Choi criteria / GTD

1. Radiology Night
5/10/2015
Cases by
Dr. Naglaa Mahmoud Khalil
Registrar of Clinical Radiology
KCCC

2. Case 1
Shared by Dr. Kavitha Nair
FRCR

3. Case 1
20 year old lady with H/O abortion 3 months back
presented with high ß-HCG.

6. 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

7. 2- Abnormal trophoblastic tissue with myometrial
invasion is present.
1. True
2. False

8. 3- Which is the most appropriate next step?
1. Hysterectomy
2. Further evaluation with CT
3. Further evaluation with MRI

11. 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

12. 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

13. 6- Regarding choriocarcinomas:
Choriocarcinoma requires surgical removal.
1. True
2. False

14. 7- Regarding choriocarcinomas:
A negative ultrasound of the pelvis can rule out
choriocarcinoma.
1. True
2. False

15. 8- Regarding choriocarcinomas:
The lung is the most common site of metastatic
disease from choriocarcinoma.
1. True
2. False

16. 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).

17. 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.

23. Imaging of GTD

24. 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.

25. 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.

28.  It includes:
1- Hydatidiform mole (benign):
a.Complete.
b.Partial.
and,
2- Gestational trophoblastic tumors (malignant):
a. Invasive mole.
b. Choriocarcinoma.

29. Diagnosis of molar pregnancy

30. 1) Clinical Presentation
2) β-HCG level
3) Imaging

31. 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.

32. 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.

33. 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.

34. (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.

37. (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.

38. (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.

41. 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.

42. 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.

44. 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.

45. COMPLICATIONS OF GTN

46. 1. Metastasis (especially pulmonary).

47. 2. Acute pulmonary embolism.

48. 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.

50. 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

51. 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

52. Case 2
44 year old lady, a known case of malignant tumour
on follow up CT scan

54. 1- Contrast enhanced CT of the pelvis shows
1. Uterine cervix mass
2. Right adnexal mass
3. Circumferential rectal wall thickening
4. Lymphadenopathy

55. 2- Which of the following is the LEAST likely
diagnosis of circumferential rectal wall thickening
1. Adenocarcinoma
2. GIST
3. TB
4. Metastasis

57. 3- Which of the following is the LEAST likely
diagnosis
1. Metastasis from adenocarcinoma
2. Haemangioma
3. Metastasis from GIST
4. HCC

58. Pretreatment
Posttreatment

59. 4- In the posttreatment image there is
1. Response to treatment
2. Progressive course
3. No change

61. 5- Hepatic and portal veins
1. Normal
2. Invaded
3. Thrombosed
4. Displaced

62. History
44 year old lady, a known case of rectal GIST on follow
up CT scan

67. Tumor Response Criteria in
Targeted Cancer Therapies

68. The mechanisms of action of targeted therapies
differ from those of traditional cytotoxic
chemotherapy.
Some agents can induce apoptosis; however, some
agents stop progression.

69. 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.

70. Choi Response Criteria

71. 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.

72. Imatinib
mesylate
Tyrosine kinase
receptor blocker
+
Kinase
domains
“KIT” receptor

73. 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.

74. Pre-Treatment 2 Months Post
43 HU 30 HU

75. Pretreatment Follow up 1

76. Follow up 2Follow up 1

77. 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.

79. 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.

80. Thank you