This document reviews the use of imaging techniques in the diagnosis and management of gestational trophoblastic neoplasia (GTN). Ultrasound is useful for initial diagnosis of GTN as it can identify molar pregnancies and assess for invasive or recurrent disease. Magnetic resonance imaging helps evaluate extra-uterine spread, tumor vascularity, and staging. Positron emission tomography and computed tomography are helpful for recurrent or metastatic disease. Imaging plays an important role in diagnosing and managing the spectrum of conditions that make up GTN.

1. Clinical Radiology (2006) 61, 301–313
REVIEW
Radiology of gestational trophoblastic neoplasia
S.D. Allena, A.K. Lima, M.J. Secklb, D.M. Blunta, A.W. Mitchella,*
Departments of aRadiology, and bMedical Oncology, Charing Cross Hospital, Hammersmith Hospitals NHS
Trust, London, UK
Received 5 September 2005; received in revised form 26 October 2005; accepted 5 December 2005
Gestational trophoblastic neoplasia (GTN) encompasses a broad spectrum of placental lesions from the pre-malignant
hydatidiform mole (complete and partial) through to the malignant invasive mole, choriocarcinoma and rare placental
site trophoblastic tumour (PSTT). Ultrasound remains the radiological investigation of choice for initial diagnosis, and it
can also predict invasive and recurrent disease. Magnetic resonance imaging is of invaluable use in assessing extra-
uterine tumour spread, tumour vascularity, and overall staging. Positron emission tomography and computed
tomography undoubtedly have a role in recurrent and metastatic disease, while angiography has a place in disease and
complication management. This review will describe the relevant pathophysiology and natural history of GTN, and the
use of imaging techniques in the diagnosis and management of these conditions.
Q 2006 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction 0.5–1/1000 and PHM are 3/1000 pregnancies in
Europe, though in Southeast Asia they are highest,2
Gestational trophoblastic neoplasia (GTN) com- up to 8/1000 in Thailand.3 The reason for this
prises a spectrum of placental lesions that arise variation is not understood, though genetic, as well
from pregnancy and vary considerably in their as socio-economic/dietary and environmental
clinicopathological behaviour. Hydatidiform factors, have been implicated.3,4
moles, which often behave benignly, are best Increased risk of CHM and PHM occurs at the
regarded as pre-malignant because 16% of complete extremes of reproductive life, with women over 40
(CHM) and 0.5% of partial moles (PHM) can trans- years having at least a fivefold increase in risk.5
form into the malignant forms of GTN, which Also, a previous molar pregnancy is a predisposing
include invasive mole, choriocarcinoma and pla- factor.6 Choriocarcinoma and PSTT can arise after
cental site trophoblastic tumour (PSTT).1 The latter any type of pregnancy including CHM, PHM,
disorders are also termed collectively as gestational miscarriage and term delivery.7,8 The incidence of
trophoblastic tumours (GTT). choriocarcinoma arising after miscarriage or term
It is important to recognize GTN, as it is almost delivery is estimated to be 1/50,000 pregnancies.
always curable with preservation of fertility. The PSTT is so rare that accurate data on its incidence
many roles of imaging in this disease, from diagnosis or prevalence are not available.
to treatment, are discussed. Clinical assessment is difficult particularly early
in the course of the disease, as few clinical
characteristics are present to distinguish it from a
Background normal pregnancy. GTN is suspected in patients
with vaginal bleeding and a clinically enlarged
The frequency of GTN varies tremendously with uterus, though these features are non-specific.
geography. Rates of CHM are approximately The presence and course of the disease is monitored
with quantitative levels of serum beta human
chorionic gonadotrophin (hCG), which provides a
* Guarantor and correspondent: A.W. Mitchell, Department of
valuable evaluation of the amount of trophoblastic
Radiology, Charing Cross Hospital, Hammersmith Hospitals NHS
Trust, Fulham Palace Road, London W6 8RF, UK. Tel.: C44 20
disease present.9 The radiological diagnosis of CHM
8846 1863; fax: C44 20 8846 1885. and PHM is also often made at an early pregnancy
E-mail address: amitchell@hhnt.org (A.W. Mitchell). ultrasound scan.
0009-9260/$ - see front matter Q 2006 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.crad.2005.12.003

2. 302 S.D. Allen et al.
The majority of CHM have a 46XX diploid slow growing, tends to spread locally through the
chromosomal pattern and occur most commonly uterus and can involve lymph nodes (a very rare
when a single haploid sperm fertilizes an ovum finding for choriocarcinoma) before metastasizing
lacking maternal genes, and then undergoes dupli- elsewhere. PSTT also tend to be relatively poorly
cation. Macroscopically CHM classically resembles a vascularized tumours.17,19 Due to the lack of
bunch of grapes, due to generalized swelling of syncytiotrophoblastic tissue, serum hCG levels
chorionic villi, and pathologically, is composed of are often only modestly elevated, although we
syncytiotrophoblastic and cytotrophoblastic have never had a case at our institute where the
cells.10 These are usually intrauterine in site, hCG was not elevated. PSTT are also relatively
though may contain some foetal tissue if coexistent chemoinsensitive, so when the disease is localized
with a normal foetus and placenta in a dizygotic to the uterus hysterectomy is recommended.
twin pregnancy. This can be a cause of pathological However, women with metastatic disease can
misdiagnosis, as they may be classified as PHMs.11 still be cured with aggressive chemotherapy. The
PHMs are genetically triploid, most commonly main factor in determining outcome is the
the result of fertilization of a normal egg by two duration from the causative pregnancy: those
sperm.12 Villous swelling is less intense, and an treated within 4 years are nearly always cured
embryo is usually present, which may live into the whilst those diagnosed beyond this time have so
early second trimester. However, the villous far had a 100% death rate.
swelling and trophoblast may be so subtle, that Several systems have been used to classify the
many PHM are missed during evacuation for a severity of GTN, including the Bagshawe scoring
“miscarriage”, or during spontaneous abortions.10 system,20 WHO score,21 and Charing Cross Hospi-
Flow cytometry can be useful to distinguish these tal prognostic scoring system.22 These all use
from hydropic abortions and other non-molar factors that have long been recognized as
chromosomal duplication syndromes.13 predictive of poor outcome. More recently a
A CHM or PHM that invades the myometrium is new International Federation of Gynaecologists
termed an invasive mole and can be diagnosed on and Obstetricians (FIGO) scoring system has been
ultrasound and on a rising hCG after uterine developed and most centres use this to enable
evacuation. Choriocarcinoma encompasses many better comparison of patient response and
abnormal karyotypes and can arise following any outcome (Fig. 1).23
pregnancy, including PHMs. It is highly malignant, The scoring systems have enabled simple strati-
necrotic and haemorrhagic, microscopically resem- fication of patients into two therapeutic groups.
bling an implanting blastocyst containing cytotro- Those with a low FIGO score (%6) have a low risk of
phoblastic elements and absent chorionic villi. It is developing disease resistant to single drug therapy
locally angio-invasive.10 Choriocarcinoma arising (methotrexate or actinomycin D) whilst those with
after a miscarriage or term delivery may not a high score (O6) require multi-agent combination
present for many years, can be normal on pelvic chemotherapy (Table 1 and Fig. 1). The FIGO
ultrasonography and simply display as distant staging carries little prognostic significance and is
metastatic disease with an elevated hCG. It is noted but not used to determine therapy. It should
typically highly vascular and patients may present be noted that PSTT are not classified under this
with signs of haemorrhage at any involved sites.14 scoring system and those patients with metastatic
Rarely patients may present with concurrent PSTT require very aggressive multi-agent
metastatic disease, most commonly in the lung chemotherapy.
and vagina, but this can occur anywhere, including Approximately 84% of patients with CHM and
the liver and brain. 99.5% of patients with PHM will be cured after
PSTT is the rarest form of GTN, but deserves suction evacuation of the uterus.7,24 Other surgi-
separate consideration, as it behaves in a distinct cal techniques such as hysteroscopy and hyster-
fashion.15 This represents a neoplastic prolifer- ectomy are not favoured as they significantly
ation of intermediate trophoblasts that invade the increase the likelihood of the need for chemother-
myometrium at the placental site after preg- apy, thought to be due to the uterine manipu-
nancy.16 They may develop from an antecedent lation. Second evacuation is only rarely successful
normal pregnancy, abortion or after either a CHM at reducing the risk for chemotherapy and is
or PHM,8 though the foremost is the commonest generally not recommended. 10 Patients with
scenario.17 Clinical presentation is often with malignant disease following CHM or PHM are
irregular vaginal bleeding but may be a conse- usually at low risk of developing disease that is
quence of metastatic disease.18 Unlike other resistant to treatment with a single drug (metho-
forms of malignant GTN, PSTT is often more trexate or actinomycin D) and overall have an

3. Radiology of gestational trophoblastic neoplasia 303
Figure 1 Algorithm for the management of gestational trophoblastic neoplasia.
almost 100% cure rate.25 However, patients with Imaging features
high scoring disease that receive multidrug
combination chemotherapy with etoposide, meth- Ultrasound
otrexate, adriamycin, alternating weekly with
cyclophosphamide and vincristine (Oncovin) Ultrasound is the radiological investigation of choice
(EMA–CO) have an 80–90% cure rate.25–27 for initial diagnosis of GTN. As well as identification
Table 1 The revised FIGO 2000 scoring system.
FIGO score 0 1 2 4
Age (years) !40 R40 – –
Antecedent pregnancy Mole Abortion Term –
Interval months from index pregnancy !4 4–6 6–12 O12
Pre-treatment hCG (mIU/ml) !1000 1000–10,000 10,000–100,000 O100,000
Largest tumour size including uterus (cm) !3 3–5 O5 –
Site of metastases Lung Spleen, kidney Gastro-intestinal Liver, brain
Number of metastases – 1–4 5–8 O8
Previous failed chemotherapy – – Single drug Two or more drugs
FIGO staging for gestational trophoblastic neoplasia 2000. FIGO Oncology Committee. Int J Gynaecol Obstet 2002;77:285–7. Low risk
patients scoring 6 or less receive single drug therapy with either methotrexate or actinomycin D and those scoringO7 are treated
with multi-agent EMA/CO chemotherapy.

4. 304 S.D. Allen et al.
after evacuation of the molar tissue. However,
this distinction does not affect the management as
both need to be evacuated. Classically with PHM,
the placenta is enlarged and thickened and contains
multiple diffuse anechoic lesions consistent with
cystic degeneration.32 The mole itself tends to be
less advanced than a complete mole of a compar-
able gestational age, hence “partial”. It can be
associated with amniotic membranes, a functioning
circulation and even an embryo (usually non
viable).33 It may also occur as a tubal pregnancy,
appearing similarly as a heterogeneous adnexal
mass containing numerous hypoechoic structures
consistent with cysts.34 Naumoff et al.,35 estab-
lished ultrasound criteria for the diagnosis of PHM,
Figure 2 An axial image from a transabdominal stating that first the placenta should be enlarged
ultrasound image showing an enlarged uterus with a with numerous cysts, second there should be a
markedly heterogeneous echo texture. A large complex gestational sac present, and third any foetal
mass is present centrally, with the endometrium not material present is growth retarded. However,
identified separately. These are features of a molar these criteria are not specific. Sebire et al.,36,37
pregnancy with probable endometrial encroachment. reviewed 155 histologically proven CHM or PHM
whom had had a preceding sonographic diagnosis. In
of a mole, ultrasound should also be obtained to only 34% was the diagnosis made of a molar
exclude an intrauterine pregnancy before initiating pregnancy, with the remainder misdiagnosed as
chemotherapy. The most frequent transabdominal miscarriages. Accuracy was higher in CHM (58%)
sonographic appearance of a CHM in the first compared with PHM (17%). Although ultrasound is
trimester is that of an enlarged uterus containing a very useful to raise the suspicion of CHM/PHM the
predominantly echogenic endometrial mass final diagnosis rests with the pathology.36,37
(Fig. 2).28 Unfortunately this appearance is non- Although uterine disease is sometimes absent in
specific and an incomplete miscarriage may appear patients presenting with choriocarcinoma, like
identical. The presence of a gestational sac invasive moles they may appear as heterogeneous,
surrounding the echogenic oval-shaped mass, has echogenic masses characterized by necrosis and
been reported.29 In these cases, only a significant haemorrhage. They are markedly hypervascular on
clinical concern and correlation with a high hCG Doppler interrogation, though in some cases endo-
level will facilitate correct diagnosis. Transvaginal metrial, myometrial and parametrial invasion can
sonography (TVS) will demonstrate more findings, be difficult to demonstrate (Fig. 3). In such cases,
however, at our centre patients coming for assess-
ment pre-chemotherapy do not normally undergo
TVS as this might trigger bleeding from a possible
vaginal metastasis. This technique will show the
interface between abnormal trophoblastic tissue
and normal myometrium with higher resolution, and
hence may allow the diagnosis of myometrial
invasion. This is particularly relevant, as this
invasive disease may remain after surgical evacua-
tion.30 It also may show the characteristic patho-
logical molar vesicles. These typically punctuate the
lesion and appear as multiple small anechoic spaces,
ranging from 1–30 mm in diameter.31 Within the
second trimester a CHM will further expand the
uterus, and the anechoic spaces will become more Figure 3 A longitudinal image from a transabdominal
numerous and visible, even transabdominally. ultrasound image with power Doppler interrogation.
There can be diagnostic difficulty in distinguish- Marked myometrial power Doppler signal surrounds an
ing a PHM from a CHM and practically, the echogenic endometrial mass of molar tissue in an
distinction is usually made histopathologically enlarged uterus.

5. Radiology of gestational trophoblastic neoplasia 305
magnetic resonance imaging (MRI) can play an
important role, although it is rarely clinically
necessary.30 Choriocarcinoma is distinguished his-
tologically from an invasive mole by absent
placental villous structures, but this distinction is
seldom possible sonographically.
PSTT may also appear as a heterogeneous,
hyperechoic mass with multiple cystic spaces within
the myometrium of an enlarged uterus.38 These
features alone do not allow distinction from other
forms of GTN, though on Doppler both hypervas-
cular and hypovascular forms of the disease have
been described with or without cystic masses, but
none of these features are diagnostic of PSTT.39,40
After treatment some patients may retain
vascular abnormalities associated sometimes with
residual heterogeneous scaring but this is of no
significance providing the serum and or urine hCG
levels remain normal and there is no associated
blood loss. These appearances may normalize with
time. Recurrent disease always manifests itself
with a rising hCG and this should prompt repeat
whole-body imaging including a Doppler ultrasound
of the pelvis.41
As well as assessing the molar tissue present,
an accurate measurement of uterine volume
should be obtained. The uterine volume is known
to correlate with tumour burden and is used
amongst other factors to determine the risk
Figure 4 (a) A normal pulsed wave Doppler interrog-
stratification of the disease.20 At Charing Cross ation of the right uterine artery in a patient with treated
we have preferred three-dimensional assessment GTN. This shows normal high impedance flow waveforms
by volume as this is more accurate, but inter- with a uterine artery pulsatility index (UAPI) of 2.88
nationally, most centres rely on a single measure- (minimum normal UAPIO1.5).46 (b) An abnormal pulsed
ment to determine the FIGO score (Fig. 1). wave Doppler interrogation of the right uterine artery in a
Endometrial encroachment can also be assessed, patient with active GTN. This shows low impedance
but this has not yet been shown to correlate with waveforms with a UAPI of 0.56. Note is also made of
the degree of endometrial bleeding. marked myometrial colour flow Doppler signal.
The use of colour flow and spectral Doppler has
increased the sensitivity of ultrasound in the molar pregnancy, similarly arterial trophoblastic
primary diagnosis of GTN as well as having a invasion occurs, but at an abnormal rate. As a
role in monitoring disease response to treat- result, high velocity, low impedance waveforms
ment.42 The uterine vessels can be sampled, and on Doppler interrogation occur prominently in the
waveform patterns, peak velocities, resistive first and early second trimesters, far earlier than
index (RI) and pulsatility index (PI) determined. in a normal pregnancy (Fig. 4).45 The uterine
Both RI and PI are indices that quantify resistance artery PI as an indirect in vivo measure of
to flow, with high resistive flow producing an functional tumour vascularity, has been shown to
increased RI and PI, and vice versa.43 During a independently predict response to chemotherapy
normal pregnancy, in the first trimester, Doppler (more specifically methotrexate resistance), in
interrogation of the intrauterine arterial system GTN.42,46 Thus patients with a low PI indicating
shows high impedance waveforms with low increased arteriovenous shunting, probably associ-
diastolic velocities. At the implantation site, low ated with neovascularization found in GTN, are
impedance flow may be present due to physio- significantly more likely to become resistant to
logical vascular invasion of trophoblastic tissue. single drug therapy with methotrexate. If a
Vascular impedance may reduce further in the prospective study confirms these retrospective
second and third trimesters, as physiological results, it is likely that PI assessments will need
trophoblastic arterial invasion continues.44 In a to be included in the GTN scoring system.46

6. 306 S.D. Allen et al.
Computed tomography (CT) trimester. A focal rim of hypointense myometrium
may surround this.
The role of CT in GTN is principally in the detection In the second trimester CHM and PHM are
of metastatic disease, and is discussed in a later typically of similar or higher signal intensity than
section. Although ultrasound is a more suitable the adjacent myometrium on T1-weighted imaging.
technique for evaluation of the primary disease, an Focal signal hyperintensity may reflect areas of
enlarged uterus with focal irregular low attenuation haemorrhage within the lesion. Numerous cystic
lesions are typical appearances.47 When visualized spaces may also be present within the mass and may
extrauterine pelvic disease appears as bilateral be characteristic.51 On T2-weighted imaging,
ovarian enlargement with multilocular theca lutein tumours typically have a heterogeneous high signal
cysts. Enhancing parametrial soft tissue is charac- intensity, with an indistinct boundary between the
teristic of local spread. endometrium and myometrium. 52 Diffusely
increased myometrial signal with obliteration of
the normal zonal architecture on T2-weighted
MRI imaging may reflect diffuse myometrial involve-
ment by tumour, but this is not specific.50 This also
MRI does not have a role in routine assessment of has been shown to occur with missed and incom-
persistent disease following a CHM or PHM, and is plete miscarriage, and in patients who have had a
only indicated in our practice in difficult cases such recent diagnostic currettage.48,53 After treatment
as in relapsed patients, suspected PSTT, or very this appearance returns to normal, paralleling
advanced disease. The MRI findings in GTN can be decreasing hCG levels as disease load decreases.
relatively non-specific, and it may be difficult to The converse has also been shown to apply, with
distinguish GTN from an incomplete miscarriage or patients with a rising hCG having a continued
an ectopic pregnancy.48 architectural disruption and a large tumour load.50
In CHM and PHM in the first trimester, little or no There appears to be correlation of uterine findings
abnormality may be present, though primary molar at levels of hCG O1500 mIU/ml, but at levels !
tissue may be visualized as heterogeneously high 500 mIU/ml there is usually no MRI
signal intensity tumour on T2-weighted imaging abnormality.48,50
(Fig. 5).48–50 Molar tissue may be seen to slightly Using contrast-enhanced dynamic MRI, areas of
distend the endometrium and enlarge the uterus, focal enhancement are visualized that relate to the
amount of active trophoblastic tissue and also
with a “cluster of grapes appearance”.49 This
correlate to hCG levels.54 Marked enhancement in
feature reflects the vesicular nature of the tumour,
the early dynamic phase indicates active disease in
but is not usually present until the second
the form of viable trophoblastic cells with sur-
rounding inflammatory response, and in patients
with markedly elevated hCG levels, there is strong
enhancement. Non-dynamic post-contrast-
enhanced T1-weighted imaging is not of similar
value, as tumour–myometrial contrast is much
decreased (normal myometrium is also enhancing).
Features to indicate high tumour vascularity, are
tortuous flow voids consistent with vessels, passing
through the tumour and within the adjacent
myometrium, parametrium and adnexae on both
T1 and T2-weighted imaging.55,56 Internal iliac and
arcuate vessel engorgement, especially with
respect to the external iliac vessels are also a
feature.52
As patients respond to chemotherapy, the
uterine volume and the tumour vascularity
decrease. As normal uterine zonal anatomy
reappears on T2-weighted imaging, signal hetero-
Figure 5 A sagittal T2-weighted MRI image in a patient geneity usually decreases, though intra-lesional
with known GTN. This shows a heterogeneous high signal haemorrhage may develop. At an interval of 6–9
uterine mass, with endometrial encroachment, but months after treatment, the majority of patients
appears confined to the uterine corpus. have normal uterine appearances on both T1 and

7. Radiology of gestational trophoblastic neoplasia 307
isointense mass on T1-weighted imaging and
slightly hyperintense on T2, relative to normal
myometrium.59 Numerous signal voids are visual-
ized on all sequences, and marked dilatation of
gonadal vessels may be present. After the admin-
istration of intravenous gadolinium, avid tumour
enhancement is shown.60 The hypovascular tumour
type is described as being typically smaller in size,
hyperintense to normal myometrium on both T1 and
T2-weighted sequences, with some enhancement
after gadolinium administration. There is an
absence of signal voids or prominent vascular-
ity.60,61 MRI allows more accurate tumour localiz-
ation, clarifies vascularity, and shows extension
through the myometrium (if present), thus allowing
Figure 6 An axial T2-weighted MRI image showing a more appropriate surgical planning. However, the
heterogeneous high signal mass, arising from the uterus. appearances described are not specific, and do not
There is clear extrauterine extension and probable pelvic allow definitive distinction from other forms of
side wall involvement (arrow). This lesion was histologi- GTN.39
cally a choriocarcinoma. MRI is also employed to assess pelvic lymph node
status, however, this is only relevant in PSTT as the
T2-weighted imaging, though incidental adnexal other forms do not tend to metastasize to lymph
cysts of 2–4 cm in size were shown to be a common nodes.
finding.52,57 Residual tortuous and coiled vessels
within a thickened myometrium are a hallmark of a
uterine vascular malformation, a well-recognized
Metastatic disease
sequelae of treated GTN.58
Invasive moles have parametrial involvement
Metastatic disease has been reported in up to 19% of
that can be readily visualized and appear as an
all GTN, but the vast majority of these cases occur
enlarged high signal mass on T2-weighted imaging,
in choriocarcinoma.62 Principally the route of
within the parametrium and beyond the confines of
spread is haematogenous,63 and most commonly
the uterus (Fig. 6). This is identified better on MRI
metastases occur in the lungs; in up to 87% in one
than ultrasound. Vaginal involvement appears as a series.64 With the exception of vaginal disease, it is
bulbous wall of the fornix with indistinct margins in fact rare to have other metastatic disease in the
and an abnormally high signal intensity.52 Contrast- absence of lung metastases.65
enhanced dynamic MRI, has potential for early Pulmonary metastases occur due to embolization
demonstration of invasive disease in post molar of trophoblastic tissue that has escaped from the
GTN. Invasive GTN typically manifests as focal uterus into the venous outflow. Usually the amount
hyperintense areas within the myometrium, on T2- of tissue that has entered the bloodstream is too
weighted imaging.51 The tumour may be hypervas- small to block the pulmonary vasculature, and
cular, and it may distort uterine zonal structures. invades the pulmonary parenchyma, establishing
The boundaries between the tumour and the parenchymal metastases. Typical lesions are
myometrium are typically indistinct. Haemorrhage rounded, and are of soft tissue density, measuring
and necrosis are more common with this type of usually up to 3 cm in diameter, and may rarely
disease, which can be difficult to distinguish from cavitate.64,66,67 They usually number less than 10,
viable tumour, though this is easier with contrast- but can be solitary or even miliary.68 However, if a
enhanced dynamic MRI.51,54 The MRI features of significant amount of tissue enters the blood-
haemorrhage are of course quite variable depend- stream, it can block the pulmonary vasculature
ing on the age, but are often manifest by high signal and will produce symptoms and signs of acute
intensity on T1-weighted imaging. pulmonary embolism.69 On CT this may appear as a
Few studies have described the MRI features of large intravascular tumour, though pulmonary
PSTT. As with ultrasound, two different MRI infarction may also result.68 On MRI high signal
appearances undoubtedly correspond to the hyper- intravascular tumour may occlude the pulmonary
vascular and relatively hypovascular tumour artery on the T1-weighted sequence, with wedge-
types.39 The hypervascular type is described as an shaped infarctions and parenchymal metastases

8. 308 S.D. Allen et al.
also visualized.70 Both pulmonary emboli and Recommended staging of the brain is with MRI,
parenchymal disease are highly vascular, so an where signal characteristics are widely variable
alveolar airspace shadowing may be the predomi- depending on the age of associated haemor-
nant pattern, if there is extensive parenchymal rhage.23,81 Enhancement with gadolinium is usual.
haemorrhage.66,71 Other reported findings include At Charing Cross all patients with lung metastases
pleural effusions, presumed to occur when meta- undergo MRI brain imaging as these patients are at
static nodules bleed into the pleural space.72 Also significant risk of CNS involvement.
endobronchial tumours have been reported, pre- Metastatic vaginal disease is common though it
senting with features of bronchial obstruction.73 usually occurs through continuous spread from the
The recommended radiographic staging for primary uterine lesion. MRI is preferred for
patients with malignant GTN includes an initial radiological evaluation, though if vaginal disease
chest radiograph, but in high risk patients, a CT is the isolated region of metastasis, selective
examination is advisable, as up to 41% of patients embolization may be effective management.65
have lung metastases that are not detectable on the A variety of other sites of metastatic disease
plain film.74,75 However, the clinical importance of have been reported, including the kidneys, gastro-
solitary pulmonary micrometastatic disease has not intestinal tract and skin.82–84 Another rare site of
yet been fully evaluated.74–76 In fact FIGO still metastatic disease is to the neonate, which has
recommend a chest radiograph rather than a chest been reported when choriocarcinoma is concurrent
CT to assess the number of metastatic lesions, as with a normal pregnancy.85
although CT detects more metastases than a plain
film, that has not been shown to affect
management.23,75
PET and PET/CT
Liver metastases occur later in the course of the
disease and are markers of a prognostically poor
There are limited data on the efficacy of PET and
outcome. Liver ultrasound can be carried out at the
PET/CT in the evaluation of recurrent and meta-
same time as the pelvic assessment, but in high risk
static GTN, with studies to date limited to case
patients or patients with known vaginal or lung
reports and small case series. 2-[F-18]fluoro-2-
metastases, abdominal CT is recommended.23
deoxy-D-glucose (FDG)-PET has been shown to be
Lesions are typically multiple, heterogeneous,
effective in the identification of malignant tissue in
usually hypointense masses, that avidly enhance
many different primary and metastatic tumour
after intravenous contrast medium administration.
types.86 A study by Grisaw et al. in which 53
Contrast medium enhancement is typical in the
patients underwent PET/CT for staging of primary
arterial phase, and haemorrhagic transformation is
or recurrent pelvic malignancy, showed the tech-
frequent. These lesions are not readily distinguish-
nique to be both sensitive and specific for assessing
able from other hypervascular hepatic tumours on
extent of disease, however, only one patient in the
CT alone, although a couple of angiographic specific
series had GTN.87 In patients with GTN it has been
abnormalities have been reported. A hypervascular
shown to identify occult disease when ultrasound,
mass with aneurysmal dilatation of the peripheral
CT and MRI are equivocal, at sites including the lung
end of the hepatic arteries in the arterial phase,
parenchyma, pulmonary artery, liver and broad
and persistent vascular lakes in the venous phase
ligament.88–90 In our own experience at Charing
are characteristic.77 These lesions may be amen-
Cross, nine patients have undergone FDG-PET as
able to selective chemoembolization and should
part of their restaging for relapsed malignant GTN.
never be biopsied because of the risk of fatal
This investigation has been helpful in assessing
haemorrhage.78 On MRI, the appearances are
uterine scar versus recurrence, and in locating the
essentially identical to other hypervascular liver
site of active disease in six of the patients, one of
metastases.
which had no other abnormality on all other imaging
Central nervous system disease is present in up to
techniques (CT, MRI and ultrasound).
15% of patients with metastatic GTN, but has been
reported as even more prevalent on autopsy
studies.79,80 Clinical presentation includes head-
aches, seizures and motor and sensory deficits. The Complications
majority of lesions are multiple, occur at the grey–
white matter junction, and are most commonly GTN is often highly vascular and is the commonest
located in the parietal lobe. Surrounding oedema cause of uterine vascular malformations.91 Despite
and secondary haemorrhage are occur frequently, complete tumour response to chemotherapy, these
with many lesions hyperintense on unenhanced CT. vascular malformations persist in up to 15% of

9. Radiology of gestational trophoblastic neoplasia 309
patients.92 A complication of these malformations predominantly supplied by the uterine arteries,
is haemorrhage in up to 2%, which is usually vaginal, and are amenable to endovascular management.95
but may be intraperitoneal and can be life- Uterine artery embolization is a safe alternative
threatening, requiring massive blood transfusion.93 treatment, performed via a common femoral artery
Traditionally, surgical management has been the approach, with aortograms to outline the main
mainstay of treatment in these cases, with uterine blood supply to the vascular malformation from the
artery ligation or even hysterectomy required.94 uterine arteries (Fig. 7).91 After selective uterine
However, the majority of these lesions are artery catheterization, the embolic agent is
employed, which is ideally polyvinyl alcohol par-
ticles. When stasis is visualized within the system,
embolization is considered complete and the
procedure terminated following a final “check”
aortogram, to assess for any residual disease. A
reduction in 80% or more in size of the malfor-
mation has a proven therapeutic benefit.91 As with
other indications for uterine artery embolization,
side effects include pain, which is usually respon-
sive to opiates and non-steroidal analgesics.96
Otherwise side effects are rare and relate to the
previously employed embolic agents, such as
cyanoacrylate.97,98 Uterine infarction does not
occur, due to the extensive pelvic vessel collater-
alization. Subsequent conception in these patients
after embolization is now being increasingly
reported.99,100 Another indication for selective
embolization is isolated vaginal metastases.101
Theca lutein cysts develop due to hyperstimula-
tion of the ovaries, by high levels of hCG in up to
37% of patients with GTN.102 Usually patients
complain of only mild discomfort, though they
occasionally rupture and presentation may be with
an acute abdomen. Transvaginal sonography or MRI
will readily demonstrate these cysts.
Hyperthyroidism is a rare association, due to
cross-reaction of hCG with thyroid stimulating
hormone as a consequence of their shared alpha
subunit. Thyroid function tests will show sup-
pressed thyroid stimulating hormone (TSH) and
both an I123 scan and a Tc99 scan will show diffusely
increased uptake within the thyroid gland.
Post-treatment surveillance
and follow-up
After surgery the vast majority of patients with non-
Figure 7 (a) A digital subtraction angiogram showing a invasive molar disease are cured. However, per-
uterine vascular malformation in a patient with previous sistent disease will develop in a minority, virtually
GTN. This procedure was performed via a right common
all of which will be cured with further treatment,
femoral artery approach, with subsequent selective
catheterization of the uterine arteries bilaterally, using
but these need to be identified. Since 1973, all
a 5 F glide catheter. (b) A digital subtraction angiogram in patients with GTN are registered at one of three
the same patient after embolization, demonstrating national follow-up services.11 After treatment,
complete obliteration of the vascular malformation. patients will have an hCG level taken initially at
Embolization was carried out with polyvinyl alcohol gel 48 h post-evacuation.11,103 When registered, 2
foam slurry, with a particle size of 355–500 mm. weekly blood and urine samples are sent to one of

10. 310 S.D. Allen et al.
the reference laboratories until the levels have other CNS pathology. Patients with heavy bleeding
normalized. Follow-up continues for a further 6 can be cured by angiographic embolization of the
months, and assuming the levels have remained main feeding blood vessels to the tumour.
normal, patients are allowed to proceed with a The radiologist plays an essential role in the
further pregnancy.11,104 If patients have had diagnosis and management of GTN. Knowledge of
chemotherapy, conception is not advised for 12 the spectrum and course of the disease, and
months after completion because the greatest risk capabilities of the different techniques will allow
of relapse is within this period and a pregnancy appropriate technique selection and interpretation
would mask early detection. Furthermore, it is of the imaging findings.
possible that the preceding chemotherapy may
have damaged ova and the 12 month period allows
time for such eggs to either undergo repair or die
off. Despite this advice, 230 women have become Acknowledgements
pregnant within the first year of follow-up, and
fortunately, there does not appear to be any The authors thank the Department of Health for
increased risk of relapse for the mother or their continued support and NTRAC.
teratogenecity in the resulting offspring.105
The vast majority of patients with previous molar
pregnancies, even if they undergo multiagent
chemotherapy, can still anticipate normal repro- References
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