Author Information
* Madhu kumari, ** Chavan NN, *** Changede P, **** Gupta S.
(* Speciality medical officer, ** Additional Professor, *** Assistant professor, **** Registrar, Department of Obstetrics & Gynaecology, LTMM College & General Hospital, Mumbai, India.)
Abstract
Gestational trophoblastic neoplasms (GTN) are rare tumors that contribute to less than 1% of all gynecological malignancies. Invasive mole is a type of GTN. This is a case of an invasive mole of the uterus, which developed following a molar pregnancy evacuation. It was diagnosed by persistent raised level of β-HCG, transvaginal ultrasonography and color Doppler study. The tumor was treated successfully with chemotherapy.
Introduction
Gestational trophoblastic disease (GTD) is group of disorders related to pregnancy arising from abnormal placental trophoblast cells. It is of two types: pre-malignant conditions and malignant gestational trophoblastic neoplasia. Pre-malignant conditions include partial and complete hydatidiform moles. Gestational trophoblastic neoplasia includes: invasive mole, choriocarcinoma (CC) and placental site trophoblastic tumor (PSTT).[1] Invasive moles are localized GTN.[2] Diagnosis is done by persistent raised β-HCG and imaging. The imaging of choice is ultrasonography and color Doppler study. MRI helps in diagnosis of the spread of tumor. With early diagnosis the cure rate is high with chemotherapy.[3]
Case Report
A 26 years old patient married since two years, gravida 1 abortion 1, came to our tertiary care hospital outpatient department with complaints of three month of amenorrhea, pain in abdomen and bleeding per vagina since five days. The patient was apparently alright six months back when she missed her period for which urine pregnancy test was done and was tested positive. Ultrasonography of pelvis was suggestive of hydatidiform mole. She underwent suction evacuation in Rajasthan for the same. β-HCG level was not done.
Two month later a repeat check curettage was done in a private hospital in view of persistent bleeding with β-HCG level 5,000miu/ml and ultrasonography of pelvis suggestive of persistent hydatidiform mole.
The patient followed up with serial serum β-HCG level and ultrasonography. β-HCG showed gradual rise in level up to 14,000 miu/ml. Ultrasonography was suggestive of development of left adnexal mass with multiple cysts with increased vascularity. Ultrasonography showed gradual increase in size of adnexal mass up to 5 x 3 x 2 cm inseparable from uterus and left ovary.
The patient came to our tertiary care hospital OPD with above said reports. On her examination vital parameters were normal, per abdomen - soft, per speculum - minimal bleeding present, cervix and vagina healthy, per vaginum – uterus of normal size, anteverted, cystic swelling of 4 × 4 cm in left adnexa was felt and 2 × 3 cm small cystic mass was felt in right adnexa. Both the masses were non-tender and mobile. A gestational trophoblastic neoplasm was suspected. Tumor marker, ultrasonography with colour Doppler and MRI pelvis were done. All were suggestive of invasive mole with left adnexal involvement without distant metastasis. WHO prognostic score was suggestive of low risk. An opinion of a medical oncologist was taken, based on which she was started on chemotherapy with two cycles of injection methotrexate 1 mg/kg on alternate day with injection leucoverin 0.1 mg/Kg. The treatment was started with monitoring of total blood cell count, liver function tests and renal function tests. Serial monitoring of serum β-HCG level was done. Post second cycle β-HCG fell to undetectable level after 2 month. Regular follow up with monitoring of β-HCG level was done which showed no further increase.
Figures 1. Invasive gestational trophoblastic neoplasm, all showing involvement of uterus and left adnexa (red arrow).
Discussion
An invasive mole occurs commonly after the evacuation of GTD. Edematous chorionic villi with trophoblastic proliferation are its characteristic. It can invade into the myometrium of the uterus or to adjacent structures.[4] Invasive mole usually presents with vaginal bleeding, an enlarged uterus and high urinary or serum β-HCG level. It mostly occurs following the evacuation of a molar pregnancy. Choriocarcinoma can occur after a hydatidiform mole or even after a normal pregnancy. Choriocarcinoma usually occurs after interval of more than six months. β-HCG levels are much higher than in invasive mole.[5] Persistent raised level of β-HCG, should suggest GTN after evacuation of a complete mole.
The cancer committee of the international federation of gynecologists and obstetricians (FIGO) has established the regression guidelines for the diagnosis of post molar gestational trophoblastic neoplasia.[6]
Ultrasonography (USG) is one of the important tools in diagnosis of suspected GTN.[7] On USG an invasive hydatidiform mole, a placental site trophoblastic tumor, and choriocarcinoma typically exhibit a heterogeneous, hyperechoic, solid mass with cystic vascular spaces, located within the myometrium.[7,8] Color doppler imaging helps in the assessment of neovascularisation in these tumors. A combination of both biochemical findings and USG appearances helps to differentiate between these.[9] Invasive mole can rarely metastases to the lungs. Metastases are more common with choriocarcinoma.[10] The absence of metastases helps to rule out choriocarcinoma.
Management of an invasive mole includes treatment with chemotherapy as well as continuous monitoring of β-HCG. Methotrexate is helpful in treatment of most non-metastatic and low risk cases.[11,12] Follow up of Patients with GTN should be with weekly quantitative β-HCG levels until the values are normal for three consecutive weeks, then should be monitored monthly for 12 months.
Conclusion
Gestational trophoblastic disease (GTD) is a group of disorders related to pregnancy arising from abnormal placental trophoblast cells. Early diagnosis in cases of persistent raised level of β-HCG helps in successful treatment with chemotherapy.
References
Madhu kumari, Chavan NN, Changede P, Gupta S. Invasive Gestational Trophoblastic Neoplasm: A Rare Interesting Case Managed Successfully With Chemotherapy. JPGO 2015. Volume 2 Number 10. Available from: http://www.jpgo.org/2015/10/invasive-gestational-trophoblastic.html
* Madhu kumari, ** Chavan NN, *** Changede P, **** Gupta S.
(* Speciality medical officer, ** Additional Professor, *** Assistant professor, **** Registrar, Department of Obstetrics & Gynaecology, LTMM College & General Hospital, Mumbai, India.)
Abstract
Gestational trophoblastic neoplasms (GTN) are rare tumors that contribute to less than 1% of all gynecological malignancies. Invasive mole is a type of GTN. This is a case of an invasive mole of the uterus, which developed following a molar pregnancy evacuation. It was diagnosed by persistent raised level of β-HCG, transvaginal ultrasonography and color Doppler study. The tumor was treated successfully with chemotherapy.
Introduction
Gestational trophoblastic disease (GTD) is group of disorders related to pregnancy arising from abnormal placental trophoblast cells. It is of two types: pre-malignant conditions and malignant gestational trophoblastic neoplasia. Pre-malignant conditions include partial and complete hydatidiform moles. Gestational trophoblastic neoplasia includes: invasive mole, choriocarcinoma (CC) and placental site trophoblastic tumor (PSTT).[1] Invasive moles are localized GTN.[2] Diagnosis is done by persistent raised β-HCG and imaging. The imaging of choice is ultrasonography and color Doppler study. MRI helps in diagnosis of the spread of tumor. With early diagnosis the cure rate is high with chemotherapy.[3]
Case Report
A 26 years old patient married since two years, gravida 1 abortion 1, came to our tertiary care hospital outpatient department with complaints of three month of amenorrhea, pain in abdomen and bleeding per vagina since five days. The patient was apparently alright six months back when she missed her period for which urine pregnancy test was done and was tested positive. Ultrasonography of pelvis was suggestive of hydatidiform mole. She underwent suction evacuation in Rajasthan for the same. β-HCG level was not done.
Two month later a repeat check curettage was done in a private hospital in view of persistent bleeding with β-HCG level 5,000miu/ml and ultrasonography of pelvis suggestive of persistent hydatidiform mole.
The patient followed up with serial serum β-HCG level and ultrasonography. β-HCG showed gradual rise in level up to 14,000 miu/ml. Ultrasonography was suggestive of development of left adnexal mass with multiple cysts with increased vascularity. Ultrasonography showed gradual increase in size of adnexal mass up to 5 x 3 x 2 cm inseparable from uterus and left ovary.
The patient came to our tertiary care hospital OPD with above said reports. On her examination vital parameters were normal, per abdomen - soft, per speculum - minimal bleeding present, cervix and vagina healthy, per vaginum – uterus of normal size, anteverted, cystic swelling of 4 × 4 cm in left adnexa was felt and 2 × 3 cm small cystic mass was felt in right adnexa. Both the masses were non-tender and mobile. A gestational trophoblastic neoplasm was suspected. Tumor marker, ultrasonography with colour Doppler and MRI pelvis were done. All were suggestive of invasive mole with left adnexal involvement without distant metastasis. WHO prognostic score was suggestive of low risk. An opinion of a medical oncologist was taken, based on which she was started on chemotherapy with two cycles of injection methotrexate 1 mg/kg on alternate day with injection leucoverin 0.1 mg/Kg. The treatment was started with monitoring of total blood cell count, liver function tests and renal function tests. Serial monitoring of serum β-HCG level was done. Post second cycle β-HCG fell to undetectable level after 2 month. Regular follow up with monitoring of β-HCG level was done which showed no further increase.
Figures 1. Invasive gestational trophoblastic neoplasm, all showing involvement of uterus and left adnexa (red arrow).
Discussion
An invasive mole occurs commonly after the evacuation of GTD. Edematous chorionic villi with trophoblastic proliferation are its characteristic. It can invade into the myometrium of the uterus or to adjacent structures.[4] Invasive mole usually presents with vaginal bleeding, an enlarged uterus and high urinary or serum β-HCG level. It mostly occurs following the evacuation of a molar pregnancy. Choriocarcinoma can occur after a hydatidiform mole or even after a normal pregnancy. Choriocarcinoma usually occurs after interval of more than six months. β-HCG levels are much higher than in invasive mole.[5] Persistent raised level of β-HCG, should suggest GTN after evacuation of a complete mole.
The cancer committee of the international federation of gynecologists and obstetricians (FIGO) has established the regression guidelines for the diagnosis of post molar gestational trophoblastic neoplasia.[6]
Ultrasonography (USG) is one of the important tools in diagnosis of suspected GTN.[7] On USG an invasive hydatidiform mole, a placental site trophoblastic tumor, and choriocarcinoma typically exhibit a heterogeneous, hyperechoic, solid mass with cystic vascular spaces, located within the myometrium.[7,8] Color doppler imaging helps in the assessment of neovascularisation in these tumors. A combination of both biochemical findings and USG appearances helps to differentiate between these.[9] Invasive mole can rarely metastases to the lungs. Metastases are more common with choriocarcinoma.[10] The absence of metastases helps to rule out choriocarcinoma.
Management of an invasive mole includes treatment with chemotherapy as well as continuous monitoring of β-HCG. Methotrexate is helpful in treatment of most non-metastatic and low risk cases.[11,12] Follow up of Patients with GTN should be with weekly quantitative β-HCG levels until the values are normal for three consecutive weeks, then should be monitored monthly for 12 months.
Conclusion
Gestational trophoblastic disease (GTD) is a group of disorders related to pregnancy arising from abnormal placental trophoblast cells. Early diagnosis in cases of persistent raised level of β-HCG helps in successful treatment with chemotherapy.
References
- Ngan HY, Bender H, Benedet JL, Jones H, MontruccoliGC, Pecorelli S; FIGO Committee on Gynecologic Oncology. Gestational trophoblastic neoplasia, FIGO 2000 staging and classification. Int J Gynaecol Obstet 200383 Suppl1: 175-177.
- Hammond CB. Gestational trophoblastic neoplasms. In: Scott JR, DiSaia PJ, Spellacy WN (eds). Danforth’s Ob178 Kavitha Nair et al Invasive mole of the uterus – a rare case diagnosed by ultrasound: a case report obsstetrics and Gynecology, 8th ed. Philadelphia: LippincottWilliams& Wilkins 1999: 927-937.
- Tie W, Tajnert K, Plavsic SK. Ultrasound imaging of gestational trophoblastic disease. DSJUOG 2013; 7: 105-112.
- Soper JT, Mutch DG, Schink JC; American College of Obstetricians and Gynaecologists. Diagnosis and treatment of gestational trophoblastic disease: ACOG Practice Bulletin No.53. GynecolOncol 2004; 93: 575-585.
- Maeda K, Kurjak A, Varga G, Honemeyer U. Trophoblastic diseases. DSJUOG 2012; 6: 27-42.
- Goldstein DP, Berkowitz RS. Current management of gestational trophoblastic neoplasia. HematolOncolClin North Am 2012; 26: 111-131.
- Jauniaux E. Ultrasound diagnosis and follow up of gestational trophoblastic disease. Ultrasound ObstetGynecol1998; 11: 367-377.
- Zhou Q, Lei XY, Xie Q, Cardoza JD. Sonographic and Doppler imaging in the diagnosis and treatment of gestational trophoblastic disease: a 12-year experience. J Ultrasound Med 2005; 24: 15-24.
- Timmerman D, Wauters J, Van Calenbergh S, et al. Color Doppler imaging is a valuable tool for the diagnosis and management of uterine vascular malformations. Ultrasound ObstetGynecol 2003; 21: 570-577.
- Smith HO, Kohorn E, Cole LA. Choriocarcinoma and gestational trophoblastic disease. Obstetrics andGynaecology Clin North Am 2005; 32: 661-684.
- May T, Goldstein DP, Berkowitz RS. Current chemo therapeutic management of patients with gestational trophoblastic neoplasia. Chemother Res Pract 2011; 2011: 806256.
- Homeslay HD. Single agent therapy for non-metastatic andlow risk gestational trophoblastic disease. J.Reprod.Med 1998:43; 69-74
Madhu kumari, Chavan NN, Changede P, Gupta S. Invasive Gestational Trophoblastic Neoplasm: A Rare Interesting Case Managed Successfully With Chemotherapy. JPGO 2015. Volume 2 Number 10. Available from: http://www.jpgo.org/2015/10/invasive-gestational-trophoblastic.html