Case Report
A Rare Giant Placental Chorioangioma with Favorable Outcome: A Case Report and Review of the Literature Miaoying Fan, MD, RDMS, Hamid Mootabar, MD Department of Obstetrics and Gynecology, Columbia University, PH12-15, 622W, 168th Street, New York, NY 10032 Received 17 December 2012; accepted 27 May 2014
ABSTRACT: We describe a rare giant placental chorioangioma in a patient who had a favorable outcome with close prenatal surveillance in a 28-year-old primigravida who was referred to our clinic for ultrasound evaluation of a suspected placental mass at 23 weeks’ gestation. A detailed ultrasound scan revealed a well-circumscribed, echogenic lesion measuring 11.0 3 10.3 3 7.3 cm and protruding into the amniotic cavity. A diagnosis of placental chorioangioma was made and intensive prenatal surveillance was scheduled. A small-for-gestational age (2,325 g) but normal female neonate was delivered at 37 weeks by cesarean section and discharged from hospital on the second day of the delivery. A giant chorioangioma may not cause any adverse effect to the fetus and may not require any medication or invasive intervenC 2014 Wiley Periodicals, Inc. J Clin Ultrasound tion. V 43:254–256, 2015; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22187 Keywords: placenta; chorioangioma; prenatal ultrasound; obstetrics
C
horioangioma is the most common benign tumor of the placenta, occurring in approximately 1% of pregnancies.1 Most chorioangiomas are of no significant clinical importance; however, those measuring more than 5 cm in diameter may be associated with maternal and fetal complications.2–5 Herein, we report a case of a pregnant patient who presented with a rare giant placental chorioangioma with a favorable outcome upon close surveillance.
Correspondence to: M. Fan C 2014 Wiley Periodicals, Inc. V
254
CASE REPORT
A 28-year-old African-American primigravida with unremarkable medical history was referred to our clinic for ultrasound evaluation due to a suspected placental mass at 23 weeks’ gestation. Ultrasound examination was performed using a Voluson 730 Expert scanner and a 2–7-MHz transducer (GE Healthcare, Austria). It revealed a single live intrauterine fetus. Fetal anatomic assessment and Doppler blood flow studies of the middle cerebral artery (MCA), umbilical artery, and ductus venosus were unremarkable. The amniotic fluid index was within normal range. A well-defined, oval-shaped, echogenic homogeneous mass was seen near the chorionic surface, measuring 11.0 3 10.3 3 7.3 cm, protruding into the amniotic cavity (Figure 1). Color Doppler ultrasound (CDUS) showed no blood flow within or around the tumor, leading to a presumed diagnosis of placental chorioangioma. The estimated fetal weight was calculated at the tenth percentile for gestational age. Follow-up ultrasound (US) scans for fetal growth velocity, monitoring the placental mass size, and Doppler studies of MCA, umbilical artery, and ductus venosus were conducted every 2 weeks in an effort to rule out possible complications of a giant placental chorioangioma. During the follow-up period, the fetus grew appropriately, and the estimated fetal weight was between the 8th and 13.5th percentile for gestational age. The placental tumor size increased gradually, measuring 13.7 3 11.3 3 8.7 cm at 30 weeks and 4 days’ gestation. JOURNAL OF CLINICAL ULTRASOUND
A RARE GIANT PLACENTAL CHORIOANGIOMA WITH FAVORABLE OUTCOME
FIGURE 1. Sonogram obtained at 23 weeks’ gestation shows a welldefined, homogeneous, echogenic placental mass measuring 11.0 3 10. 3 3 7.3 cm, which projects from the fetal surface of the placenta into the amniotic cavity.
FIGURE 2. Sonogram obtained at 36 weeks and 3 days’ gestation shows that the echotexture of the placental mass has changed dramatically, with an irregular anechoic area and with fibrous septa. The mass has increased in size to 17.9 3 16.0 3 14.0 cm.
The echogenicity pattern of the tumor remained unchanged with homogeneous echogenicity. At 32 weeks 0 days’ gestation, the placental mass appeared heterogeneous with both solid and cystic elements and fibrous septa (Figure 2). There was no blood flow detected within the tumor on CDUS. Most importantly the MCA peak systolic velocity (PSV) peaked at 57. 6 cm/s, which indicated the fetus had mild fetal anemia. Due to the abrupt change of the echotexture of the placental chorioangioma and an increased fetal MCA PSV, intensive perinatal surveillance was planned, including fetal heart rate monitoring, biophysical profile, and MCA PSV Doppler study twice weekly. At 32 weeks and 3 days’ gestation, the MCA PSV had returned to normal range without intervention. VOL. 43, NO. 4, MAY 2015
FIGURE 3. Photomicrograph of the angiomatous-type chorioangioma shows numerous capillary-type vessels with intravascular red blood cells (original magnification, 3200; hematoxylin-eosin stain).
Follow-up US examinations showed that the chorioangioma grew constantly as gestation advanced, with the maximum size of 17.9 3 16.0 3 14.0 cm at 36 weeks 3 days’ gestation. At 37 weeks’ gestation, the patient requested delivery by cesarean section. A small-forgestational-age (2,325 g) but normal female neonate was delivered with Apgar scores of 9 and 10, respectively, at 1 and 5 minutes. The neonatal hematocrit was normal (13.1 g/ml). Two days after delivery, mother and infant both in good condition were discharged from the hospital. The pathologic examination of the placenta showed a large ruptured cyst measuring 12 3 12 3 3 cm containing blood clots with peripheral laminated appearance. Microscopically, numerous capillary-type vessels were seen with intravascular red blood cells (Figure 3). Other vessels were thrombosed. Pathologic diagnosis was consistent with placental angiomatous type of chorioangioma with thrombotic degeneration.
DISCUSSION
Chorioangioma is the most common benign tumor of the placenta, occurring in 0.5% to 1% of all pregnancies.1 Large tumors (>5 cm) are rare, occurring at a rate of 1:3,500–1:9,0002 and may result in significant maternal and fetal complications, including polyhydramnios, preterm labor, fetal congestive heart failure, anemia, fetal growth restriction, and intrauterine fetal death.3–5 Gray-scale US, CDUS, threedimensional (3D) US have been used to diagnose placental chorioangiomas.4,6,7 Gray-scale US is the primary diagnostic tool to identify chorioangiomas, which appear as hypo- or 255
FAN AND MOOTABAR
hyperechoic, circumscribed masses that are distinctly different from the placenta. Those masses may contain anechoic cystic areas that may contain fibrous septa that create the appearance of a complex mass.6,7 CDUS plays an important role in diagnosing placental chorioangioma.5,8 CDUS can confirm the presence of vascular channels in the tumor contiguous with the fetal circulation. These channels help to differentiate chorioangiomas from other placental lesions such as placental teratoma, degenerating fibroid and placental hematoma. CDUS also provides information in predicting and managing the outcomes for these cases.7 3D US and 3D Doppler US may aid in the diagnosis of placental chorioangioma. However, CDUS will not reveal any blood flow within some avascular chorioangiomas and therefore the absence of blood flow in a chorioangioma should not be used to rule out the diagnosis.5,9 In this case, the chorioangioma was an avascular chorioangioma, which was confirmed at pathologic examination. MRI may also be a useful adjunct to US for the antenatal diagnosis of placental chorioangioma. It is especially sensitive to the presence of placental hemorrhage.10 The management and treatment of a chorioangioma depend highly on its size and the presence of associated complications. Small chorioangiomas usually are asymptomatic and do not require treatment except monitoring of the tumor growth by US. Larger chorioangiomas (>5 cm) may be associated with maternal and/or fetal complications. Possible interventions include fetal transfusion in the presence of fetal anemia, and amniodrainage for cases presenting with polyhydramnios.11 However, fetal transfusion and amniodrainage do not affect the underlying pathophysiology of arteriovenous shunting within the chorioangioma. Therefore, ideal treatments should be targeted to block arteriovenous shunting within the chorioangioma to prevent further complications. These treatments to block arteriovenous shunting include alcohol injection,12 microcoil embolization,13 endoscopic laser coagulation, and interstitial laser therapy.11,13 Large placental tumors usually cause severe complications. However, despite the giant size in this case (maximum size of 17.9 3 16.0 3 14.0 cm), there were no significant complications. The fetus had mild anemia, which was
256
detected by an increased MCA PSV at 30 weeks. The mild fetal anemia resolved spontaneously presumably due to thrombosis of the chorioangioma. The maternal and neonatal outcomes were favorable and both mother and neonate were discharged without complications on the second day of delivery. This case demonstrates that giant placental chorioangioma may have a favorable outcome without any medical intervention. However, close prenatal surveillance is required to detect any complication.
REFERENCES 1. Fox H. Pathology of Placenta, 2nd ed. Philadelphia: W.B. Saunders; 1997. 2. Quintero RA, Reich H, Romero R, et al. In utero endoscopic devascularization of a large chorioangioma. Ultrasound Obstet Gynecol 1996;8:48. 3. Mendez-Figueroa H, Papanna R, Popek EJ, et al. Endoscopic laser coagulation following amnioreduction for the management of a large placental chorioangioma. Prenat Diagn 2009;29:1277. 4. Shafgat G, Igbal F, Rizvi F. Chorioangioma of the placenta with hydrops foetalis. J Pak Med Assoc 2009;59:411. 5. Jauniaux E, Ogle R. Color Doppler imaging in the diagnosis and management of chorioangioma. Ultrasound Obstet Gynecol 2000;15:463. 6. Kirkpatric AD, Podberesky DJ, Gray AE, et al. Best case from AFIP: placental chorioangioma. Radiographics 2007;27:1187. 7. Taori K, Patil P, Attarde V, et al. Chorioangioma of placenta: sonographic features. J Clin Ultrasound 2008;36:113. 8. Zalel Y, Weisz B, Gamzu R, et al. Chorioangiomas of the placenta: sonographic and Doppler flow characteristics. J Ultrasound Med 2002;21:909. 9. Sepulveda W, Alcalde JL, Schnapp C, et al. Perinatal outcome after prenatal diagnosis of placental chorioangioma. Obstet Gynecol 2003;102:1028. 10. Kawamotoa S, Ogawa F, Tanaka J, et al. Chorioangioma: antenatal diagnosis with fast MR imaging. Magn Reson Imaging 2000;18:911. 11. Zanardini C, Papageorghiou A, Bhide A, et al. Giant placental chorioangioma: natural history and pregnancy outcome. Ultrasound Obstet Gynecol 2010;35:332. 12. Nicolini U, Zuliani G, Caravelli E, et al. Alcohol injection: a new method of treating placental chorioangioma. Lancet 1999;15:1674. 13. Lau TK, Leung TY, Yu SC, et al. Prenatal treatment of chorioangioma by microcoil embolisation. BJOG 2003;110:70.
JOURNAL OF CLINICAL ULTRASOUND
A Rare Giant Placental Chorioangioma with Favorable Outcome: A Case Report and Review of the Literature Miaoying Fan, MD, RDMS, Hamid Mootabar, MD Department of Obstetrics and Gynecology, Columbia University, PH12-15, 622W, 168th Street, New York, NY 10032 Received 17 December 2012; accepted 27 May 2014
ABSTRACT: We describe a rare giant placental chorioangioma in a patient who had a favorable outcome with close prenatal surveillance in a 28-year-old primigravida who was referred to our clinic for ultrasound evaluation of a suspected placental mass at 23 weeks’ gestation. A detailed ultrasound scan revealed a well-circumscribed, echogenic lesion measuring 11.0 3 10.3 3 7.3 cm and protruding into the amniotic cavity. A diagnosis of placental chorioangioma was made and intensive prenatal surveillance was scheduled. A small-for-gestational age (2,325 g) but normal female neonate was delivered at 37 weeks by cesarean section and discharged from hospital on the second day of the delivery. A giant chorioangioma may not cause any adverse effect to the fetus and may not require any medication or invasive intervenC 2014 Wiley Periodicals, Inc. J Clin Ultrasound tion. V 43:254–256, 2015; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22187 Keywords: placenta; chorioangioma; prenatal ultrasound; obstetrics
C
horioangioma is the most common benign tumor of the placenta, occurring in approximately 1% of pregnancies.1 Most chorioangiomas are of no significant clinical importance; however, those measuring more than 5 cm in diameter may be associated with maternal and fetal complications.2–5 Herein, we report a case of a pregnant patient who presented with a rare giant placental chorioangioma with a favorable outcome upon close surveillance.
Correspondence to: M. Fan C 2014 Wiley Periodicals, Inc. V
254
CASE REPORT
A 28-year-old African-American primigravida with unremarkable medical history was referred to our clinic for ultrasound evaluation due to a suspected placental mass at 23 weeks’ gestation. Ultrasound examination was performed using a Voluson 730 Expert scanner and a 2–7-MHz transducer (GE Healthcare, Austria). It revealed a single live intrauterine fetus. Fetal anatomic assessment and Doppler blood flow studies of the middle cerebral artery (MCA), umbilical artery, and ductus venosus were unremarkable. The amniotic fluid index was within normal range. A well-defined, oval-shaped, echogenic homogeneous mass was seen near the chorionic surface, measuring 11.0 3 10.3 3 7.3 cm, protruding into the amniotic cavity (Figure 1). Color Doppler ultrasound (CDUS) showed no blood flow within or around the tumor, leading to a presumed diagnosis of placental chorioangioma. The estimated fetal weight was calculated at the tenth percentile for gestational age. Follow-up ultrasound (US) scans for fetal growth velocity, monitoring the placental mass size, and Doppler studies of MCA, umbilical artery, and ductus venosus were conducted every 2 weeks in an effort to rule out possible complications of a giant placental chorioangioma. During the follow-up period, the fetus grew appropriately, and the estimated fetal weight was between the 8th and 13.5th percentile for gestational age. The placental tumor size increased gradually, measuring 13.7 3 11.3 3 8.7 cm at 30 weeks and 4 days’ gestation. JOURNAL OF CLINICAL ULTRASOUND
A RARE GIANT PLACENTAL CHORIOANGIOMA WITH FAVORABLE OUTCOME
FIGURE 1. Sonogram obtained at 23 weeks’ gestation shows a welldefined, homogeneous, echogenic placental mass measuring 11.0 3 10. 3 3 7.3 cm, which projects from the fetal surface of the placenta into the amniotic cavity.
FIGURE 2. Sonogram obtained at 36 weeks and 3 days’ gestation shows that the echotexture of the placental mass has changed dramatically, with an irregular anechoic area and with fibrous septa. The mass has increased in size to 17.9 3 16.0 3 14.0 cm.
The echogenicity pattern of the tumor remained unchanged with homogeneous echogenicity. At 32 weeks 0 days’ gestation, the placental mass appeared heterogeneous with both solid and cystic elements and fibrous septa (Figure 2). There was no blood flow detected within the tumor on CDUS. Most importantly the MCA peak systolic velocity (PSV) peaked at 57. 6 cm/s, which indicated the fetus had mild fetal anemia. Due to the abrupt change of the echotexture of the placental chorioangioma and an increased fetal MCA PSV, intensive perinatal surveillance was planned, including fetal heart rate monitoring, biophysical profile, and MCA PSV Doppler study twice weekly. At 32 weeks and 3 days’ gestation, the MCA PSV had returned to normal range without intervention. VOL. 43, NO. 4, MAY 2015
FIGURE 3. Photomicrograph of the angiomatous-type chorioangioma shows numerous capillary-type vessels with intravascular red blood cells (original magnification, 3200; hematoxylin-eosin stain).
Follow-up US examinations showed that the chorioangioma grew constantly as gestation advanced, with the maximum size of 17.9 3 16.0 3 14.0 cm at 36 weeks 3 days’ gestation. At 37 weeks’ gestation, the patient requested delivery by cesarean section. A small-forgestational-age (2,325 g) but normal female neonate was delivered with Apgar scores of 9 and 10, respectively, at 1 and 5 minutes. The neonatal hematocrit was normal (13.1 g/ml). Two days after delivery, mother and infant both in good condition were discharged from the hospital. The pathologic examination of the placenta showed a large ruptured cyst measuring 12 3 12 3 3 cm containing blood clots with peripheral laminated appearance. Microscopically, numerous capillary-type vessels were seen with intravascular red blood cells (Figure 3). Other vessels were thrombosed. Pathologic diagnosis was consistent with placental angiomatous type of chorioangioma with thrombotic degeneration.
DISCUSSION
Chorioangioma is the most common benign tumor of the placenta, occurring in 0.5% to 1% of all pregnancies.1 Large tumors (>5 cm) are rare, occurring at a rate of 1:3,500–1:9,0002 and may result in significant maternal and fetal complications, including polyhydramnios, preterm labor, fetal congestive heart failure, anemia, fetal growth restriction, and intrauterine fetal death.3–5 Gray-scale US, CDUS, threedimensional (3D) US have been used to diagnose placental chorioangiomas.4,6,7 Gray-scale US is the primary diagnostic tool to identify chorioangiomas, which appear as hypo- or 255
FAN AND MOOTABAR
hyperechoic, circumscribed masses that are distinctly different from the placenta. Those masses may contain anechoic cystic areas that may contain fibrous septa that create the appearance of a complex mass.6,7 CDUS plays an important role in diagnosing placental chorioangioma.5,8 CDUS can confirm the presence of vascular channels in the tumor contiguous with the fetal circulation. These channels help to differentiate chorioangiomas from other placental lesions such as placental teratoma, degenerating fibroid and placental hematoma. CDUS also provides information in predicting and managing the outcomes for these cases.7 3D US and 3D Doppler US may aid in the diagnosis of placental chorioangioma. However, CDUS will not reveal any blood flow within some avascular chorioangiomas and therefore the absence of blood flow in a chorioangioma should not be used to rule out the diagnosis.5,9 In this case, the chorioangioma was an avascular chorioangioma, which was confirmed at pathologic examination. MRI may also be a useful adjunct to US for the antenatal diagnosis of placental chorioangioma. It is especially sensitive to the presence of placental hemorrhage.10 The management and treatment of a chorioangioma depend highly on its size and the presence of associated complications. Small chorioangiomas usually are asymptomatic and do not require treatment except monitoring of the tumor growth by US. Larger chorioangiomas (>5 cm) may be associated with maternal and/or fetal complications. Possible interventions include fetal transfusion in the presence of fetal anemia, and amniodrainage for cases presenting with polyhydramnios.11 However, fetal transfusion and amniodrainage do not affect the underlying pathophysiology of arteriovenous shunting within the chorioangioma. Therefore, ideal treatments should be targeted to block arteriovenous shunting within the chorioangioma to prevent further complications. These treatments to block arteriovenous shunting include alcohol injection,12 microcoil embolization,13 endoscopic laser coagulation, and interstitial laser therapy.11,13 Large placental tumors usually cause severe complications. However, despite the giant size in this case (maximum size of 17.9 3 16.0 3 14.0 cm), there were no significant complications. The fetus had mild anemia, which was
256
detected by an increased MCA PSV at 30 weeks. The mild fetal anemia resolved spontaneously presumably due to thrombosis of the chorioangioma. The maternal and neonatal outcomes were favorable and both mother and neonate were discharged without complications on the second day of delivery. This case demonstrates that giant placental chorioangioma may have a favorable outcome without any medical intervention. However, close prenatal surveillance is required to detect any complication.
REFERENCES 1. Fox H. Pathology of Placenta, 2nd ed. Philadelphia: W.B. Saunders; 1997. 2. Quintero RA, Reich H, Romero R, et al. In utero endoscopic devascularization of a large chorioangioma. Ultrasound Obstet Gynecol 1996;8:48. 3. Mendez-Figueroa H, Papanna R, Popek EJ, et al. Endoscopic laser coagulation following amnioreduction for the management of a large placental chorioangioma. Prenat Diagn 2009;29:1277. 4. Shafgat G, Igbal F, Rizvi F. Chorioangioma of the placenta with hydrops foetalis. J Pak Med Assoc 2009;59:411. 5. Jauniaux E, Ogle R. Color Doppler imaging in the diagnosis and management of chorioangioma. Ultrasound Obstet Gynecol 2000;15:463. 6. Kirkpatric AD, Podberesky DJ, Gray AE, et al. Best case from AFIP: placental chorioangioma. Radiographics 2007;27:1187. 7. Taori K, Patil P, Attarde V, et al. Chorioangioma of placenta: sonographic features. J Clin Ultrasound 2008;36:113. 8. Zalel Y, Weisz B, Gamzu R, et al. Chorioangiomas of the placenta: sonographic and Doppler flow characteristics. J Ultrasound Med 2002;21:909. 9. Sepulveda W, Alcalde JL, Schnapp C, et al. Perinatal outcome after prenatal diagnosis of placental chorioangioma. Obstet Gynecol 2003;102:1028. 10. Kawamotoa S, Ogawa F, Tanaka J, et al. Chorioangioma: antenatal diagnosis with fast MR imaging. Magn Reson Imaging 2000;18:911. 11. Zanardini C, Papageorghiou A, Bhide A, et al. Giant placental chorioangioma: natural history and pregnancy outcome. Ultrasound Obstet Gynecol 2010;35:332. 12. Nicolini U, Zuliani G, Caravelli E, et al. Alcohol injection: a new method of treating placental chorioangioma. Lancet 1999;15:1674. 13. Lau TK, Leung TY, Yu SC, et al. Prenatal treatment of chorioangioma by microcoil embolisation. BJOG 2003;110:70.
JOURNAL OF CLINICAL ULTRASOUND
