EUROP. J. OBSTET. GYNEC. REPROD. BIOL., 1973, 316, 207-214. EXCERPTA MEDICA

CASE REPORT

The application of ultrasound techniques in the follow-up of a patient with a choriocarcinoma

A. L. TROOSTWIJK”‘, B. DONKERS’:‘“‘, P. A. DE JONG AND L. A. M. STOLTE

Department of Obstetrics and Gynecology, Vr+ Universiteit, Amsterdam, The Netherlands

TROOSTWIJK, A. L., DONKERS, B., DE JONG, P. A. and STOLTE, L. A. M. (1973): The application of ultrasound techni- ques in the follow-up of a patient with a choriocarcinoma. Europ. J. Obstet. Gynec. reprod. Biol., 3/6, 207-214.

Repeated ultrasound examination of a 32-yr-old patient with a choriocarcinoma is described. Ultrasound techniques may be a welcome addition in the follow-up of such patients.

choriocarcinoma; ultrasound

Introduction

Ultrasound has been established as a valuable tool for the diagnosis of hydatidiform mole (Donald, 1966, 1969; Robinson, Garrett and Kossof, 1968; Troostwijk, 1972). It also provides a useful method of differentiating an early normal pregnancy from a recurrent molar pregnancy or persistent tropo- blastic neoplasia when there is a reelevated gonado- tropin titer associated with amenorrhea or irregular bleeding (Campbell, 1972; Scheer and Goldstein, 1972).

In cases of choriocarcinoma the assays of urinary excretion of human chorionic gonadotropin (HCG) prove the existence of disease somewhere in the body. Besides curettage, pelvic arteriography may

* Present address: Department of Obstetrics and Gyne- cology, Ziekenhuis ‘De Weezenlanden’, Zwolle, The Netherlands

** Present address: Department of Obstetrics and Gyne- cology, St. Geertruiden-Ziekenhuis and St. Jozef-Zieken-

huis, Deventer, The Netherlands

help to localize the tumor in the uterus, but the reliability of arteriographic abnormalities as an index of progression or regression of the disease is limited (Bagshawe, 1969).

The present paper considers the possible value of ultrasound techniques in the follow-up of pa- tients with uterine choriocarcinoma.

Case report

The patient, para 1 mola 1, born in 1940 was admitted on May 17, 1971 to our department following the diagnosis elsewhere of choriocarcinoma. Her pertinent history is sum- marized hereafter.

August 1968:

March 1970:

April 1971:

Spontaneous -incomplete abortion; cu- rettage. Histopathology: tissue of hy- datidiform mole. Spontaneous delivery, 38th week of pregnancy, girl, 2600 g, no abnormal- ities. Periods of irregular vaginal hemor- rhage; period with positive pregnancy test; missed abortion?; curettage. His- topathology: tissue of choriocarcinoma.

208 A. L. Troostwijk et al., Choriocarcinoma and ultrasound

bladder

uterus

bladder

echoes

uterus

Fig. 1. Ultrasonograms May 19, 1971. a. Lor lgitudinal view. b. Transverse view. An enlarged uterus; in the anterior

part vague nondescript echoes are visible. On the right side of the uterus transonic masses, presumably cysts.

fUl adal

May 17, 1971:

May 19, 1971: May 21, 1971:

June 2, 1971: June 3, 1971:

Admittance Department of Gynecology, Vrije Universiteit, Amsterdam. General physical examination: no ab- normalities. General biochemical in- vestigations: no abnormalities. Gynecologic examination: enlarged uterus, right ovarian cyst. Urinary HCG-test (pregnosticon): 6400 U/24 h. Ultrasonograms (Fig. 1). Laparoscopy: enlarged uterus (2 x

normal size); enlarged right ovary; otherwise normal appearances. Curet- tage: indifferent endometrial tissue, some areas with atypical cells. Ultrasonograms (Fig. 2). Pelvic arteriography: results inconclu- sive (Fig. 3).

June 9, 1971:

June 16, 1971: July 7, 1971:

August 11, 1971: August 20, 1971:

August 20, 1971 until October 18, 1971: August 31, 1971:

September 3, 1971:

Chemotherapy started with metho- trexate@ 25 mg/d i.v. and Leucovorin@ 12 mg/d i.m. (Fig. 4). Ultrasonogram (Fig. 5). Ultrasonogram (Fig. 6). Ultrasonograms (Fig. 7). Laparoscopy and curettage because of pelvic tumor(s). Uterus ‘normal’ (8 cm), endometrium in proliferative phase, bluish right ovarian cyst, small left ovarian cyst. Lynestrenol 5 mg/d to suppress endog- enous gonadotropin production (Fig.

4). Pelvic arteriography: although some decrease, same pictures as June 3, 1971

(Fig. 3). Laparotomy: enlarged right ovarian

A. L. Troostwijk et al., Choriocarcinoma and ultrasound 209

echoes - bladder 3 /

uterus

echoes

Fig. 2. Ultrasonograms June 2, 1971. a. Longitudinal view. b. Transverse view. Enlarged intrauterine echo patterns. Pos- sible enlarged ovarian cysts (b).

October 1971:

November 1, 1971:

December 30, 1971:

January 12, 1972:

cyst, ruptured, hemorrhagic mass;

wedge excision; biopsies of left ovary. Histopathology: luteal cyst with recent bleeding (right ovary); tissue of mu- cinous benign cyst (left ovary). Chemotherapy discontinued temporar- ily (Fig. 4).

Rise in HCG-excretion in the urine (Fig.

4). Chemotherapy resumed - same regimen (Fig. 4). irregular vaginal hemorrhage; curet- tage. Histopathology: endometrial tis- sue with decidual reaction. Oxytocin infusion to control bleeding. Addition to chemotherapy regime: 0.5

February 20, 1972: March 43, 1972:

March 23, 1972:

mg/d actinomycin D. According to HCG-excretion in the urine, good re- sponse (Fig. 4). Ultrasonograms (Fig. 8). Vaginal bleeding. According to basal temperature charts and pregnanediol excretions, ovulatory menstruation? Uncontrollable uterine hemorrhage. Laparotomy and hysterectomy with adnexal extirpation. Good postoperative recovery. Pathological investigation of the spec- imen (Figs. 9a and b) shows a diffusely enlarged uterus (corpus 6.5 x 6.5 x 3 cm; cervix 4.5 x 3.5 x2 cm). The myome- trium shows besides areas with fi-

A. L Troostwijk et al., Choriocarcinoma and ultrasound

Fig. 3. Pelvic arteriograms. a. After 3 min. b. After 6 min. c. After 7 min. d. After 8 min.

brosis and dilated vessels also a multi- enlargement, especially in the left ovary locular mass (2.5 x 4 x 3 cm) protruding (Dr. H. B. Oey, Department of Pathol- into the left parametrial region (Fig. 9c, ogy, Vrije Universiteit, Amsterdam). detail). Microscopically the mass shows The clinical postoperative course was irregular spaces with blood clots. The uncomplicated. The HCG-excretions in walls shows areas with remnants of the urine showed values within normal choriocarcinomatous tissue. Multiple limits (Fig. 4). follicular cysts in both ovaries caused January 23, 1973: No abnormalities since April 1972.

MTX 25 mg/d. + Leucovor~n 12 mg/d

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Le~cwonn 12 mgld + Actrnmyan D 0.5 mg /d

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A. L. Troostwijk et al., Choriocnrcinoma and ultrasound

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Fig. 4. Diagram of the assays of the urinary excretion of HCG in relation to therapy.

Fig. 5. Ultrasonogram June 16, 1971. Lo lngitudinal view. The intrauterine echoes still ex .ist.

- bladder

211

uteius

bladder

Fig. 6. Ultrasonogram July 7, 1971. Longitudinal view. Enlarged uterus. The intrauterine echoes seem to have decreased.

uterus

echoes

uterus

Fig. 7. Ultrasonograms August 11, 1971. Longitudinal views. a. Right side of the midline. b. Left side of the midline. A cyst on the right side is pushing the uterus to the left. The uterus appears larger. The intrauterine echoes have definitely increased.

A. L. TroostwQk et al., Choriocarcinoma and ultrasound 213

S

echoes

uterus

- bladder

Fig. 8. Ultrasonograms February 20, 1972. Transverse views. a. Intrauterine echoes still visible. b. Cyst at the left side.

Ultrasonic examination

During the period of May 1971-February 1972 ultrasound examination (Diasonograph) of the pelvic region was performed 8 times. (The examina- tions were done at a frequency of 2.5 mHz and usually with an output of -15 dB.) Besides diag- nosis of cystic malformations of the ovary (Figs. 1 b, 2b, 7a, and 8b) confirmed by laparoscopy and laparotomy, there were always vague, nondescript echoes in the enlarged uterus (Figs. 1, 2, 5, 6, 7, and 8). These echoes sometimes increased (Figs. 2a and 7b). After two courses of chemotherapy, when a sharp drop in HCG excretion in the urine was detectable, the intrauterine echo pattern seemed to

decrease (Fig. 6). However, during a period with low HCG excretion in the urine (August 1971), the ultrasonograms showed further uterine en- largement and the echoes had increased in size and density (Fig. 7). Some time later there was an in- crease of HCG excretion in the urine. Even during the periods of low HCG excretion in the urine, prior to the hysterectomy, ultrasonic ‘lesions’ remained visible in the uterus (Fig. 8).

Discussion

In our opinion this is the first report of a follow- up by ultrasound technique of a patient with a uterine choriocarcinoma. The observed ultrasound

214 A. L. Troostwijk et al., Choriocarcinoma and ultrasound

Fig 9. a. Operative specimen. b. Line drawing of Fig. 9a. Note the tumor mass protruding into the left parametrium. c. Detail of the opened tumor mass in the left uterine wall.

patterns could be regarded as echoes of the tumor. On the other hand they might as well reflect changes in the myometrium due to the cicatrizing reaction to the chemotherapy.

The significance of the observed uterine echoes is difficult to assess as yet. The reliability of ultra- sound techniques might be comparable to the in- formation obtained by pelvic arteriography. An advantage of ultrasound examination is that it can easily be repeated. Combination of this technique with the established diagnostic procedures may add a new dimension to the follow-up of patients with a choriocarcinoma.

References

Bagshawe, K. D. (1969): Chcriocarcinoma, pp. 107-133. Edward Arnold Publishers Ltd., London.

Campbell, S. (1972): Ultrasound in obstetrics. Bit. J. Hcsp. Med., 00, 541.

Donald, I. (1966): Interpretation of abdominal ultrasono- grams. In: Diagnostic Ultrasound, p. 316. Editors: C. C. Grossman et al. Plenum Press, New York, N.Y.

Donald, I. (1969): On launching a new diagnostic science. Amer. J. Obstet. Gynec., 103, 609.

Robinson, D. E., Garrett, W. J. and Kossof, G. (1968): The diagnosis of hydatidiform mole by ultrasound. Aust. N. Z. J. Obstet. Gynaec., 8, 74.

Scheer, K. 1. and Goldstein, D. P. (1972): An alternative in trophoblastic disease follow-up. Amer. J. Obstet. Gynec., 114, 838.

Troostwijk, A. L. (1972): Echoscopie in de Jonge Zwanger- schap (Ultrasonic Examination in Early Pregnancy). Thesis. Amsterdam.