Gestational trophoblastic disease: a multimodality imaging approach with impact on diagnosis and management

Correlation Between the Clinical Diagnosis and Sonographic Diagnosis in Women with First-Trimester Vaginal Bleeding

BACKGROUND

Vaginal bleeding is the most common cause of presentation at the emergency department in the first trimester. Clinical presentation helps determine the likely cause of first-trimester vaginal bleeding. However, ultrasound imaging is required to reach a definitive diagnosis.

OBJECTIVE

To determine the relationship between clinical diagnosis and ultrasonographic findings in women with first-trimester vaginal bleeding.

METHODS

A prospective longitudinal study was conducted on 94 pregnant patients with a history of bleeding per vagina (PV) in the first trimester by using transvaginal ultrasound.

RESULTS

PV spotting was noted in 64.9% and heavy bleeding in 35.1%. The most common clinically associated symptom was abdominal pain (68, 72.3%), and the least common clinically associated symptom was vesicle expulsion (2.1%). The most common predisposing factor was fever (31, 33.0%). The most frequent clinical diagnosis was threatened abortion (48, 51.1%), and the least common clinical diagnosis was gestational trophoblastic disease (GTD) and inevitable abortion (1, 1.1%). The most common ultrasound diagnosis at the initial scan was incomplete abortion (19.2%), while at follow-up scans, it was threatened abortion (48, 51.1%). The overall concordance between clinical diagnosis and ultrasound was 38.8%, with both complete abortion and GTD showing a concordance of 100%. The least concordance was seen in missed abortions (25%).

CONCLUSION

Clinical assessment is insufficient in the identification of the cause of vaginal bleeding due to the overall low concordance rate. A combination of clinical assessment and ultrasonography is required for decision-making in every case.

Recurrent Hydatidiform Moles: A Clinical Challenge-A Case Report and an Update on Management and Therapeutical Strategies

Hydatidiform mole, complete or partial (CHM/PHM), is the most common type of gestational trophoblastic disease (GTD), which is characterized by excessive trophoblastic proliferation and abnormal embryonic development. Some patients present with sporadic or familiar recurrent hydatidiform moles (RHMs), which are characterized by two or more episodes of the disease. A healthy 36-year-old woman was admitted to the Obstetrics and Gynecology Unit of Santa Maria Goretti Hospital, Latina, because of RHMs at 6 weeks of amenorrhea, with an obstetrical anamnesis of RHMs. We performed uterine dilatation and curettage with suction evacuation. The histological examination confirmed the diagnosis of PHM. The clinical follow-up was conducted according to recent guidelines on the diagnosis and management of GTD. After the return to the baseline values of the beta-human chorionic gonadotropin hormone, a combined oral contraceptive therapy was proposed, and the patient was invited to undergo in vitro fertilization (IVF) techniques, specifically oocyte donation, to reduce the possibility of similar future cases of RHMs. Although some etiopathogenetic mechanisms involved in RHMs are still unknown, all patients of childbearing age who are affected by this syndrome should be properly treated and directed towards a correct clinical path as IVF, to have a successful and safe pregnancy.

A Metastatic Invasive Mole in a Perimenopausal Woman: A Rare Case

Gestational trophoblastic neoplasia (GTN) represents a heterogeneous group of pregnancy-related tumors that usually develop from the malignant transformation of trophoblastic tissue after molar evacuation. The first presentation as an invasive mole is particularly rare. GTN is considered the most curable gynecological malignancy as most cases are treated successfully with chemotherapy agents. Although extremes of reproductive age are an established risk factor for complete moles, GTN is extremely rare in perimenopausal women. GTN should be considered in the differential diagnosis of patients with abnormal uterine bleeding. Delays in the diagnosis and treatment can worsen the prognosis of patients with GTN. Here, we describe the case of a 54-year-old woman who presented to the emergency department with abdominal pain and heavy vaginal bleeding. She reported pregnancy-related symptoms that had developed over two months but was apprehensive to search for medical care. The final diagnosis was an invasive mole that had a catastrophic clinical course. Arterial embolization should be considered in patients with uncontrollable vaginal bleeding and hemodynamic instability.

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].

International Academy of Perinatal Medicine (IAPM) guidelines for screening, prediction, prevention and management of pre-eclampsia to reduce maternal mortality in developing countries

Approximately 800 women die from pregnancy or childbirth-related complications around the world every day, 99% of which occur in developing countries. In majority of cases deaths are related to pre-eclampsia and eclampsia. The purpose of new adjusted and simplified IAPM guidelines is specifically lowering maternal mortality by decreasing preventable deaths in developing countries (particularly in remote rural areas) by using rather cheap medicines used to control chronic and gestational hypertension, prevent pre-eclampsia in high-risk pregnancies and treat severe pre-eclampsia and eclampsia. IAPM guidelines should be implemented and evaluated in each developing country respecting specific problems, needs and resources. It is of essential importance to: 1. Identify specific high-risk pregnancies, 2. Commence timely appropriate ASA and calcium supplementation, 3. Organize basic antenatal care and adequate referral of pregnancies with early onset of pre-eclampsia to the appropriate institutions and ensure induction of labour in well-equipped delivery facility for women with near-term and term pre-eclampsia 4. Ensure magnesium sulphate availability to prevent severe pre-eclampsia and eclampsia-related maternal deaths, and 5. Identify specific barriers for implementation of these guidelines and correct them accordingly. Only by systematic implementations of these guidelines, we may have a chance to decrease the mortality of pre-eclampsia an its complications as a killer number one of mothers in developing countries.

Gestational Choriocarcinoma Manifesting as Spontaneous Hemothorax in Third Trimester of Pregnancy: A Case Report

Gestational trophoblastic neoplasia (GTN) is an aggressive malignancy arising from the trophoblastic tissue. It is rarely seen in association with advanced intrauterine pregnancy. Most common manifestations are due to bleeding caused by the rich vascularity of trophoblastic tissue. We describe here a case of a 28-year-old female patient who presented to us at 32 weeks of pregnancy with sudden onset dyspnea and hemodynamic instability. On evaluation, imaging techniques revealed a gross left hemothorax requiring intercostal tube insertion for stabilization. Emergency thoracotomy and hemothorax drainage were performed wherein a tumor mass in the lower lobe of left lung was identified and resected. Histopathological examination confirmed the diagnosis of choriocarcinoma. Beta HCG levels were found to be elevated. Final diagnosis of a FIGO stage IV high-risk gestational choriocarcinoma was made. Following this, six cycles of multi-agent EMA-CO chemotherapy was administered to the patient. Patient had an excellent response to treatment with documented serial fall in β HCG levels and she continues to be in remission after 6 months of follow-up. In conclusion, in the circumstance of any pregnant women presenting with abnormal bleeding symptoms such as hemothorax, choriocarcinoma as a cause should be considered for early diagnosis and effective management.

Effect of single-dose methotrexate injection to prevent neoplastic changes in high risk complete hydatidiform mole: A randomised control trial

Background

Complete hydatidiform mole affects women in their reproductive age. About 15-20% develops persistent molar gestational trophoblastic neoplasia (GTN), which is linked with delayed (beyond 56 days) normalization of serum βHCG after surgical evacuation.

Objective

The objective of the article is to shorten the duration of normalization time of βHCG with single-dose methotrexate injection in women with high risk complete hydatidiform mole (CHM) after suction evacuation.

Methods

Total 76 women with CHM were randomized into intervention and control groups. In the intervention arm (n = 34) women received single dose 100 mg intramuscular methotrexate injection post evacuation and the control group (n = 42) had standard care. Surveillance was done in both groups at two weeks intervals for next six months and duration of normalization of βHCG level was recorded.

Results

Total 94.7% women completed follow-up. Mean of normalization time was significantly lower in the intervention group compared to controls (9.7 weeks versus 14.7 week; P < 0.01). Time to event curve showed significantly earlier cumulative normalization time for the intervention group.

Conclusion

Single-dose 100 mg methotrexate injection is a low-cost, simple intervention to help one out of three women with CHM with high-risk features to achieve normalization of βHCG within 56 days. This might be helpful for people in resource-poor countries where adherence to prolonged surveillance is poor.

Cervical Hydatidiform Moles Pregnancy: Diagnosis and Treatment

Cervical partial hydatidiform mole is a rare condition and difficult to diagnose. A 39-year-old Balinese woman from Sanglah General Hospital, Bali, Indonesia complained vaginal bleeding with abdominal pain. The patient was diagnosed with a partial hydatidiform mole based on physical examination, ultrasound, beta HCG levels and pathology examinations. Mass evacuation surgery followed by arterial ligation to stop the bleeding and periodically examination of beta HCG levels was carried out until the 14th week after the procedure. Beta HCG decreased gradually to normal level and indicate no risk of trophoblastic malignancy. Establishing the early diagnosis significantly affects the outcome of patient. Keywords: partial cervical hydatidiform mole, blighted ovum, pregnancy, diagnosis, therapy.

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.

Disseminated gestational choriocarcinoma presenting with hepatic and uveal metastases, hook effect, and choriocarcinoma syndrome

Choriocarcinoma is a human chorionic gonadotrophin (HCG)-secreting tumor that comprises vascular channels. It has a tendency for widespread metastasis, common sites for which include the lung, vagina, brain, liver, bone, intestine, and kidney. We describe a 30-year-old female who presented with hepatitis-like features and bilateral diminution of vision, and subsequently developed hemothorax and hemoperitoneum-all rare and seemingly unrelated manifestations which were finally attributable to metastases from gestational choriocarcinoma. To further complicate the clinical scenario, the serum HCG of the patient was mildly raised (due to a phenomenon called hook effect). Subsequently, the patient developed disseminated intravascular coagulation and succumbed to her illness. In this report, we discuss the imaging findings of choriocarcinoma, its potential sites of metastases, and the hook effect.

Haemoptysis in third trimester-sole manifestation of stage IV gestational choriocarcinoma

Gestational choriocarcinoma is a rare neoplasm of pregnancy that is often undiagnosed until the advanced stage manifests with metastatic complications. Herein, we present a case of a 22-year-old young woman with metastatic gestational choriocarcinoma with unidentified primary origin, who presented with haemoptysis as a chief problem in her third trimester. The case emphasises on the rarity of this neoplasm in a viable pregnancy. Prompt diagnosis and treatment is the key for good maternal and fetal prognosis.

Could MicroRNAs Be Useful Tools to Improve the Diagnosis and Treatment of Rare Gynecological Cancers? A Brief Overview

Gynecological cancers pose an important public health issue, with a high incidence among women of all ages. Gynecological cancers such as malignant germ-cell tumors, sex-cord-stromal tumors, uterine sarcomas and carcinosarcomas, gestational trophoblastic neoplasia, vulvar carcinoma and melanoma of the female genital tract, are defined as rare with an annual incidence of <6 per 100,000 women. Rare gynecological cancers (RGCs) are associated with poor prognosis, and given the low incidence of each entity, there is the risk of delayed diagnosis due to clinical inexperience and limited therapeutic options. There has been a growing interest in the field of microRNAs (miRNAs), a class of small non-coding RNAs of ∼22 nucleotides in length, because of their potential to regulate diverse biological processes. miRNAs usually induce mRNA degradation and translational repression by interacting with the 3' untranslated region (3'-UTR) of target mRNAs, as well as other regions and gene promoters, as well as activating translation or regulating transcription under certain conditions. Recent research has revealed the enormous promise of miRNAs for improving the diagnosis, therapy and prognosis of all major gynecological cancers. However, to date, only a few studies have been performed on RGCs. In this review, we summarize the data currently available regarding RGCs.

Uterine mass after caesarean section: a report of two cases

BACKGROUND

Caesarean scar pregnancy (CSP) is a rare complication of caesarean delivery and a special type of ectopic pregnancy. Gestational trophoblastic neoplasia (GTN) is an uncommon complication of pregnancy. Early diagnosis of the two diseases is crucial because a delay or misdiagnosis can lead to increased maternal morbidity and mortality.

CASE PRESENTATION

We report two cases of uterine isthmus lesions with a previous caesarean section (CS). Two patients were misdiagnosed based on the first ultrasound exam. The first case of trophoblastic tumour was initially diagnosed as CSP, while the second case, which had a scar pregnancy, was misdiagnosed as GTN. The misdiagnoses were due to the particularity of the locations of the lesions in the two patients, complicating the ultrasound-based diagnosis and hindering early clinical diagnosis and treatment.

CONCLUSIONS

A medical history, β-hCG measurements and transvaginal ultrasound are necessary to diagnose lesions in the lower anterior wall of the uterus early. However, when the location cannot be determined, magnetic resonance imaging (MRI) can be further performed to determine whether the lesion is located at the uterine scar. Combined with the degree of increased β-hCG, differentiate CSP, myometrial GTN or caesarean scar GTN is helpful.

Two Cases of Ectopic Pregnancy Mimicking Gestational Trophoblastic Disease

A well-known typical feature of ectopic pregnancy is an evident gestational sac structure outside of the uterus. However, some cases show atypical appearance that is described as a heterogeneous hypervascular mass. We report two cases of ectopic pregnancy that presented heterogeneous findings mimicking gestational trophoblastic diseases but were correctly diagnosed as ectopic pregnancies on MRI. The first case was an interstitial pregnancy in which the patient underwent surgical treatment. The second case was a cesarean scar pregnancy that was treated conservatively but showed spurious enlargement of pregnancy-related lesions after the treatment. Both cases lacked myometrial invasion on MRI, and the patients were diagnosed with ectopic pregnancies. Invasive findings on MRI may discriminate ectopic pregnancy from trophoblastic tumors and avoid unnecessary hysterectomy.

Hemoptysis as the first symptom in the diagnosis of metastatic choriocarcinoma in the third trimester of pregnancy: A case report

Introduction

Choriocarcinoma is a rare neoplasm (1/40000 pregnancies). In the context of a viable pregnancy, the incidence is even lower (1/160000).

Case report

A woman in her second pregnancy was admitted at 31 + 6 weeks of gestation with hemoptysis and abnormal vaginal bleeding. Numerous placental venous lakes, bilateral pulmonary nodules and a pleural effusion were found. Pleural fluid β-HCG levels were elevated and a brain-chest-abdominal-pelvic CT scan led to the diagnosis of a high-risk gestational trophoblastic neoplasm. A caesarean section at 32 + 1 weeks of gestation was performed. Six cycles of an EMA-CO chemotherapy regime were administered. β-HCG levels normalized after 3 cycles. Placental histopathology confirmed the presence of a gestational choriocarcinoma.

Conclusion

Choriocarcinoma is a highly aggressive tumor. In high-risk tumors, combination chemotherapy is the first-line treatment, offering high remission rates. Treatment response is evaluated by monitoring blood β-HCG levels, which should be long-term.

[Epidemioclinical and ultrasonographic profile of hydatidiform moles in Abidjan]

Introduction

The purpose of our study was to describe the epidemioclinical and ultrasonographic features of hydatidiform moles (HM) in Abidjan.

Methods

We conducted a cross-sectional study in the Department of Radiology, University Teaching Hospital of Yopougon over a 6-year period (January 2011-December 2016). In this study we describe the epidemioclinical and ultrasonographic profile of patients with HM. Ultrasonographic exams were performed using a mixed-methods approach (intravaginal and subpubic) based on B-mode and Color Doppler by senior radiologists. Anatomopathological examination of uterine content was performed.

Results

Out of 12190 obstetric ultrasound performed, twenty-five cases of HM were diagnosed reflecting a radiological referral rate of 0.2%. The average age of patients was 33.4 years, ranging from 22 to 50 years. There was no dominant age class. The main clinical signs associated with amenorrhea (100%) included abdominal mass 36% and vaginal bleeding 28%. Ultrasound showed hypertrophic uterus in 100% of cases, homogeneous uterus in 96% of cases and myomatous uterus in 4% of cases. MH had an average thickness of 42.7 mm with vesicular appearance in 68% of cases, "honeycomb" appearance in 16%, multicystic appearance in 12% and snowstorm appearance in 4%. MHs were classified as partial in 4% of cases, complete in 92% of cases and invasive in 4% of cases. Hypertrophic ovaries were found in 44% of cases with macrofollicles in 32% of cases and cysts in 8% of cases. Ultrasonographic diagnosis of HM was confirmed by anatomopathological examination in 100% of cases.

Conclusion

HMs are rare in Abidjan and are dominated by the complete hydatidiform mole. Its occurrence at the extreme ages wasn't found.

Gestational Trophoblastic Disease at Sultan Qaboos University Hospital: Prevalence, Risk Factors, Histological Features, Sonographic Findings, and Outcomes

Objectives

We sought to assess the prevalence of gestational trophoblastic diseases (GTD) among pregnant women at Sultan Qaboos University Hospital (SQUH) and compare our results with the international studies. We also sought to determine the risk factors, histological features, sonographic findings, and outcomes in women with GTD.

Methods

We conducted a retrospective cohort study of all women diagnosed with GTD and followed at SQUH between November 2007 and October 2015. We collected data on maternal demographics, risk factors, sonographic features, histological diagnosis, follow-up period, and chemotherapy treatment from the hospital information system.

Results

Sixty-four women with GTD were included in the study with a mean age of 31.0±7.5 years, mean gravidity 4.0, and parity 2.0. The prevalence of GTD was 0.3% (one in 386 births), and the most common risk factors were increased maternal age and multiparity. A partial hydatidiform mole was diagnosed in 54.7%, complete hydatidiform mole in 43.8%, and invasive mole in 1.6% of women. Eleven percent of women required chemotherapy. Typical ultrasound features for partial molar pregnancy were present in 54.7% of our sample, while snowstorm appearance was seen in 89.3% of those with complete mole. Negative beta-human chorionic gonadotropin was achieved 70 days after diagnosis in 41 women.

Conclusions

The awareness of the risks and complications of GTD among physicians with close follow-up is paramount. There is a need to establish a national registry of GTD cases in Oman.

Imaging in Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD) is a spectrum of disorders characterized by abnormal trophoblastic proliferation. GTD includes benign conditions such as hydatidiform moles and malignant diseases that are referred as gestational trophoblastic neoplasia (GTN). Ultrasound plays a central role in the diagnosis of patients with hydatidiform mole. Other imaging modalities are useful in molar pregnancy, mainly for evaluating pulmonary complications and atypical presentation of hydatidiform mole. GTN typically arises after 20% of molar pregnancies but can uncommonly occur after nonmolar gestations. After uterine evacuation, serial human chorionic gonadotropin levels are evaluated in patients for early detection of GTN. Once GTN is suspected, Doppler ultrasound is the primary tool to confirm the diagnosis; however, magnetic resonance imaging can also help in selected cases. Metastatic disease workup can involve various modalities, including ultrasound, X-ray, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. In this article, we review the main imaging modalities used to evaluate patients with GTD.

Diagnosing and treating rare lesions in a low resource setting: lessons from ahybrid epithelioid trophoblastic tumor and choriocarcinoma

OBJECTIVE

To raise awareness of the existence of a rare type of malignant trophoblastic tumor and discuss the diagnostic challenges and management of this lesion in a low resource setting.

CASE REPORT AND INTERVENTION

A 35 -year -old G⁶P³ woman was referred to our facility on account of persistent vaginal bleeding due to a suspected incomplete miscarriage with a cervical mass. Her serum β-HCG was elevated (36,900 mIU/ml) and examination showed a bleeding cervical mass. An initial histopathological diagnosis of moderately differentiated squamous cell carcinoma was reviewed to epithelioid trophoblastic tumor resulting in an extra-fascial hysterectomy. A final histopathological diagnosis of hybrid Epithelioid Trophoblastic Tumor and Choriocarcinoma (ETT/CC) was made after external review and immunohistochemistry. She received subsequent chemotherapy.

CONCLUSION

Epithelioid trophoblastic tumor and its hybrids are difficult to diagnose. They may be diagnosed as moderately differentiated squamous cell carcinoma especially in low resource settings where cervical squamous cell carcinoma is relatively more common. A high index of suspicion, a serum β HCG test and close collaboration between clinicians and pathologists can help make the diagnosis.

FUNDING

None.

First-trimester emergencies: a radiologist's perspective

The purpose of this article is to help the practitioner ensure early diagnosis and response to emergencies in the first trimester by reviewing anatomy of the developing embryo, highlighting the sonographic appearance of common first-trimester emergencies, and discussing key management pathways for treating emergent cases. First-trimester fetal development is a stepwise process that can be challenging to evaluate in the emergency department (ED) setting. This is due, in part, to the complex anatomy of early pregnancy, subtlety of the sonographic findings, and the fact that fewer than half of patients with ectopic pregnancy present with the classic clinical findings of a positive pregnancy test, vaginal bleeding, pelvic pain, and tender adnexa. Ultrasound (US) has been the primary approach to diagnostic imaging of first-trimester emergencies, with magnetic resonance imaging (MRI) and computed tomography (CT) playing a supportive role in a small minority of cases. Familiarity with the sonographic findings diagnostic of and suspicious for early pregnancy failure, ectopic pregnancy, retained products of conception, gestational trophoblastic disease, failed intrauterine devices, and complications associated with assisted reproductive technology (ART) is critical for any emergency radiologist. Evaluation of first-trimester emergencies is challenging, and knowledge of key imaging findings and familiarity with management pathways are needed to ensure early diagnosis and response.

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

•

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

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

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

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

[Role of ultrasound in elective abortions]

Ultrasound plays a fundamental role in the management of elective abortions. Although it can improve the quality of post-abortion care, it must not be an obstacle to abortion access. We thus studied the role of ultrasound in pregnancy dating and possible alternatives and analyzed the literature to determine the role of ultrasound in post-abortion follow-up. During an ultrasound scan, the date of conception is estimated by measurement of the crown-rump length (CRL), defined by Robinson, or of the biparietal diameter (BPD), as defined by the French Center for Fetal Ultrasound (CFEF) after 11 weeks of gestation (Robinson and CFEF curves) (grade B). Updated curves have been developed in the INTERGROWTH study. In the context of abortion, the literature recommends the application of a safety margin of 5 days, especially when the CRL and/or BPD measurement indicates a term close to 14 weeks (that is equal or below 80 and 27mm, respectively) (best practice agreement). Accordingly, with the ultrasound measurement reliable to±5 days when its performance meets the relevant criteria, an abortion can take place when the CRL measurement is less than 90mm or the BPD less than 30mm (INTERGROWTH curves) (best practice agreement). While a dating ultrasound should be encouraged, its absence is not an obstacle to scheduling an abortion for women who report that they know the date of their last menstrual period and/or of the at-risk sexual relations and for whom a clinical examination by a healthcare professional is possible (best practice agreement). In cases of intrauterine pregnancy of uncertain viability or of a pregnancy of unknown location, without any particular symptoms, the patient must be able to have a transvaginal ultrasound to increase the precision of the diagnosis (grade B). Various reviews of the literature on post-abortion follow-up indicate that the routine use of ultrasound during instrumental abortions should be avoided (best practice agreement). If it becomes clear immediately after the procedure that the endometrial thickness exceeds 8mm, immediate reaspiration is necessary. Ultrasound examination of the endometrium several days after an instrumental elective abortion does not appear to be relevant (grade B). An analysis of the literature similarly shows that routine ultrasound scans after medical abortions should be avoided. If a transvaginal ultrasound is performed after a medical abortion, it should take place at least two weeks afterwards (best practice agreement). The only aim of an ultrasound examination during follow-up should be to determine whether a gestational sac is present (best practice agreement). Finally, if an ultrasound is performed at any point during pre- or post-abortion care, a report should be drafted, specifying any potential gynecologic abnormalities found, but its absence must not delay the scheduling of the abortion (best practice agreement).

Clinical and radiological correlations in patients with gestational trophoblastic disease

Gestational trophoblastic disease is an abnormality of pregnancy that encompasses a group of diseases that differ from each other in their propensity for regression, invasion, metastasis, and recurrence. In the past, it was common for patients with molar pregnancy to present with marked symptoms: copious bleeding; theca lutein cysts; uterus larger than appropriate for gestational age; early preeclampsia; hyperemesis gravidarum; and hyperthyroidism. Currently, with early diagnosis made by ultrasound, most patients are diagnosed while the disease is still in the asymptomatic phase. In cases of progression to trophoblastic neoplasia, staging-typically with Doppler flow studies of the pelvis and chest X-ray, although occasionally with computed tomography or magnetic resonance imaging-is critical to the choice of an appropriate antineoplastic therapy regimen. Because it is an unusual and serious disease that affects women of reproductive age, as well as because its appropriate treatment results in high cure rates, it is crucial that radiologists be familiar with gestational trophoblastic disease, in order to facilitate its early diagnosis and to ensure appropriate follow-up imaging.