Uterine artery Doppler flow velocimetry parameters for predicting gestational trophoblastic neoplasia after complete hydatidiform mole, a prospective cohort study

Diagnosis and Management of Molar Pregnancies

Complete and partial molar pregnancies arise from abnormal fertilization with marked proliferation of syncytiotrophoblasts. Earlier diagnosis has reduced the frequency of severe medical complications at presentation; however, the risk of progression to gestational trophoblastic neoplasia (GTN) has remained unchanged. Initial assessment should include serum hCG measurement after physical examination, laboratory testing for organ dysfunction, and Doppler ultrasound. Following uterine evacuation, pathologic assessment can distinguish complete from partial moles or non-molar gestations. Close surveillance is essential for the timely diagnosis of GTN. Cure rates and subsequent obstetrics outcomes are excellent, but all patients should be referred for psychologic support and expert level care.

Combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios for early prediction of postmolar gestational trophoblastic neoplasia

PURPOSE

To investigate factors predicting postmolar gestational trophoblastic neoplasia (GTN) by combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios.

METHODS

This retrospective study enrolled patients with histopathologically proven molar pregnancy. Patients lost to follow-up before remission or developing postmolar GTN were excluded. Demographic and clinical characteristics and hCG data obtained before and after molar evacuation were collected. Area under the receiver operating characteristic curve (AUC) analysis was used to identify the hCG and hCG ratio cutoff values that predict postmolar GTN. Multivariate analysis was employed to identify independent predictors of GTN.

RESULTS

There were 113 complete moles, 11 partial moles, and 52 unspecified moles included in the final analysis. Of the 176 cases, 90 achieved remission and 86 developed post-molar GTN. The incidence of postmolar GTN was 48.9%, with a median time to GTN development of 5 weeks. Univariate analysis showed age, molar evacuation performed elsewhere, pre-evacuation hCG, hCG at 2nd week post-evacuation, and ratio of hCG at 2nd week post-evacuation to post-evacuation hCG significantly predict GTN. Multivariate analysis revealed an hCG value ≥ 1400 IU/L at 2nd week post-evacuation (AUC: 0.92, aOR: 6.51, 95% CI 1.28-33.16; p = 0.024) and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 (AUC: 0.88, aOR: 12.27, 95% CI 2.15-70.13; p = 0.005) to independently predict GTN.

CONCLUSIONS

An hCG value ≥ 1400 IU/L at 2nd week post-evacuation and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 independently and reliably predict postmolar GTN.

Immune cell composition in the endometrium of patients with a complete molar pregnancy: Effects on outcome

OBJECTIVE

In 15% of patients with complete hydatidiform mole (CHM), disease progresses to post-molar gestational trophoblastic neoplasia (GTN) after curettage. Tumor infiltrating lymphocytes (TILs) are essential in overcoming disease in many tumors. Infiltrating lymphocyte composition and density may influence trophoblast regression and development of post-molar GTN. We analyzed immune cell composition and density in curettaged endometrium of patients with CHM which spontaneously regressed, and of patients with CHM which progressed to post-molar GTN.

METHODS

Sixteen patients with CHM and spontaneous regression, and 16 patients with CHM which progressed to post-molar GTN were selected. Immune cell composition and density of natural killer (NK) cells, natural killer T (NKT)-like cells, Cytotoxic T cells, T-Regulatory and T-Helper cells, were determined by multiplex immunohistochemistry (mIHC).

RESULTS

Curettaged endometrium of patients with CHM and spontaneous regression contained a slightly higher number of immune cells compared to patients with CHM which progressed to post-molar GTN. NKT-like cell density was significantly higher in patients with spontaneous regression compared to patients with CHM which progressed to post-molar GTN (483 ± 296 vs.295 ± 143 (mean ± SD), p = 0.03) respectively. NKT-like cell density in the spontaneous regression group was split in 'high' and 'low' (i.e. above and below the median number of NKT-like cells). In patients with high NKT-like cell density, hCG normalized earlier than in patients with low NKT-like cell density (9.5 weeks, (range 3.7-14) vs. 12.9 weeks, (range 8.6-17.9), p = 0.05).

CONCLUSION

A high number of NKT-like cells in the endometrium of CHMs may contribute to spontaneous regression of molar trophoblast cells.

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.

Role of hysteroscopy and ultrasound in early identification of post-molar gestational trophoblastic neoplasia

OBJECTIVE

To evaluate the role of hysteroscopy and ultrasound in early identification of gestational trophoblastic neoplasia (GTN) after molar evacuation.

METHODS

This was a prospective study involving 52 women with an ultrasound diagnosis of complete hydatidiform mole, attending a tertiary centre in south India between August 2016 and August 2019. Baseline characteristics such as age, serum beta-human chorionic gonadotropin(β-hCG) level, gestational age, and uterine size were noted. After the evacuation of molar pregnancy, weekly follow-up with β-hCG was performed, until three consecutive values were normal and then monthly for six months. Findings of transvaginal ultrasound and diagnostic hysteroscopy, performed on follow up at three weeks, were noted. Primary outcome was the development of GTN. Area under the curve(AUC) was calculated to assess the usefulness of these methods in early identification of GTN.

RESULTS

Thirteen women (25 %) developed GTN during follow up, within 6 months. Twenty six(50 %) cases had high-risk molar pregnancy. Positive findings on hysteroscopy and ultrasonography were noted in 44.2 % and 19.2 % respectively. AUC was 0.83(95 % CI, 0.70-0.97) for ultrasound and 0.82(95 % CI, 0.72-.92) for hysteroscopy. Sensitivity and specificity were 69.2 % and 97.4 % for ultrasound and it was 92.3 % and 71.8 % respectively for hysteroscopy in identifying those who developed GTN on follow-up.

CONCLUSIONS

Transvaginal ultrasound as well as hysteroscopy may help in early identification of women at risk of developing GTN following a molar evacuation. Being a non-invasive method with similar discriminative value, ultrasonographic evaluation may be used for early identification of women with GTN after validation in future studies.

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.

Differential expression of SALL4 in CTCs derived from hydatidiform moles and gestational trophoblastic neoplasms

PROBLEM

To investigate EMT phenotype and SALL4 expression of circulating tumour cells (CTCs) in patients with gestational trophoblastic neoplasm (GTN).

METHOD OF STUDY

CanPatrol CTC detection system in combination with SALL4 RNA in situ hybridization was used to investigate the profile of CTCs in different types of gestational trophoblastic disease (GTD). Circulating CTCs were phenotyped and annotated with SALL4 expression in 41 GTD patients, including 12 HM and 29 GTN, as well as 22 pregnant volunteers.

RESULTS

A positive correlation between the number of CTC and serum β-hCG concentration was found among the GTN patients. The number of E/M-CTC was positively correlated with serum β-hCG, while M-CTC was positively correlated with prognostic score. Comparison among malignant GTD, benign GTD and healthy pregnant women revealed a significant difference in the number of total CTC, E/M-CTC, and M-CTC but not in E-CTC. ROC analysis was conducted to evaluate the performance of CTC phenotypes in distinguishing GTD patients from healthy pregnant women yielding an AUC as 0.826. Youden's index was maximal at the cutoff value of 8.5/4 mL with sensitivity and specificity at 53.66% and 100%, respectively. SALL4 expression was evaluated in GTD patients with CTC count greater than cutoff value. SALL4 high expressing CTCs (>2 signal dots) were detected in 66.67% (10/15) of malignant GTD patients but not in benign patients (0/5).

CONCLUSION

Differential expression of SALL4 was seen in CTCs derived from hydatidiform moles and GTN. CTC profiling may be developed as an adjunct marker to diagnose GTN.

A Pictorial Ultrasound Essay of Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD) includes a wide variety of clinical and histopathologic entities that require prompt identification and definition by the integration of clinical, laboratory, and imaging data. Recently, the role of grayscale ultrasound and spectral and power/color Doppler techniques has become pivotal in the diagnosis, staging, and management of GTD, thanks to both technical improvements and the growing expertise of dedicated operators. The aim of this essay is to summarize the most recent data on the ultrasound and Doppler findings of GTD and to provide a pictorial overview, including useful prognostic and therapeutic implications for clinical practice.

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.