High-intensity focused ultrasound as a pretreatment combined with hysteroscopic resection for gestational trophoblastic neoplasia with chemotherapy intolerance: a case report.

BACKGROUND: Due to resistance and intolerance to chemotherapy, localized lesion resection may be required in some patients with Gestational trophoblastic neoplasia (GTN), which may lead to massive bleeding. In this case report, we describe the successful use of high-intensity focused ultrasound (HIFU) as an effective pretreatment method for surgical procedure in a patient with GTN to reduce the perioperative risk and the impact on fertility. CASE PRESENTATION: A 26-year-old woman was diagnosed with high-risk GTN (FIGO Stage III: 12 prognostic scores) after a hydatidiform mole. The fifth chemotherapy cycle was interrupted due to severe chemotherapy toxicity. However, the uterine lesion was still present and the beta-human chorionic gonadotropin (ß-hCG) level was not restored to normal. Therefore, ultrasound-guided HIFU was performed as a pretreatment method to shrink the lesion and prevent massive bleeding during localized lesion resection. The effectiveness of ablation was evaluated immediately using contrast-enhanced ultrasound and Color Flow Doppler ultrasonography. One month after HIFU treatment, the uterine lesion was completely resected under hysteroscopic surgery. During the surgery, HIFU was found to have shrunk the lesion and there was minimal bleeding (5 mL). The uterine cavity morphology and menstruation returned to normal after surgery. The patient has showed no signs of recurrence as of one-year follow-up. CONCLUSION: Ultrasound-guided HIFU ablation may be a new choice for high-risk GTN patients with chemoresistance or chemo-intolerance. As a noninvasive pretreatment method, HIFU can shrink the uterine lesion, and reduce the risk of bleeding with no obvious effect on fertility.

Chimeric Singleton Placenta Comprising Placental Mesenchymal Dysplasia and Complete Hydatidiform Mole with Live Birth and Postpartum Diagnosis of Gestational Trophoblastic Neoplasia.

INTRODUCTION: Placental mesenchymal dysplasia (PMD) is a benign lesion that is often misdiagnosed as complete (CHM) or partial hydatidiform mole. PMD usually results in live birth but can be associated with several fetal defects. Herein, we report PMD with CHM in a singleton placenta with live birth. CASE PRESENTATION: A 34-year-old gravida 2, para 1, living 1 (G2P1L1) woman was referred on suspicion of a molar pregnancy in the first trimester. Maternal serum human chorionic gonadotrophin levels were increased during early pregnancy, with multicystic lesions and placentomegaly observed on ultrasonography. Levels decreased to normal with no fetal structural abnormalities observed. A healthy male infant was delivered at 34 gestational weeks. Placental p57KIP2 immunostaining and short tandem repeat analysis revealed three distinct histologies and genetic features: normal infant and placenta, PMD, and CHM. Gestational trophoblastic neoplasia was diagnosed and up to fourth-line chemotherapy administered. CONCLUSION: Distinguishing PMD from hydatidiform moles is critical for avoiding unnecessary termination of pregnancy. CHM coexisting with a live fetus rarely occurs. This case is unique in that a healthy male infant was born from a singleton placenta with PMD and CHM.

Long-term outcome of ultrasound-guided focused ultrasound ablation for gestational trophoblastic neoplasia in the cesarean scar: a case report.

BACKGROUND: The treatment of gestational trophoblastic neoplasia (GTN) is one of the success stories in medical oncology. GTN in the cesarean scar is a rare entity, but most cases need to be treated with hysterectomy or localized uterine lesion resection because of chemoresistant lesions and/or massive bleeding. We present a patient with post-molar GTN in the cesarean scar who was non-invasively treated with ultrasound-guided high intensity focused ultrasound (HIFU) to preserve the uterus and fertility. CASE PRESENTATION: A 32-year-old woman was diagnosed with low-risk GTN (FIGO Stage I: 2 prognostic score) after partial hydatidiform mole. The 5th cycle of chemotherapy was interrupted because of persistent hepatic toxicity and impaired ovarian reserve function. However, the uterine lesion persisted (diameter of residual uterine lesion in the cesarean scar: 2.0 cm). Therefore, ultrasound-guided HIFU treatment was performed. A significant gray-scale change was observed during the HIFU treatment. Color Doppler ultrasonography and contrast-enhanced ultrasound (CEUS) was performed to evaluate the ablation effectiveness. Color Doppler ultrasonography showed disappearance of the signal of vascularity and CEUS showed no perfusion in the lesion located in the cesarean scar. The uterine lesion was obviously shrunken one month after HIFU treatment. Menstrual cycle resumed 48 days after HIFU. HIFU treatment decreased the number of chemotherapy cycles and there was complete disappearance of the GTN lesion at 4-month follow-up. The patient has shown no signs of recurrence as of 58-month follow-up. CONCLUSION: Ultrasound-guided HIFU may be a useful alternative to lesion resection for GTN in the cesarean scar in patients who show chemoresistance or are not suitable for chemotherapy. It has the potential to ablate the residual uterine lesion noninvasively to preserve the uterus and fertility, avoiding perioperative risks of lesion resection, especially acute bleeding.

Computed tomography chest imaging offers no advantage over chest X-ray in the initial assessment of gestational trophoblastic neoplasia.

BACKGROUND: The International Federation of Gynaecology and Obstetrics (FIGO) score identifies gestational trophoblastic neoplasia (GTN) patients as low- or high-risk of single-agent chemotherapy resistance (SACR). Computed tomography (CT) has greater sensitivity than chest X-ray (CXR) in detecting pulmonary metastases, but effects upon outcomes remain unclear. METHODS: Five hundred and eighty-nine patients underwent both CXR and CT during GTN assessment. Treatment decisions were CXR based. The number of metastases, risk scores, and risk category using CXR versus CT were compared. CT-derived chest assessment was evaluated as impact upon treatment decision compared to patient outcome, incidence of SACR, time-to-normal human chorionic gonadotrophin hormone (TNhCG), and primary chemotherapy resistance (PCR). RESULTS: Metastasis detection (p < 0.0001) and FIGO score (p = 0.001) were higher using CT versus CXR. CT would have increased FIGO score in 188 (31.9%), with 43 re-classified from low- to high-risk, of whom 23 (53.5%) received curative single-agent chemotherapy. SACR was higher when score (p = 0.044) or risk group (p < 0.0001) changed. Metastases on CXR (p = 0.019) but not CT (p = 0.088) lengthened TNhCG. Logistic regression analysis found no difference between CXR (area under the curve (AUC) = 0.63) versus CT (AUC = 0.64) in predicting PCR. CONCLUSIONS: CT chest would improve the prediction of SACR, but does not influence overall treatment outcome, TNhCG, or prediction of PCR. Lower radiation doses and cost mean ongoing CXR-based assessment is recommended.

Use of Methotrexate in Gynecologic and Obstetric Practice: What the Radiologist Needs to Know.

Methotrexate (MTX) is the primary pharmaceutical agent that is used for management of disorders arising from trophoblastic tissue. Its widespread international use is mostly attributable to its noninvasive, safe, and effective characteristics as a treatment option for ectopic pregnancy (EP) and gestational trophoblastic disease (GTD), with the large added benefit of fertility preservation. Although the effects of MTX usage are well documented in the gynecologic and obstetric literature, there is a scarcity of radiologic literature on the subject. Depending on the type of EP, the route of MTX administration and dosage may vary. US plays an essential role in the diagnosis and differentiation of various types of EPs, pregnancy-related complications, and complications related to MTX therapy, as well as the assessment of eligibility criteria for MTX usage. A knowledge of expected imaging findings following MTX treatment, including variability in echogenicity and shape of the EP, size fluctuations, changes in vascularity and gestational sac content, and the extent of hemoperitoneum, is essential for appropriate patient management and avoidance of unnecessary invasive procedures. A recognition of sonographic findings associated with pregnancy progression and complications such as tubal or uterine rupture, severe hemorrhage, septic abortion, and development of arteriovenous communications ensures prompt patient surgical management. The authors discuss the use of MTX in the treatment of disorders arising from trophoblastic tissue (namely EP and GTD), its mechanism of action, its route of administration, and various treatment regimens. The authors also provide a focused discussion of the role of US in the detection and diagnosis of EP and GTD, the assessment of the eligibility criteria for MTX use, and the identification of the sonographic findings seen following MTX treatment, with specific emphasis on imaging findings associated with MTX treatment success and failure. Online supplemental material is available for this article. ©RSNA, 2021.

Doppler-based predictive model for methotrexate resistance in low-risk gestational trophoblastic neoplasia with myometrial invasion: prospective study of 147 patients.

OBJECTIVES: This prospective clinical study aimed to evaluate the vascularization characteristics of low-risk gestational trophoblastic neoplasia (GTN) using Doppler imaging and to develop a predictive model for resistance to methotrexate (MTX). METHODS: Patients with low-risk GTN receiving primary MTX treatment were enrolled from the Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China, from September 2012 to August 2018. The primary endpoint was to develop and internally validate a predictive model for resistance to MTX therapy in these patients. In the training set, clinical features and Doppler hemodynamic parameters before MTX therapy were analyzed using logistic regression to identify independent predictors of MTX resistance, which were integrated into the model. The predictive performance of the model was evaluated by leave-one-out cross-validation in the training dataset and internal validation in an independent-sample test dataset. RESULTS: The entire imaging protocol was completed by 147 eligible patients, of which 110 comprised the training set and 37 the test set. In the training set, cases with myometrial invasion (81.8%; 90/110) showed vascular-enriched areas in the myometrium and high velocity and low impedance ratios of the uterine artery (UtA) compared to cases without myometrial invasion (18.2%; 20/110). On multivariate logistic regression analysis, time-averaged mean velocity in UtA (UtA-TAmean) and the International Federation of Gynecology and Obstetrics (FIGO) score were identified as independent predictors (P = 0.009 and P = 0.043, respectively) of MTX resistance. The Doppler-based predictive model, developed based on the 90 cases with myometrial invasion, was y = -2.95332 + 0.41696 × FIGO score + 0.03551 × UtA-TAmean. The model showed an area under the curve of 0.757 (95% CI, 0.653-0.862) and the optimal cut-off value was 0.50622, which had 45.2% sensitivity and 96.6% specificity. The model stratified patients with low-risk GTN into low (< 10%), intermediate (10-90%) and high (> 90%) probability of MTX resistance, based on the threshold values of -1.59544 and 0.10046. The model had an accuracy of 74.4% (95% CI, 64.5-82.3%) in the cross-validation and 72.7% (95% CI, 55.8-84.9%) in the internal validation. CONCLUSIONS: The Doppler-based predictive model, combining a non-invasive marker of tumor vascularity with the FIGO scoring system, can differentiate cases with low from those with high probability of developing MTX resistance and therefore has the potential to guide treatment options in patients with low-risk GTN and myometrial invasion. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

High-intensity focused ultrasound ablation as an adjuvant surgical salvage procedure in gestational trophoblastic neoplasia chemotherapy with chemoresistance or recurrence: two case reports.

BACKGROUND: Chemotherapy is the main treatment strategy for gestational trophoblastic neoplasia (GTN). Surgical resection is crucial to deal with chemoresistance and recurrence following chemotherapy. The aim of this study was to explore if high-intensity focused ultrasound (HIFU) can be used as a complementary technique to surgical procedures in the management of GTN. CASE REPORT: This case report described two females who previously developed chemoresistance or recurrence during chemotherapy and then underwent HIFU as an adjuvant surgical salvage procedure. For high-risk GTN patients with chemoresistance, HIFU treatment decreased the risk of chemoresistance and shortened the course of chemotherapy. It also reduced the dosage of chemotherapeutic agents used for the patient who suffered a recurrence. CONCLUSION: For patients with GTN who desire to preserve their uterus, HIFU may be used as a complementary technique to surgical resection in the management of GTN.

Histopathological examination of the curettage material in nonviable pregnancies and evaluation of the frequency of hydatidiform mole.

AIM: The study aimed to determine the frequency of possible missed diagnosis of gestational trophoblastic disease in nonviable pregnancies and to evaluate the importance of histopathological examination. METHODS: In this retrospective study, the results of the histopathological assessment of patients undergoing uterine surgery with a diagnosis of nonviable pregnancy were analyzed before 14 weeks of gestation. Nonviable pregnancy was defined as anembryonic pregnancy and intrauterine exitus (IU-ex) based on ultrasound findings. The frequency and sonographic characteristics of molar pregnancy in nonviable pregnancy were analyzed. RESULTS: Molar pregnancy was detected in 24 (1.62%) of 1481 patients diagnosed with nonviable pregnancy on ultrasound. One thousand one hundred and twenty-one of the cases were IU-ex (75.69%) and the remaining were anembryonic pregnancy (24.31%). The mean crown-rump length of pregnancies in the IU-ex group was 16.7 mm and the mean gestational age was 8 weeks. The average gestational sac diameter was found to be 26 mm in anembryonic pregnancy patients. The hydatidiform mole ratio was significantly higher in anembryonic pregnancy patients (3.06%) than in IU-ex patients (1.16%) (p = 0.013). CONCLUSIONS: The appearance of early molar pregnancy on ultrasound evaluation may mimic anembryonic pregnancies. Therefore, histopathological examination of anembryonic pregnancies may be useful in early diagnosis and for the treatment of gestational trophoblastic neoplasia.

Following chemotherapy for gestational trophoblastic neoplasia, do residual lung lesions increase the risk of relapse?

BACKGROUND: There remains uncertainty about the prognostic significance of residual lung lesion on imaging after completion of treatment of low- or high-risk gestational trophoblastic neoplasia (GTN). Here, we determine if such residual lung lesions are associated with an increased risk of relapse. METHODS: We retrospectively screened our electronic database to identify patients with low- or high-risk GTN and lung metastases between 2004 and 18. Recurrences among patients with or without residual lung lesions on imaging were compared. Chi square analysis and Kaplan-Meier survival curves were constructed. As the numbers of cases were low, we combined this data with our previously published and non-overlapping patient cohort (1995-2004). RESULTS: Of 1304 GTN patients treated at our centre between 2004 and 18, 99 had lung metastases without other distant sites. There were 40 patients (40.4%) with residual lung lesions. Whilst an increased rate of relapse was observed among patients with residual lung lesions (4/40; 10.0%) compared to without such lesions (3/59; 5.1%), this difference was not statistically significant (p = .35). By combining the data with our previous cohort, there was an increase in relapse rate of patients with residual lung lesions (5/63; 7.9%) compared to those without such lesions (4/112; 3.6%). However, this difference was also not statistically significant (p = .21). CONCLUSION: Residual lung lesions on imaging after completion of GTN treatment are common. However, this finding did not statistically increase relapse rate. Due to low number of recurrent events, a multi-centre, larger dataset would be needed to provide more definitive evidence.

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.

MRI evaluation of the placenta from normal variants to abnormalities of implantation and malignancies.

Even though the placenta has been known for millennia, it is still considered one of the most complex and least understood human organs. Imaging of the placenta is gaining attention due to its impact on fetal and maternal outcomes. MRI plays a vital role in evaluation of inconclusive cases by ultrasonography. It enables precise mapping of placental abnormalities for proper multidisciplinary planning and management. In this article we provide a comprehensive in-depth review of the role of antenatal MR in evaluating "The Placenta." We will describe the protocols and techniques used for MRI of the placenta, review anatomy of the placenta, describe MRI features of major placental abnormalities including those related to position, depth of implantation, hemorrhage, gestational trophoblastic neoplasia, and retained products of conception and discuss the added value of MRI in the management and preoperative planning of such abnormalities. Level of Evidence: 3 Technical Efficacy Stage: 5 J. Magn. Reson. Imaging 2019;50:1702-1717.

Placental site trophoblastic tumor and epithelioid trophoblastic tumor: Clinical and pathological features, prognostic variables and treatment strategy.

Placental site trophoblastic tumor [PSTT] and epithelioid trophoblastic tumor [ETT] are the rarest gestational trophoblastic neoplasias, developing from intermediate trophoblast of the implantation site and chorion leave, respectively. PSTT and ETT share some clinical-pathological features, such as slow growth rates, early stage at presentation, relatively low ßhCG levels and poor response to chemotherapy. The mortality rate ranges from 6.5% to 27% for PSTT and from 10% to 24.2% for ETT. Advanced stage, long interval between antecedent pregnancy and diagnosis, and presence of clear cells are the independent prognostic variables for PSTT, and they may be similar for ETT. Hysterectomy can represent the only therapy for early disease, whereas adjuvant chemotherapy should be reserved to patients with poor risk factors, such as an interval from the antecedent pregnancy >4 years, deep myometrial invasion or serosal involvement. Few cases of fertility-sparing treatment in young women have been reported. An individualized multidisciplinary approach, including chemotherapy and debulking surgery with abdominal and/or extra-abdominal procedures, is warranted for advanced disease. EP/EMA and TP/TE are the preferred regimens in this setting. Immunohistochemistry has sometimes shown expression of EGFR, VEGF, MAPK, PDGF-R and PD-L1, and therefore investigational studies on biological agents targeting these molecules are strongly warranted for chemotherapy resistant-disease.

GestaTIonal TrophoblAstic NeoplasIa Ultrasound assessMent: TITANIUM study.

BACKGROUND: There are limited data on ultrasound morphologic features of gestational trophoblastic neoplasia. A predictive model to determine predictors of response to therapy would be ideal in the management of patients with this rare disease. PRIMARY OBJECTIVES AND STUDY HYPOTHESIS: TITANIUM is a prospective, multicenter, observational study aiming to describe ultrasound features of gestational trophoblastic neoplasia and to investigate the role of ultrasound in identifying patients at high risk of resistance to single-drug therapy. The study hypothesis is that ultrasound could improve the International Federation of Gynecology and Obstetrics (FIGO) scoring system for early identification of patients predisposed to single-drug resistance. TRIAL DESIGN AND MAJOR INCLUSION/EXCLUSION CRITERIA: Patients eligible have a diagnosis of gestational trophoblastic neoplasia according to FIGO or the criteria set by Charing Cross Hospital, London, UK. At diagnosis, patients are classified as low-risk (score 0-6) or high-risk (score >6) according to the FIGO risk scoring system, and a baseline ultrasound scan is performed. Patients receive treatment according to local protocol at each institution. Follow-up ultrasound examinations are performed at 1, 4, 10, 16, and 22 months after start of chemotherapy, and at each scan, serum human chorionic gonadotropin (hCG) level, and chemotherapy treatment, if any, are recorded. PRIMARY ENDPOINTS: Our aims are to define ultrasound features of gestational trophoblastic neoplasia and to develop a predictive model of resistance to single-drug therapy in low-risk patients. SAMPLE SIZE: The sample size was calculated assuming that 70% of patients with gestational trophoblastic neoplasia are at low risk, and estimating the rate of resistance to single-drug therapy in this group to be 40%. Assuming a dropout rate of 10%, we should recruit at least 120 patients. With this sample size, we can attempt to create a mathematical model with three variables (either two ultrasound parameters in addition to the risk score or three ultrasound variables statistically significant at univariate analysis) to predict resistance to single-drug therapy in low-risk patients. ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: The accrual started in February 2019. Additional referral centers for gestational trophoblastic disease, with similar ultrasound expertise, are welcome to participate in the study. Enrollment should be completed by December 2021, and analysis will be conducted in December 2023. TRIAL REGISTRATION: The study received the Ethical Committee approval of the Coordinator Center (Rome) in January 2019 (Protocol No. 0004668/19).

Evaluation and suggestions for improving the FIGO 2000 staging criteria for gestational trophoblastic neoplasia: A ten-year review of 1420 patients.

BACKGROUND: To re-evaluate the efficacy of the prognostic factors currently employed in the treatment of malignant gestational trophoblastic neoplasia. METHODS: Clinical data from the Gestational Trophoblastic Disease (GTD) Center at Peking Union Medical Hospital (PUMCH) collected between January 2002 and December 2013 were retrospectively analyzed. Univariate and multivariate analyses of prognostic factors were performed using the Cox proportional hazards model. A new hazard ratio (HR)-based prognostic scoring scale was established and compared with the original scoring system. RESULTS: In total, 1420 cases were included in the study (median follow-up=40months, overall complete remission (CR) rate=95.8%, relapse rate=7.1%, mortality rate=5.5%, median disease-free survival (DFS)=36months). Low-risk (0-6 points) and high-risk (≥6 points) patients exhibited CR rates of 99.8% (915/917) and 88.5% (445/503) and mortality rates of 0.3% and 15.1% (P<0.001), respectively. Univariate and multivariate analyses showed that age, pretreatment serum levels of human chorionic gonadotropin beta-subunit (ß-hCG) and maximum tumor diameter were not independent prognostic risk factors. Antecedent pregnancy, the interval from the index pregnancy, the number of metastases and a history of failed chemotherapy treatments were independent prognostic risk factors. By modifying the scoring system based on the variables identified in a Cox analysis, we significantly increased the area under the receiver operating characteristics (ROC) curve. CONCLUSION: Though effective, the accuracy of the International Federation of Gynecology and Obstetrics (FIGO) 2000 Trophoblastic Neoplasia Staging System requires improvement. Irrelevant prognostic factors should be removed, and the weights of other factors should be adjusted appropriately.

Outcome of First-Line Hysterectomy for Gestational Trophoblastic Neoplasia in Patients No Longer Wishing to Conceive and Considered With Isolated Lung Metastases: A Series of 30 Patients.

OBJECTIVE: This study aimed to assess the outcome of first-line hysterectomy in patients diagnosed as having gestational trophoblastic neoplasia (GTN) whose postoperative imaging showed lung images considered as metastases. METHODS: From 1999 to 2016, patients no longer wishing to conceive, treated by their initial physician by hysterectomy, and whose postoperative imaging workup showed lung images considered as metastasis were identified in the French Trophoblastic Disease Reference Center database. We sought to identify significant predictive factors of requiring salvage chemotherapy. RESULTS: Thirty patients were identified with a maximum number of 2 visible lung nodules and a median largest size of 14 mm on chest x-ray. Nine of these patients had an International Federation of Gynecology and Obstetrics score of higher than 6, and there were no postterm GTN. Twenty-two patients (73.33%; 95% confidence interval, 54.11-87.72; P = 0.0053) normalized their human chorionic gonadotropin (hCG) without salvage chemotherapy, whereas 7 received 1 line of salvage monochemotherapy (8-day methotrexate) and 1 required 2 lines of monochemotherapy (5-day actinomycin D after failure of methotrexate). After a 12.45-month median follow-up (range, 3-48.4 months) since the first normalized hCG, none of these patients died. The median interval between successful hysterectomy and hCG normalization was 3.15 months (range, 1.6-8.7 months). Patients who required salvage chemotherapy had a median size of the largest lung metastasis on chest computed tomography of 4 mm larger than those cured by hysterectomy (P = 0.0455). CONCLUSIONS: For GTN patients no longer wishing to conceive with lung metastases discovered postoperatively, treated by hysterectomy, and whose hCG is decreasing, it is reasonable to expect and to inform patients that approximately 27% will require salvage chemotherapy. However, in patients with lung metastases discovered preoperatively, evidence to recommend first-line hysterectomy is insufficient and these patients should receive first-line chemotherapy.

Laparoscopic diagnosis and treatment of an isolated epithelioid trophoblastic tumor in recto-uterine pouch.

A 30-year-old Chinese woman with irregular vaginal bleeding was admitted to our department. Serum ß-human chorionic gonadotropin (ß-hCG) was moderately elevated, and ultrasound and magnetic resonance imaging revealed an irregular, retro-uterine lesion without intrauterine pregnancy. Ectopic pregnancy was the primary consideration, with trophoblastic tumor being another possibility. Laparoscopy revealed a 2 × 3 × 3 cm3 irregular, infiltrating, yellow-white lesion in the left recto-uterine pouch, which was completely resected without rectal damage. Final pathological/immunohistochemical analyses revealed an epithelial trophoblastic tumor (ETT) (Ki-67 reactive index~45%). Postoperative recovery was smooth, and the patient received three chemotherapy courses (etoposide, methotrexate and actinomycin, alternating weekly with cyclophosphamide and vincristine) beginning 6 days postsurgery (ß-hCG = 46.4 mIU/mL). ß-hCG returned to an undetectable level after one chemotherapy course. Herein, we describe a rare case of isolated ETT that was difficult to differentiate from other pregnancy-related diseases. Laparoscopy could be an effective, safe diagnostic method in select patients.

[Application of chest CT scan in gestational trophoblastic neoplasia with lung metastasis].

Objective: To explore the role of CT scan for the diagnosis of lung metastasis in stage Ⅲ gestational trophoblastic neoplasia (GTN) . Methods: To figure out the role of CT scan for lung metastasis in GTN initial diagnosis, treatment and follow-up, 93 GTN patients with lung metastasis from January, 2015 to December, 2016 were retrospectively analyzed in Obstetrics and Gynecology Hospital of Fudan University. Results: (1) Among 93 GTN patients with lung metastasis, 70 patients with the International Federation of Gynecology and Obstetrics (FIGO) score ≤6 were defined as low risk GTN and 23 patients score score ≥7 were defined as high risk GTN. Forty nine patients had negative chest X-ray findings and 39 cases with pulmonary lesions were identified both by chest X-ray compared to CT scan. Five cases were excluded due to no consensus could make for the results of chest X-ray. The true positive rate of chest X-ray for lung metastasis were 41% (29/70) in low risk GTN and 43% (10/23) in high risk GTN patients without statistical difference (χ(2)=0.090, P=0.925) . For those patients with positive chest CT scan and negative chest X-ray finding, pulmonary lesions in 32 (65%, 32/49) cases were blocked by heart, chest wall or diaphragm in chest X-ray. Seventeen (35%,17/49) patients with lung lesions less than 5 mm had negative chest X-ray results due to the lower sensitivity compared to CT scan. (2) In 88 patients with stage Ⅲ, 78 patients had successful initial treatment, but 4 of them were recurrence in twelve months follow-up. Ten patients were chemotherapy resistance for the initial treatment. The initial chemotherapy remission rate in low risk GTN patients was higher than that in high risk ones (χ(2)=4.911, P=0.027) . In 49 cases with negative chest X-ray, there was no correlation with the rate of remission,chemotherapy resistance and recurrence in stage Ⅲ patients (P>0.05) . (3) For those patients who had poorly response to initial chemotherapy, the diameters of lesions in lung were unchanged or increased during the treatment, form (5.1±4.1) mm to (7.4±2.8) mm. The pulmonary lesions were continuously shrunk from (7.8±5.3) mm to (4.7±4.4) mm for those patients with complete and partial remission including the recurrent GTN patients (Z=-2.713, P=0.007) . Conclusions: Patients with GTN in stage Ⅲ have down staging if only use chest X-ray for imaging at the initial diagnosis. Chest CT scan is recommended for primary imaging evaluation of FIGO staging in qualified medical organization. For those patients with persistent abnormal serum hCG level and negative chest X-ray, chest CT scan is strongly recommended to identify the persist or resistant lung lesions and follow up.

Role of hysterectomy in chemoresistant gestational trophoblastic neoplasia.

No abstract provided.

Epithelioid Trophoblastic Tumor Around an Abdominal Cesarean Scar: A Pathologic and Molecular Genetic Analysis.

Epithelioid trophoblastic tumor (ETT) is a rare chemoresistant gestational trophoblastic neoplasm that typically presents as an intrauterine lesion. To our knowledge, no isolated abdominal wall ETT around a Cesarean scar has been reported. Here we describe a 54-yr-old woman with a complex obstetric history who presented with a solitary abdominal wall tumor adjacent to the abdominal Cesarean section scar. The tumor demonstrated typical morphologic and immunophenotypic features of ETT. The gestational origin of the tumor was confirmed by microsatellite genotyping. The tumor enlarged despite the patient undergoing multiagent chemotherapy. Whole-exome sequencing was performed to explore the mechanisms underlying chemoresistance. The ATP-binding cassette subfamily B member 1 (ABCB1) 3435CC genotype, and a putative deleterious x-ray cross-complementing group 4 (XRCC4) Ala73Pro mutations were found. In conclusion, ETT may present as a solitary abdominal wall lesion and microsatellite genotyping could facilitate the determination of its gestational origin. More studies are required to provide mechanistic insights into the chemoresistance of ETT.

Gestational Trophoblastic Disease: Clinical and Imaging Features.

Gestational trophoblastic disease (GTD) is a spectrum of both benign and malignant gestational tumors, including hydatidiform mole (complete and partial), invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. The latter four entities are referred to as gestational trophoblastic neoplasia (GTN). These conditions are aggressive with a propensity to widely metastasize. GTN can result in significant morbidity and mortality if left untreated. Early diagnosis of GTD is essential for prompt and successful management while preserving fertility. Initial diagnosis of GTD is based on a multifactorial approach consisting of clinical features, serial quantitative human chorionic gonadotropin (ß-hCG) titers, and imaging findings. Ultrasonography (US) is the modality of choice for initial diagnosis of complete hydatidiform mole and can provide an invaluable means of local surveillance after treatment. The performance of US in diagnosing all molar pregnancies is surprisingly poor, predominantly due to the difficulty in differentiating partial hydatidiform mole from nonmolar abortion and retained products of conception. While GTN after a molar pregnancy is usually diagnosed with serial ß-hCG titers, imaging plays an important role in evaluation of local extent of disease and systemic surveillance. Imaging also plays a crucial role in detection and management of complications, such as uterine and pulmonary arteriovenous fistulas. Familiarity with the pathogenesis, classification, imaging features, and treatment of these tumors can aid in radiologic diagnosis and guide appropriate management. ©RSNA, 2017.