevated human chorionic gonadotropin β-subunit level combined with characteristic appearance of PET-CT, the diagnosis of primary pulmonary artery with choriocarcinoma was established based on guidelines of the European Society for Medical Oncology and the criteria formulated by the International Federation of Gynecology and Obstetrics. The patient underwent chemotherapy and responded well to the treatment. Although rare, choriocarcinoma should be considered for any fertile women who presents with a massive PE. These findings emphasize the importance of the early diagnosis and treatment of this disease.

Gestational Trophoblastic Disease with Coexisting Progressing Pregnancy: Personalised Treatment Modalities

Purpose

Gestational trophoblastic disease (GTD) coexisting with a steadily progressing pregnancy is an extremely rare condition presented in the literature as a single case or case series of successful delivery. The purpose of this study was to describe five cases of GTD and present possible management strategies for such patients.

Methods

Clinical data of five pregnancies with coexisting GTD were identified within the Almazov National Medical Research Centre from 2018 to 2021.

Results

Three cases of multiple pregnancies with complete hydatidiform moles and two cases of singleton pregnancies with intraplacental choriocarcinoma and invasive hydatidiform moles were identified. Three pregnancies were prolonged and ended with preterm deliveries. Malignant transformation of the GTD accounted for 60% of the cases. The condition of newborns was based on the level of prematurity and functional immaturity, and in all cases, it was aggravated by anemia.

Conclusion

GTD coexisting with progressing pregnancy is threatened by the risks of preterm delivery, miscarriage, hemorrhage, and disease progression and requires monitoring in a multidisciplinary clinic experienced in the management of patients with malignant tumors during pregnancy. In cases of prolonged pregnancy against the background of GTD, we suggest the following monitoring during pregnancy: pelvic, abdominal ultrasound/MRI (without contrast), prenatal invasive fetal karyotype testing in cases of singleton pregnancy, lung X-ray/CT with uterine shielding, weekly assessment of β-hCG levels, and dynamic monitoring of the fetus. The following postnatal monitoring should be performed: morphological examination of the placenta, weekly assessment of β-hCG levels up to normalization, then monthly assessment up to six months, and control of β-hCG level of the newborn.

Outcomes of Gestational Trophoblastic Disease Management: A Single Centre Review

Background and Objectives: Gestational trophoblastic disease (GTD) is a group of pregnancy-related malignant and premalignant diseases. The aim of this study was to assess the prognostic value of clinical characteristics to predict treatment outcomes in women with GTD. Materials and Methods: In this retrospective study, 34 patients treated for GTD at the Division of Gynaecology and Perinatology, University Medical Centre Maribor, between 2008 and 2022 were identified. Clinical and pathological characteristics were obtained by analysing patient data records. Results: Within the cohort of 34 patients with GTD, 29 patients (85.3%) had a partial hydatidiform mole (HM) and five patients545 (14.7%) had a complete HM. Two patients with a complete HM developed a postmolar gestational trophoblastic neoplasia (GTN), which represents 5.8% of all cases. Conclusions: GTD is a rare disease that is frequently asymptomatic. The subsequent consequences of GTD, which can lead to malignant transformation, as well life-threatening disease complications, warrant training for early recognition of HMs and timely treatment and surveillance.

A real-time computer-aided diagnosis method for hydatidiform mole recognition using deep neural network

BACKGROUND AND OBJECTIVE

Hydatidiform mole (HM) is one of the most common gestational trophoblastic diseases with malignant potential. Histopathological examination is the primary method for diagnosing HM. However, due to the obscure and confusing pathology features of HM, significant observer variability exists among pathologists, leading to over- and misdiagnosis in clinical practice. Efficient feature extraction can significantly improve the accuracy and speed of the diagnostic process. Deep neural network (DNN) has been proven to have excellent feature extraction and segmentation capabilities, which is widely used in clinical practice for many other diseases. We constructed a deep learning-based CAD method to recognize HM hydrops lesions under the microscopic view in real-time.

METHODS

To solve the challenge of lesion segmentation due to difficulties in extracting effective features from HM slide images, we proposed a hydrops lesion recognition module that employs DeepLabv3+ with our novel compound loss function and a stepwise training strategy to achieve great performance in recognizing hydrops lesions at both pixel and lesion level. Meanwhile, a Fourier transform-based image mosaic module and an edge extension module for image sequences were developed to make the recognition model more applicable to the case of moving slides in clinical practice. Such an approach also addresses the situation where the model has poor results for image edge recognition.

RESULTS

We evaluated our method using widely adopted DNNs on an HM dataset and chose DeepLabv3+ with our compound loss function as the segmentation model. The comparison experiments show that the edge extension module is able to improve the model performance by at most 3.4% regarding pixel-level IoU and 9.0% regarding lesion-level IoU. As for the final result, our method is able to achieve a pixel-level IoU of 77.0%, a precision of 86.0%, and a lesion-level recall of 86.2% while having a response time of 82 ms per frame. Experiments show that our method is able to display the full microscopic view with accurately labeled HM hydrops lesions following the movement of slides in real-time.

CONCLUSIONS

To the best of our knowledge, this is the first method to utilize deep neural networks in HM lesion recognition. This method provides a robust and accurate solution with powerful feature extraction and segmentation capabilities for auxiliary diagnosis of HM.

MR"I": An "eye" for the preoperative diagnosis of ectopic molar pregnancy, a case report

Hydatidiform mole (complete and partial), invasive mole, choriocarcinoma, placental site trophoblastic disease, and epithelioid trophoblastic tumour constitute the spectrum of benign and malignant gestational trophoblastic disease[1] Invasive mole, choriocarcinoma, placental site trophoblastic disease, and epithelioid trophoblastic tumour also classify under gestational trophoblastic neoplasia.[1] The prevalence of molar pregnancy shows great worldwide variation with reported rates of 12 per 1,000 pregnancies in Indonesia, India, and Turkey; one to two per 1,000 pregnancies in Japan and China; and 0.5 to one per 1,000 pregnancies in North America and Europe.[1] Ectopic pregnancy, which is primarily tubal, is the leading cause of first trimester maternal mortality.[2] Diagnosis of ectopic pregnancy is a combinatorial analysis of clinical signs and symptoms; beta-hCG trends; and ultrasonography.[2] Since ectopic gestations cause maternal deaths, the decisive role of the diagnostic test employed measured by its discriminative potential for a reliable preoperative diagnosis is paramount.[2] Although ultrasonography demonstrates high sensitivity and specificity in diagnosing ectopic gestations, inconsistencies in sonographic identification have been known to occur.[2] Particularly, ultrasonography suffers from limitations such as specifying the exact location of infrequent extrauterine presentations and identifying ectopic gestations with atypical features.[2] Molar pregnancies that are largely known to be placental in location have a known but rare potential for extrauterine proliferation.[3] Ectopic molar gestations are rare with only more than a hundred reported cases in scientific literature.[4] Our case delineates this uncommon entity and the superiority of magnetic resonance imaging in terms of diagnostic performance in characterizing the gestational mass over ultrasonography. This is pertinent considering the need to differentiate an ectopic molar pregnancy from an ectopic pregnancy without molar tissue because the potential for malignancy in the former atypical form is akin to that of an intrauterine molar pregnancy.[4].

Hysteroscopic management of molar pregnancy: A series of 36 cases

Background: Hydatidiform Mole (HM) is the most common form of gestational trophoblastic disease. Dilatation and curettage is the classical treatment of this affection. Hysteroscopic resection (HsR) is an alternative for the treatment of intra-uterine pathology.

Objective: To describe the feasibility of HsR for the management of HM.

Result: Case series of patients who had a complete or partial HM confirmed by histological examination of the trophoblastic tissue resected by operative hysteroscopy between 2007 and 2019. After approval of our ethics committee, we evaluated 36 patients who underwent hysteroscopic resection for molar pregnancy. Histological analysis showed partial HM in 28 patients (77.8%) and complete HM in 8 (22.2%). Main surgical complications were uterine perforation in one patient and glycine resorption in 10 patients with two cases of hyponatremia corrected by standard treatment. We performed an ultrasound control 1 month after the intervention in 19 patients (52.8%) as they had slow decrease of HCG or bleeding complaints and found retained product of conception (RPOC) in six patients (16.7%).

Conclusion: This first report on a small number of patients demonstrate that hysteroscopic resection is a feasible procedure for the management of molar pregnancy. Direct visualization of the procedure helps the surgeon to control the resection. Further studies are mandatory to compare this technique with D&C in term of RPOC and fertility outcomes as it remains the standard treatment.

[Radiologic Evaluation of Uterine Lesions Using a Pattern Recognition Approach]

It is important to distinguish uterine lesions from other lesions occurring in the pelvic cavity for the proper management. The primary radiological evaluation of uterine lesions is performed using transvaginal ultrasonography, and if the lesion is too large or shows atypical benign imaging findings, magnetic resonance imaging should be performed. Analyzing radiological findings of uterine lesions through a pattern recognition approach can help establish the accurate diagnosis and treatment plan. In this pictorial assay, we describe imaging characteristics of various lesions arising from the uterus and evaluate them based on the pattern recognition approach.

Antenatal imaging: A pictorial review

Today, in parallel with the use of imaging modalities increases in all fields, the use of imaging methods in pregnant women is increasing. Imaging has become an integral component of routine pregnancy follow-up. Imaging provides parents with an early opportunity to learn about the current situation, including prenatal detection of anomalies or diseases, etiology, prognosis, and the availability of prenatal or postnatal treatments. Various imaging modalities, especially ultrasonography, are frequently used for imaging both maternal and fetal imaging. The goal of this review was to address imaging modalities in terms of usefulness and safety, as well as to provide demonstrative examples for disorders. And this review provides current information on selecting a safe imaging modality to evaluate the pregnant and the fetus, the safety of contrast medium use, and summarizes major pathological situations with demonstrative sonographic images to assist radiologists and obstetricians in everyday practice.

Advances in diagnostics and management of gestational trophoblastic disease

BACKGROUND

Gestational trophoblastic disease (GTD) is a heterogeneous group of rare tumours characterised by abnormal proliferation of trophoblastic tissue. It consists of benign or premalignant conditions, such as complete and partial molar pregnancy and variants of malignant diseases. The malignant tumours specifically are commonly referred to as gestational trophoblastic neoplasia (GTN). They consist of invasive mole, choriocarcinoma, placental-site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT).

CONCLUSIONS

Patients with GTD are often asymptomatic, although vaginal bleeding is a common presenting symptom. With the advances in ultrasound imaging in early pregnancy, the diagnosis of molar pregnancy is most commonly made in the first trimester of pregnancy. Sometimes, additional imaging such as chest X-ray, CT or MRI can help detect metastatic disease. Most women can be cured, and their reproductive function can be preserved. In this review, we focus on the advances in management strategies for gestational trophoblastic disease as well as possible future research directions.

Molar pregnancy with a coexisting living fetus: a case series

Background

Coexistence of molar pregnancy with living fetus represents a challenge in diagnosis and treatment. The objective of this study to present the outcome of molar pregnancy with a coexisting living fetus who were managed in our University Hospital in the last 5 years.

Methods

We performed a retrospective analysis of patients who presented with molar pregnancy with a coexisting living fetus to our Gestational Trophoblastic Clinic, Mansoura University, Egypt from September, 2015 to August, 2020. Clinical characteristics of the patients, maternal complications as well as fetal outcome were recorded. The patients and their living babies were also followed up at least 6 months after delivery.

Results

Twelve pregnancies were analyzed. The mean maternal age was 26.0 (SD 4.1) years and the median parity was 1.0 (range 0–3). Duration of the pregnancies ranged from 14 to 36 weeks. The median serum hCG was 165,210.0 U/L (range 7662–1,200,000). Three fetuses survived outside the uterus (25%), one of them died after 5 months because of congenital malformations. Histologic diagnosis was available for 10 of 12 cases and revealed complete mole associated with a normal placenta in 6 cases (60%) and partial mole in 4 cases (40%). Maternal complications occurred in 6 cases (50%) with the most common was severe vaginal bleeding in 4 cases (33.3%). There was no significant association between B-hCG levels and maternal complications (P = 0.3).

Conclusion

Maternal and fetal outcomes of molar pregnancy with a living fetus are poor. Counseling the patients for termination of pregnancy may be required.

Trial registration

The study was approved by Institutional Research Board (IRB), Faculty of Medicine, Mansoura University (number: R.21.10.1492).

Acute pelvic pain: A pictorial review with magnetic resonance imaging

Acute uterine emergencies constitute both obstetric and gynecologic conditions. The superior image resolution, superior soft-tissue characterization, and lack of ionizing radiation make magnetic resonance imaging (MRI) preferable over ultrasonography (USG) and computed tomography (CT) in investigating uterine emergencies. Although USG is the first-line imaging modality and is easily accessible, it has limitations. USG is an operator dependent and limited by patient factors such as obesity and muscle atrophy. CT is limited by its risk of teratogenicity in pregnant females, poor tissue differentiation, and radiation effect. The non-specific findings on CT may lead to misinterpretation of the pathology. MRI overcomes all these limitations and is emerging as the most crucial imaging modality in the emergency room (ER). The evolving 3D MR sequences further reduce the acquisition times, expanding its ER role. Although MRI is not the first-line imaging modality, it is a problem-solving tool when the ultrasound and CT are inconclusive. This pictorial review discusses the various MRI techniques used in uterine imaging and the appearances of distinct etiologies of uterine emergencies across different MRI sequences.

From Uterus to Brain: An Update on Epidemiology, Clinical Features, and Treatment of Brain Metastases From Gestational Trophoblastic Neoplasia

In this review, we provide the state of the art about brain metastases (BMs) from gestational trophoblastic neoplasia (GTN), a rare condition. Data concerning the epidemiology, clinical presentation, innovations in therapeutic modalities, and outcomes of GTN BMs are comprehensively presented with particular attention to the role of radiotherapy, neurosurgery, and the most recent chemotherapy regimens. Good response rates have been achieved thanks to multi-agent chemotherapy, but brain involvement by GTNs entails significant risks for patients’ health since sudden and extensive intracranial hemorrhages are possible. Moreover, despite the evolution of treatment protocols, a small proportion of these patients ultimately develops a resistant disease. To tackle this unmet clinical need, immunotherapy has been recently proposed. The role of this novel option for this subset of patients as well as the achieved results so far are also discussed.

miR-30a targets STOX2 to increase cell proliferation and metastasis in hydatidiform moles via ERK, AKT, and P38 signaling pathways

Background

A hydatidiform mole is a condition caused by abnormal proliferation of trophoblastic cells. MicroRNA miR-30a acts as a tumor suppressor gene in most tumors and participates in the development of various cancers. However, its role in hydatidiform moles is not clear.

Methods

Quantitative real-time reverse transcription PCR was used to verify the expression level of miR-30a and STOX2 (encoding storkhead box 2). Flow cytometry assays were performed to detect the cell cycle in cell with different expression levels of miR-30a and STOX2. Cell Cycle Kit-8, 5-ethynyl-2′-deoxyuridine, and colony formation assays were used to detect cell proliferation and viability. Transwell assays was used to test cell invasion and migration. Dual-luciferase reporter assays and western blotting were used to investigate the potential mechanisms involved.

Result

Low miR-30a expression promoted the proliferation, migration, and invasion of trophoblastic cells (JAR and HTR-8). Dual luciferase assays confirmed that STOX2 is a target of miR-30a and resisted the effect of upregulated miR-30a in trophoblastic cells. In addition, downregulation of STOX2 by miR-30a could activate ERK, AKT, and P38 signaling pathways. These results revealed a new mechanism by which ERK, AKT, and P38 activation by miR-30a/STOX2 results in excessive proliferation of trophoblast cells in the hydatidiform mole.

Conclusions

In this study, we found that miR-30a plays an important role in the development of the hydatidiform mole. Our findings indicate that miR-30a might promote the malignant transformation of human trophoblastic cells by regulating STOX2, which strengthens our understanding of the role of miR-30a in regulating trophoblastic cell transformation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12935-022-02503-3.

Angiogenin and MMP-2 as potential biomarkers in the differential diagnosis of gestational trophoblastic diseases

BACKGROUND

Gestational trophoblastic diseases (GTDs) are characterized by vascular abnormalities of the trophoblast, but their pathogenesis is unknown. Angiogenin (ANG) and matrix metalloproteinase (MMP)-2, which are molecules implicated in the angiogenic process, may play some role in this process.

MATERIAL AND METHODS

We determined ANG and MMP-2 in the placental tissues of 26 patients who had a benign mole (BM), 12 patients with gestational trophoblast neoplasia (GTN) (1 invasive hydatidiform mole, 10 choriocarcinomas, and 1 placental-site trophoblastic tumor), and 28 normal chorionic villi (NCV) subjects using immunohistochemistry staining. We obtained the serum samples from 20 patients with GTDs and 20 early pregnant women and evaluated them by the enzyme linked immunosorbent assay.

RESULTS

ANG expression in GTN (66.7%) and BM (100%) samples were both significantly higher (strong/intermediate staining) than in NCV (60.7%) samples (P < .001). Similarly, the immunoreactivities of MMP-2 in the GTN (66.7%) and BM (80.8%) samples were significantly elevated compared to that of the NCV (57.1%) samples (P < .001). The levels of ANG and MMP-2 in the maternal serum of the GTN group were both significantly higher than those of the control group (P < .001). ANG and MMP-2 expressions were associated with gestation age, clinical stage, and FIGO stage. A positive correlation between ANG and MMP-2 expression was observed (rs = 0.725; P < .01).

CONCLUSION

ANG and MMP-2 levels were significantly elevated in the placental tissues and maternal serum from patients with GTDs. Further studies with more patients may clarify the vascular abnormalities in GTDs and determine potential biomarkers in the differential diagnosis of GTDs.

A rare cause of postpartum vaginal bleeding

Background

Invasive mole is a trophoblastic disease (GTD) caused by trophoblast cells invading the myometrium during pregnancy. The GTD range also includes mole hydatidiform, choriocarcinoma, and placental site trophoblastic tumor (PSTT). Invasive moles are most common following molar pregnancies; however, they can even rarely occur after a full-term birth. Despite the fact that pathology is the only way to make a clear diagnosis, clinic and radiologic evaluation can be helpful. We wanted to highlight a rare incidence of invasive mole following a healthy full-term delivery in this case.

Case presentation

A 28-year-old female patient presented with intermittent prolonged severe vaginal bleeding for 2 weeks after a term healthy vaginal delivery. In workup, beta human chorionic gonadotropin levels (b-hCG) value was 7540 mIU/ml. After suspicion of gestational trophoblastic neoplasm (GTN), the patient was sent to ultrasonography (US) and magnetic resonance imaging (MRI). GTN was confirmed by radiological and clinical findings, and a conclusive diagnosis of an invasive mole was made histopathologically.

Conclusion

Invasive mole should be considered in the differential diagnosis in patients with postpartum bleeding and a persistently high b-hCG level after a healthy term delivery.

Metastatic choriocarcinoma with hemorrhagic complications and spontaneous ovarian hyperstimulation syndrome: A case report

Gestational choriocarcinoma is a malignant trophoblastic tumor arising from any gestational event, even with a long latency period, generally in the reproductive female. It is associated with a high level of beta-human chorionic gonadotropin. Its primary site is usually the uterus but not all patients have a detectable lesion in this site. Regression of the primary tumor after it has metastasized is not uncommon, and one-third of cases manifest as complications of metastatic disease. In this report we present an uncommon case of gestational choriocarcinoma with lung, liver and jejunal metastases at the time of diagnosis without evidence of pelvic disease, in 34-year-old woman. The main points of interest of our case were the development of the ovarian hyperstimulation syndrome with massive multicystic ovarian enlargement induced by high level of beta-human chorionic gonadotropin and the bleeding of jejunal and liver metastases, due to the high vascularity of the tumor tissue, a condition known as "Choriocarcinoma Syndrome". We will focus on the radiological findings of metastases, bleeding complications and ovarian hyperstimulation syndrome.

Direct comparisons of efficacy and safety between actinomycin-D and methotrexate in women with low-risk gestational trophoblastic neoplasia: a meta-analysis of randomized and high-quality non-randomized studies

Background

Actinomycin-D (Act-D) and Methotrexate (MTX) are both effective first-line agents for low-risk gestational trophoblastic neoplasia (LRGTN) with no consensus regarding which is more effective or less toxic. The primary objective of this meta-analysis is to compare Act-D with MTX in the treatment of LRGTN.

Methods

We systematically searched electronic databases, conferences abstracts and trial registries for randomized controlled trials (RCTs) and high-quality non-randamized controlled trials (non-RCTs), comparing Act-D with MTX for patients with LRGTN. Studies were full-text screened for quality assessment and data extraction. Eligible studies must have reported complete remission rate. A fixed-effects meta-analysis was conducted to quantify the efficacy and safety of Act-D and MTX on odds ratios (ORs) and 95% confidence intervals (95%CIs), respectively.

Results

A total of 8 RCTs and 9 non-RCTs (1674 patients) were included. In terms of efficacy, Act-D is superior to MTX in complete remission (80.2% [551/687] vs 65.1% [643/987]; OR 2.15, 95%CI 1.70 to 2.73). In the stratified analysis, patients from RCTs and non-RCTs both had a better complete remission from Act-D-based regimen (RCTs: 81.2% [259/319] vs 66.1% [199/301], OR 2.17, 95%CI 1.49 to 3.16; non-RCTs: 79.3% [292/368] vs 65.0% [444/686], OR 2.14, 95%CI 1.57 to 2.92). In terms of safety, patients receiving Act-D had higher risks of suffering nausea (OR 2.35, 95%CI 1.68 to 3.27), vomiting (OR 2.40, 95%CI 1.63 to 3.54), and alopecia (OR 2.76, 95%CI 1.60 to 4.75). Notably, liver toxicity (OR 0.38, 95%CI 0.19 to 0.76) was the only one that was conformed to have a higher risk for patients receiving MTX. In addition, the pooled results showed no significant difference of anaemia, leucocytopenia, neutropenia, thrombocytopnia, constipation, diarrhea, anorexia, and fatigue between Act-D and MTX.

Conclusions

Our meta-analysis suggests that Act-D had better efficacy profile in general, and MTX had less toxicities in LRGTN. Future clinical trials should be better orchestrated to provide more valid data on efficacy and toxicity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08849-7.

Use of Methotrexate in Gynecologic and Obstetric Practice: What the Radiologist Needs to Know

Methotrexate (MTX) is the primary pharmaceutical agent that is used for management of disorders arising from trophoblastic tissue. Its widespread international use is mostly attributable to its noninvasive, safe, and effective characteristics as a treatment option for ectopic pregnancy (EP) and gestational trophoblastic disease (GTD), with the large added benefit of fertility preservation. Although the effects of MTX usage are well documented in the gynecologic and obstetric literature, there is a scarcity of radiologic literature on the subject. Depending on the type of EP, the route of MTX administration and dosage may vary. US plays an essential role in the diagnosis and differentiation of various types of EPs, pregnancy-related complications, and complications related to MTX therapy, as well as the assessment of eligibility criteria for MTX usage. A knowledge of expected imaging findings following MTX treatment, including variability in echogenicity and shape of the EP, size fluctuations, changes in vascularity and gestational sac content, and the extent of hemoperitoneum, is essential for appropriate patient management and avoidance of unnecessary invasive procedures. A recognition of sonographic findings associated with pregnancy progression and complications such as tubal or uterine rupture, severe hemorrhage, septic abortion, and development of arteriovenous communications ensures prompt patient surgical management. The authors discuss the use of MTX in the treatment of disorders arising from trophoblastic tissue (namely EP and GTD), its mechanism of action, its route of administration, and various treatment regimens. The authors also provide a focused discussion of the role of US in the detection and diagnosis of EP and GTD, the assessment of the eligibility criteria for MTX use, and the identification of the sonographic findings seen following MTX treatment, with specific emphasis on imaging findings associated with MTX treatment success and failure. Online supplemental material is available for this article. ^©RSNA, 2021.

Imaging evaluation of uterine perforation and rupture

Uterine perforation and rupture, denoting iatrogenic and non-iatrogenic uterine wall injury, respectively, are associated with substantial morbidity,and at times mortality. Diverse conditions can result in injury to both the gravid and the non-gravid uterus, and imaging plays a central role in diagnosis of such suspected cases. Ultrasound (US) is the initial imaging modality of choice, depicting the secondary signs associated with uterine wall injury and occasionally revealing the site of perforation. Computed tomography can be selectively used to complement US findings, to provide a more comprehensive picture, and to investigate complications beyond the reach of US, such as bowel injury. In certain scenarios, magnetic resonance imaging can be an important problem-solving tool as well. Finally, catheter angiography is a valuable tool with both diagnostic and therapeutic capability, with potential for fertility preservation. In this manuscript, we will highlight the clinical and imaging approach to uterine perforation and rupture, while emphasizing the value of various imaging modalities in this context. In addition, we will review the multi-modality imaging features of uterine perforation and rupture and will address the role of the radiologist as a crucial member of the management team. Finally, a summary diagrammatic depiction of imaging approach to patients presenting with uterine perforation or rupture is provided.

Placental spectrum features between mesenchymal dysplasia and partial hydatidiform mole coexisting with a live fetus

We report a case of a singleton hydrops pregnancy with placental gross and microscopic features between partial hydatidiform mole (PHM) and placental mesenchymal dysplasia (PMD) in a diploid live fetus. Pregnancy was complicated by early onset of growth restriction and pre-eclampsia. A female newborn was born at 29 weeks with no congenital malformations. Histology of the placenta revealed mixed phenotype of PMD and PHM, and genetic test results were normal.

Ten steps to establish a national centre for gestational trophoblastic disease

PURPOSE OF REVIEW

Gestational trophoblastic disease (GTD) is a group of heterogeneous disorders characterized by abnormal proliferation of trophoblastic tissue. GTD is a rare disease that is curable in the vast majority of patients when managed appropriately. The aim of the review is to discuss the important steps necessary to establish a center of excellence for GTD.

RECENT FINDINGS

Care of patients with a rare disease is complicated by lack of strong evidence, scattering of patients across the country and limited expertise of medical professionals. The establishment of a center of excellence requires awareness of its benefit, funding, a solid business case and most of all dedicated clinicians. A multidisciplinary team and formulation of national guidelines are important steps before clinical pathways can be developed and treatment can be evaluated for improvement of care and research purposes. International embedding can facilitate the process and lead to the development of a (inter) national acknowledged sustainable center of excellence.

SUMMARY

Centers of excellence could optimize the care of patients with GTD and promote research.

PADI6 Regulates Trophoblast Cell Migration-Invasion Through the Hippo/YAP1 Pathway in Hydatidiform Moles

Purpose

Peptidyl arginine deiminase, type VI (PADI6), a member of the subcortical maternal complex, plays an important role in oocyte growth and the development of fertilized oocytes. Human patients with PADI6 mutations can suffer from multiple reproductive deficiencies including hydatidiform moles and miscarriages. Recent studies have demonstrated that the Hippo signaling pathway plays a central role in the specification of the first cell fates and the maintenance of the human placental trophoblast epithelium. The present study aimed to verify the hypothesis that PADI6 regulates the biological functions of trophoblast cells by targeting YAP1 and to explore the mechanism by which PADI6 accomplishes this in trophoblast cells.

Methods

Villi from HMs and human trophoblast cell lines were used to identify the localization of PADI6 and YAP1 by immunohistochemistry and immunocytochemistry. PADI6 overexpression and knockdown were induced in human trophoblast cells. Co-immunoprecipitation was used to explore the interaction between PADI6 and YAP1. Wound healing, Transwell and EdU staining assays were used to detect migration, invasion and proliferation. Flow cytometric analysis was used to analyze the cell cycle and apoptosis. β-Tubulin and F-actin levels were determined by Western blot, quantitative real-time PCR and phalloidin staining.

Results

The results showed that PADI6 and YAP1 had the same expression pattern in villi and colocalized in the cytotrophoblast. An interaction between PADI6 and YAP1 was also confirmed in human trophoblast cell lines. We found that PADI6 positively regulated the expression of YAP1. Functionally, overexpression of PADI6 promoted cell cycle progression and enhanced migration, invasion, proliferation and apoptosis, whereas downregulation of PADI6 showed the opposite effects.

Conclusion

This study demonstrates that YAP1 is a novel target of PADI6 that serves as an important regulator of trophoblast dysfunction. The crosstalk between the Hippo/YAP1 pathway and the SCMC might be a new topic to explore to uncover the pathological mechanisms of HMs.

Guideline No. 408: Management of Gestational Trophoblastic Diseases

OBJECTIVE

This guideline reviews the clinical evaluation and management of gestational trophoblastic diseases, including surgical and medical management of benign, premalignant, and malignant entities. The objective of this guideline is to assist health care providers in promptly diagnosing gestational trophoblastic diseases, to standardize treatment and follow-up, and to ensure early specialized care of patients with malignant or metastatic disease.

INTENDED USERS

General gynaecologists, obstetricians, family physicians, midwives, emergency department physicians, anaesthesiologists, radiologists, pathologists, registered nurses, nurse practitioners, residents, gynaecologic oncologists, medical oncologists, radiation oncologists, surgeons, general practitioners in oncology, oncology nurses, pharmacists, physician assistants, and other health care providers who treat patients with gestational trophoblastic diseases. This guideline is also intended to provide information for interested parties who provide follow-up care for these patients following treatment.

TARGET POPULATION

Women of reproductive age with gestational trophoblastic diseases.

OPTIONS

Women diagnosed with a gestational trophoblastic disease should be referred to a gynaecologist for initial evaluation and consideration for primary surgery (uterine evacuation or hysterectomy) and follow-up. Women diagnosed with gestational trophoblastic neoplasia should be referred to a gynaecologic oncologist for staging, risk scoring, and consideration for primary surgery or systemic therapy (single- or multi-agent chemotherapy) with the potential need for additional therapies. All cases of gestational trophoblastic neoplasia should be discussed at a multidisciplinary cancer case conference and registered in a centralized (regional and/or national) database.

EVIDENCE

Relevant studies from 2002 onwards were searched in Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and Cochrane Systematic Reviews using the following terms, either alone or in combination: trophoblastic neoplasms, choriocarcinoma, trophoblastic tumor, placental site, gestational trophoblastic disease, hydatidiform mole, drug therapy, surgical therapy, radiotherapy, cure, complications, recurrence, survival, prognosis, pregnancy outcome, disease outcome, treatment outcome, and remission. The initial search was performed in April 2017 and updated in May 2019. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional significant articles were identified through cross-referencing the identified reviews. The total number of studies identified was 673, with 79 studies cited in this review.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of Directors of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of Directors for the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework. See the online appendix tables for key to grading and interpretation of recommendations.

BENEFITS

These guidelines will assist physicians in promptly diagnosing gestational trophoblastic diseases and urgently referring patients diagnosed with gestational trophoblastic neoplasia to gynaecologic oncology for specialized management. Treating gestational trophoblastic neoplasia in specialized centres with the use of centralized databases allows for capturing and comparing data on treatment outcomes of patients with these rare tumours and for optimizing patient care.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Histopathological examination of the curettage material in nonviable pregnancies and evaluation of the frequency of hydatidiform mole

AIM

The study aimed to determine the frequency of possible missed diagnosis of gestational trophoblastic disease in nonviable pregnancies and to evaluate the importance of histopathological examination.

METHODS

In this retrospective study, the results of the histopathological assessment of patients undergoing uterine surgery with a diagnosis of nonviable pregnancy were analyzed before 14 weeks of gestation. Nonviable pregnancy was defined as anembryonic pregnancy and intrauterine exitus (IU-ex) based on ultrasound findings. The frequency and sonographic characteristics of molar pregnancy in nonviable pregnancy were analyzed.

RESULTS

Molar pregnancy was detected in 24 (1.62%) of 1481 patients diagnosed with nonviable pregnancy on ultrasound. One thousand one hundred and twenty-one of the cases were IU-ex (75.69%) and the remaining were anembryonic pregnancy (24.31%). The mean crown-rump length of pregnancies in the IU-ex group was 16.7 mm and the mean gestational age was 8 weeks. The average gestational sac diameter was found to be 26 mm in anembryonic pregnancy patients. The hydatidiform mole ratio was significantly higher in anembryonic pregnancy patients (3.06%) than in IU-ex patients (1.16%) (p = 0.013).

CONCLUSIONS

The appearance of early molar pregnancy on ultrasound evaluation may mimic anembryonic pregnancies. Therefore, histopathological examination of anembryonic pregnancies may be useful in early diagnosis and for the treatment of gestational trophoblastic neoplasia.

A Rare Case of Early Transformation of Gestational Trophoblastic Neoplasia Following Molar Pregnancy

BACKGROUND Gestational trophoblastic disease (GTD) encompasses a group of disorders that arise from abnormal growth of trophoblastic tissue. The spectrum of GTD includes 2 major groups: benign and malignant. The benign form is a hydatidiform mole, either complete or partial; the malignant forms, referred to as gestational trophoblastic neoplasia (GTN), consist of invasive moles, choriocarcinomas, placental site trophoblastic tumors, and epithelioid trophoblastic tumors. Most patients who undergo evacuation of a hydatidiform mole by curettage have a disease-free period before a new tumor develops that can be considered malignant. In rare cases, metastasis occurs rapidly and manifests coincidentally before the hydatidiform mole can be evacuated. CASE REPORT A 19-year-old woman in Bandung City, West Java, Indonesia, was diagnosed with a molar pregnancy with early evidence of a mass in her vagina that was suspicious for stage II GTN. The early emergence of a vaginal mass was a rare case of early transformation of a molar pregnancy into GTN. CONCLUSIONS Careful evaluation is warranted of patients with characteristics typical of an intrauterine molar pregnancy who have an early presentation of a vaginal mass because of the possibility that the diagnosis could be GTN.

Diagnosis of Interventional Transvaginal Maternal Diseases Based on Color Doppler Ultrasound

In recent years, with the development of color Doppler ultrasound technology in obstetrics, this noninvasive, direct, convenient, and sensitive inspection method has become one of the best methods to observe the fetal circulation in the uterus. This paper discusses the clinical value of using transvaginal color Doppler ultrasound in the differential diagnosis of ovarian corpus luteum disease and ectopic pregnancy disease. This paper selects 100 cases of ectopic pregnancy and 100 cases of pregnant corpus luteum as the experimental research objects. Clinical analysis of transvaginal color Doppler ultrasonography was performed on all patients. In the process of measuring the patient's ectopic pregnancy, the size of the patient's adnexal mass is mainly measured, and the blood flow spectrum is measured. The clinical choice of transvaginal color Doppler ultrasound method to distinguish ectopic pregnancy disease and corpus luteum pregnancy disease can play a significant value. It can be effectively diagnosed according to the type of disease, then effective methods can be studied for clinical treatment, the quality of life of patients with the two diseases can be significantly improved, and the clinical application value of color Doppler ultrasound can be improved.

Adenomyosis in Pregnancy: Diagnostic Pearls and Pitfalls

Adenomyosis is a common benign uterine disorder in which ectopic endometrial glands extend into the myometrium. Adenomyosis is increasingly diagnosed in young women, affecting 20%-35% of women of reproductive age. Features of adenomyosis can be seen with either US or MRI, especially with newer imaging technology. With advances in reproductive endocrinology as well as a trend toward later maternal age, adenomyosis is increasingly noted during pregnancy, often while performing imaging for other reasons. Hormonal changes during pregnancy alter the appearance of adenomyosis, which includes diffuse, focal, and cystic adenomyosis. Recognizing these imaging changes in pregnancy proves essential for accurately diagnosing adenomyosis as a benign condition, as it mimics serious placental and myometrial abnormalities. Using a lower-frequency US transducer or MRI can be helpful in distinguishing among these entities. Describing the location of adenomyosis in relationship to the site of placentation is also important. Diagnosing adenomyosis is crucial because it can be associated with poor pregnancy outcomes, including spontaneous abortion, preterm birth, and fetal growth restriction. Adenomyosis is also a risk factor for preeclampsia. Intramural ectopic pregnancy is a rare but serious condition that can mimic cystic adenomyosis, and comparison with prepregnancy images can help differentiate the two conditions. The authors review the unique imaging characteristics of adenomyosis in pregnancy, focusing on accurate diagnosis of an underrecognized benign condition that can mimic myometrial and placental pathologic conditions.^©RSNA, 2021.

The many faces of ectopic pregnancies: demystifying the common and less common entities

Ectopic pregnancy is a major cause of 1st trimester pregnancy deaths. It occurs in various locations in the abdominopelvic cavity. Ultrasonography is a first-line, rapid, and noninvasive modality for ectopic pregnancy evaluation. MRI can help clarify equivocal cases. When in doubt about the location, one should give an intrauterine pregnancy the benefit of the doubt with close ultrasound and hCG follow-up. Here, we will review the imaging findings and mimickers of ectopic pregnancies.

An invasive mole with pulmonary metastases in a 55-year-old postmenopausal Syrian woman: a case report and review of the literature

BACKGROUND

Invasive mole is a subtype of gestational trophoblastic neoplasms (GTNs) that usually develops from the malignant transformation of trophoblastic tissue after molar evacuation. Invasive moles mostly occur in women of reproductive age, while they are extremely rare in postmenopausal women.

CASE PRESENTATION

We present the case of a 55-year-old postmenopausal Syrian woman who was admitted to the emergency department at our hospital due to massive vaginal bleeding for 10 days accompanied by constant abdominal pain with diarrhea and vomiting. Following clinical, laboratory and radiological examination, total hysterectomy with bilateral salpingo-oophorectomy was performed. Histologic examination of the resected specimens revealed the diagnosis of an invasive mole with pulmonary metastases that were diagnosed by chest computed tomography (CT). Following surgical resection, the patient was scheduled for combination chemotherapy. However, 2 weeks later the patient was readmitted to the emergency department due to severe hemoptysis and dyspnea, and later that day the patient died in spite of resuscitation efforts.

CONCLUSION

Although invasive moles in postmenopausal women have been reported previously, we believe our case is the first reported from Syria. Our case highlights the difficulties in diagnosing invasive moles in the absence of significant history of gestational trophoblastic diseases. The present study further reviews the diagnostic methods, histological characteristics and treatment recommendations.

Directive clinique no 408 : Prise en charge des maladies gestationnelles trophoblastiques

OBJECTIF

Cette directive passe en revue l'évaluation clinique et la prise en charge des maladies gestationnelles trophoblastiques, notamment les traitements chirurgicaux et médicamenteux des tumeurs bénignes, prémalignes et malignes. L'objectif de la présente directive clinique est d'aider les fournisseurs de soins de santé à rapidement diagnostiquer les maladies gestationnelles trophoblastiques, à normaliser les traitements et le suivi et à assurer des soins spécialisés précoces aux patientes dont l'atteinte est maligne ou métastatique. PROFESSIONNELS CONCERNéS: Gynécologues généralistes, obstétriciens, médecins de famille, sages-femmes, urgentologues, anesthésistes, radiologistes, anatomopathologistes, infirmières autorisées, infirmières praticiennes, résidents, gynécologues-oncologues, oncologues médicaux, radio-oncologues, chirurgiens, omnipraticiens en oncologie, infirmières en oncologie, pharmaciens, auxiliaires médicaux et autres professionnels de la santé qui traitent des patientes atteintes d'une maladie gestationnelle trophoblastique. La présente directive vise également à fournir des renseignements aux parties intéressées qui prodiguent des soins de suivi à ces patientes après le traitement.

POPULATION CIBLE

Femmes en âge de procréer atteintes d'une maladie gestationnelle trophoblastique.

OPTIONS

Les femmes ayant reçu un diagnostic de maladie gestationnelle trophoblastique doivent être orientées vers un gynécologue afin qu'il réalise une évaluation initiale, envisage une intervention chirurgicale primaire (évacuation ou hystérectomie) et effectue un suivi. Il y a lieu d'orienter les femmes ayant reçu un diagnostic de tumeur trophoblastique gestationnelle vers un gynécologue-oncologue afin qu'il effectue la stadification tumorale, établisse le score de risque et envisage l'intervention chirurgicale primaire ou un traitement systémique (mono- ou polychimiothérapie) et la nécessité d'éventuels traitements supplémentaires. Il est recommandé de discuter de chaque cas de néoplasie gestationnelle trophoblastique lors d'une réunion multidisciplinaire de cas oncologiques et de l'inscrire dans une base de données centralisée (régionale et/ou nationale). DONNéES PROBANTES: Des recherches ont été effectuées au moyen des bases de données Embase et MEDLINE, du Cochrane Central Register of Controlled Trials et de la Cochrane Database of Systematic Reviews afin de trouver les études publiées depuis 2002 utilisant un ou plusieurs des mots clés suivants : trophoblastic neoplasms, choriocarcinoma, trophoblastic tumor, placental site, gestational trophoblastic disease, hydatidiform mole, drug therapy, surgical therapy, radiotherapy, cure, complications, recurrence, survival, prognosis, pregnancy outcome, disease outcome, treatment outcome et remission. La recherche initiale a été effectuée en avril 2017; une mise à jour a été faite en mai 2019. Les données probantes pertinentes ont été sélectionnées aux fins d'inclusion selon l'ordre suivant : méta-analyses, revues systématiques, directives cliniques, essais cliniques randomisés, études de cohortes prospectives, études observationnelles, revues non systématiques, études de séries de cas et rapports. D'autres articles pertinents ont été trouvés en recoupant les revues répertoriées. Le nombre total d'études relevées était de 673, dont 79 études sont citées dans la présente revue. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs. La direction et le conseil d'administration de la Société de gynéco-oncologie du Canada ont passé en revue le contenu de la version préliminaire et ont soumis des commentaires à prendre en considération. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication. La qualité des données probantes a été évaluée au moyen des critères de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). Consulter les tableaux dans l'annexe en ligne pour connaître les critères de notation et d'interprétation des recommandations. BéNéFICES, RISQUES, COûTS: Les présentes recommandations aideront les médecins à diagnostiquer rapidement les maladies gestationnelles trophoblastiques et à orienter de façon urgente les patientes ayant reçu un diagnostic de maladie gestationnelle trophoblastique en gynécologie oncologique pour une prise en charge spécialisée. Le traitement des néoplasies gestationnelles trophoblastiques en centre spécialisé combiné à l'utilisation de bases de données centralisées permet de recueillir et de comparer des données sur les résultats thérapeutiques des patientes atteintes de ces tumeurs rares et d'optimiser les soins aux patientes. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).

Clinical presentation and diagnosis of Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD) is a heterogeneous group of pregnancy-related disorders characterized by abnormal proliferation of trophoblastic tissue. It encompasses the premalignant partial and complete hydatidiform mole but also the malignant invasive mole, choriocarcinoma, placental-site trophoblastic tumor, and epithelioid trophoblastic tumor. The clinical presentation changed to earlier detection after the introduction of first trimester ultrasounds. Patients are often asymptomatic, but vaginal bleeding continues to be the most common presenting symptom. Other symptoms can develop in the case of metastatic disease. Ultrasound, serum human chorionic gonadotrophin, and sometimes additional imaging such as CT, MRI, or PET can confirm the diagnosis and stage of disease. Familiarity with the pathogenesis, classification, imaging features, and treatment of GTD facilitates diagnosis and appropriate management.

The Role of Contrast-Enhanced Ultrasound in Evaluating Gestational Trophoblastic Neoplasia: A Preliminary Study

Objective

We aimed to compare the imaging features of gestational trophoblastic neoplasias (GTNs) and benign pregnancy-related uterine diseases on contrast-enhanced ultrasound (CEUS) to explore the clinical value of CEUS in differentiating these two types of uterine lesions.

Materials and Methods

In this prospective study, patients with GTNs before and after chemotherapy and benign pregnancy-related uterine lesions received conventional US and CEUS. The imaging features and parameters of CEUS of the lesions were assessed.

Results

A total of 73 patients were enrolled in this study, including 48 with GTNs and 25 with benign lesions. The enhancement pattern of newly diagnosed GTNs was mainly diffuse enhancement (70.8%), with a non-enhanced area of less than 1/3 of the entire lesion. For the benign group, the enhancement pattern was mainly ring-shaped enhancement (72.0%), and the non-enhanced area was more than 1/2 (68.0%), significantly different from that of GTNs (P = 0.000 and 0.002, respectively). Forty-one lesions demonstrated unclear boundaries on greyscale US but clearly displayed on CEUS. In both the benign and malignant groups, the measurements of lesion size on CEUS were larger than those on greyscale US (P = 0.000). The measurement differences (ΔD: D2-D1) of the malignant cases were higher than those of the benign cases (P = 0.001).

Conclusion

GTNs and benign pregnancy-related uterine diseases have different imaging characteristics on CEUS. The boundary and involved range of the lesion can be clearly demonstrated on CEUS. CEUS possesses clinical value in diagnosing and evaluating GTNs and benign pregnancy-related diseases.

Deceptology in cancer and vaccine sciences: Seeds of immune destruction-mini electric shocks in mitochondria: Neuroplasticity-electrobiology of response profiles and increased induced diseases in four generations - A hypothesis

From Rockefeller's support of patent medicine to Gates' patent vaccines, medical establishment invested a great deal in intellectual ignorance. Through the control over medical education and research it has created a public illusion to prop up corporate profit and encouraged the lust for money and power. An overview of data on cancer and vaccine sciences, the status of Americans' health, a survey of repeated failed projects, economic toxicity, and heavy drug consumption or addiction among young and old provide compelling evidence that in the twentieth century nearly all classic disease categories (congenital, inheritance, neonatal, or induced) shifted to increase induced diseases. Examples of this deceptology in ignoring or minimizing, and mocking fundamental discoveries and theories in cancer and vaccine sciences are attacks on research showing that (a), effective immunity is responsible for defending and killing pathogens and defective cancerous cells, correcting and repairing genetic mutations; (b) viruses cause cancer; and (c), abnormal gene mutations are often the consequences of (and secondary to) disturbances in effective immunity. The outcomes of cancer reductionist approaches to therapies reveal failure rates of 90% (+/-5) for solid tumors; loss of over 50 million lives and waste of $30-50 trillions on too many worthless, out-of-focus, and irresponsible projects. Current emphasis on vaccination of public with pathogen-specific vaccines and ingredients seems new terms for drugging young and old. Cumulative exposures to low level carcinogens and environmental hazards or high energy electronic devices (EMF; 5G) are additional triggers to vaccine toxicities (antigen-mitochondrial overload) or "seeds of immune destruction" that create mini electrical shocks (molecular sinks holes) in highly synchronized and regulated immune network that retard time-energy-dependent biorhythms in organs resulting in causes, exacerbations or consequences of mild, moderate or severe immune disorders. Four generations of drug-dependent Americans strongly suggest that medical establishment has practiced decades of intellectual deception through its claims on "war on cancer"; that cancer is 100, 200, or 1000 diseases; identification of "individual" genetic mutations to cure diseases; "vaccines are safe". Such immoral and unethical practices, along with intellectual harassment and bullying, censoring or silencing of independent and competent professionals ("Intellectual Me Too") present grave concerns, far greater compared with the sexual harassment of 'Me Too' movement that was recently spearheaded by NIH. The principal driving forces behind conducting deceptive and illogical medical/cancer and vaccine projects seem to be; (a) huge return of investment and corporate profit for selling drugs and vaccines; (b) maintenance of abusive power over public health; (c) global control of population growth via increased induction of diseases, infertility, decline in life-span, and death. An overview of accidental discoveries that we established and extended since 1980s, on models of acute and chronic ocular inflammatory diseases, provides series of the first evidence for a direct link between inflammation and multistep immune dysfunction in tumorigenesis and angiogenesis. Results are relevant to demonstrate that current emphasis on vaccinating the unborn, newborn, or infant would induce immediate or long-term immune disorders (eg, low birth weight, preterm birth, fatigue, autism, epilepsy/seizures, BBB leakage, autoimmune, neurodegenerative or digestive diseases, obesity, diabetes, cardiovascular problems, or cancers). Vaccination of the unborn is likely to disturb trophoblast-embryo-fetus-placenta biology and orderly growth of embryo-fetus, alter epithelial-mesenchymal transition or constituent-inducible receptors, damage mitochondria, and diverse function of histamine-histidine pathways. Significant increased in childhood illnesses are likely due to toxicities of vaccine and incipient (eg, metals [Al, Hg], detergents, fetal tissue, DNA/RNA) that retard bioenergetics of mitochondria, alter polarization-depolarization balance of tumoricidal (Yin) and tumorigenic (Yang) properties of immunity. Captivated by complex electobiology of immunity, this multidisciplinary perspective is an attempt to initiate identifying bases for increased induction of immune disorders in three to four generations in America. We hypothesize that (a) gene-environment-immune biorhythms parallel neuronal function (brain neuroplasticity) with super-packages of inducible (adaptive or horizontal) electronic signals and (b) autonomic sympathetic and parasympathetic circuitry that shape immunity (Yin-Yang) cannot be explained by limited genomics (innate, perpendicular) that conventionally explain certain inherited diseases (eg, sickle cell anemia, progeria). Future studies should focus on deep learning of complex electrobiology of immunity that requires differential bioenergetics from mitochondria and cytoplasm. Approaches to limit or control excessive activation of gene-environment-immunity are keys to assess accurate disease risk formulations, prevent inducible diseases, and develop universal safe vaccines that promote health, the most basic human right.

Nanotechnology in reproductive medicine: Opportunities for clinical translation

In recent years, nanotechnology has revolutionized global healthcare and has been predicted to exert a remarkable effect on clinical medicine. In this context, the clinical use of nanomaterials for cancer diagnosis, fertility preservation, and the management of infertility and other pathologies linked to pubertal development, menopause, sexually transmitted infections, and HIV (human immunodeficiency virus) has substantial promise to fill the existing lacunae in reproductive healthcare. Of late, a number of clinical trials involving the use of nanoparticles for the early detection of reproductive tract infections and cancers, targeted drug delivery, and cellular therapeutics have been conducted. However, most of these trials of nanoengineering are still at a nascent stage, and better synergy between pharmaceutics, chemistry, and cutting-edge molecular sciences is needed for effective translation of these interventions from bench to bedside. To bridge the gap between translational outcome and product development, strategic partnerships with the insight and ability to anticipate challenges, as well as an in-depth understanding of the molecular pathways involved, are highly essential. Such amalgamations would overcome the regulatory gauntlet and technical hurdles, thereby facilitating the effective clinical translation of these nano-based tools and technologies. The present review comprehensively focuses on emerging applications of nanotechnology, which holds enormous promise for improved therapeutics and early diagnosis of various human reproductive tract diseases and conditions.

Sonographic characteristics of post-molar gestational trophoblastic neoplasia at diagnosis and during follow-up, and relationship with methotrexate resistance

OBJECTIVES

To describe the sonographic characteristics of post-molar gestational trophoblastic neoplasia (GTN) at diagnosis and during follow-up, and to assess their association with methotrexate (MTX) resistance (R) as first-line chemotherapy.

METHODS

This was a retrospective study of all women treated for post-molar GTN at Karolinska University Hospital, Stockholm, Sweden, between October 2010 and December 2017, who had undergone expert transvaginal ultrasound assessment ≤ 2 weeks prior to, or ≤ 1 week after, the start of first-line MTX treatment. Women with a detectable uterine lesion were followed up with repeat scans during treatment, as well as after treatment in cases of persistent lesions. The association between MTX-R and sonographic findings at inclusion was assessed.

RESULTS

Of 47 eligible women, 36 were included in the analysis after excluding those who had not undergone structured transvaginal ultrasound assessment and those who started treatment at another center. The median age at diagnosis was 33 (interquartile range (IQR), 27-43) years and 35/36 (97%) women were in the FIGO low-risk group (risk score, 0-6). At inclusion, no uterine lesions were found in eight (22%) women, focal lesions in 24 (67%) women and global lesions in four (11%) women. Median maximum lesion diameter was 40.4 (IQR, 31.3-49.4) mm and 26/28 (93%) lesions had a color score of 3 or 4. Arteriovenous fistulas were found in 9/28 (32%) women and theca lutein cysts in 4/36 (11%) women. Four women with GTN lesion at inclusion underwent hysterectomy prior to the first follow-up ultrasound scan and a fifth woman with a growing lesion underwent hysterectomy, which revealed persistent viable trophoblastic tissue. All remaining women reached complete remission and median time to human chorionic gonadotropin normalization was 2.7 (IQR, 1.4-3.7) months. During ultrasound follow-up, 88% (21/24) of lesions resolved completely. Two women with a persisting lesion remained in complete remission. Median time to disappearance of vascularity was 5.8 (IQR, 3.7-9.3) months and median time to resolution of the lesion was 6.8 (IQR, 3.7-9.3) months. MTX-R developed in 12/31 (39%) women. Uterine tumors ≥ 4 cm (73% vs 17%; P = 0.008) and global lesions (25% vs 0%; P = 0.03) were significantly more common in women with compared to those without MTX-R.

CONCLUSION

Uterine lesions were detected at the time of diagnosis in 78% of women with post-molar GTN. The vast majority of the lesions resolved completely during follow-up, after a median of 7 months. MTX-R was more common in uterine tumors of 4 cm, or larger, and in global lesions. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Choriocarcinoma with lumbar muscle metastases: A case report

BACKGROUND

Choriocarcinoma is a highly malignant trophoblastic tumor that presents with early symptoms similar to those of an ectopic pregnancy. Here we present a patient with suspected ectopic pregnancy diagnosed by laparoscopic surgery in our hospital. The patient was found to have choriocarcinoma that had metastasized to the lumbar muscle and presented with symptoms similar to those of an ectopic pregnancy.

CASE SUMMARY

The patient was a 34-year-old female who complained of amenorrhea lasting 53 d, 7 d of right lower back pain, and 3 d of right lower abdominal pain. Transvaginal ultrasonography revealed the absence of a gestational sac in the uterus and a mass in the left adnexa. After 6 d of re-examination, ultrasound and computed tomography (CT) examination were performed on the mass located in the left adnexa area. We also noted that the patient’s serum β-human chorionic gonadotropin (hCG) level was increased. Considering an ectopic pregnancy, we performed a laparoscopy and hysteroscopy. During the operation, a left ovarian mixed echogenic mass approximately 2.5 cm × 2.0 cm with no villous tissue was found. Postoperative levels of serum hCG continued to increase. Lung CT examination showed lung nodules. Both CT and magnetic resonance imaging showed a mixed echogenic mass in the lumbar muscle. Considering lumbar metastasis of choriocarcinoma, six courses of cisplatin, dactinomycin, and etoposide chemotherapy were given after surgery. The patient’s serum β-hCG level decreased to normal and the mixed echogenic mass in the lumbar muscle decreased in size after the fifth course of chemotherapy. All symptoms subsequently disappeared after treatment.

CONCLUSION

In summary, lumbar metastasis from choriocarcinoma is extremely rare. Appropriate chemotherapy can successfully treat these metastasized tumors.

ACR Appropriateness Criteria® Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD), a rare complication of pregnancy, includes both benign and malignant forms, the latter collectively referred to as gestational trophoblastic neoplasia (GTN). When metastatic, the lungs are the most common site of initial spread. Beta-human chorionic gonadotropin, elaborated to some extent by all forms of GTD, is useful in facilitating disease detection, diagnosis, monitoring treatment response, and follow-up. Imaging evaluation depends on whether GTD manifests in one of its benign forms or whether it has progressed to GTN. Transabdominal and transvaginal ultrasound with duplex Doppler evaluation of the pelvis are usually appropriate diagnostic procedures in either of these circumstances, and in posttreatment surveillance. The appropriateness of more extensive imaging remains dependent on a diagnosis of GTN and on other factors. The use of imaging to assess complications, typically hemorrhagic, should be guided by the location of clinical signs and symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.