Doppler Ultrasound in Post-Molar Gestational Trophoblastic Neoplasia

Amr H. El-Shalakany,Nashwa E. Hassan,Ghada M. Mansour,Sahar S. Ez-Elarab,Ibrahim Ali,Gamal H. Sari

doi:10.4236/ojog.2020.1040052

Abstract

Objectives: To evaluate the role of Doppler ultrasound in prediction and follow up during management of gestational trophoblastic neoplasia (GTN). Methods: The study was performed at Oncology Unit, Maternity Hospital, Ain Shams University in the period from November 2015 to December 2018. Forty cases of complete mole, after evacuation and follow up of serum human chorionic gonodotrophin (β-hCG) titre until it reached zero level (group I) and forty post molar GTN cases (group II) were included in the study. Doppler ultrasound of the subendometrial and intramural blood flow was done for all cases of group I and II. Doppler included two dimensional and three dimensional power Doppler indices. Group II received Methotrexate (MTX) and folinic acid in a dose of 8-day MTX-FA regimen. Doppler follow up for six months of group II concurrently with the chemotherapy regimen was done. Results: A statistically significant difference was found between group I and II regarding initial readings of all Doppler parameters. Follow up for 6 months of GTN cases revealed progressive statistically significant decrease of intramural and subendometrial three dimensional power Doppler (3DPD) indices, while there was a significant increase in two dimensional (2D) Doppler parameters. Four cases were resistant to Methotrexate chemotherapy. Cut off values were determined for prediction of GTN. Multivariate analysis revealed that the most predictive parameter was the subendometrial pulsatility index (PI), odds ratio = 10.63 (95% CI: 1.30 - 86.89). The cut-off point for sub-endometrial PI was: 2.05 (AUC, 90%; sensitivity, 88%; specificity, 76%, PPV 78%, and NPV 86%) with a diagnostic accuracy of 87%. To and Fro sign may be considered a pathognomonic intramural ultrasound sign for prediction of GTN chemo-resistance or choriocarcinoma. Conclusion: Cut off values for Doppler parameters can be used for early predication of GTN. Doppler ultrasound indices can be used during follow up of GTN cases concurrently with serum β-hCG to monitor the response to treatment.

Highlights

Gestational trophoblastic disease comprises a group of disorders that are characterized by abnormal trophoblast proliferation and invasion as hydatidiform mole, invasive mole, choriocarcinoma, placental site trophoblastic tumour and epithelioid trophoblastic tumour [1].Post-molar gestational trophoblastic neoplasia (GTN) is often curable [2], late presentation of many cases may change the prognosis and response to chemotherapy
The cut-off point for sub-endometrial pulsatility index (PI) was: 2.05 (AUC, 90%; sensitivity, 88%; specificity, 76%, PPV 78%, and NPV 86%) with a diagnostic accuracy of 87%
Doppler ultrasound was used during follow up of post molar GTN cases and was used to predict GTN using cut off values for each parameter

Summary

Introduction

Post-molar GTN is often curable [2], late presentation of many cases may change the prognosis and response to chemotherapy. Serial serum β-hCG titre measurement is considered an exceptional tumor marker for GTN, the compliance of patients differs and many cases are lost during follow up. They may develop GTN and progress to choriocarcinoma until becoming symptomatic with a late presentation. Prediction of GTN by a non invasive method after evacuation of molar pregnancy may help in selecting the high risk group for developing GTN and encourage them to have a strict follow up. Prediction of GTN was suggested in the literature by many authors as using post evacuation serum β-hCG level [3] [4], the slope of linear regression of β-hCG as an independent risk factor [5] [6]; placental hormones as human placental lactogen (hPL), inhibin, activin, progesterone were evaluated as tumor markers for GTN [2] and uterine artery Doppler [7]

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