Gestational Trophoblastic Neoplasms

History

• 21 years G3 P1 M1

• Normal vaginal delivery 10 months ago

• Depo-Provera after delivery, now abnormal menses

• Feels and looks healthy

Examination

• Normal observations

• Normal general and systemic examination

• Gynecological examination: Bulky uterus

Management

• Referred for pelvic ultrasound as first line investigation

Differential diagnosis

1. Invasive mole

2. Choriocarcinoma

Other investigations

• Beta-HCG

• CXR

• Brain CT

• Liver functions and liver scan

The patient was managed by the clinicians as a young patient with choriocarcinoma

CHORIOCARCINOMA

Gestational trophoblastic neoplasia represents a spectrum of diseases of which choriocarcinoma known to be one of the most malignant neoplasms affecting women.  This epithelial tumor is composed of highly anaplastic strands of interlacing syncytiotrophoblastic and cytotrophoplasic elements.

Classification of gestational trophoblastic neoplasms:

1. Histopathologic:        

• Molar pregnancy (hydatidiform mole)

• Infiltrating molar pregnancy (chorioadenoma destruens)

• Choriocarcinoma

2. Clinical:

• Benign

• Malignant

3. Morphological:

• Complete mole

• Incomplete mole

Incidence

• Common in Asia 1:85 pregnancies

• Taiwan 1:120

• South-Africa 1:2000

• Increased risk in the age groups younger than 20 years and older than 40 years and a history of previous miscarriage or molar pregnancy

Ultrasound diagnosis

Gray scale imaging:

Making the diagnosis hydatidiform mole is important because after the mole has been evacuated from the uterus these women must have careful follow-up to exclude subsequent development of choriocarcinoma.  The classic ultrasound appearance of a hydatiform mole will result in multiple small sonolucent areas  which correspond to the "grape-like" vesicles that one sees on gross pathologic examination.  When the products of conception undergo further hydropic change and proliferation with neo-vascularization a chorio-carcinoma develops.  On ultrasound the tissue becomes more hyperechoic with less sonolucent areas.  Refer to images.

Colour doppler:

Typically displays a colour-coded "hot" area representing pre-existing and newly formed vessels. All of these vessels show high-velocity, low-impedance blood flow signals. Colour  Doppler  flow imaging and pulsed Doppler can be used to evaluate chemotherapeutic results

Interesting fact!

Choriocarcinoma  tissue does not contain any HLA anti-bodies( like sperms) which may explain way it is so highly malignant - the body does not recognize it as foreign.

References:

1. Kurjack A, Kupesic S. An Atlas of transvaginal Colour doppler(2nd edition) .The Parthenon Publishing Group ,2000;75 -8

2. Jauniaux E, Gavriil P, Nicolaides K.  Ultrasonographic assessment of early pregnancy complications. In  Jurkovic d,Jauniaux,eds. Ultrasound and Early Pregnancy. Carnforth, UK: Parthenon Publishing,1996:53-64

3. Berkowittz RS, Golstein DP, Bernstein MR. Evolving concepts of molar pregnancy. J Reprod Med 1991;36:40 - 4

4. Aoki S,Hata H, Hata K, et al .Doppler colour flow mapping on an invasive mole. Gynecol Obstet Invest 1989;27:52 -4

5. HsiehFJ ,Wu CC,Lee CN,et al. Vascular patterns of gestationla trophoblastic tumors by colour Doppler ultrasound. Cancer 1994;74:2361-5

6. Lindholm H, Radestad A ,Flam F. Hysteroscopy provides proof of trophoblastic tumors in the three in cases with negative colour Doppler images. Ultrasound Obstet Gynecol 1997;9:59 -61.

7. Goldstein RS, Timor-trich IE. Ultrasound in Gynecology(1st edition). Churchhill Livingstone Inc,1995:163 -4