27 set. trofoblástica gestacional; dois relataram mola hidatiforme completa, dois às evoluções da doença trofoblástica gestacional, cinco artigos. (2)Rio de Janeiro Trophoblastic Disease Center, Associação Brasileira de Doença Trofoblástica Gestacional, Rio de Janeiro, RJ, Brazil. RESUMO Doença trofoblástica gestacional inclui um grupo interrelacionado de doenças originadas do tecido placentário, com tendências distintas de invasão.
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Clinical and radiological correlations in patients with gestational trophoblastic disease.
Hydatidiform mole; Gestational trophoblastic disease; Radiology. Gestational trophoblastic disease is an abnormality of pregnancy that encompasses a group of diseases that differ from each other in their propensity for regression, invasion, metastasis, and recurrence.
In the past, it was common for patients with molar pregnancy to present with marked symptoms: Currently, with early diagnosis made by ultrasound, most patients are diagnosed while the disease is still in the asymptomatic phase.
Because it is an unusual and serious disease that affects trofonlastica of reproductive age, as well as because its appropriate treatment results in high cure rates, it is crucial that radiologists be familiar with gestational trophoblastic gstacional, in order to facilitate its early diagnosis and to ensure appropriate follow-up imaging.
No passado, era comum a paciente portadora de gravidez molar apresentar sintomas exuberantes: In most cases of GTN, cure can be achieved 4.
To that end, the radiologist should play an important role in its early diagnosis, decreasing the morbidity and mortality of molar pregnancy, as well as in the staging and follow-up of patients with GTN, guiding the rigorous and systematic treatment. Although chest X-ray is recommended as an initial means of screening for metastases, computed tomography CT and magnetic resonance imaging MRI have generally been incorporated into the evaluation of metastatic disease 2,4especially in more complex clinical cases 2.
In this review, we present clinical and radiological correlations in patients with GTD, describing the diagnostic requirements for the use of the various ancillary methods, together with details regarding their radiological aspects and therapeutic utility in Trofoblaxtica, as well as summarily updating the information about this important complication of pregnancy.
Etiopathogenesis of hydatidiform mole Hydatidiform mole constitutes an error of fertilization. Complete hydatidiform mole originates from the fertilization of an oocyte without maternal chromosomes by a haploid sperm with subsequent duplication of paternal DNA, giving rise to an egg of exclusively parthenogenetic origin, with a diploid 46,XX karyotype.
That aberration does not allow the formation of embryonic tissue or its attachments. Partial hydatidiform mole results from the fertilization of a normal egg by two sperm, resulting in a zygote with a triploid 69,XXY or 69,XXX diandric karyotype In such cases, it is common to identify an embryo, or getacional a fetus, that is malformed and has anomalous attachments. Certain signs and symptoms of hydatidiform mole have become uncommon because the systematic use of ultrasound has resulted gedtacional the early first-trimester detection of pregnancy.
Such signs and symptoms include anemia, hyperemesis gravidarum, hyperthyroidism, respiratory failure, and preeclampsia Therefore, ultrasound is considered the principal method of diagnosing hydatidiform mole 1,6, After being diagnosed, patients with GTD should be evaluated at a referral center for its treatment, where the uterine contents can be evacuated by vacuum aspiration 1,2.
Because it has a lower risk of uterine perforation, vacuum aspiration is preferable to curettage. Histopathological examination should be performed in order to confirm the diagnosis and to identify the histological type of the hydatidiform mole. Patients should not attempt to conceive avoided during this period.
The most common type of GTN is invasive mole, because, in most cases, the diagnosis is made when the cancer is still confined to the uterus Choriocarcinoma is a rarer type that often generates distant metastases. Characteristically, choriocarcinoma is associated with extensive tissue necrosis and hemorrhage After being diagnosed with GTN, patients should first be geestacional for metastases. We followed the guidelines established by the European Society of Medical Oncology, which recommend an initial assessment by Doppler flow study of the pelvis and chest X-ray.
Treatment of GTN The treatment of GTN essentially consists of chemotherapy, for which the histopathological diagnosis is not a prerequisite 1, However, the treatment is preceded by anatomical staging Table 1which allows the results to be compared among various referral centers 20as well as allowing the determination of the FIGO risk score for chemoresistance 7as shown in Table 2, which is fundamental to choosing the treatment strategy, except in cases of PSTT or ETT Transvaginal ultrasound in a patient with bleeding at 14 weeks trofoblastics pregnancy, trofoblaastica an enlarged uterus with an endometrial cavity dena with amorphous material with multiple anechoic areas, suggestive of complete hydatidiform mole.
Note the absence of embryonic tissue and its attachments. Note that, in the Doppler flow study, there was no vascular flow among the vesicles, gestaciobal their avascular nature. Routine transvaginal ultrasound at 12 weeks of pregnancy, showing a fetus with normal morphology and a placental area suggestive of complete hydatidiform mole. MRI scan trofobastica 27 weeks of pregnancy, showing a fetus without morphological anomalies and two distinct placental areas: The extremely premature neonate survived without sequelae.
Transvaginal ultrasound showing an embryo and a deciduous area filled with anechoic images suggestive of partial hydatidiform mole. Because the patient was clinically stable and there was a fetal heartbeat, we opted for watchful waiting, until fetal death was confirmed at 14 weeks of pregnancy, indicating the induction of a molar abortion. Pelvic ultrasound showing a massive theca lutein trofoblsstica in a patient with complete hydatidiform mole.
Transvaginal ultrasound showing an empty endometrial cavity, adjacent to a large quantity of amorphous, anechoic, multivesicular material, suggesting tubal molar pregnancy, which was subsequently confirmed by histopathology. Transvaginal ultrasound, acquired during post-molar pregnancy follow-up, when hCG levels were elevated. Note the presence doenz hypoechoic areas in the myometrium, resembling the hypervascular “Swiss cheese” aspect, suggestive of an invasive mole, on the Doppler flow study.
Posteroanterior chest X-ray, acquired during follow-up, showing numerous, dense, bilateral metastatic nodules, of varying sizes.
The role of surgery in the management of women with gestational trophoblastic disease.
Contrast-enhanced CT of the chest, acquired during follow-up, showing numerous metastatic lung lesions. Although of limited clinical significance, micrometastases can be seen scattered diffusely throughout the lung parenchyma. CT of the abdomen showing three hypointense, hypovascular lesions with peripheral enhancement in a patient with GTN.
The patient evolved to liver rupture, hemoperitoneum, and death. The autopsy revealed metastatic choriocarcinoma of the liver. PET scan, using 18 F-fluorodeoxyglucose, showing intense metabolic tumor activity in the liver, featuring metastatic choriocarcinoma nodules, in a patient under follow-up treatment.
Gadolinium contrast-enhanced MRI scan of the pelvis, showing, hypointense lesions with avid uptake and vascular dilation in the myometrium, sometimes in close contact with the uterine effusion, in patients treated for GTN.
The role of surgery in the management of women with gestational trophoblastic disease.
MRI scan of the brain, showing a mass suggestive of metastatic choriocarcinoma, in a 32 year-old patient presenting with headache, speech articulation disorder, and dysphagia. Most GTN metastases are hematogenous, except for those to the vagina, which occur by contiguous dissemination One of the most common treatment regimens is the combination of etoposide, methotrexate, and actinomycin-D, alternating weekly with cyclophosphamide plus vincristine Surgery and radiotherapy are necessary in some patients with high-risk GTN, especially in those with chemoresistance.
Because PSTT and ETT respond poorly to chemotherapy, they should be treated with chemotherapy and hysterectomy, sometimes including pelvic lymphadenectomy Therefore, careful monitoring of hCG and contraception are essential.
In such cases, ultrasound is mandatory in order to exclude this form of reproductive counterfeiting The ultrasound examination can be transabdominal or transvaginal. Due to its higher spatial resolution and anatomical proximity to the study area, transvaginal ultrasound provides a detailed study of uterine lesions, including the morphology and degree of invasion 2. Ultrasound of hydatidiform mole can reveal an intrauterine mass of variable echogenicity, although most hydatidiform moles are echogenic 1,27,28with multiple, small, diffusely distributed vesicles within an enlarged uterus 1,2, These classic vesicular lesions, the aspect of which has been described as “snow storm”, “bunch of grapes”, or “granular”, range from 1 mm to 30 mm in size and represent the hyperplastic and hydropic villi seen on transvaginal ultrasound during the first trimester Figure 1.
In the second trimester, the anechoic spaces increase in number and size, thus facilitating the diagnosis, including that made by transabdominal ultrasound At some facilities, despite the superiority of transvaginal imaging, pre-chemotherapy molar pregnancy patients often do not undergo transvaginal ultrasound due trocoblastica the chance that a vaginal metastasis, which has a risk of major bleeding 2will be encountered.
Gestaciobal ultrasound imaging, it can be difficult to differentiate between complete and partial hydatidiform moles. The sensitivity of ultrasound is higher for the detection of complete hydatidiform mole and increases after 16 weeks of pregnancy 7.
The diagnosis should always be confirmed by histopathological examination of tissue obtained through uterine evacuation 2. In such cases, partial hydatidiform mole with trisomy is differentiated by identifying a separate, normal, placenta 1,2, Partial hydatidiform mole presents as thickened placental tissue containing various anechoic cystic lesions 31and some cases can present amniotic membranes and a functional umbilical circulation, as depicted in Figure 3 It is usually accompanied by malformation of trooblastica gestational sac or of the fetus, which can have characteristics such as hydrocephalus, syndactyly, cleft lip, and growth restriction Hydropic degeneration of the placenta, which occurs in some cases of abortion, produces images of the placenta similar to those seen in cases of partial hydatidiform mole, thus increasing the difficulty of making the diagnosis with ultrasound 3.
Characteristically, they trofoblastixa bilateral and multilocular Figure 4 ; they typically do not require treatment 1. In rare cases, there is adnexal torsion with acute vascular abdomen or rupture that results in hemoperitoneum, both of which call for immediate treatment Although quite rare, tubal molar pregnancy, as depicted in Figure 5, does occur The treatment is the same as that used in tubal ectopic pregnancy, and the follow-up is similar to that required for intrauterine hydatidiform mole.
Some cases of mole show nonspecific alterations on Doppler flow studies, although ultrasound is more widely used in the evaluation of cases of GTN 2, Ultrasound in GTN Myometrial invasion is best defined by transvaginal ultrasound. Anechoic spaces within the mass are related to hemorrhage, tissue necrosis, cysts, or vascular spaces 2, Patients with more advanced disease can present with an bestacional uterus, with lobulated, heterogeneous contours, or a pelvic mass that extends to adjacent organs The volume gestacjonal the uterine lesion must be determined because it has an established relationship with the size of the tumor and the risk of chemoresistance The changes seen on ultrasound of GTN are nonspecific, and the differential diagnosis should include other pelvic malignancies, as well as myoma and adenomyosis Because GTN subtypes are indistinguishable from each other in imaging studies, the diagnostic hypothesis follows a specific sequence.
The initial assumption is invasive mole. However, if metastasis is detected, the focus shifts to choriocarcinoma. Chemotherapy is started even before histological confirmation has been obtained, and both entities are treated with the same chemotherapy regimen 1. Effective post-treatment ultrasound usually identifies a hypoechoic lesion that progressively decreases in size Unlike invasive mole and choriocarcinoma, PSTT is distinguished by its relative chemoresistance and the potential need for surgical treatment 2, Doppler flow studies in GTN Color gestaciional spectral Doppler flow studies are used together with an ultrasound gray scale in the assessment of GTN and in its post-treatment follow-up The vasculature has a chaotic appearance, with color distortion and vascular changes, due to arteriovenous communications and neovascularization of the myometrial mass The uterine vessels can be evaluated by determining their wave patterns, peak systolic velocity, resistance index RIand pulsatility index PI.
In the evaluation of uterine arteries during the first trimester of a normal pregnancy, Doppler flow studies show high impedance wave patterns with low diastolic velocities, except at the placental implantation site. Because of physiological vascular invasion by tofoblastica tissue, the placental implantation site has a low-impedance flow 2, In the second and third trimesters, there is reduced impedance due to the physiological advance of arterial invasion of the trophoblast.
However, in the first trimester of a molar pregnancy, there is high flow velocity and low-impedance wave patterns due to the greater arterial invasion caused by abnormal proliferation of the trophoblast 27, It should be borne in mind that the color Doppler ultrasound features of GTN are nonspecific.
Other conditions can have a similar appearance, such conditions including the presence of residual trophoblastic tissue from a miscarriage or ectopic pregnancy, pelvic inflammatory disease, other uterine malignancies, diverticulitis or appendicitis with uterine abscesses, and uterine arteriovenous malformations The PI of the uterine artery is an indirect measure of functional vasculature of the tumor, being considered a predictor of resistance to chemotherapy, especially to methotrexate, regardless of the FIGO score It is known that a low PI indicates a higher number of arteriovenous communications and greater neovascularization.
Doppler flow studies can also be used to evaluate the response to chemotherapy. During the post treatment follow-up, ultrasound can also serve to diagnose disease complications such as uterine arteriovenous malformations 2,