Koji Fushida

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 β‐human chorionic gonadotropin (β‐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 β‐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. Copyright

Multiple pregnancies with complete mole and coexisting normal fetus in North and South America: A retrospective multicenter cohort and literature review

OBJECTIVE To determine the clinical characteristics of multiple gestation with complete mole and coexisting fetus (CHMCF) in North and South America. METHODS Retrospective non-concurrent cohorts compromised of CHMCF from New England Trophoblastic Disease Center (NETDC) (1966-2015) and four Brazilian Trophoblastic Disease Centers (BTDC) (1990-2015). RESULTS From a total of 12,455 cases of gestational trophoblastic disease seen, 72 CHMCF were identified. Clinical characteristics were similar between BTDC (n=46) and NETDC (n=13) from 1990 to 2015, apart from a much higher frequency of potentially life-threatening conditions in Brazil (p=0.046). There were no significant changes in the clinical presentation or outcomes over the past 5 decades in NETDC (13 cases in 1966-1989 vs 13 cases in 1990-2015). Ten pregnancies were electively terminated and 35 cases resulted in viable live births (60% of 60 continued pregnancies). The overall rate of gestational trophoblastic neoplasia (GTN) was 46%; the cases which progressed to GTN presented with higher chorionic gonadotropin levels (p=0.026) and higher frequency of termination of pregnancy due to medical complications (p=0.006) when compared to those with spontaneous remission. CONCLUSIONS The main regional difference in CHMCF presentation is related to a higher rate of potentially life-threatening conditions in South America. Sixty percent of the expectantly managed CHMCF delivered a viable infant, and the overall rate of GTN in this study was 46%. Elective termination of pregnancy did not influence the risk for GTN; however the need for termination due to complications and higher hCG levels were associated with development of GTN in CHMCF.

Isolated Epithelioid Trophoblastic Tumor Mimicking Non-small Cell Lung Cancer

A 31-year-old Bolivian woman, nonsmoker, mother of two children, whose last pregnancy had occurred 8 years before, presented in our hospital with vaginal bleeding and high levels of -human chorionic gonadotropin ( hCG) 320 mIU/ml (normal value 3 mIU/ml). She was submitted to a curettage due to suspected miscarriage. At this moment, the endometrial biopsy showed normal glands, without atypical cells. The gynecology team chose to perform seriated hCG measurements and carry out the clinical follow-up. After 2 months, a new bleeding episode occurred, and the hCG level was 700 mIU/ml; a new curettage was performed, which disclosed proliferative endometrium. At this time, radiological assessment was requested to investigate a second source of hCG production. A transvaginal ultrasound disclosed no abnormalities; however, a thoracic computed tomographic scan showed a mass with 5 cm in the right lower lobe (Figure 1). Percutaneous biopsy of this mass showed squamous cell carcinoma, which was confirmed by immunohistochemical analysis (positive immunoreactivity for p63 and cytokeratin but negative for hCG, human placental lactogen, placental alkaline phosphate, and thyroid transcription factor-1). In the absence of metastasis, after staging for non-small cell lung cancer, the patient was scheduled for complete tumor resection. The tumor was exposed through right posterolateral thoracotomy approach. Intraoperatively, a large mass without extensive involvement of other structures was identified. The right lower lobe was removed, and systematic mediastinal lymphadenectomy was performed. The anatomopathological study demonstrated that the tumor was an epithelioid trophoblastic tumor (ETT), which confirmed by immunohistochemical analysis (Figure 2), without mediastinal lymph node involvement. The patient had an uneventful recovery and was discharged 5 days after the surgery. The gynecology team chose not to perform a hysterectomy, as there was no histological evidence of tumor in any sample analyzed from the curettage procedure. One year after the surgery, the patient has had no further episodes of vaginal bleeding or signs of uterine or lung recurrence. The hCG levels normalized, and she did not require adjuvant chemotherapy.

Is Doppler ultrasound useful for evaluating gestational trophoblastic disease

Doppler ultrasound is a non-invasive method for evaluating vascularization and is widely used in clinical practice. Gestational trophoblastic neoplasia includes a group of highly vascularized malignancies derived from placental cells. This review summarizes data found in the literature regarding the applications of Doppler ultrasound in managing patients with gestational trophoblastic neoplasia. The PubMed/Medline, Web of Science, Cochrane and LILACS databases were searched for articles published in English until 2014 using the following keywords: “Gestational trophoblastic disease AND Ultrasonography, Doppler.” Twenty-eight articles met the inclusion criteria and were separated into the 4 following groups according to the aim of the study. 1 Doppler ultrasound does not seem to be capable of differentiating partial from complete moles, but it might be useful when evaluating pregnancies in which a complete mole coexists with a normal fetus. 2 There is controversy in the role of uterine artery Doppler velocimetry in the prediction of development of gestational trophoblastic neoplasia. 3 Doppler ultrasound is a useful tool in the diagnosis of gestational trophoblastic neoplasia because abnormal myometrial vascularization and lower uterine artery Doppler indices seem to be correlated with invasive disease. 4 Lower uterine artery Doppler indices in the diagnosis of gestational trophoblastic neoplasia are associated with methotrexate resistance and might play a role in prognosis. CONCLUSION: Several studies support the importance of Doppler ultrasound in the management of patients with gestational trophoblastic neoplasia, particularly the role of Doppler velocimetry in the prediction of trophoblastic neoplasia and the chemoresistance of trophoblastic tumors. Doppler findings should be used as ancillary tools, along with human chorionic gonadotropin assessment, in the diagnosis of gestational trophoblastic neoplasia.

Massive Necrosis of a Complete Hydatidiform Mole in a Twin Pregnancy With a Surviving Coexistent Fetus

We describe a case of a twin pregnancy with a complete hydatidiform mole and a coexistent fetus diagnosed at 15 weeks’ gestation that resulted in a surviving fetus and massively necrotic molar tissue at 32 weeks 2 days’ gestation. Sonographic examination of a 27-year-old woman, gravida 2, para 1, showed a 15-week-old live fetus with a normal placenta and a mass with multiple cysts in the right lateral portion of the uterus (Figure 1A). Both ovaries were enlarged and multicystic. The serum β-human chorionic gonadotropin (β-hCG) value was greater than 200,000 mIU/mL. Amniocentesis revealed a normal 46,XY karyotype at 16 weeks, and a diagnosis of a complete hydatidiform mole with a coexistent fetus was made. On subsequent sonographic examinations the molar tissue was seen to have changed in appearance; at 26 weeks, it showed a heterogeneous texture with irregular cystic areas (Figure 1B), and at 32 weeks it was indistinguishable from a normallooking placenta with few anechoic images (Figure 1C). Fetal growth restriction was detected. At 32 weeks, a rise in blood pressure to 150/90 mm Hg and proteinuria of 1.8 g/24 h were observed after a decrease in the platelet count to 57,000 cells/mm3 had occurred 2 days earlier. Other laboratory test results for HELLP syndrome (hemolysis, elevated liver enzyme lev-

Gestational Tubal Choriocarcinoma Presenting as a Pregnancy of Unknown Location following Ovarian Induction

The management of pregnancy of unknown location (PUL) can be a challenging situation, since it can present as several different conditions. Here we describe a rare case of gestational choriocarcinoma arising in the fallopian tube after ovarian induction in an infertile patient. The patient received clomiphene for ovarian induction and had rising levels of human chorionic gonadotropin (hCG) over nine months without sign of pregnancy. After referral to our center, the patient was diagnosed with a paraovarian tumor, which revealed a gestational choriocarcinoma arising in the fallopian tube; the final diagnosis was supported by pathological and cytogenomic analysis. Malignancies, such as gestational trophoblastic disease, should be in the differential diagnosis of PUL; the early recognition of these conditions is key for the proper treatment and favorable outcome.

Triploid twin gestation with single fetal demise associated with partial mole and pre-eclampsia

Both partial mole and twin gestation are conditions associated with the risk of the early onset of pre‐eclampsia. In cases of twin gestation, the death or selective termination of a severely growth‐restricted fetus may lead to the reversal of maternal pre‐eclampsia because of the involution or death of the pathological placenta, as has been reported by some authors. This case demonstrates that in a twin triploid gestation, in spite of the demise of one of the fetuses, the respective partial molar placenta can continue to grow and may contribute to the development or to the worsening of the pre‐eclampsia.

Sonographic appearance of an advanced invasive mole and associated metastatic thrombus in the inferior vena cava

We present a case of an advanced invasive mole with a metastatic thrombus in the inferior vena cava in which sonography clearly showed vesicles in the myometrium, ovaries, and metastatic thrombus leading to a diagnosis of invasive mole rather than choriocarcinoma.

P14.10: Massive necrosis of complete hydatidiform mole in a twin pregnancy with coexisting fetus

Methods: Six monochorionic diamniotic (MD) and eight dichorionic diamniotic (DD) pregnancies were studied for 30 min with transabdominal 4D sonography at 12–13 weeks’ gestation. The frequencies of no reaction (twins appear to touch each other but there is no clear reaction) and reaction (twins appear to touch each other and there is a clear reaction by the co-twin) movements were evaluated. Results: There was no significant difference in the rate of reaction movements between MD (median, 33.6%) and DD (median, 33.9%) twins. The median rate of reaction movements in all 14 twins was 33.9% (range, 27 to 64.1%). Conclusions: Our findings suggest that the incidence of reflex movement of the co-twin on being touched by the other twin late in the first trimester is more frequent than that assessed by conventional 2D ultrasound.

P21.09: Sonographic appearance of epithelioid trophoblastic tumor

medical facilities reducing this interaction. Images are uploaded from GE Voluson Expert equipment into a server as they are performed to be reviewed elsewhere. For two years the author has interpreted NMS gynecological teleradiology studies. The sonographers have been trained to report on pain severity by anatomic location and videotape brief cine runs if organ mobility is in question. Color Doppler images and 3D views of the uterus and of masses are obtained on all patients however the computer setup does not allow the 3D views to be manipulated by the interpreter. Patient requisitions normally have sparse details about the patient’s background. A detailed patient encounter form filled in before the exam has improved sonographic and interpretation quality. Many of these rural New Mexican patients are Spanish speaking and others have low literacy rates; only 60% of the initial forms provided complete information. The encounter form covers menstrual history, symptoms, medications, contraceptive technique, surgical history, sexual history and sexual infections and has segments on abnormal bleeding, infertility and pelvic pain. Of particular value has been information about past surgery, contraception approach, STD history and pain location however questions about menopausal symptoms were misleading since many young patients reported hot flashes and vaginal dryness. Although initially unpopular, the sonographers operating without direct medical supervision now find the forms helpful. A steady improvement in report and image quality has occurred over the course of 1100 gynecological ultrasound studies.