Sonographic image of cervix epithelioid trophoblastic tumor coexisting with mucinous adenocarcinoma in a postmenopausal woman: A case report.

RATIONALE: Epithelioid trophoblastic tumor (ETT) is a distinctive but rare gestational trophoblastic neoplasia (GTN) composed of chorionic-type intermediate trophoblast cells. Approximately 50% ETT arose from the uterine cervix or lower uterine segment following a previous pregnancy with vaginal bleeding. With its unusual ability to simulate an invasive epithelioid neoplasm, ETT frequently poses a diagnostic challenge, especially involving the uterine cervix. PATIENT CONCERNS: We herein report the case of a 60-year-old female with persistent vaginal bleeding and middle-level elevation of serum human chorionic gonadotropin (hCG). Ultrasound revealed a 3.0 × 2.7 cm well-circumscribed, strongly echogenic lesion in the cervix, with a peripheral pattern of Doppler signals. The enhanced pattern by contrast-enhanced ultrasound displayed strong peripheral enhancement accompanied with globular appearance, then centripetal filling completely, and fading away rapidly. DIAGNOSES: The final pathological diagnosis was ETT accompanying mucinous adenocarcinoma. INTERVENTIONS: Due to the pre-operative evaluation of a presumed IB2 cervix mucinous adenocarcinoma, the patient was treated with 2 courses of neoadjuvant chemotherapy followed by radical hysterectomy. OUTCOMES: The patient is currently disease-free for the past 1 year. LESSONS: This case report demonstrates that sonographic image of tumor shapes and blood flow could be helpful in differentiating ETT from another GTN and enable more accurate diagnosis before treatment.

Epithelioid trophoblastic tumor of the uterus: A case report with radiologic-pathologic correlation.

Herein, we report a rare case of an epithelioid trophoblastic tumor of the uterus with radiologic-pathologic correlation in a 56-year-old postmenopausal woman. On T2-weighted magnetic resonance (MR) imaging, the tumor appeared as a hypointense irregular mass compared with the surrounding myometrium of the uterine corpus and encircled the cavity of the lower uterine segment. On dynamic contrast-enhanced MR images, the tumor appeared as a hypovascular mass and an inhomogeneously hyperintense mass in the delayed phase. In addition, non-contrast computed tomography images showed some spotty areas of very high density within the tumor. These radiologic findings were well correlated with the histological features, such as abundant hyalinization and calcification within the tumor. Accurate interpretation of MR and computed tomography findings was helpful to differentiate epithelioid trophoblastic tumor from other gestational trophoblastic diseases and uterine carcinomas.

MR Imaging of Uterine Epithelioid Trophoblastic Tumor: A Case Report.

Epithelioid trophoblastic tumor (ETT) is a rare gestational trophoblastic neoplasm of chorionic-type intermediate trophoblasts, and it is most frequently located in the lower uterine segment and endocervix. Due to the epithelial-growth pattern with geographic necrosis exhibited by the neoplastic cells, ETT is commonly confused, both clinically and pathologically, with squamous cell carcinoma. Although there have been no previous reports of ETT focusing on computed tomography (CT) or magnetic resonance imaging (MRI) findings, we report a case of uterine ETT with special attention to the MRI findings referring to the pathological findings and MR images of previous reports. A 42-year-old Japanese woman (gravid 1, para 1) presented with uterus enlargement during screening, and complained of recent-onset lower abdominal pain. The MRI showed a solid tumor throughout the entire myometrium of the lower uterine segment, with the hemorrhagic cystic portion extending to the posterior subserosal space. Following hysterectomy, the final pathological diagnosis was ETT. An ETT is essentially a solid tumor composed of intermediate trophoblasts that exhibit an epithelial-like growth pattern and contain geographic necrosis with calcification. In our case, MRI revealed a non-specific-intensity solid tumor in the lower uterine segment with massive necrosis and hemorrhage extending to the subserosa. While it is difficult to distinguish between ETT and uterine carcinomas, recognition of certain tumor shapes and necrosis could enable more accurate diagnosis before treatment.

Diagnostic challenges in cornual epithelioid trophoblastic tumor.

OBJECTIVE: We present a case of primary cornual epithelioid trophoblastic tumor (ETT) because of its rarity and diagnostic and therapeutic challenge. CASE REPORT: A 28-year-old woman, gravida 1, para 1, who missed menstruation for 3 months, had an elevated ß-human chorionic gonadotropin serum level of 2764 mIU/mL, an absence of intrauterine pregnancy, and the presence of an adnexal mass detected by transvaginal ultrasound. As an ectopic pregnancy was suspected, laparoscopic surgery was performed and showed a right corneal mass. Complete excision of the tumor was done through exploratory laparotomy. Frozen pathology favored the diagnosis of squamous cell carcinoma. Since there was no apparent tumor at other sites, no additional surgery was done. The final pathology showed ETT. Primary ETT is often misdiagnosed as an ectopic pregnancy, leading to delayed treatment, and poses a diagnostic challenge in distinguishing it from squamous cell carcinoma during pathological examination. CONCLUSION: Careful evaluation and avoidance of overtreatment are emphasized.

Misdiagnosed ectopic pregnancy mimicking adnexal malignancy: a report of two cases.

We present two cases of nulliparous women with no history of amenorrhea who were referred to our unit following finding of a hypervascularized solid adnexal mass. In both cases a malignant tumor of tubal origin was suspected at transvaginal sonography. However, following laparoscopy, histological examination revealed that the masses were the result of an undetected tubal ectopic pregnancy that had failed spontaneously, with massive vasodilatation of pelvic blood vessels surrounding the trophoblastic tissue. We recommend consideration of the potential diagnosis of a previously undetected, failed tubal ectopic pregnancy in fertile women presenting with an adnexal mass, even when there is no history of amenorrhea or a positive pregnancy test.

Clinical features of early-stage nonhydropic mole for diagnosis of persistent trophoblastic disease.

OBJECTIVES: To characterize the clinical features of "nonhydropic" hydatidiform mole and to investigate regression of serum human chorionic gonadotropin (hCG) as an aid in detecting persistent trophoblastic disease after nonhydropic hydatidiform mole. METHODS: Our study included women with histologically diagnosed nonhydropic molar pregnancies. Women did not exhibit macroscopic or characteristic ultrasonographic appearances specific to hydatidiform mole. Regression of serum hCG levels was compared with abortions of nonmolar pregnancies, which were histologically confirmed. RESULTS: Among 34 nonhydropic molar pregnancies, 32 complete hydatidiform moles were analyzed, excluding two partial hydatidiform moles. Compared with nonmolar aborted pregnancies, pre-evacuation hCG levels were significantly higher in the 32 complete hydatidiform moles. The 32 molar pregnancies progressed to 24 cases of spontaneous remission and eight cases of persistent trophoblastic disease. Among patients with spontaneous remission, the time at which serum hCG levels became undetectable and the onset of first postabortion menstruation were similar to those in patients who had nonmolar abortions. In all patients who experienced regression, serum hCG was undetectable after the third postabortion menstruation. In all patients with persistent trophoblastic disease, serum hCG levels exceeded 25 milli-international units/mL 4 weeks after evacuation. CONCLUSION: Without histological confirmation, it is difficult to diagnose nonhydropic molar pregnancy based solely on clinical presentation. Follow-up studies of serum hCG levels 4 weeks after abortion and after the third postabortion menstruation may aid in detecting impending persistent trophoblastic disease. LEVEL OF EVIDENCE: II.

Sonographic appearance of gestational trophoblastic disease evolving into epithelioid trophoblastic tumor.

Epithelioid trophoblastic tumor is a distinctive but rare trophoblastic tumor. It derives from intermediate trophoblastic cells of the chorion laeve and is usually associated with a previous gestational event. We report the case of a patient who had undergone dilatation and curettage for a missed miscarriage. Three months later gestational trophoblastic disease was suspected because of persistent vaginal bleeding and high levels of beta-human chorionic gonadotropin (beta-hCG). Transvaginal ultrasound revealed irregular echolucent lacunae within the myometrium, some of them filled with low-resistance, turbulent blood flow on Doppler examination, emphasizing the diagnosis of gestational trophoblastic disease. The patient was treated with 12 courses of multiagent chemotherapy. After a 2-year remission, a low rise in serum beta-hCG was observed. Transvaginal ultrasound revealed a well-circumscribed echogenic lesion with a diameter of 1.8 cm in the uterine fundus, with no detectable blood flow on Doppler imaging. A diagnosis of tumor of intermediate trophoblastic cells was suspected and total hysterectomy was performed. On pathological examination, the histological and immunohistochemical features were characteristic of epithelioid trophoblastic tumor. Most reported cases of epithelioid trophoblastic tumor have solitary nodules with sharp margins, which is consistent with our ultrasound findings. Ultrasound may be helpful in differentiating epithelioid trophoblastic tumor from placental-site trophoblastic tumor, another tumor of intermediate trophoblastic cells, which shows infiltrative growth insinuating between muscle fibers.

[Trophoblastic pregnancy persistant disease with a menopausal woman: ultrasonography-Doppler benefits]. / Maladie trophoblastique persistante chez une patiente ménopausée: apport de l'échographie-Doppler.

We present the case of a 53-year-old menopaused woman who developed an invasive persistent trophoblastic uterine disease with several lung metastasis. Patient case was listed in a highly risked group in the WHO classification. As the patient refused primary hysterectomy she received polychemotherapy alone. Monitoring of the treatment and vascularity evolution of the tumor was followed through pelvic endovaginal ultrasound using 3D and contrast enhancement as well as HCG decrease in the context of uterus conservation that was wished by the patient.

Myometrial trophoblastic implant as a complication of surgically induced first-trimester termination of pregnancy.

Persistent trophoblastic tissue has been described in the abdominal cavity after surgical treatment of tubal ectopic pregnancy. More infrequently the cause of the ectopic trophoblast is linked to uterine perforation due to surgically induced termination of pregnancy (TOP). Ultrasonographic images may suggest an ectopic pregnancy. A case of myometrial trophoblastic tissue implantation following surgically induced first-trimester TOP is described.

Color Doppler imaging in the sonohysterographic diagnosis of residual trophoblastic tissue.

PURPOSE: The purpose of this study was to evaluate the role of color Doppler imaging during sonohysterography in the diagnosis of residual trophoblastic tissue. METHODS: This prospective cohort study involved 25 consecutive women with clinical and sonographic signs of an echogenic intrauterine mass who were referred to the sonography unit of our institution for evaluation. All women underwent saline infusion sonohysterography with color Doppler sonographic evaluation. An operative hysteroscopy with histologic examination was performed in 17 cases. RESULTS: Thirteen women (group A) had sonohysterographic features suggestive of residual trophoblastic tissue (ie, an echogenic intrauterine lesion not detached from the uterine wall after introduction of saline). The initial diagnosis was confirmed by histologic analysis in all cases. Blood flow was detected within the intrauterine mass in 6 (46%) of these 13 women; the resistance indices were low in all 6 cases (mean +/- standard error, 0.38 +/- 0.01). Twelve women (group B) had sonohysterographic findings negative for retained tissue, and no blood flow was detected within any of the intrauterine masses in this group (p < 0.05). CONCLUSIONS: Our results confirm the potential role of color Doppler sonography in the initial diagnosis of residual trophoblastic tissue. The detection of color Doppler signals, especially with low-resistance flow, within an intrauterine lesion should increase the confidence of the sonologist in the diagnosis of residual trophoblastic tissue.

Radiographic imaging in gynecologic oncology.

Current radiographic techniques are useful for evaluating and managing patients with gynecologic malignancies. Lymphoscintigraphy may prove useful in limiting surgery in women with vulvar cancer who have negative sentinel groin nodes. Selected patients benefit from pretherapy MRI scanning to help determine treatment of cervical or endometrial malignancies. Sonographic techniques are helpful in discriminating benign from malignant adnexal or pelvic masses, and preoperative CT scans are helpful in determining the extent of advanced ovarian cancer. The FDG PET scans appear to help localize occult disease in patients with a variety of gynecologic malignancies. Further refinements of currently available techniques or newer techniques, however, are needed to increase the sensitivity for detection of subclinical or microscopic metastases in patients with gynecologic malignancies.

Color Doppler energy and related quantitative analysis of gestational trophoblastic tumors.

OBJECTIVE: To assess the reliability of color Doppler energy (CDE) and a related quantitative analysis for detection and follow-up of uterine involvement in gestational trophoblastic tumor. METHOD: CDE was performed in 19 patients with trophoblastic tumor, in 25 women in early pregnancy and 25 non-pregnant women. The blood flow area ratio (BFAR) in CDE was used as an index representing uterine involvement. In nine of the 19 patients, BFAR was measured before, during and at termination of chemotherapy. RESULT: The BFAR (mean +/- S.D.) of uterine profiles in 19 patients (39.9 +/- 1.3%) was significantly higher than that in 25 pregnant women (24.6 +/- 10.1%, P = 0.002) and in 25 non-pregnant women (14.8 +/- 5.7%, P = 0.001). In the follow-up of nine patients, when beta-hCG was less than 3.1 ng/ml during the treatment, the BFAR (38.7 +/- 11.9%) decreased below that (44.2 +/- 14.6%) seen prior to treatment (P = 0.009) and was much lower at termination of treatment (27.5 +/- 12.3%, P = 0.048). CONCLUSION: These data support the use of CDE and the related quantitative analysis as a new method for detecting and follow-up of uterine involvement in patients with trophoblastic tumors.

[Clinical usefulness of color doppler flow examination during treatment of gestational trophoblastic disease]. / Ocena przydatnosci klinicznej badan przeplywów naczyniowych z uzyciem kolorowego Dopplera u chorych leczonych z powodu ciazowej choroby trofoblastycznej.

Neovascularisation is the integral part of tumor development. Presence and type of pathological vascularisation can be used in therapy monitoring and follow up. The value of beta HCG and pulsatility index (PI) and resistance index (RI) in 14 women treated for nonmetastatic persistent trophoblastic disease (NMTD) were been compared. There was statistical, significant correlation between dropped BHCG level and increased value of RI. No correlation between BHCG blood concentration and values of PI was observed. In summary it should be stated that color Doppler ultrasonography is useful method in monitoring patients with NMTD.

[Radioimmunodetection of human trophoblastic cancer xenograft in nude mice].

OBJECTIVE: To study the efficiency of radioimmunodetection to locate xenograft of human trophoblastic cancer in nude mouse. METHODS: Radioimmunodetection was performed with a cocktail of 131I-labeled mouse anti-hCG monoclonal antibodies to image xenogaft of human trophoblastic cancer in nude mice. Normal mouse IgG used to treat mice bearing trophoblastic cancer xenograft was used as control. Radioactivity in different tissues was measured and the tumor/non-tumor(T/NT) ratio was calculated. RESULTS: The accumulation of radioactivity in the xenograft could be recognized as early as 24 hours after the injection of the radiolabeled anti-hCG antibodies. Radioactivity accumulation became increasingly evident with time. At 72-96 hours after injection of the radiolabled antibodies, the xenograft could be clearly shown. The minimal size of the xenograft with demonstrable radioactively was 0.8 cm in diameter. The T/NT ratio increased with time and was obviously higher than that in mice treated with normal mouse IgG. CONCLUSION: Radioimmunodetection can efficiently locate human trophoblastic cancer xenograft in nude mice.

Single-agent therapy for nonmetastatic and low-risk gestational trophoblastic disease.

OBJECTIVE: To assess the effectiveness of single-agent chemotherapy in the treatment of nonmetastatic and low-risk metastatic gestational trophoblastic tumors. STUDY DESIGN: The medical literature was reviewed concerning single-agent chemotherapy in the treatment of nonmetastatic and low-risk metastatic gestational trophoblastic tumors. RESULTS: Methotrexate and actinomycin-D have achieved excellent and comparable remission rates with acceptable levels of toxicity. CONCLUSION: The optimal single-agent chemotherapy for nonmetastatic and low-risk metastatic gestational trophoblastic tumors has not yet been identified and can be best determined through a prospective, randomized trial.

Reduced systemic toxicity from superselective chemoembolization compared with systemic chemotherapy in patients with high-risk metastatic gestational trophoblastic disease.

PURPOSE: The efficacy of chemoembolization of primary and metastatic gestational trophoblastic neoplasms was studied. METHODS: Six female patients, 19-33 years old, with high-risk trophoblastic disease were subjected to one to five chemoembolizations in 3-week intervals. Three of the patients had metastases to the liver, 2 had local tumor extension to the pelvic wall, and all 5 had failed initial systemic chemotherapy. The sixth patient was treated for a trophoblastic remnant following surgical expression of a tubal pregnancy. For follow-up, beta hCG levels in urine and serum and dynamic or angio-computed tomograms were obtained in biweekly to 6-month intervals. RESULTS: Two of 3 patients with liver metastases are alive and free of disease 6 and 7 years after initial chemoembolization. The third is alive at 3 years but with evidence of recurrent disease. Two patients treated for locally invasive trophoblastic disease died 3 months and 4 years, respectively, after initial chemoembolization. One had a 2 1/2 -year remission. The patient treated for a trophoblastic remnant in the tube is alive and free of disease at 6-year follow-up. Hematologic toxicity occurred in only one. CONCLUSION: Selective chemoembolization in our small series of patients with high-risk trophoblastic disease was equally effective as results reported for multi-drug systemic chemotherapy but had markedly lower renal, liver, and hematologic toxicity.