Sonographic characteristics of post‐molar gestational trophoblastic neoplasia at diagnosis and during follow‐up, and relationship with methotrexate resistance

Abstract

Objectives To describe the sonographic characteristics of post‐molar gestational trophoblastic neoplasia (GTN) at diagnosis and during follow‐up, and to assess their association with methotrexate (MTX) resistance (R) as first‐line chemotherapy. Methods This was a retrospective study of all women treated for post‐molar GTN at Karolinska University Hospital, Stockholm, Sweden, between October 2010 and December 2017, who had undergone expert transvaginal ultrasound assessment ≤ 2 weeks prior to, or ≤ 1 week after, the start of first‐line MTX treatment. Women with a detectable uterine lesion were followed up with repeat scans during treatment, as well as after treatment in cases of persistent lesions. The association between MTX‐R and sonographic findings at inclusion was assessed. Results Of 47 eligible women, 36 were included in the analysis after excluding those who had not undergone structured transvaginal ultrasound assessment and those who started treatment at another center. The median age at diagnosis was 33 (interquartile range (IQR), 27–43) years and 35/36 (97%) women were in the FIGO low‐risk group (risk score, 0–6). At inclusion, no uterine lesions were found in eight (22%) women, focal lesions in 24 (67%) women and global lesions in four (11%) women. Median maximum lesion diameter was 40.4 (IQR, 31.3–49.4) mm and 26/28 (93%) lesions had a color score of 3 or 4. Arteriovenous fistulas were found in 9/28 (32%) women and theca lutein cysts in 4/36 (11%) women. Four women with GTN lesion at inclusion underwent hysterectomy prior to the first follow‐up ultrasound scan and a fifth woman with a growing lesion underwent hysterectomy, which revealed persistent viable trophoblastic tissue. All remaining women reached complete remission and median time to human chorionic gonadotropin normalization was 2.7 (IQR, 1.4–3.7) months. During ultrasound follow‐up, 88% (21/24) of lesions resolved completely. Two women with a persisting lesion remained in complete remission. Median time to disappearance of vascularity was 5.8 (IQR, 3.7–9.3) months and median time to resolution of the lesion was 6.8 (IQR, 3.7–9.3) months. MTX‐R developed in 12/31 (39%) women. Uterine tumors ≥ 4 cm (73% vs 17%; P = 0.008) and global lesions (25% vs 0%; P = 0.03) were significantly more common in women with compared to those without MTX‐R. Conclusion Uterine lesions were detected at the time of diagnosis in 78% of women with post‐molar GTN. The vast majority of the lesions resolved completely during follow‐up, after a median of 7 months. MTX‐R was more common in uterine tumors of 4 cm, or larger, and in global lesions. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Doppler‐based predictive model for methotrexate resistance in low‐risk gestational trophoblastic neoplasia with myometrial invasion: prospective study of 147 patients

“…Furthermore, UtA-TAmean was identified on multivariate logistic regression analysis as a significant independent predictor of MTX resistance. Therefore, our results are not only consistent with previous research [23][24][25][26] , but also demonstrate new Doppler predictors for MTX resistance.…”

“…These two distinct groups (with and without myometrial invasion) of patients with low-risk GTN had been shown to have very different uterine vascularization characteristics. Several ultrasound parameters have been reported to predict MTX resistance in patients with low-risk GTN, such as a sizeable myometrial invasion (≥ 4 cm diameter) 26 , a low TCV-RI (≤ 0.28) 25 and a low UtA-PI (≤ 1.0 or 1.1) 23,24 . In this study, we analyzed 17 ultrasound features using univariate logistic regression analysis and identified 12 significant predictors of MTX resistance.…”

“…Doppler ultrasound is a non-invasive, radiation-free, high temporal resolution tool that assesses vascular characteristics of tumors in real time [15][16][17][18][19][20][21] . Several (mostly retrospective) studies on GTN have evaluated the usefulness of Doppler in predicting chemotherapy resistance; however, their conclusions remain controversial [22][23][24][25][26] . Such discrepancies could be attributed to the variation in the MTX regimens (e.g.…”

Doppler Ultrasound in Post-Molar Gestational Trophoblastic Neoplasia

“…Malek [26]. They did not mention indices or cut off values for prediction of GTN by Doppler and depended in the sonographic morphological assessment on size of lesion, which is usually a late sign for diagnosis, Doppler of tiny vessels of the sub endomtrium and myometrium used in the current study is an earlier predictor for the disease.…”

<p>The Role of Contrast-Enhanced Ultrasound in Evaluating Gestational Trophoblastic Neoplasia: A Preliminary Study</p>

“…Transvaginal ultrasound (US) has acquired a substantial role in diagnosing and managing GTNs with the development of Doppler techniques. [7][8][9] GTNs and other benign pregnancy-related uterine diseases can sometimes appear similar on greyscale and colour Doppler US, manifesting as focal lesions with rich blood flow signals. 10 Hence, it is crucial to develop new imaging methods as a complement to conventional US for diagnosing GTNs.…”