This is the first reported case of the use of immunotherapy in chemo-resistant Gestational Trophoblastic Neoplasia (GTN) in the country. A 41-year-old, Gravida 4 Para 3 (3013) with a diagnosis of GTN, Stage III: WHO risk score of 13 (Choriocarcinoma) was initially managed with 10 cycles of multiple agent Etoposide, Methotrexate, Actinomycin D- Cyclophosphomide and Vincristine (EMACO) and 19 cycles of Etoposide, Cisplatin- Etoposide Methotrexate and Actinomycin D (EP-EMA). With continuous rise in beta human chorionic gonadotropin (ßhCG) levels, the patient was referred to a Trophoblastic Disease Center where there was note of tumor progression to the brain. She was started on third-line salvage chemotherapy of Paclitaxel and Carboplatin (PC) with concomitant whole brain irradiation completing three cycles after which chemoresistance was again diagnosed with increasing hCG titers and increase in the number and size of the pulmonary masses which were deemed unresectable. Immunotherapy was started with Pembrolizumab showing a good response with marked fall in ßhCG levels. The onset of immune-related adverse events (irAEs) caused a marked delay in subsequent cycles of immunotherapy. With management of the irAEs, two more cycles of Pembrolizumab with fifty percent dose reduction were given with corresponding drop in ßhCG levels. However, the patient subsequently developed gram-negative septicemia with possible hematologic malignancy and finally succumbed to massive pulmonary embolism. The case highlights the importance of prompt diagnosis and referral to a Trophoblastic Disease Center and the use of immunotherapy in chemo-resistant GTN.
Gestational Trophoblastic Disease ; Choriocarcinoma ; Pembrolizumab

A 28-year old, G5P4 (4014), noted neck lymph nodes associated with cough. A chest X-ray was done showing a left nodular opacity. Antibiotics were prescribed with a resolution of symptoms. Five months after, a routine chest X-ray revealed interval progression in size of the lung nodule. A chest computed tomography (CT) scan and positron-emission tomography scan were done subsequently showing the precise location and size of the nodule and with no other focus of tumor seen. Transvaginal ultrasound was normal. With an initial diagnosis of lung carcinoma, a percutaneous needle aspiration biopsy under CT scan guidance was done. Immunohistochemical staining panel showed that beta-human chorionic gonadotropin (hCG) was positive. Subsequently, a serum beta-hCG done showed low levels from 33.48 to 59.7 mIU/ml. The final diagnosis given was a poorly differentiated malignancy highly suggestive of malignant trophoblastic tumor. A video-assisted left upper lobectomy was performed with histopathology and immunohistochemistry consistent with epithelioid trophoblastic tumor with co-existing choriocarcinoma elements. Postoperative beta-hCG level dropped to normal and remained so for 2½ years.
Choriocarcinoma ; Chorionic Gonadotropin

Pseudo-Meigs' syndrome (PMS) is a rare disease characterized by the triad of (1) an ovarian neoplasm, other than a fibroma or thecoma, (2) ascites, and (3) pleural effusion. Tumors such as struma ovarii, mucinous and serous cystadenomas, and germ cell tumors have been linked with the condition. Due to its clinical features combined with the elevation of serum cancer antigen 125 (CA-125) levels, it is often mistaken and treated as a malignant ovarian tumor. Ascites or pleural effusion could be massive leading to various life-threatening complications. Despite its presentation, this entity has an excellent prognosis when surgical excision of the tumor is performed. This article presents an unusual case of a 41-year-old gravida 10 para 10 (10-0-0-9) who was diagnosed with a case of struma ovarii associated PMS with concomitant abdominopelvic tuberculosis and elevated CA-125 resembling an ovarian malignancy.
Ascites ; Struma Ovarii ; Meigs Syndrome ; CA-125 Antigen ; Abdominal Neoplasms

Extrauterine choriocarcinoma is a rare entity. The criteria used for its diagnosis are as follows: (1) Absence of disease in the uterine cavity, (2) pathologic confirmation of diagnosis, (3) exclusion of molar pregnancy, and (4) absence of a coexistent intrauterine pregnancy. Delay in the diagnosis can be attributed to its nongynecologic manifestations such as bleeding from any organ system, unexplained systemic symptoms, and metastatic foci from an unknown primary malignancy. This is an unusual case of 27-year-old G3P3 (3-0-0-3) who underwent emergency left parietal craniotomy excision due to increased intracranial pressure symptoms secondary to left parietal tumor. Histopathology revealed metastatic adenocarcinoma. About a month later, she underwent exploratory laparotomy for acute abdominal symptoms secondary to a jejunal mass. Jejuno-jejunal resection anastomosis was done and histopathology revealed choriocarcinoma.
Choriocarcinoma ; Gestational Trophoblastic Disease

von Hippel Lindau syndrome is a rare genetic disease which may present with bilateral adrenal masses requiring surgical intervention. Previous practice at UP-PGH was to perform outright total adrenalectomy on pathologic adrenal glands and rely on lifelong steroid replacement for patients who had both adrenals removed. Presented here is a case of a patient diagnosed with von Hippel Lindau syndrome with bilateral adrenal masses, surgically managed initially with open adrenalectomy on the right side, followed by the first ever performed minimally invasive cortical sparing adrenalectomy at UP-PGH on the left side.
Adrenalectomy