A 32-year-old woman presents 8 weeks after evacuation of a complete hydatidiform mole with persistent vaginal bleeding and abdominal pain. Serum beta-hCG is 250,000 mIU/mL. Pelvic ultrasound shows a heterogeneous uterine mass with mixed solid and cystic components, intense color Doppler flow with low-resistance waveforms, and bilateral ovarian cysts measuring 8–10 cm with multiloculated "bunch-of-grapes" appearance. The structure marked **B** in the diagram represents the primary uterine pathology. Which of the following best explains the development of the bilateral ovarian cysts in this patient?
A. Metastatic spread of trophoblastic tissue to the ovaries with direct invasion and cyst formation
B. Polycystic ovarian syndrome triggered by the hormonal milieu of pregnancy
C. Ovarian hyperstimulation syndrome from exogenous gonadotropin administration during fertility treatment
D. Excessive hCG stimulation of theca cells leading to proliferation and cyst formation, which will regress spontaneously after hCG normalization with chemotherapy
Explanation
Why option 1 is right
The bilateral theca-lutein cysts seen in choriocarcinoma (structure B) are a direct consequence of the markedly elevated beta-hCG produced by the malignant trophoblastic tissue. hCG stimulates theca cells in the ovaries to proliferate, resulting in multiloculated cysts with the characteristic "bunch-of-grapes" or "spoke-wheel" appearance. Critically, these cysts are NOT metastatic deposits but rather a physiologic response to excessive hormonal stimulation. They regress spontaneously and completely once hCG levels normalize following successful chemotherapy — a key distinguishing feature that confirms their benign, hormone-responsive nature (FIGO 2018; NCCN GTN Guidelines).
Why each distractor is wrong
Option 2: While choriocarcinoma is highly aggressive with early hematogenous metastasis, the ovaries are NOT a common site of metastatic spread in GTN. The bilateral, multiloculated cysts are not metastatic lesions but rather a hormonal response. Metastatic disease typically involves lung (80%), brain (10%), liver, and vagina — not the ovaries as primary sites.
Option 3: Polycystic ovarian syndrome is a chronic endocrine disorder characterized by anovulation, hyperandrogenism, and insulin resistance. It is not triggered by the acute hormonal changes of GTN and would not regress with hCG normalization. The cysts in this case are theca-lutein cysts, not the small multiple follicles of PCOS.
Option 4: Ovarian hyperstimulation syndrome (OHSS) occurs in the context of exogenous gonadotropin use during assisted reproductive technology. This patient has no history of fertility treatment; her cysts are a direct response to endogenous hCG from the choriocarcinoma itself.
High-YieldNEET PG
Theca-lutein cysts in GTN are a benign, reversible consequence of hCG stimulation — they regress completely with chemotherapy and serve as a marker of disease burden rather than metastatic spread.
