Professional Documents
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Disease
Alampady K.P. Shanbhogue, MDa,*, Neeraj Lalwani, MDb,
Christine O. Menias, MDc
KEYWORDS
Hydatidiform mole Choriocarcinoma Magnetic resonance imaging
KEY POINTS
With the advent of routine ultrasonographic examination in first trimester, most molar pregnancies
now present with findings of early pregnancy failure rather than the classic cluster of grapes
appearance. Ultrasonography has low sensitivity, but high positive predictive value, for the diagnosis of molar pregnancy.
Pelvic magnetic resonance (MR) imaging can accurately depict the degree of uterine myometrial
and extrauterine invasion in malignant gestational trophoblastic disease, and thus aids in the
anatomic staging of disease.
Imaging detection of persistent trophoblastic disease on pelvic MR imaging is determined by the
extent of tumor burden as quantified by bhuman chorionic gonadotropin (b-hCG) levels. Patients
with low b-hCG levels (<500 mIU/mL) often have normal MR imaging findings.
18F-Fluorodeoxyglucose positron emission tomography is useful in assessing viable tumor after
chemotherapy, detecting occult chemoresistant lesions, differentiating viable from nonviable tumor
lesions seen on computed tomography, and confirming complete treatment response after salvage
therapy in placental-site trophoblastic tumor or recurrent/resistant gestational trophoblastic tumor.
Gestational trophoblastic disease (GTD) encompasses a spectrum of disease arising from uncontrolled growth of placental trophoblastic tissue,
with a spectrum of severity ranging from premalignant hydatidiform mole through malignant
invasive mole, choriocarcinoma, placental-site
trophoblastic tumor (PSTT), and the extremely
rare epithelioid trophoblastic tumor. Early, accurate diagnosis of GTD is necessary to avoid
morbidity associated with delayed diagnosis
from multidrug chemotherapy and surgery. Most
hydatidiform moles are benign, although a small
percentage may persist as invasive moles or progress to choriocarcinoma and PSTT.
radiologic.theclinics.com
INTRODUCTION
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90%, attributable to routine surveillance using
highly sensitive b subunit of human chorionic
gonadotropin (b-hCG) and high chemosensitivity
of the tumor.1,2 Although surveillance with b-hCG
can serve as an excellent surrogate tumor marker
in early detection of disease, it does not indicate
the site of recurrence or metastases. Imaging
with computed tomography (CT) of the chest,
abdomen, and pelvis, and CT or MR imaging of
the brain thus play a crucial role in determining
the site, and the number and extent of metastases,
all of which are important prognostic indicators in
the management of GTD.
EPIDEMIOLOGY
Hydatidiform mole, commonly referred to as molar
pregnancy, accounts for 80% of all GTDs.3 Hydatidiform mole is estimated to occur in 0.6 to 1.1 per
1000 pregnancies in North America.4 Choriocarcinoma, on the other hand, is rare, with an estimated
incidence of 1 in 20,000 to 40,000 pregnancies.4
Approximately 50% of choriocarcinomas arise
from molar pregnancies, 25% from term or preterm pregnancies, and the remainder from pregnancy termination.5 Regional variations have
been reported in the incidence of GTD, with an
increased incidence in Asia in comparison with
North America and Europe.6,7 For instance, the
incidence of hydatidiform mole and choriocarcinoma in southeast Asia is up to 2 per 1000 pregnancies and 9.2 per 40,000 pregnancies,
respectively.7,8 Choriocarcinoma is also reported
to be more prevalent in American Indian and African women.9 Overall, there has been significant
decrease in the incidence of GTD over the last 3
decades, which can partially be attributed to
improved socioeconomic conditions and dietary
changes.10,11 Some of the established risk factors
for GTD include maternal age (both <20 years
and >40 years), history of prior molar pregnancy,
and history of oral contraceptive use.7,12 For
instance, the risk of subsequent molar pregnancy
increases by 1% to 2% after diagnosis of 1 molar
pregnancy and 15% to 20% after diagnosis of 2
molar pregnancies.11 Choriocarcinoma is 1000
times more likely to occur after complete hydatidiform mole compared with other pregnancies.9
Several other factors such as parity and spontaneous or induced abortions, maternal A and AB
blood groups, maternal/paternal A0 or A blood
groups, smoking, exposure to pesticides/herbicides, oncogenes, and tumor-suppressor genes
have been variably attributed to increase the risk
of GTD.13 Patients with familial molar pregnancy
tend to exhibit mutations in the NLRP7 gene at
chromosome 19q13.3-13.4.11
HYDATIDIFORM MOLE
Hydatidiform mole is a benign but premalignant
subtype of GTD originating from fertilization error.
Hydatidiform mole is classified into 2 different subtypes, complete hydatidiform mole and partial or
incomplete hydatidiform mole, based on the
epidemiology, cytogenetics, pathology, natural
history, and clinical presentation. Complete hydatidiform mole arises from fertilization of an ovum
devoid of maternal chromosomes by a sperm,
with subsequent of duplication of paternal DNA.
The chromosome in a complete molar gestation
is therefore solely paternally derived and has a
46,XX karyotype14 also termed uniparental disomy. A small number of complete moles (<10%)
may carry a 46,XY androgenetic karyotype arising
from fertilization by 2 sperms.15 Partial hydatidiform moles or partial molar pregnancies arise
from fertilization of an otherwise healthy ovum by
2 sperms with resultant triploid 69,XXY karyotype.16 Complete hydatidiform moles therefore
do not have any fetal tissue, and partial hydatidiform moles may have an embryo that may survive
up to the second trimester.
Clinically the two types of molar pregnancy
differ in the mode of presentation, laboratory findings, and prognosis. Complete hydatidiform moles
classically present with vaginal bleeding (84%),
uterine enlargement (50%), and high levels of
hCG (50%).17,18 Incomplete or partial hydatidiform
moles tend to present with signs and symptoms of
missed or incomplete abortion, without an
enlarged uterus or significantly elevated b-hCG
levels.17,18 Other less common manifestations of
hydatidiform mole include anemia, toxemia of
pregnancy, hyperemesis gravidarum, hyperthyroidism, and respiratory failure.19 With the advent
of routine early antenatal care, most molar pregnancies are diagnosed on pathologic evaluation
after evacuation for early pregnancy failure, and
only about one-half of all cases present with
vaginal bleeding.20 Pregnancy-induced hypertension or gestational hypertension in the first
trimester of pregnancy is thought to be virtually
diagnostic of hydatidiform mole. From a pathologic perspective, complete hydatidiform mole
arises from villous trophoblasts and is characterized by trophoblastic hyperplasia, abnormal
budding of villi with hydropic appearance, and
abnormal villous blood vessels.11 By contrast,
villous hydrops and trophoblastic hyperplasia is
typically patchy and focal in partial moles.11
Ultrasonography is the initial investigation of
choice for the detection of hydatidiform mole. Clinical and laboratory abnormalities may favor a diagnosis of hydatidiform mole, and ultrasonography
Fig. 1. Complete hydatidiform mole. Gray-scale (A) and power Doppler (B) sonographic images of the uterus
demonstrate multiple cystic spaces within the endometrial cavity with increased vascularity (arrowheads) in a
22-year-old woman with significantly elevated b-hCG levels. No fetus or gestational sac is seen.
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Fig. 2. (A, B) Partial hydatidiform mole in a 23-year-old woman with significantly elevated b-hCG levels. Grayscale sonographic images of the uterus demonstrate cystic changes within the placenta (arrowhead in A), and
an abnormal nonviable fetus (arrows in A and B).
MALIGNANT NEOPLASMS
Malignant GTD labeled as GTN include invasive
mole, choriocarcinoma, PSTT, and the extremely
rare epithelioid trophoblastic tumor. Choriocarcinomas are tumors that arise from villous trophoblast, and PSTTs arise from the interstitial
trophoblast.11 Histologically both subtypes demonstrate malignant epithelial architecture; however, areas of necrosis and hemorrhage are more
commonly seen in choriocarcinoma.32 Similar to
Fig. 3. (A, B) Partial hydatidiform mole with twin pregnancy. Gray-scale sonographic images of the uterus demonstrate cystic changes within the placenta; a normal fetus is seen.
Fig. 4. Complete hydatidiform mole in a 22-year-old woman who presented with rapidly increasing abdominal
girth. Qualitative serum hCG was negative. Axial (A) and coronal reformatted (B) contrast-enhanced CT of the
abdomen shows an enlarged uterus with abnormal heterogeneous enhancement of the endometrium as well
as multiple small cystic spaces, typical of molar pregnancy (arrows). Enlargement of both ovaries was also
seen, resulting from increased estrogen levels. There is no evidence of myometrial extension or extrauterine disease. Quantitative b-hCG was more than 1 million IU/L. Dilatation and curettage was performed, with findings
consistent with those of complete hydatidiform mole.
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Fig. 6. Invasive mole after evacuation of a complete molar pregnancy in a 17-year-old girl with persistent vaginal
bleeding and elevated b-hCG. Axial contrast-enhanced CT images (A, B) demonstrate residual endometrial
trophoblastic tissue containing multiple cystic spaces and an enhancing component, also extending into the
myometrium of the posterior uterine wall (arrow), which signifies an invasive component. The patient underwent
repeat dilatation and curettage (D&C) and received chemotherapy, and her b-hCG level returned to normal.
and invasion through the myometrium and extrauterine invasion is also readily detectable on MR
imaging.39 MR imaging may also aid in quantifying
the tumor vascularity, and aids in disease staging.27 However, it should be noted that findings
on MR imaging are largely determined by the
extent of tumor burden as quantified by b-hCG.
Consequently, normal MR imaging findings in a
patient with low b-hCG levels (<500 mIU/mL)
does not exclude the diagnosis of persistent
trophoblastic disease.38 Following successful
chemotherapy, normalization of uterine appearance has been shown to occur within about 6 to
9 months.41 Intralesional hemorrhage and necrosis
can occur after treatment.41 Persistent uterine
vascular malformation has been reported to occur
in up to 15% of patients after complete tumor
Fig. 7. Postmolar choriocarcinoma with myometrial invasion and lung metastases. A 14-year-old girl presented
with irregular vaginal bleeding and an abnormally high b-hCG level (622,136 IU/L). Axial contrast-enhanced CT
(A) shows a distended endometrial cavity with multiple enhancing septae and nonenhancing cystic components,
consistent with molar pregnancy (arrows). D&C was performed, which confirmed the diagnosis. One month after
D&C she had persistently elevated b-hCG (29,538 IU/L). Axial contrast-enhanced CT 1 month after D&C (B, C)
shows a heterogeneously enhancing myometrial mass (arrow in B) with metastases to the lung (arrow in C).
Fig. 8. Choriocarcinoma with lung metastases. A 23-year-old woman with history of 3 prior molar pregnancies presented with abnormally high serum b-hCG and vaginal bleeding. Axial contrast-enhanced CT of the pelvis (A) shows
an abnormal heterogeneously enhancing mass within the endometrial cavity (arrows). No myometrial invasion is
seen. Axial CT of the chest (B) shows multiple pulmonary nodules consistent with metastases (arrow in B).
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Fig. 10. Invasive mole in a 37-year-old woman who presented with persistently elevated b-hCG 1 month after D&C
for complete mole. Axial T2-weighted (A) and T1-weighted gadolinium-enhanced (B) MR images demonstrate a
heterogeneous lesion seen in the uterine fundus invading the myometrium, with multiple T2-hyperintense cystic
foci, heterogeneous enhancing septae, and multiple nonenhancing cystic spaces (arrow).
MANAGEMENT
The unique epidemiology, tumor biology, and chemosensitivity of GTNs allow for an accurate
noninvasive diagnosis without histologic examination, even in patients with metastases. Treatment
is initiated once the imaging and clinical diagnosis
is established. Molar pregnancies are treated
with suction curettage followed by blunt curettage
of the uterine cavity.53 Intraoperative ultrasonography has been used as a guide to reduce the risk of
uterine perforation.11 Medical termination is rarely
used in partial mole, and carries a risk of persistent
trophoblastic disease.54 In twin pregnancies with
one living fetus, current recommendations allow
Fig. 11. Placental-site trophoblastic tumor in a 34-year-old woman who developed persistent abnormal uterine
bleeding after cesarean section. Coronal T2-weighted MR images of the pelvis demonstrate a polypoid lesion
in the left cornu (arrow) that is hypointense on T2-weighted image (A), isointense on T1-weighted image (B),
and enhances intensely after gadolinium administration (C, D). The uterus was also mildly enlarged. Serum
hCG measured 36.6 IU/L (normal 05 IU/L). Hysteroscopic resection and histopathologic analysis was consistent
with placental-site trophoblastic tumor. Total abdominal hysterectomy was performed.
Table 1
International Federation of Gynecology and
Obstetrics (FIGO) anatomic staging system
Stage
I
II
III
IV
Table 2
FIGO scoring system modified from the World Health Organization scoring system
Scores
Age
Antecedent pregnancy
Interval in months from index
pregnancy
Pretreatment serum b-hCG (IU/L)
Largest tumor size (including
uterus)
Site of metastases
No. of metastases
Previous failed chemotherapy
<40
Mole
<4
40
Abortion
46
Term
712
>12
<103
<3
103104
34 cm
104105
5 cm
>105
Lung
Spleen, kidney
14
Gastrointestinal
58
Single drug
Liver, brain
>8
2 drugs
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combination of multidrug chemotherapy and surgery, which involves hysterectomy and lymph
node dissection. The survival rate for PSTT and
epithelioid trophoblastic tumor ranges from 100%
for nonmetastatic disease to 50% to 60% for metastatic disease.56 Long-term survival has also
been reported to depend on the site of metastases.
Patients with both brain and liver metastases have
poorer results (5-year survival 10%) than isolated
hepatic metastases (5-year survival 70%).60,61
Successful pregnancy has been reported in more
than 80% of women who undergo chemotherapy.62 However, women should be advised to
avoid pregnancy for up to 12 months after completion of chemotherapy to reduce potential teratogenic effects on the fetus.11 This approach also
enables accurate detection and differentiation of
disease relapse from a normal pregnancy. Theca
lutein cysts, which often coexist with GTD, may
take several months to regress after evacuation
of uterine contents.
SUMMARY
GTD is a relatively uncommon, almost completely
curable pregnancy-related disorder encompassing a spectrum of disease ranging from benign,
premalignant hydatidiform mole to malignant
choriocarcinoma. Most hydatidiform moles are
now detected early in the antenatal period, and
may be mislabeled sonographically as miscarriages or anembryonic pregnancy. Ultrasonography plays a crucial role in excluding a normal
pregnancy and establishing the diagnosis of
molar pregnancy in women with disproportionately high b-hCG levels. Imaging also plays a
quintessential role in the diagnosis, staging, and
risk stratification in malignant GTD, including precise localization of metastases as well as determination of the site of disease relapse in patients
with elevated b-hCG following chemotherapy or
surgery. FDG PET can be used to detect viable
tumor after chemotherapy, and may aid in surgical planning for chemoresistant viable residual
or recurrent disease.
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