Is Doppler ultrasound useful for evaluating gestational trophoblastic disease?

Lin, Lawrence H.; Bernardes, Lisandra S.; Hase, Eliane A.; Fushida, Koji; Francisco, Rossana P.V.

doi:10.6061/clinics/2015(12)08

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Sumário

REVIEW • Clinics 70 (12) • Dec 2015 • https://doi.org/10.6061/clinics/2015(12)08 copy

Is Doppler ultrasound useful for evaluating gestational trophoblastic disease?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Doppler ultrasound is a non-invasive method for evaluating vascularization and is widely used in clinical practice. Gestational trophoblastic neoplasia includes a group of highly vascularized malignancies derived from placental cells. This review summarizes data found in the literature regarding the applications of Doppler ultrasound in managing patients with gestational trophoblastic neoplasia.

The PubMed/Medline, Web of Science, Cochrane and LILACS databases were searched for articles published in English until 2014 using the following keywords: “Gestational trophoblastic disease AND Ultrasonography, Doppler.”

Twenty-eight articles met the inclusion criteria and were separated into the 4 following groups according to the aim of the study. (¹1. Chan F, Chau M, Pun T, Lam C, Ngan H, Wong R. A comparison of colour Doppler sonography and the pelvic arteriogram in assessment of patients with gestational trophoblastic disease. Br J Obs Gynaecol. 1995;102(9):720-5, 10.1111/j.1471-0528.1995.tb11430.x.
http://dx.doi.org/10.1111/j.1471-0528.19... ) Doppler ultrasound does not seem to be capable of differentiating partial from complete moles, but it might be useful when evaluating pregnancies in which a complete mole coexists with a normal fetus. (²2. Abramowicz JS, Sheiner E. In Utero Imaging of the Placenta?: Importance for Diseases of Pregnancy. Placenta. 2007;28(7):S14-22, 10.1016/j.placenta.2007.02.004.
http://dx.doi.org/10.1016/j.placenta.200... ) There is controversy in the role of uterine artery Doppler velocimetry in the prediction of development of gestational trophoblastic neoplasia. (³3. Shimamoto K, Sakuma S, Ishigaki T, Makino N. Intratumoral blood flow: evaluation with color Doppler echography. Radiology. 1987;165(3):683-5, 10.1148/radiology.165.3.2825234.
http://dx.doi.org/10.1148/radiology.165.... ) Doppler ultrasound is a useful tool in the diagnosis of gestational trophoblastic neoplasia because abnormal myometrial vascularization and lower uterine artery Doppler indices seem to be correlated with invasive disease. (⁴4. Zhou Q, Lei X, Xie Q, Cardoza JD. Sonographic and Doppler imaging in the Diagnosis and Treatment of Gestational Trophoblastic Disease A 12 year experience. J Ultrasound Med. 2005;24(1):15-24.) Lower uterine artery Doppler indices in the diagnosis of gestational trophoblastic neoplasia are associated with methotrexate resistance and might play a role in prognosis.

CONCLUSION:

Several studies support the importance of Doppler ultrasound in the management of patients with gestational trophoblastic neoplasia, particularly the role of Doppler velocimetry in the prediction of trophoblastic neoplasia and the chemoresistance of trophoblastic tumors. Doppler findings should be used as ancillary tools, along with human chorionic gonadotropin assessment, in the diagnosis of gestational trophoblastic neoplasia.

Gestational Trophoblastic Disease; Trophoblastic Neoplasms; Hydatidiform Mole; Ultrasonography, Doppler; Neovascularization, Pathologic

Study	Patients with spontaneous remission				Patients with persistent disease				Conclusion
	n	S/D	PI	RI	n	S/D	PI	RI
Yalcin et al., 2001	16	5.1	1.82	0.8	5	2.27	0.86	0.55	Lower uterine artery indices (S/D, PI, RI) before uterine evacuation were associated with persistent disease (p<0.01).
Gungor et al., 1998	20	-	-	0.46	12	-	-	0.29	Lower uterine artery RI before uterine evacuation was associated with persistent disease (p<0.001).
Chan et al., 1996	11	-	-	0.76	21	-	-	0.69	No association between uterine artery RI before uterine evacuation and persistent disease.

Study	GTN		HM		Pregnant		Non-pregnant		Conclusion
	n	UA RI	n	UA RI	n	UA RI	n	UA RI
Tepper et al., 1994	3	0.410 ± 0.04	-	-	20	0.494 ± 0.06	-	-	Lower UA RI in GTN compared with first-trimester pregnant woman
Chan et al., 1996	32	0.68 ± 0.16	-	-	18	0.8 ± 0.09	23	0.9 ± 0.08	Lower UA RI in GTN compared with non-pregnant and first-trimester pregnant woman
Hsieh et al., 1994	23	0.56 ± 0.19	15	0.75 ± 0.06	-	-	55	0.80 ± 0.05	Higher peak systolic velocity and lower UA RI in GTN compared with non-pregnant and post-evacuation uneventful moles
Zhou et al., 2005	32 (CC) 184 (IM)	0.25± 0.05 (CC) 0.28 ± 0.06 IM)	106 (CHM) 33 (PHM)	0.55 ± 0.06 (CHM) 0.56 ± 0.04 (PHM)	13	0.66 ± 0.05	-	-	Lower UA RI in GTN compared with hydatidiform moles and first-trimester pregnant woman

Study	Chemo-resistant GTN	Chemo-sensitive GTN	Conclusion
Park et al., 1994	5	11	UA S/D before treatment was not significantly different in patients with chemoresistant and sensitive disease. After completion of chemotherapy, UA S/D increased in patients with remitted disease (2.72±1.31 to 6.23±2.38), whereas in patients with resistant GTN, UA S/D did not change (2.69±1.8 to 3.08±1.54)
Oguz et al., 2004	7	30	A cuff-off value of 4 cm or higher of myometrial invasion and vascularization RI≤0.28 were proposed to predict single-agent chemotherapy resistance
Long et al., 1992	8	42	This prospective study established a cut-off value of UA PI≤1.1 associated with an elevated likelihood of GTN patients developing chemoresistance
Agarwal et al., 2002	47	117	This retrospective study established that a UA PI≤1.0 detected resistance with a sensitivity of 68% and specificity of 62%, with an adjusted odds ratio of 2.27 for methotrexate resistance in low-risk GTN
Sita-Lumsden et al., 2013	43	30	In patients with a GTN FIGO score of 5-6, the risk of chemoresistance was 67% with a UA PI≤1, compared with 42% when the UA PI was >1
Agarwal et al., 2012	113	126	A lower UA PI in patients with low-risk GTN with chemoresistance and UA PI≤1 was a risk factor independent of the FIGO score for methotrexate resistance. Patients with a FIGO score of 6 and UA PI≤1 had 100% resistance to methotrexate
Hsieh et al., 1994	13 (GTN needing ≥5 courses of chemotherapy)	10 (GTN needing <5 courses of chemotherapy)	Higher mean UA RI in patients requiring fewer than 5 cycles of chemotherapy (0.71±0.09) compared to patients requiring longer chemotherapy (0.47±0.14). There was an evident decrease in the UA peak systolic velocity after the first three chemotherapy cycles in the group requiring less courses of treatment (54.2 to 23.6 cm/s compared to 60.1 to 60 cm/s)

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[1] Lin LH, Bernardes LS and Hase EA performed the literature search and wrote the manuscript. Fushida K and Francisco RPV reviewed and corrected the manuscript.