This is a case of a 33-year-old, G3P3(3003) female patient with a clinical presentation of vaginal bleeding associated with on and off hypogastric pain. The patient was diagnosed and managed as a case of tubo-ovarian abscess and subsequently underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO). Microscopic sections of both ovaries, however, showed dual population of tumor cells composed of medium-sized, mononucleated cells admixed with multinucleated giant cells with marked pleomorphism, extensive hemorrhage and necrosis. Immunohistochemistry studies using beta-hCG was diagnostic of ovarian choriocarcinoma, favoring non-gestational in origin. Classification of non-gestational choriocarcinoma (NGOC) was established using diagnostic criteria for NGOC established by Saito et al., and Mangla et al. DNA analysis, however, remains to be the gold-standard for differentiating between gestational (GOC) and non-gestational (NGOC) etiology.

Introduction: Obstetrical hemorrhage remains to be one of the most common causes of maternal morbidity and mortality. Postpartum hemorrhage occurs after delivery and is usually secondary to uterine atony, genital tract lacerations, and retained placental fragments. Case: A case of a 21-year old, primipara, presented with profuse vaginal bleeding and hemoptysis at 3 weeks' postpartum. A clinical diagnosis of gestational trophoblastic neoplasia was established after an elevated serum beta human chorionic gonadotropin was obtained and an intrauterine mass was seen on ultrasonography, including metastasis to the lungs and liver seen through imaging studies. Discussion Chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and oncovin (EMACO) is the mainstay treatment for Stage IV disease. However, complications such as hemorrhage and tumor rupture are best managed surgically. Although rare, a diagnosis of choriocarcinoma should be considered in patients with persistent bleeding after a normal pregnancy to institute proper management and avoid associated complications of tumor progression.
Choriocarcinoma ; Gestational Trophoblastic Disease ; Postpartum Hemorrhage

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

Female ; Humans ; Endodermal Sinus Tumor/pathology* ; Adenocarcinoma/pathology* ; Choriocarcinoma/pathology*

Objective: Despite the widespread use and measurement of beta‑human chorionic gonadotropin (β‑HCG) among hydatidiform mole (HM) patients, models derived from this biomarker to predict the remission or postmolar gestational trophoblastic neoplasia (GTN) rarely perform well. The study aimed to generate cutoff points for postevacuation β‑HCG levels and evaluate their performance among women with complete molar pregnancies Methods: A retrospective cohort study composed of women with complete HM underwent bivariate procedures comparing characteristics between the comparison groups. Cut points using Liu’s and Youden’s indices were estimated, and their performance was evaluated using receiver operating characteristic curve analysis. Cox regression to compare time‑to‑progression across these proposed β‑HCG cutoffs was also performed. Results: The incidence of postmolar GTN among the 155 women in the study was 15.5% (95% confidence interval: 10.2%–22.2%). Postevacuation HCG levels had a better prediction of disease status than preevacuation and HCG ratio models (χ2 : 163.07, P < 0.01). A cutoff at 508 mIU/mL the 3rd‑week postevacuation (area under the curve [AUC]: 0.89, sensitivity: 87.5%, specificity: 90.1%) was comparable with the 185 mIU/mL cutoff at the 5th‑week postevacuation (AUC: 0.89, sensitivity: 91.7%, specificity: 87%). The hazards ratio of postmolar GTN was 29.74 (8.53–103.71) and 39.89 (8.82–180.38) for the 3rd and 5th weeks HCG after evacuation adjusting for clinically relevant variables Conclusion The first 3rd‑ and 5th‑week postevacuation levels of β‑HCG demonstrated potential in predicting postmolar GTN. However, further refinement and adjustment for clinically relevant risk factors are still needed.
Choriocarcinoma ; Gestational Trophoblastic Disease ; Prognosis

Choriocarcinoma/pathology* ; Female ; Gene Deletion ; Humans ; PTEN Phosphohydrolase/genetics* ; Pregnancy ; Sequence Deletion ; Stomach Neoplasms/surgery*

Pregnancy ; Female ; Humans ; Choriocarcinoma/pathology* ; Endometrial Neoplasms/pathology*

Gestational trophoblastic neoplasias (GTN) are extremely aggressive tumors derived from placental trophoblasts. These tumors are always the sequalae of a pregnancy. Choriocarcinoma, which is the most common of these, is typically characterized by early extra-pelvic hematogenous spread. Since the progression of illness is rapid, timely diagnosis and treatment will favor improved chances for cure, whereas late commencement of therapy will make resolution difficult. The diagnosis of GTN is straightforward with an elevated beta-human chorionic gonadotropin (β-hCG) and distinct sonographic features of the tumor inside the uterus. However, very rarely, this disease may occur in the absence of uterine tumors. Practicing physicians must be mindful that GTN may initially manifest with pulmonary symptoms and/or radiographic evidence of metastatic lung lesions. In this series, the features pertaining to the clinical course of three patients are described, all of whom presented with pulmonary masses, elevated β-hCG, and normal transvaginal sonograms.
Choriocarcinoma ; Gestational Trophoblastic Disease

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

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