Multimodality Imaging in the Diagnosis and Staging of Gestational Choriocarcinoma

Abstract

Choriocarcinoma is an uncommon, highly invasive malignancy arising from the placental trophoblastic tissue. Though staging is clinical, imaging has significant role in the diagnosis, staging, prognostic risk scoring, and management of choriocarcinomas. The purpose of this article is to review the role of multimodality imaging in the diagnosis, staging, and management of choriocarcinomas in correlation with clinicopathologic findings.

Keywords: choriocarcinoma; color Doppler; computed tomography; magnetic resonance imaging; positron emission tomography; ultrasound.

Fig. 1

Féderation Internationale de Gynécologie et d'Obstétrique (FIGO) staging of choriocarcinoma with corresponding American Joint Committee on Cancer (AJCC) TNM ( t umor size, n ode involvement, and m etastasis status) classification in parenthesis. Stage I (T1) is tumor confined to the uterus. Stage II (T2) is tumor extending outside the uterus, but limited to the genital structures (adnexa, vagina, and broad ligament). Stage III (M1a) includes lung metastases with or without genital tract involvement. Stage IV (M1b) includes all other metastatic sites.

Fig. 2

A 32-year-old woman with stage I choriocarcinoma. ( A ) Transvaginal scan at presentation showing mixed echogenic lesion with internal cystic spaces invading the myometrium in an enlarged uterus (★). ( B ) Axial fusion positron emission tomography (PET)/computed tomography (CT) image of the pelvis after 3 months of therapy shows hypermetabolic lesion in the uterus suggestive of residual malignancy. ( C, D ) Split-screen grayscale, color, and spectral Doppler ultrasound images show ill-defined heterogenous residual uterine mass with internal vascularity (★) exhibiting pulsatility index (PI) of <1.

Fig. 3

Stage II choriocarcinoma in a 34-year-old woman with contiguous extrauterine spread to adjacent genital tract. ( A–D ) Axial, sagittal, and coronal reconstructed contrast-enhanced computed tomography (CECT) images of the pelvis show enlarged uterus with large heterogeneously enhancing hypodense lesion (★), enlarged ovaries in both adnexa ( thick arrows ), vaginal metastasis ( white arrow ), and a hypodense deposit in the vulva ( black arrows ).

Fig. 4

Stage I choriocarcinoma confined to the uterus in a 24-year-old woman. ( A, B ) Sagittal T2-weighted (T2W) and axial short tau inversion recovery (STIR) T2W images show a heterogeneously hyperintense lesion (★) in the uterus. ( C, D ) Axial diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) images show the lesion appearing bright on DWI and dark on ADC (★).

Fig. 5

Stage IV choriocarcinoma in a 29-year-old woman with lung and brain metastases. ( A ) Sagittal T2-weighted (T2W) image shows heterogeneously hyperintense lesion (★) diffusely involving the entire myometrium with loss of normal zonal anatomy in a grossly enlarged uterus. ( B, C ) Coronal and axial T2W magnetic resonance (MR) images of the abdomen and chest show primary uterine lesion (★) and multiple lung metastases ( arrows ). ( D, E ) T1W sagittal and T2W axial MR images of the brain show hemorrhagic metastases that are hyperintense on T1 and hypointense on T2 sequences with perilesional edema ( arrows ).

Fig. 6

Stage III choriocarcinoma with lung metastases. ( A ) Coronal reformatted contrast-enhanced computed tomography (CECT) image of the abdomen and pelvis reveals large heterogeneously enhancing hypodense lesion in an enlarged uterus (★) with a metastatic lung nodule ( arrow ). ( B ) Axial CT of the chest in the lung window shows multiple nodules (“cannon ball” metastases). ( C ) Two weeks later, the patient developed acute breathlessness due to pulmonary hemorrhage and radiograph of the chest shows multiple nodules of varying sizes ( arrows ) with adjacent opacities.

Fig. 7

Choriocarcinoma with metastatic lymphangitis carcinomatosis in 28-year-old woman. ( A ) Radiograph of the chest shows irregular reticulonodular opacities in both lungs. ( B, C ) Axial contrast-enhanced computed tomography (CECT) and fusion positron emission tomography (PET)/computed tomography (CT) images of the pelvis show the residual malignancy in the uterus as a hypoattenuating lesion with peripheral hypermetabolic areas (★).

Fig. 8

Stage IV choriocarcinoma in a 26-year-old woman with liver metastases. ( A ) Split screen grayscale and color Doppler ultrasound of the pelvis shows heterogeneously hyperechoic lesion with internal vascularity (★) in an enlarged uterus. ( B ) Grayscale ultrasound image shows multiple well-defined hyperechoic vascular liver metastases ( arrows ).

Fig. 9

Choriocarcinoma and its mimics in patients of childbearing age. Sagittal contrast-enhanced computed tomography (CECT) images showing enlarged uterus with heterogeneously enhancing lesions (★). ( A ) Choriocarcinoma. ( B ) Invasive mole. ( C ) Uterine fibroid with sarcomatous changes. ( D ) Carcinoma cervix invading the uterus. ( E ) Uterine leiomyosarcoma.

Fig. 10

Choriocarcinoma in a 32-year-old woman with arteriovenous malformation. ( A ) Split-screen grayscale and color Doppler ultrasound images show an ill-defined mixed echogenic lesion with internal cystic spaces invading the uterine myometrium (★) and multiple tortuous vessels in the lower uterine segment ( arrows ). ( B ) Sagittal contrast-enhanced computed tomography (CECT) images of the pelvis in early arterial phase show enlarged uterus with heterogeneously enhancing hypodense lesion (★) and multiple enhancing tortuous dilated vessels confirming the arteriovenous malformation (AVM).

Fig. 11

Flowchart depicting the diagnostic criteria of gestational trophoblastic neoplasm (GTN) and the management of choriocarcinoma. CECT, contrast-enhanced computed tomography; CT, computed tomography; hCG, human chorionic gonadotropin; MRI, magnetic resonance imaging; PET, positron emission tomography; US, ultrasound.