Original article
Gestatational Trophoblastic Disease: Multimodality Imaging Assessment With Special Emphasis on Spectrum of Abnormalities and Value of Imaging in Staging and Management of Disease

https://doi.org/10.1067/j.cpradiol.2011.06.002Get rights and content

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.

Section snippets

Normal Trophoblast

The trophoblast begins as the outer covering of the blastocyst and ultimately forms the fetal portion of the placenta. It has 3 major components: cytotrophoblast, syncytiotrophoblast, and intermediate trophoblast. The cytotrophoblast is a stem cell with high mitotic activity, while the syncytiotrophoblast synthesizes the hormone, human chorionic gonadotropin (hCG), and forms the chorionic villi.1 The intermediate trophoblast has features of the other 2 and is responsible for endometrial

Hydatiform Mole

Hydatiform mole comprises 80% of cases of GTD and includes both complete (also called classic) molar pregnancies and partial moles.1 In North America molar pregnancy occurs with an incidence of 0.6-1.1 in 1000 pregnancies.6 There are wide geographic differences in the incidence of hydatidiform mole with molar pregnancy occurring in 8 per 1000 pregnancies in some Asian populations.3 The risk factors for molar pregnancy are extremes of maternal age, prior molar gestations, and history of

Ultrasound Features of Molar Pregnancies

On pelvic ultrasound, complete hydatiform mole may appear as an echogenic mass with multiple, diffusely distributed, small (1-30 mm) vesicles, in an enlarged uterus (Fig 1).1, 3, 8 This characteristic “cluster of grapes” appearance corresponds to the diffusely hyperplastic and hydropic villi described in the pathology literature. It is usually evident with transabdominal ultrasound on second-trimester ultrasound, and in some cases, in the first trimester with transvaginal ultrasound.1 A fetus

Management of Molar Pregnancies

In addition to pelvic ultrasound, the only other routine imaging study performed in molar pregnancies before the institution of definitive therapy is a chest x-ray, with pelvic MRI being reserved as a problem-solving tool in selected cases.2 The treatment of choice for hydatiform moles is suction curettage, which is successful in most cases.2 Approximately 15%-20% of complete moles and 0.5%-5% of partial moles go on to develop persistent trophoblastic disease.1, 2, 3

The likelihood of persistent

Persistent Trophoblastic Neoplasia (Gestational Trophoblastic Tumors)

Invasive mole, choriocarcinoma, and placental site trophoblastic tumor are classified as persistent trophoblastic neoplasia (PTN). PTN may present weeks or years after molar or nonmolar pregnancies.1, 3 The components needed to diagnose postmolar GTT include at least 1 of the following: (1) hCG plateau for 4 consecutive values over 3 weeks; (2) hCG rise of ≥10% for 3 values over 2 weeks; (3) hCG persistence 6 months after molar evacuation; (4) histopathologic diagnosis of choriocarcinoma; or

Ultrasonographic Features of Persistent Trophoblastic Neoplasia

The various types of PTN may appear similar sonographically.1 Transvaginal ultrasound is an essential tool for the evaluation of PTN.8 The most common appearance of PTN on pelvic ultrasound is a focal myometrial mass that is best appreciated with transvaginal ultrasound (Fig 5A).15, 16, 23, 24 The myometrial mass may be uniformly echogenic or hypoechoic, or complex and multicystic.15, 16, 23, 24 Anechoic spaces within the mass may be due to hemorrhagic or necrotic tissue, cysts, or vascular

MRI of Gestational Trophoblastic Disease

Pelvic MRI does not have a routine role in the assessment of GTD and is usually used as a problem-solving tool in equivocal or complicated cases.27 On pelvic MRI, hydatiform mole usually appears as a heterogeneous, markedly hyperintense mass that distends the endometrial cavity on T2-weighted images (Fig 6A).5, 28 On contrast-enhanced T1-weighted images, especially during the second trimester, diffusely distributed small cystic spaces are typically noted within the mass (Fig 6B).5 The normal

Computed Tomography of Persistent Trophoblastic Neoplasia

Metastatic disease has been reported in up to 19% of patients with GTT, with the vast majority of cases occurring in choriocarcinomas.3 CT is primarily performed for evaluation of metastases, although the primary tumor may be seen as a focal, low-attenuation lesion within an enlarged uterus in some cases (Fig 10).35 Except for brain and vaginal metastases that are more accurately evaluated with MRI, CT scanning is the most suitable method for evaluation of the more common sites of metastases of

Positron Emission Tomography/Computed Tomography of Persistent Trophoblastic Neoplasia

There are limited data on the efficacy of positron emission tomography (PET)/CT in the evaluation of patients with gestational trophoblastic neoplasia. 18F-fluorodeoxyglucose-PET has the potential to identify occult disease in patients with recurrent or metastatic GTT: it may identify sites of metabolically active disease not evident by other imaging modalities or be helpful in differentiating uterine scars from metabolically active recurrent disease.37, 38

Management of Persistent Trophoblastic Neoplasia

Most centers use the International Federation of Obstetrics and Gynecology (FIGO) staging and scoring system for gauging the severity and determining the appropriate type of therapy in individual cases of invasive moles and choriocarcinomas (placental site trophoblastic tumors are classified separately).4, 19 Imaging findings that affect the overall scoring in this system include largest tumor along with number and site of metastases. When a diagnosis of gestational trophoblastic tumor is

Follow-Up Imaging After Treatment of Gestational Trophoblastic Disease

Follow-up imaging after initiation or completion of therapy for GTD is routinely performed only when (a) complications are suspected; or (b) during the first trimester of a subsequent pregnancy (quantitative serum hCG levels at 6 weeks along with first-trimester pelvic ultrasound is recommended in subsequent pregnancies due to increased risk of GTD recurrence).19

On follow-up imaging, uterine and ovarian abnormalities usually resolve with effective therapy. On sonography, lesions usually become

Conclusions

Gestational trophoblastic disease is a spectrum of diseases with varying malignant potential, broadly categorized into hydatidiform moles and persistent trophoblastic neoplasia. Ultrasound is the main imaging modality for evaluation of complete hydatidiform moles and persistent trophoblastic neoplasia. Pelvic MRI is usually used as a problem-solving tool in equivocal or complicated GTD cases. Chest x-rays, brain MRI, and body CT scans are primarily used to rule out metastatic disease. 18

References (41)

  • B.J. Wagner et al.

    From the archives of the AFIP. Gestational trophoblastic disease: Radiologic-pathologic correlation

    Radiographics

    (1996)
  • M. Nagayama et al.

    Fast MR imaging in obstetrics

    RadioGraphics

    (2002)
  • M.A. Fraser-Hill

    Gestational Trophoblastic Neoplasia

    (2005)
  • C.M. Wang et al.

    Identification of 13 novel NLRP7 mutations in 20 families with recurrent hydatidiform mole: Missense mutations cluster in the leucine-rich region

    J Med Genet

    (2009)
  • N.J. Sebire et al.

    The diagnostic implications of routine ultrasound examination in histologically confirmed early molar pregnancies

    Ultrasound Obstet Gynecol

    (2001)
  • L.O. Vejerslev

    Clinical management and diagnostic possibilities in hydatidiform mole with coexistent fetus

    Obstet Gynecol Surv

    (1991)
  • M.A. Steller et al.

    Natural history of twin pregnancy with complete hydatidiform mole and coexisting fetus

    Obstet Gynecol

    (1994)
  • M. Crade et al.

    Appearance of molar pregnancy 9.5 weeks after conception. Use of transvaginal ultrasound for early diagnosis

    J Ultrasound Med

    (1991)
  • R.A. Bronson et al.

    An unusual first-trimester sonographic finding associated with development of hydatidiform mole: The hyperechoic ovoid mass

    AJR

    (1993)
  • B.P. DeBaz et al.

    Imaging of gestational trophoblastic disease

    Semin Oncol

    (1995)
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