Rare ultrasound image of malignant trophoblastic tumor

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Abstract

Background: Ultrasound assessment of the pelvic organs, along with the serum levels of human chorionic gonadotropin (hCG) is a key step in the diagnosis of malignant trophoblastic tumors. However, despite the great experience and achieved success in ultrasound diagnosis of trophoblastic tumors, rare types of the disease are associated with an unusual picture; thus, it is necessary to perform additional magnetic resonance imaging with a comprehensive evaluation of the obtained data by a group of experts in the field of diagnosis and treatment of trophoblastic disease.

Case report: This case study presents an observation of an atypical clinical picture of placental site trophoblastic tumor in a 37-year-old patient. During the diagnostic phase, an ambiguous ultrasound image of trophoblastic tumor was obtained. The diagnosis was made by a group of experts in the field of trophoblast pathology on the basis of obstetric history and examination findings: slightly elevated hCG with a tendency to slow increase with a massive locally advanced tumor process in the pelvis according to ultrasound examination and MRI, and high placental lactogen levels. EMA-ER chemotherapy was prescribed. The patient underwent a total of 5 courses of chemotherapy according to the recommended scheme; the 6th course was terminated due to complications. Taking into account the resistance of placental site trophoblastic tumor to standard high-dose chemotherapy which is accompanied by severe complications, immunotherapy was administered to the patient according to the following scheme: pembrolizumab 200 mg intravenously 1 h every 3 weeks in a day hospital. During treatment, hCG and echography indicators were monitored every 3 months; positive dynamics was noted. There were 24 cycles of pembrolizumab, the last 4 were consolidation ones. Complete clinical remission was confirmed. Menstrual function gradually restored.

Conclusion: In this clinical observation, the treatment was successfully achieved through the combination of standard high-dose chemotherapy and immunotherapy, which represents a novel approach. The result was not only a cure, but also the preservation of the young patient’s ability to have children in the future. Thus, consolidation of knowledge and clinical experience of experts in the field of diagnosis and treatment of trophoblast pathology should always be the standard of specialized medical care for patients with this disease.

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About the authors

Marina A. Chekalova

Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies FMBA of Russia

Author for correspondence.
Email: ch2me@yandex.ru

Dr. Med. Sci., Professor, Doctor of Ultrasound Diagnostics

Russian Federation, Moscow

Lyudmila A. Meshcheryakova

Yu.M. Lopukhin Federal Scientific and Clinical Center for Physical and Chemical Medicine FMBA of Russia

Email: ch2me@yandex.ru

Dr. Med. Sci., Professor, Oncologist

Russian Federation, Moscow

Olga N. Streltsova

European Medical Center

Email: ch2me@yandex.ru

PhD, Radiologist

Russian Federation, Moscow

Evgeniy Yu. Cherkasov

Polyclinic No. 2 of the Medical Unit of the Ministry of Internal Affairs of Russia in Moscow

Email: ch2me@yandex.ru

PhD, Head of Gynecological Department, Obstetrician-Gynecologist

Russian Federation, Moscow

Sergey N. Berdnikov

N.N. Blokhin National Medical Research Center of Oncology, Ministry of Health of Russia

Email: ch2me@yandex.ru

PhD, Head of the Department of Ultrasound Diagnostics

Russian Federation, Moscow

Ilona V. Torosyan

N.N. Blokhin National Medical Research Center of Oncology, Ministry of Health of Russia

Email: intriga8686@yandex.ru

Ultrasound Diagnostics Doctor

Russian Federation, Moscow

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2. Fig. 1. On T2-WI in the coronal (A) and axial (B) planes, a large volumetric formation (black arrows) of a heterogeneous fine-mesh structure is determined in the uterine cavity, deeply infiltrating the underlying myometrium; the endometrium is not differentiated; in the preserved myometrium, numerous different-sized tortuous pathological vessels of the arteriovenous malformation type (white arrow) are traced with signal loss due to rapid blood flow, spreading along the broad ligament of the uterus, more on the right, and the right infundibulopelvic ligament, with the involvement of the ovarian vessels (shown fragmentarily)

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3. Fig. 2. A. Ultrasound tomogram of the uterus in the transverse plane: the tumor is indicated by arrows; B. Ultrasound tomogram of the uterus in the longitudinal plane: the uterine cavity is well contoured (white arrows); C. Ultrasound tomogram using MV flow rexim: pathological vascular chaotic clusters of the arteriovenous malformation type are determined (black arrows) and a fragment of a solid avascular tumor (white arrow)

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4. Fig. 3. A. Ultrasound tomogram obtained by transabdominal access at the level of the right rib of the uterus and parametrium region: pathological vascular clusters and lacunae are determined; B. Ultrasound tomogram obtained during transabdominal examination of the hypogastric region on the right: a cluster of dilated veins near the pelvic walls

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5. Fig. 4. A. Ultrasound tomogram of the uterus obtained by transvaginal access: the lower pole of the tumor at the level of the isthmus is indicated (white arrows); B. Ultrasound tomogram of the uterus obtained by transvaginal access, ED mode: the lower pole of the tumor at the level of the isthmus is indicated (white arrows)

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6. Fig. 5. A. On T2- and post-contrast T1-WI with suppression of the signal from adipose tissue in the sagittal plane, the uterus has decreased in size, the uterine cavity can be traced along its entire length (yellow arrow), without additional formations; the endometrium is not clearly differentiated; the subendometrial layer of the myometrium has a heterogeneous structure (black arrow); in the rest of the myometrium, the stroma of the cervix, numerous different-sized tortuous pathological vessels of the arteriovenous malformation type are preserved (white arrow), with the formation of a large lacuna along the posterior wall of the uterus, completely filled with a contrast agent; B. NaT2-VI in the axial and coronal planes in the myometrium, stroma of the cervix, broad ligament of the uterus, parametrium, right infundibulopelvic ligament, numerous different-sized tortuous pathological vessels of the type of arteriovenous malformation (white arrow) are preserved, with the involvement of the ovarian vessels on the right

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7. Fig. 6. A. Ultrasound tomogram of the uterus obtained by transabdominal access: thin unchanged myometrium is visualized in the subendometrial region, its other parts are changed by diffusely dilated veins (calipers indicate unchanged myometrium, yellow arrow - uterine cavity, white arrows - dilated veins); B. Ultrasound tomogram of the uterus obtained by transabdominal access, MVflow mode (yellow arrow - uterine cavity, black arrows - diffusely dilated veins); C. Ultrasound tomogram of the uterus obtained by transvaginal access: yellow arrows - uterine cavity, white arrows indicate the uterus under bimanual pressure, which changes its configuration due to compression of the veins.

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