Uterine artery Doppler flow velocimetry parameters for predicting gestational trophoblastic neoplasia after complete hydatidiform mole, a prospective cohort study.

OBJECTIVES:: Doppler ultrasonography can be used to assess neoangiogenesis, a characteristic feature of postmolar gestational trophoblastic neoplasia. However, there is limited information on whether uterine artery Doppler flow velocimetry parameters can predict gestational trophoblastic neoplasia following a complete hydatidiform mole. The purpose of this study was as follows: 1) to compare uterine blood flow before and after complete mole evacuation between women who developed postmolar gestational trophoblastic neoplasia and those who achieved spontaneous remission, 2) to assess the usefulness of uterine Doppler parameters as predictors of postmolar gestational trophoblastic neoplasia and to determine the best parameters and cutoff values for predicting postmolar gestational trophoblastic neoplasia. METHODS:: This prospective cohort study included 246 patients with a complete mole who were treated at three different trophoblastic diseases centers between 2013 and 2014. The pulsatility index, resistivity index, and systolic/diastolic ratio were measured by Doppler flow velocimetry before and 4-6 weeks after molar evacuation. Statistical analysis was performed using Wilcoxon's test, logistic regression, and ROC analysis. RESULTS:: No differences in pre- and post-evacuation Doppler measurements were observed in patients who developed postmolar gestational trophoblastic neoplasia. In those with spontaneous remission, the pulsatility index and systolic/diastolic ratio were increased after evacuation. The pre- and post-evacuation pulsatility indices were significantly lower in patients with gestational trophoblastic neoplasia (odds ratio of 13.9-30.5). A pre-evacuation pulsatility index ≤1.38 (77% sensitivity and 82% specificity) and post-evacuation pulsatility index ≤1.77 (79% sensitivity and 86% specificity) were significantly predictive of gestational trophoblastic neoplasia. CONCLUSIONS:: Uterine Doppler flow velocimetry measurements, particularly pre- and post-molar evacuation pulsatility indices, can be useful for predicting postmolar gestational trophoblastic neoplasia.

Uterine artery Doppler flow velocimetry parameters for predicting gestational trophoblastic neoplasia after complete hydatidiform mole, a prospective cohort study

OBJECTIVES: Doppler ultrasonography can be used to assess neoangiogenesis, a characteristic feature of postmolar gestational trophoblastic neoplasia. However, there is limited information on whether uterine artery Doppler flow velocimetry parameters can predict gestational trophoblastic neoplasia following a complete hydatidiform mole. The purpose of this study was as follows: 1) to compare uterine blood flow before and after complete mole evacuation between women who developed postmolar gestational trophoblastic neoplasia and those who achieved spontaneous remission, 2) to assess the usefulness of uterine Doppler parameters as predictors of postmolar gestational trophoblastic neoplasia and to determine the best parameters and cutoff values for predicting postmolar gestational trophoblastic neoplasia. METHODS: This prospective cohort study included 246 patients with a complete mole who were treated at three different trophoblastic diseases centers between 2013 and 2014. The pulsatility index, resistivity index, and systolic/diastolic ratio were measured by Doppler flow velocimetry before and 4-6 weeks after molar evacuation. Statistical analysis was performed using Wilcoxon’s test, logistic regression, and ROC analysis. RESULTS: No differences in pre- and post-evacuation Doppler measurements were observed in patients who developed postmolar gestational trophoblastic neoplasia. In those with spontaneous remission, the pulsatility index and systolic/diastolic ratio were increased after evacuation. The pre- and post-evacuation pulsatility indices were significantly lower in patients with gestational trophoblastic neoplasia (odds ratio of 13.9-30.5). A pre-evacuation pulsatility index ≤1.38 (77% sensitivity and 82% specificity) and post-evacuation pulsatility index ≤1.77 (79% sensitivity and 86% specificity) were significantly predictive of gestational trophoblastic neoplasia. CONCLUSIONS: Uterine Doppler flow velocimetry measurements, particularly pre- and post-molar evacuation pulsatility indices, can be useful for predicting postmolar gestational trophoblastic neoplasia.

Uterine artery pulsatility index: a predictor of methotrexate resistance in gestational trophoblastic neoplasia.

BACKGROUND: Neo-angiogenesis is a hallmark of cancer. The aim of this study was to test the hypothesis, in a prospective patient cohort, that in low-risk gestational trophoblastic neoplasia (LR-GTN) the uterine artery pulsatility index (UAPI), a measure of tumour vascularity, can predict resistance to methotrexate chemotherapy (MTX-R). METHODS: 286 LR-GTN patients (Charing Cross Hospital (CXH) score 0-8, or FIGO score 0-6) were treated with methotrexate between January 2008 and June 2011 at CXH. During staging investigations, patients underwent a Doppler ultrasound to assess the UAPI. RESULTS: 239 patients were assessable for both UAPI and MTX-R. The median UAPI was lower (higher vascularity) in MTX-R compared with MTX-sensitive patients (0.8 vs 1.4, P<0.0001). In multivariate logistic regression, UAPI≤1 predicted MTX-R, independent of both CXH and FIGO scores. The risk of MTX-R in patients with a FIGO score of 6 and UAPI≤1 was 100% vs 20% in patients with UAPI>1 (χ(2) P<0.0001). CONCLUSION: UAPI represents an independently validated clinically useful predictor of MTX-R in LR-GTN. Further, consideration of whether to incorporate UAPI into the FIGO scoring system is now warranted so that patients with a score of 6 and a UAPI ≤1 might be upstaged and offered combination chemotherapy rather than MTX.

Clinical usefulness of contrast-enhanced color Doppler ultrasonography in invasive and noninvasive gestational trophoblastic diseases: a preliminary study.

OBJECTIVE: To examine the usefulness of contrast-enhanced color Doppler ultrasonography (CDU) in differentiating between invasive and noninvasive gestational trophoblastic disease (GTD). STUDY DESIGN: In 23 patients with findings suggestive of GTD by transvaginal gray-scale ultrasonography, the presence or absence of blood flow within uterine lesions was assessed by contrast-enhanced CDU using Levovist (Schering, Berlin, Germany) microbubble contrast agent. Intratumoral blood flow waveforms were analyzed using resistance indices. Tumor size in each invasive or malignant GTD was assessed by magnetic resonance imaging. RESULTS: Intratumoral blood flow was detected in all invasive or malignant GTDs (7/7: 5 invasive moles, 1 choriocarcinoma and 1 placental site trophoblastic tumor), whereas it was not seen in any noninvasive GTD (0/16:10 complete moles, 5 partial moles and 1 exaggerated placental site) (p <0.0001). A marked increase in uterine vascularity was thus shown in all invasive or malignant GTDs following enhancement. In small invasive moles (<2 cm) in the uterine myometrium, color flow was remarkably increased by contrast-enhanced CDU. Intratumoral blood flow waveforms showed low resistance indices in all invasive and malignant GTDs. CONCLUSION: Contrast-enhanced CDU may be useful in differentiating invasive or malignant GTDs from noninvasive GTDs. By enhancing color flow, this minimally invasive approach may be helpful for detecting small invasive GTD lesions within the uterine myometrium.

Management of massive hemorrhage in patients with gestational trophoblastic neoplasia by angiographic embolization: a safer alternative.

OBJECTIVE: To assess the usefulness of angiographic embolization in hemorrhage due to gestational trophoblastic neoplasia (GTN). STUDY DESIGN: We conducted a retrospective analysis of data of patients with gestational trophoblastic disease within the time period 2002-2008. RESULTS: Eight women with GTN presented with massive hemorrhage during this time period. According to the International Federation of Gynecology and Obstetrics Scoring system 2000, 4 of those patients had high-risk GTN. Vaginal metastasis was present in 50% of the women. All women underwent angiography, and embolization was performed in 7 of the 8 patients. One patient could not undergo embolization due to technical reasons. Two patients underwent embolization of bilateral internal iliac arteries, 4 had bilateral uterine artery embolization and 1 had bilateral uterine and hepatic artery embolization. Embolization was successful in 85.7% of the patients. All patients received chemotherapy: high-risk patients received combined regimen chemotherapy (EMA-CO), while low-risk cases received methotrexate/folinic acid regimen. Out of the 8 patients, 5 are in remission and 3 succumbed to the disease. In 2 women who tried to conceive, 1 delivered a term infant and the other had a miscarriage. The most common side effect of embolization was pain requiring parenteral analgesia. CONCLUSION: Transcatheter embolization is a safe and quick procedure and should be considered in GTN patients with acute hemorrhagic life-threatening complications.

Intratumoral blood flow analysis in epithelioid trophoblastic tumors.

OBJECTIVE: The purpose of this series was to describe the transvaginal color pulsed Doppler sonographic features of epithelioid trophoblastic tumors (ETTs) and to evaluate whether there were specific sonographic criteria to accurately distinguish them from other lesions. METHODS: Seven cases of ETTs treated in the Women's Hospital of Zhejiang University were retrospectively analyzed. Doppler indices, including the Pourcelot resistive index (RI), pulsatility index (PI), and peak systolic to diastolic velocity (S/D) ratio from blood flow signals within the tumors were calculated from each waveform sample by using the software of the ultrasound machines. RESULTS: Patients with ETTs had heterogeneously echoic masses and highly abnormal flow patterns. The mean PI, RI, and S/D ratio for the patients were 0.57 (range, 0.22-1.09), 0.42 (range, 0.2-0.7), and 1.89 (range, 1.25-3.40), respectively. CONCLUSIONS: The clinical usefulness of intratumoral blood flow assessment in ETTs is yet to be established. However, the multiparameter sonographic approach can help in diagnosis of an ETT.