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Radiology night 10/2015


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Choi criteria / GTD

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Radiology night 10/2015

  1. 1. Radiology Night 5/10/2015 Cases by Dr. Naglaa Mahmoud Khalil Registrar of Clinical Radiology KCCC
  2. 2. Case 1 Shared by Dr. Kavitha Nair FRCR
  3. 3. Case 1 20 year old lady with H/O abortion 3 months back presented with high ß-HCG.
  4. 4. 1- Ultrasound imaging of the pelvis shows which of the following? 1. An enlarged pelvic lymph node 2. A hypervascular mass within the uterus 3. An ovarian mass 4. Thickening of the cervix
  5. 5. 2- Abnormal trophoblastic tissue with myometrial invasion is present. 1. True 2. False
  6. 6. 3- Which is the most appropriate next step? 1. Hysterectomy 2. Further evaluation with CT 3. Further evaluation with MRI
  7. 7. 4- Based on the CT imaging findings, the most likely cause for the uterine abnormality is: 1. Retained products of conception 2. Invasive mole 3. Endometrial cancer 4. Choriocarcinoma
  8. 8. 5- Choriocarcinoma can be found in all of the following EXCEPT 1. In relation to gestation 2. Following a hydatiform mole 3. After abortion or after tubal pregnancy 4. Following pelvic inflammatory disease
  9. 9. 6- Regarding choriocarcinomas: Choriocarcinoma requires surgical removal. 1. True 2. False
  10. 10. 7- Regarding choriocarcinomas: A negative ultrasound of the pelvis can rule out choriocarcinoma. 1. True 2. False
  11. 11. 8- Regarding choriocarcinomas: The lung is the most common site of metastatic disease from choriocarcinoma. 1. True 2. False
  12. 12. History 20 year old lady. Mother of 2 year old boy Presented with inevitable abortion after 8 weeks pregnancy on 1/5/15 at Al-Jahra hospital, E & C (HPE: hydatiform mole), 2 weeks later she was re-admitted with vaginal bleeding, E & C was done again (HPE: partial mole).
  13. 13. History The patient was having amenorrhea until 10/8/15 and US showed bulky uterus with highly vascular lesion. High ß-HCG (200000 IU/ml). Referred to KCCC for management of GTN.
  14. 14. Imaging of GTD
  15. 15. GTD Characterized by abnormal proliferation of pregnancy-associated trophoblastic tissue with malignant potential. Represents a spectrum of disease that, although usually benign and easily treatable, occasionally progresses to an aggressive, potentially fatal process.
  16. 16. GTD Incidence is highest in Asian women: 1 in 200 pregnancies, lower in United States: 1 in 2000 pregnancies.  Recurrence rate is 2%.  Associated with dietary deficiencies such as folic acid.
  17. 17.  It includes: 1- Hydatidiform mole (benign): a.Complete. b.Partial. and, 2- Gestational trophoblastic tumors (malignant): a. Invasive mole. b. Choriocarcinoma.
  18. 18. Diagnosis of molar pregnancy
  19. 19. 1) Clinical Presentation 2) β-HCG level 3) Imaging
  20. 20. 1)Clinical Presentation: − Usually occur in first 20 24 weeks of gestation. – Vaginal bleeding. – Passing tissue: grape-like clusters. – Nausea/vomiting. – Cervical os may be dilated. −Uterus larger than expected by gestational age estimated by LMP. − Lack of fetal heart sounds.
  21. 21. 2) β-HCG level • Useful serologic marker for diagnosis, assessment of response to treatment, and surveillance for recurrence. •Detected in maternal plasma and urine within 9 days of conception. • Reaching a peak at 9-12 weeks, then • Declining to a stable plateau for the remainder of the pregnancy.
  22. 22. 3) Imaging: • US is the initial examination of choice for diagnosis. However, myometrial invasion and extension into the parametrium are difficult to detect with US alone. • Doppler US may be useful in the evaluation of GTD (vascular). • Relative to US and CT, MRI demonstrates the tumor, myometrial invasion, and extension into the parametrium clearly with excellent soft tissue contrast. • Assessment of local extension and distant metastasis (including to the lung, brain, and liver) is required for optimal therapy.
  23. 23. (A) HYDATIDIFORM MOLE • Complete →→→ –Most common type, 90% of all molar pregnancies. − No fetus only trophoblastic tissue. − 15−20% will become malignant. • Partial →→→ − 1 of every 1000-2000 pregnancies. −Focal trophoblastic proliferation in the placenta. –Abnormal fetus or even associated with fetal demise. – 3% will become malignant.
  24. 24. (B) GESTATIONAL TROPHOBLASTIC TUMORS: 1) Invasive mole:  Distinguished by excessive trophoblastic overgrowth and extensive penetration by trophoblastic elements including whole villi deep into the myometrium.  Sometimes there is penetration of the peritoneum, adjacent parametria or the vaginal vault.
  25. 25. (B) GESTATIONAL TROPHOBLASTIC TUMORS: 1) Invasive mole:  locally invasive but rarely metastasize.  50% arise following hydatiform mole, 25% following abortion, and 25% following an apparently normal or ectopic pregnancy.  The pathological diagnosis of an invasive mole is rarely made, because most cases are treated medically, without the need for hysterectomy.
  26. 26. 2) Choriocarcinoma  Carcinoma of the chorionic epithelium secondary to invasive growth of trophoblast and erosion of blood vessels.  50 % arise from complete hydatiform mole.  25% arise after normal pregnancies.  25% follow spontaneous abortion or ectopic pregnancy.
  27. 27. 2) Choriocarcinoma  Metastasis often develops early and is generally blood borne.  The majority go to the lungs and vagina.  The vulva, kidneys, liver, ovaries, brain, and bowel also may contain metastasis in many cases.  Less common in bone and LNs.
  28. 28. Although aggressive malignancy, choriocarcinoma has a spectacular response to CT that may reach up to 100% cure and 85% in metastatic cases. Many of the cured patients have subsequently had normal pregnancies and deliveries.
  30. 30. 1. Metastasis (especially pulmonary).
  31. 31. 2. Acute pulmonary embolism.
  32. 32. 3. Theca-lutein cysts: 20%-50% of hydatiform moles. Result from overstimulation of lutein element by large amounts of HCG secreted by proliferating trophoblast. Typically bilateral but occasionally unilateral. Multilocular cysts. It may take 2-4 months for the cysts to regress after molar evacuation. Torsion or hemorrhage within these cysts may occur and cause symptoms.
  33. 33. Take home message…. GTN can be confidently diagnosed with transvaginal USG, and Doppler, in the setting of elevated ßHCG and past h/o of molar pregnancy Presence of highly vascular intramural uterine mass- invasive mole vs. choriocarcinoma
  34. 34. Take home message…. MRI play an important role in both detection and follow up of myometrial invasion and extension into the parametrium which can be difficult to detect with US alone. CT is the imaging procedure of choice for detection of extra pelvic metastases. Presence of metastases is highly suggestive of choriocarcinoma
  35. 35. Case 2 44 year old lady, a known case of malignant tumour on follow up CT scan
  36. 36. 1- Contrast enhanced CT of the pelvis shows 1. Uterine cervix mass 2. Right adnexal mass 3. Circumferential rectal wall thickening 4. Lymphadenopathy
  37. 37. 2- Which of the following is the LEAST likely diagnosis of circumferential rectal wall thickening 1. Adenocarcinoma 2. GIST 3. TB 4. Metastasis
  38. 38. 3- Which of the following is the LEAST likely diagnosis 1. Metastasis from adenocarcinoma 2. Haemangioma 3. Metastasis from GIST 4. HCC
  39. 39. Pretreatment Posttreatment
  40. 40. 4- In the posttreatment image there is 1. Response to treatment 2. Progressive course 3. No change
  41. 41. 5- Hepatic and portal veins 1. Normal 2. Invaded 3. Thrombosed 4. Displaced
  42. 42. History 44 year old lady, a known case of rectal GIST on follow up CT scan
  43. 43. Tumor Response Criteria in Targeted Cancer Therapies
  44. 44. The mechanisms of action of targeted therapies differ from those of traditional cytotoxic chemotherapy. Some agents can induce apoptosis; however, some agents stop progression.
  45. 45. Because of differences in the mechanism of action, tumors treated with targeted therapies do not necessarily demonstrate the same radiographic findings as tumors treated with standard cytotoxic therapies. Therefore, traditional anatomic size–based criteria can lead to the miscategorization of treatment response for tumors like GIST, HCC, or melanoma when treated with targeted therapies.
  46. 46. Choi Response Criteria
  47. 47. The therapeutic options for advanced GISTs were limited until the introduction of Imatinib, a competitive inhibitor of tyrosine kinase receptor that has demonstrated remarkable efficacy.
  48. 48. Imatinib mesylate Tyrosine kinase receptor blocker + Kinase domains “KIT” receptor
  49. 49. During the course of treatment with Imatinib, tumor size usually decreases; however, changes in tumor dimension do not necessarily reflect tumor response. In some cases, size can actually increase secondary to internal hemorrhage, necrosis or myxoid degeneration. Decrease in tumor size is usually minimal during the early stages of posttreatment, whereas dramatic changes in internal characteristics (e.g. tumor attenuation, nodularity, and number of vessels) will occur.
  50. 50. Pre-Treatment 2 Months Post 43 HU 30 HU
  51. 51. Pretreatment Follow up 1
  52. 52. Follow up 2Follow up 1
  53. 53. The Choi response criteria for GIST proposed that tumor attenuation could provide an additional measure of response to Imatinib therapy. The response can be seen very early during treatment.
  54. 54. Take home message…. Choi response criteria is the method of choice for assessment response to treatment in GIST treated with Imatinib. The response can be seen very early during treatment. RECIST response criteria may underestimate tumor response depending only on tumor size.
  55. 55. Thank you