Diagnostic Ultrasound - Abdomen and Pelvis

Gestational Trophoblastic Disease
798
Diagnoses: Female Pelvis
• Complex echogenic mass with increased vascularity
• Normal to slightly elevated hCG levels
○ Helps differentiate from invasive molar pregnancy
Androgenic Biparental Mosaicism With Placental
Mesenchymal Dysplasia (PMD)
• Rare placental disorder
• Associated with Beckwith-Wiedemann syndrome (BWS)
○ Absence of trophoblastic hyperplasia distinguishes PMD
from molar pregnancy
PATHOLOGY
General Features
• Etiology
○ Complete hydatidiform mole
– Abnormal trophoblast proliferation
○ Theca lutein cysts
– Ovarian hyperstimulation by ↑ hCG
– Only present in 50%
– Rare < 13 weeks
• Genetics
○ Partial mole (triploidy)
– Karyotypes: 69,XXY (most common); 69,XXX; 69,XXY
□ Normal ovum + 2 normal (haploid) sperm
□ Normal ovum + 2 abnormal (diploid) sperm
○ Complete hydatidiform mole
– Androgenetic pregnancy: 100% paternal genetic
make-up
– 46,XX more common than 46,XY
– No fetal tissue present
Staging, Grading, & Classification
• Choriocarcinoma
○ Stage I: Confined to uterus
○ Stage II: Limited to pelvis
○ Stage III: Lung metastases
○ Stage IV: Other metastases
Gross Pathologic & Surgical Features
• Cystic villi resemble "cluster of grapes"
Microscopic Features
• Trophoblastic hyperplasia
• Hydropic villi
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Partial mole (triploidy)
– Vaginal bleeding
– Abnormal fetal tissue + thickened, cystic placenta
○ 1st trimester CHM
– Variable appearance
□ hCG levels may be normal
– Rapid uterine enlargement
– Hyperemesis 2⁰ to↑ hCG levels
○ 2nd trimester CHM
– ↑ hCG levels
– Preeclampsia symptoms
○ Invasive mole
– Persistent ↑ hCG levels after CHM treatment
○ Choriocarcinoma
– Symptoms of metastatic disease
– ↑ hCG levels
○ PSTT
– ↓ hCG levels and↑ human placental lactogen (hPL)
level
□ Minimal syncytiotrophoblastic tissue
• Other signs/symptoms
○ Adnexal pain or mass
– Theca lutein cysts
Demographics
• Age
○ ↑ risk at extremes of reproductive age
• Ethnicity
○ ↑ risk for Asian women
• Epidemiology
○ Partial mole (triploidy)
– 2-4% become invasive
○ Complete hydatidiform mole
– Most common type of GTD
– 0.5:1,000 in United States
– 8:1,000 in Asia
– 12-15% become invasive
– Coexistent mole and fetus is variant of CHM
○ Choriocarcinoma
– 50% originate from CHM
– 25% occur after failed pregnancy
– 25% after normal pregnancy
Natural History & Prognosis
• CHM has excellent prognosis
○ Evacuation often curative
• Invasive disease
○ Near 100% cure with chemotherapy
○ 75% remission even if extensive metastases
Treatment
• Complete hydatidiform mole
○ Dilation and curettage with serial hCG measurements
• Invasive disease
○ Low-risk malignant cases: Single agent chemotherapy
with methotrexate or actinomycin D
○ High-risk malignant cases: Multiagent chemotherapy
○ Hysterectomy in nonresponsive cases or if fertility
preservation is not desired
SELECTED REFERENCES
1. Lane BF et al: ACR Appropriateness Criteria® first trimester bleeding.
Ultrasound Q. 29(2):91-6, 2013
2. Kohorn EI: Imaging practices in the diagnosis and management of
gestational trophoblastic disease: an assessment. J Reprod Med. 57(5-
6):207-10, 2012
3. Emoto M et al: Clinical usefulness of contrast-enhanced color Doppler
ultrasonography in invasive and noninvasive gestational trophoblastic
diseases: a preliminary study. J Reprod Med. 56(5-6):224-34, 2011
4. Lurain JR: Gestational trophoblastic disease I: epidemiology, pathology,
clinical presentation and diagnosis of gestational trophoblastic disease, and
management of hydatidiform mole. Am J Obstet Gynecol. 203(6):531-9,
2010
5. Betel C et al: Sonographic diagnosis of gestational trophoblastic disease and
comparison with retained products of conception. J Ultrasound Med.
25(8):985-93, 2006