Gestational trophoblastic disease

1. US and MRI of GTD
By
DR. Naglaa Mahmoud
KCCC

2. GTD
Represents a spectrum of disease that, although usually benign and
easily treatable, occasionally progresses to an aggressive, potentially
fatal process.
Characterized by abnormal proliferation of pregnancy-associated
trophoblastic tissue with malignant potential.
Incidence is highest in Asian women: 1 in 200 pregnancies, lower in
United States: 1 in 2000 pregnancies.
 Recurrence rate is 2%.
 Associated with dietary deficiencies such as folic acid.

6.  It includes:
1- Hydatidiform mole (benign):
a.Complete.
b.Partial.
and,
2- Gestational trophoblastic tumors (malignant):
a. Invasive mole.
b. Choriocarcinoma.

7. Diagnosis of molar pregnancy

8. 1) Clinical Presentation:
− Usually occur in first 20 - 24 weeks of gestation.
– Vaginal bleeding.
– Passing tissue: grape-like clusters.
– Nausea/vomiting.
– Cervical os may be dilated.
−Uterus larger than expected by gestational age estimated by LMP.
− Lack of fetal heart sounds.
− Hyperthyroidism may develop as a result of high HCG levels.
− Pregnancy-induced hypertension before 24 weeks.

9. 2) β-HCG level
• Useful serologic marker for diagnosis, assessment of response to
treatment, and surveillance for recurrence.
• detected in maternal plasma and urine within 9 days of conception.
• reaching a peak at 9-12 weeks, then
• declining to a stable plateau for the remainder of the pregnancy.

10. 3) Imaging:
• US is the initial examination of choice for diagnosis. However,
myometrial invasion and extension into the parametrium are
difficult to detect with US alone.
• Doppler US may be useful in the evaluation of GTD (vascular).
• Relative to US and CT, MRI demonstrates the tumor, myometrial
invasion, and extension into the parametrium clearly with
excellent soft tissue contrast.
• Assessment of local extension and distant metastasis (including
to the lung, brain, and liver) is required for optimal therapy.

11. (A) HYDATIDIFORM MOLE
• Complete →→→
– Most common type, 90% of all molar pregnancies.
− No fetus only trophoblastic tissue.
– Results from fertilization of blighted ovum by a haploid sperm which
duplicates.
– Genetic makeup is 46 XX – 10 % 46 XY.
− 15−20% will become malignant.
• Partial →→→
− 1 of every 1000-2000 pregnancies.
−Focal trophoblastic proliferation in the placenta.
–Results from one set of maternal chromosomes and two sets of
paternal chromosomes.
• Two sperm fertilize one ovum
• Genetic makeup is 69 XXY or 69 XYY.
− Abnormal fetus or even associated with fetal demise.
– 3% will become malignant.

12.  US appearance: a large echogenic mass with multiple cystic spaces
is noted within the endometrial cavity “bunch of grapes”.
 The vesicles range from 1 to 30 mm in diameter and ↑ in size with ↑
gestational age.

15.  In partial moles, the placenta is enlarged and contains areas of multiple,
anechoic lesions (hydropic degeneration).
 The fetus is usually non viable or abnormal with multiple congenital
anomalies.

18. (B) GESTATIONAL TROPHOBLASTIC TUMORS:
 Characterized by persistent trophoblastic proliferation.
1) Invasive mole:
Distinguished by excessive trophoblastic overgrowth and extensive
penetration by trophoblastic elements including whole villi deep into the
myometrium.
Sometimes there is penetration of the peritoneum, adjacent parametria or
the vaginal vault.
locally invasive but rarely metastasize.
50% arise following hydatiform mole, 25% following abortion, and 25%
following an apparently normal or ectopic pregnancy.

22. 2) Choriocarcinoma
Carcinoma of the chorionic epithelium secondary to invasive growth
of trophoblast and erosion of blood vessels.
50 % arise from complete hydatiform mole.
25% arise after normal pregnancies.
25% follow spontaneous abortion or ectopic pregnancy.
Metastasis often develops early and is generally blood borne.
The majority go to the lungs and vagina.
The vulva, kidneys, liver, ovaries, brain, and bowel also may contain
metastasis in many cases.
Less common in bone and LNs.

23.  US findings are indistinguishable from those of a complete mole except in
cases in which obvious extension into the parametria can be visualized.

24.  Although aggressive malignancy, choriocarcinoma has a spectacular
response to CT that may reach up to 100% cure and 85% in metastatic cases.
 Many of the cured patients have subsequently had normal pregnancies and
deliveries.

25. COMPLICATIONS OF GTD

26. 1. Metastasis (especially pulmonary) which tend to show evidence for
hemorrhage and may be quite large at the time of diagnosis.

27. 2. Acute pulmonary embolism.
3. Theca-lutein cysts:
20%-50% of hydatiform moles.
Result from overstimulation of lutein element by large amounts of HCG
secreted by proliferating trophoblast.
Multilocular cysts.
It may take 2-4 months for the cysts to regress after molar evacuation.
Torsion or hemorrhage within these cysts may occur and cause
symptoms.

29. FIGO staging:
Stage 1
Persistently elevate β-HCG levels and tumor confined to the
uterine corpus.
Stage 2
Involvement of vagina or pelvis or both.
Stage 3
Pulmonary metastases with or without genital tract involvement.
Stage 4
Advanced disease and involvement of the brain, liver, kidney or
gastrointestinal tract.

31. conclusion

32.  US is the examination of choice for initial diagnosis of
GTD.
 CT and MRI play an important role in both detection and
follow up of myometrial invasion and extension into the
parametrium which can be difficult to detect with US
alone.
 CT is the imaging procedure of choice for detection of
extra pelvic metastases.
 Plain chest radiography is still used to detect and follow
up pulmonary metastasis, although CT is superior.