Figure 1
Chorioangioma
Placental chorioangioma
SectionGenital (female) imaging
Case TypeClinical Cases
AuthorsAlves N1, Loureiro T2, Sousa M1, Ramalho C2.
Connected authors
33 years, female
Clinical History
Healthy 33-year-old patient, came for her third-trimester ultrasound evaluation.
Prenatal history was unremarkable.
This gestation was at 30 weeks and 4 days, and so far there had been no complications.
The current evaluation revealed a new imaging finding.
Prenatal history was unremarkable.
This gestation was at 30 weeks and 4 days, and so far there had been no complications.
The current evaluation revealed a new imaging finding.
Imaging Findings
Next to the insertion of the umbilical cord there was a discrete hypoechoic mass about 40 x 35 mm with internal hyperechoic linear images (fig.1a). The mass displayed prominent colour Doppler (CD) signal and vessels could be seen entering the mass (fig. 1b-e).
On the following ultrasound (US) examinations, mass growth was noted reaching a maximum diameter of 61 mm, keeping the aforementioned characteristics.
During the remainder of the pregnancy amniotic fluid was never elevated (fig. 2), nor was there an abnormality in the Doppler evaluation of the middle cerebral and umbilical arteries.
On the following ultrasound (US) examinations, mass growth was noted reaching a maximum diameter of 61 mm, keeping the aforementioned characteristics.
During the remainder of the pregnancy amniotic fluid was never elevated (fig. 2), nor was there an abnormality in the Doppler evaluation of the middle cerebral and umbilical arteries.
Discussion
Background
Chorioangioma, originally described in 1798 by Clarke, is believed to be the most common tumour of the placenta, presenting in about 1% of pregnancies [1]. On the other hand, large chorioangiomas have been reported to occur in 1:500 to 1:16, 000 births [2].
Chorioangiomas are benign vascular tumours without malignant potential, resulting from excess capillarization of the developing chorion [3].
Clinical Perspective
Most chorioangiomas are asymptomatic, but large (>4-5 cm) or multiple chorioangiomas are frequently associated (up to 50%) with fetal and maternal complications due to shunting, including: polyhydramnios, cardiomegaly, intrauterine growth restriction, fetal hemolytic anaemia and thrombocytopenia, toxaemia, placental abruption, preeclampsia, preterm labour and congenital abnormalities [2-8].
Imaging Perspective
The first sonographic diagnosis of chorioangioma was done in 1978 by Asokan [9].
Chorioangioma presents at US as well circumscribed hypo- or hyperechoic mass that may contain anechoic cystic areas [2,3,8]. Large lesions may contain fibrous septa [2,8]. It classically protrudes into the amniotic cavity near the cord insertion [2,3,6].
CD is essential to the diagnosis revealing pulsatile flow contiguous with the fetal circulation inside the cystic spaces [2,10]. Doppler distinguishes chorioangioma from other similar masses: haematoma, degenerative leiomyoma, incomplete hydatidiform mole, and teratoma. The differential diagnosis of placental tumours also includes metastases [1-6,11].
Doppler imaging may also have prognostic value in large chorioangiomas: during follow-up there may be spontaneous infarction presenting with internal calcifications, decreased echogenicity, tumour volume, and blood flow, although the only finding may be decreased vascular density at three-dimensional CD evaluation [2,8]. These findings correlate with better prognosis [2,4,8,12]. As an incidental finding, a degenerating chorioangioma without Doppler signal might be mistaken for haematoma although occasionally chorioangiomas may present without appreciable internal flow on CD [2,6]. Finally, the rare chorionic vessel aneurism also presents with internal colour flow [6].
If US is inconclusive, Magnetic Resonance is reported to help: chorioangioma presents as an heterogeneous mass hyperintense on T2-weighted images [8].
The finding of a chorioangioma should prompt a careful search for fetal complications, namely careful evaluation of middle cerebral and umbilical arteries and aorta [2,3].
Outcome
The outcome is worse when there is a larger amount of vascularised tissue for the fetal cardiovascular system to perfuse (i.e. larger chorioangiomas) [2].
These tumours are usually followed weekly [11].
Treatment options include serial fetal transfusions, laser coagulation of tumour-supplying vessels, alcohol chemosclerosis, and endoscopic surgical devascularisation [2,13,14].
Patient was asymptomatic, and followed with US weekly until uneventful delivery.
Chorioangioma, originally described in 1798 by Clarke, is believed to be the most common tumour of the placenta, presenting in about 1% of pregnancies [1]. On the other hand, large chorioangiomas have been reported to occur in 1:500 to 1:16, 000 births [2].
Chorioangiomas are benign vascular tumours without malignant potential, resulting from excess capillarization of the developing chorion [3].
Clinical Perspective
Most chorioangiomas are asymptomatic, but large (>4-5 cm) or multiple chorioangiomas are frequently associated (up to 50%) with fetal and maternal complications due to shunting, including: polyhydramnios, cardiomegaly, intrauterine growth restriction, fetal hemolytic anaemia and thrombocytopenia, toxaemia, placental abruption, preeclampsia, preterm labour and congenital abnormalities [2-8].
Imaging Perspective
The first sonographic diagnosis of chorioangioma was done in 1978 by Asokan [9].
Chorioangioma presents at US as well circumscribed hypo- or hyperechoic mass that may contain anechoic cystic areas [2,3,8]. Large lesions may contain fibrous septa [2,8]. It classically protrudes into the amniotic cavity near the cord insertion [2,3,6].
CD is essential to the diagnosis revealing pulsatile flow contiguous with the fetal circulation inside the cystic spaces [2,10]. Doppler distinguishes chorioangioma from other similar masses: haematoma, degenerative leiomyoma, incomplete hydatidiform mole, and teratoma. The differential diagnosis of placental tumours also includes metastases [1-6,11].
Doppler imaging may also have prognostic value in large chorioangiomas: during follow-up there may be spontaneous infarction presenting with internal calcifications, decreased echogenicity, tumour volume, and blood flow, although the only finding may be decreased vascular density at three-dimensional CD evaluation [2,8]. These findings correlate with better prognosis [2,4,8,12]. As an incidental finding, a degenerating chorioangioma without Doppler signal might be mistaken for haematoma although occasionally chorioangiomas may present without appreciable internal flow on CD [2,6]. Finally, the rare chorionic vessel aneurism also presents with internal colour flow [6].
If US is inconclusive, Magnetic Resonance is reported to help: chorioangioma presents as an heterogeneous mass hyperintense on T2-weighted images [8].
The finding of a chorioangioma should prompt a careful search for fetal complications, namely careful evaluation of middle cerebral and umbilical arteries and aorta [2,3].
Outcome
The outcome is worse when there is a larger amount of vascularised tissue for the fetal cardiovascular system to perfuse (i.e. larger chorioangiomas) [2].
These tumours are usually followed weekly [11].
Treatment options include serial fetal transfusions, laser coagulation of tumour-supplying vessels, alcohol chemosclerosis, and endoscopic surgical devascularisation [2,13,14].
Patient was asymptomatic, and followed with US weekly until uneventful delivery.
Differential Diagnosis List
Placental Chorioangioma
Hematoma
Leiomyoma
Teratoma
Final Diagnosis
Placental Chorioangioma
References
[1] Wallenburg HC (1971) Chorioangioma of the placenta: thirteen new cases and a review of the literature from 1939 to 1970 with special reference to the clinical complications. Obstet Gynecol Surv 26: 411–425 (PMID: 4950893)
[2] Zalel Y, Weisz B, Ronni G, Schiff E, Shalmon B, Achiron R (2002) Chorioangiomas of the placenta: sonographic and Doppler flow characteristics. J Ultrasound Med 21: 909–913 (PMID: 12164576)
[3] Polat P, Suma S, Kantarcy M, Alper F, Levent A (2002) Color Doppler US in the evaluation of uterine vascular abnormalities. RadioGraphics 22: 47–53 (PMID: 11796897)
[4] Wehrens X, Offermans J, Snijders M, Peeters L (2004) Fetal cardiovascular response to large placental chorioangioma. J Perinat Med 32: 107–112 (PMID: 15085884)
[5] Napolitano R, Maruotti G, Mazzarelli L, Quaglia F, Tessitore GP (2005) Prenatal diagnosis of placental chorioangioma: our experience. Minerva Ginecol 57: 649–654 (PMID: 16306870)
[6] Sepulveda W, Aviles G, Carstens E, Corral E, Perez N (2000) Prenatal diagnosis of solid placental masses: the value of color flow imaging. Ultrasound Obstet Gynecol 16:554–558 (PMID: 11169350)
[7] Harris RD, Cho C, Wells WA (1996) Sonography of the placenta with emphasis on pathological correlation. Semin Ultrasound CT MR 17: 66–89 (PMID: 8845194)
[8] Kirkpatrick AD, Podberesky DJ, Gray AE, McDermott JH (2007) Best cases from the AFIP: Placental chorioangioma. Radiographics 27:1187-90 (PMID: 17620474)
[9] Asokan S, Chadalavada K, Gardi R, Sastry V. (1978) Prenatal diagnosis of placental tumor by ultrasound. J Clin Ultrasound 6(3):180-1 (PMID: 97323)
[10] BromleyB, Benacerraf BR (1994) Solid masses on the fetal surface of the placenta: differential diagnosis and clinical outcome. J Ultrasound Med 13: 883–886 (PMID: 7837336)
[11] Prapas N, Liang RI, Hunter D, et al (2000) Color Doppler imaging of placental masses: differential diagnosis and fetal outcome. Ultrasound Obstet Gynecol 16:559–563 (PMID: 11169351)
[12] HataT, Kanenishi K, Inubashiri E, et al (2004) Three-dimensional sonographic features of placental abnormalities. Gynecol Obstet Invest 57: 61–65 (PMID: 14671412)
[13] WanapirakC, Tongsong T, Sirichotiyakul S, Chanprapaph P (2002) Alcoholization: the choice of intrauterine treatment for chorioangioma. J Obstet Gynaecol Res 28: 71–75 (PMID: 12078971)
[14] Quintero RA, Reich H, Romero R, Johnson MP, Goncalves L, Evans MI (1996) In utero endoscopic devascularization of a large chorioangioma. Ultrasound Obstet Gynecol 8: 48–52 (PMID: 8843620)
Case information
| URL: | https://eurorad.org/case/9163 |
| DOI: | 10.1594/EURORAD/CASE.9163 |
| ISSN: | 1563-4086 |
Figure 2
Fetal US
US shows a normal amount of fluid in the amniotic cavity.
Fetal US
US shows a normal amount of fluid in the amniotic cavity.