Original articleGestatational Trophoblastic Disease: Multimodality Imaging Assessment With Special Emphasis on Spectrum of Abnormalities and Value of Imaging in Staging and Management of Disease
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
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Cited by (36)
ACR Appropriateness Criteria® Gestational Trophoblastic Disease
2019, Journal of the American College of RadiologyCitation Excerpt :In women with persistently elevated serum β-hCG, US is generally recommended to evaluate for normal intrauterine pregnancy and may be useful to measure uterine volume and assess local tumor extension. Although the depth of uterine involvement does not directly impact the patient’s prognostic score, it may influence treatment decisions, particularly if there is imaging evidence of extensive uterine disease and if hysterectomy is considered [45,51,52]. Because treatment of invasive mole/choriocarcinoma differs from that of PSTT or ETT, distinction of these tumors has clinical importance.
Qualitative and quantitative analysis of diffusion-weighted imaging of gestational trophoblastic disease: Can it predict progression of molar pregnancy to persistent form of disease?
2017, European Journal of RadiologyCitation Excerpt :CT scans and MRIs have also been employed to evaluate GTD [7]. With its superior contrast resolution, MRI has been used to estimate the depth and extent of myometrial and parametrial invasion [8,11]. Diffusion-weighted imaging (DWI) has now been integrated into routine abdominal imaging, particularly in oncology.
Choriocarcinoma during menopause: A case report
2016, Gaceta Mexicana de OncologiaMagnetic Resonance Imaging of Abdominal and Pelvic Pain in the Pregnant Patient
2016, Magnetic Resonance Imaging Clinics of North AmericaCitation Excerpt :Unlike the classic T2 hypointense appearance of a routine fibroid, a degenerating fibroid can appear hyperintense on T2WI due to edema and/or necrosis (see Fig. 6).5,26,33,35 MR imaging can also be used as a useful adjunct to an indeterminate US examination for other nonfetal obstetric indications, including for the evaluation of known or suspected placenta accreta, increta, and percreta, atypical sites of implantation, particularly cesarean section scar and cervical implantation, for known or suspected cesarean scar dehiscence, and for the evaluation of pregnancies occurring in a congenitally malformed uterus or in abdominal pregnancy (Figs. 7–9).58–60 MR imaging is highly sensitive for evaluating abnormal placentation, when suspicious findings are seen on US.
Extrafetal Findings on Fetal Magnetic Resonance Imaging: A Pictorial Essay
2015, Seminars in Ultrasound, CT and MRIMagnetic Resonance Imaging of Benign and Malignant Uterine Neoplasms
2015, Seminars in Ultrasound, CT and MRICitation Excerpt :Invasive moles infiltrate and disrupt the JZ and myometrium on T2-weighted and postcontrast images (Fig. 14).59,61-63 However, loss of zonal anatomy may also be observed after missed or incomplete abortions or recent curettage.62-65 The management of patients with GTD varies according to histologic subtype.