Gestational trophoblastic neoplasia (GTN) with spinal metastasis is rare with few documented cases worldwide. Few studies have explored chemotherapy combined with radiotherapy in the treatment of such cases. However, because of its rarity, there is still no standardized treatment regimen. A 34-year-old Gravida 1 Para 0 (0010) was diagnosed with GTN with metastasis to the lumbosacral spine, resulting in conus medullaris syndrome with lumbar radiculopathy. She presented with a 14-month history of amenorrhea, left lower extremity pain, and urinary and bowel retention. On examination, there was a 10.0 × 7.0 cm lumbosacral mass and atrophy of the left lower extremity. Transvaginal ultrasound showed a cul de sac mass, and diluted β-human chorionic gonadotropin (β-hCG) titer was markedly elevated at more than 1000 000 mIU/mL. Magnetic resonance imaging (MRI) of the lumbosacral spine showed an ill-defined sacral mass measuring 13.3 × 11.5 × 6.3 cm with spinal canal, bone, muscle, and nerve root involvement. She was treated with 10 cycles of EMACO and palliative radiotherapy with 10 sessions of 30 Gy of external beam radiation therapy directed toward the lumbosacral mass. Repeat MRI showed a decrease in size of the mass to 6.6 × 8.2 × 4.1 cm with concurrent decrease in β-hCG to 1.30 mIU/ml, and resolution of leg pain and urinary and bowel symptoms. She was declared to be in remission 3 months after the last cycle of EMACO.

Primary choriocarcinoma originating in the lung is a rare entity. These are highly malignant intrapulmonary tumors with a notoriously poor prognosis. The pathogenesis is unclear. A 34-year-old lady, with a history of abortion six months back, presented with left-sided chest pain for one month, dyspnea on exertion, weight loss, and loss of appetite. Computed tomography (CT) of the thorax was suggestive of a mass lesion 4 x 5 cm at the left upper lobe, which was invading the chest wall, and pleural effusion, histopathologically defined as adenocarcinoma. A positron emission tomography-computed tomography (PET-CT) scan showed a fluorodeoxyglucose (FDG) avid lesion in the left upper lobe of size 4 x 5 with invasion to the chest wall with no evidence of distant metastases. Urine pregnancy test (UPT) was negative for this patient. Thus, the patient was initially diagnosed with stage cT3N0M0 adenocarcinoma of left lung cancer. The sample was sent for the lung next-generation sequencing (NGS) panel. Meanwhile, the patient was empirically started on gefitinib. Tumor markers revealed raised beta-human chorionic gonadotropin (β-hCG) to 1,79,000 IU/ml. A review biopsy was done, which was suggestive of choriocarcinoma. Genetic testing of lung biopsy suggestive of XX chromosome, confirming the diagnosis of primary pulmonary choriocarcinoma (PPC). The patient was planned for chemotherapy with etoposide and cisplatin. The patient underwent embolization of the left internal mammary artery (IMA) and branches of the left subclavian vein. There was a gradual fall in β-hCG after the second dose of chemotherapy on day 7. For the diagnosis of PPC, immunohistochemistry (IHC) staining, β-hCG measurement, and examination to exclude primary gonadal malignancies are essential. A combination of surgery and chemotherapy is a favorable treatment. As it\'s a highly vascular tumor, selective arterial embolization can be life-saving in case of bleeding.

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.

BACKGROUND: Choriocarcinoma is a highly malignant pregnancy-related trophoblastic neoplasm, characterized by early metastasis to the lungs. Therefore, patients may manifest nongynecological symptoms owing to distant metastases. The incidence of choriocarcinoma after a term pregnancy is really rare (1/160,000 pregnancies).
METHODS: We report a case of a 20-year-old Iranian woman, gravida 2 para 1 live 1 abortion 1, who was referred to our gynecology department with sudden onset dyspnea and pain in the left hemithorax the day after her labor. The index pregnancy was without any complications. After the initial workup, the elevation of β-human chorionic gonadotropin (HCG) levels (> 1,000,000) along with the identification of clinical (vaginal lesions) and radiological evidence of distant metastases (bilateral pulmonary nodes) directed us toward pulmonary metastatic choriocarcinoma diagnosis. After the oncology consult, the etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine chemotherapy regimen was started for the patient. She responded well to the treatment and is currently continuing her chemotherapy process.
CONCLUSIONS: The prognosis of choriocarcinoma is very good if the treatment is started on time. We suggest that clinicians should consider gestational trophoblastic neoplasia in their differential diagnosis of the post-natal period complications, especially after a term and nonmolar pregnancy.

A 65-year-old man with dyspnea and hemoptysis presented with a right upper lobe mass associated with enlarged mediastinal lymph nodes and bilateral pulmonary nodules on chest computed tomography (CT), suspected lung cancer. Bronchial and CT-guided biopsies revealed poorly differentiated carcinoma. His condition deteriorated rapidly before a definitive diagnosis could be made. Autopsy revealed primary mediastinal choriocarcinoma. Primary mediastinal choriocarcinomas are rare, difficult to diagnose early and have a poor prognosis. In patients with a tumor expanding across the lung and mediastinum and exhibiting pathologic findings of a pooly differentiated carcinoma, we should consider choriocarcinoma, evaluating the serum β-human chorionic gonadotropin levels.

BACKGROUND: Choricocarcinoma is a highly malignant tumor. It metastasize commonly to the lungs. Metastasis to the kidney is uncommon, and bilateral metastasis is described rarely. Initial presentation with spontaneous bleeding of the renal metastatic tumor is scarce in the literatures. Here we present a case report of a choriocarcinoma patient with bilateral renal metastasis, presenting with spontaneous renal hemorrhage.
METHODS: A 22 years old female presented to our emergency department with sudden onset of left flank pain. She has history of spontaneous abortion 02 years back with biopsy from the manual vacuum aspiration (MVA) showing molar pregnancy. Up on evaluation, patient was anemic. CT scan showed left renal bleeding tumor. Exploratory laparotomy and radical nephrectomy was done with the impression of bleeding renal cell carcinoma. The biopsy revealed choriocarcinoma. On her follow up, CT scan showed right renal and brain metastasis. She was given multi agent chemotherapy and her serum beta-hCG became undetectable after 01 year.
CONCLUSIONS: Choriocarcinoma can be gestational or nongestational. The commonest route of metastasis is hematogenous. Presenting symptoms of renal metastasis can be hematuria, pain or more commonly incidental finding during work up. Choriocarcinoma is highly chemo sensitive.
CONCLUSIONS: Bilateral renal metastatic choriocarcinoma is uncommon. Spontaneous renal hemorrhage as an initial presentation is even rare, and it can mimic a bleeding renal cell carcinoma. High index of suspicion is needed in a young women with recent history of spontaneous abortion.

BACKGROUND: Choriocarcinoma is a rare and highly malignant form of gestational trophoblastic disease that may develop following pregnancy, abortion, or a hydatiform mole. Renal metastatic involvement by post molar choriocarcinoma is even rarer. In this case report, we describe a unique case of post molar choriocarcinoma with a solitary renal metastasis in the absence of a primary uterine tumor and metastases in other sites, which presented with urological symptoms and spontaneous renal hemorrhage.
METHODS: A 41-year-old Persian woman with history of complete hydatiform mole presented with severe flank pain, nausea, vomiting, gross hematuria, and vaginal bleeding. Laboratory tests demonstrated a serum beta human chorionic gonadotropin hormone level of 60,000 mIU/mL. Imaging studies showed a lesion at the lower pole of the left kidney with active bleeding surrounded by hematoma, as well as an empty uterine cavity. Additionally, bilateral pleural effusion was detected without any lesion within the lungs. Subsequently, the patient underwent laparotomy, partial nephrectomy, and left para-ovarian cystectomy. Endometrial curettage was also carried out. The histopathology report revealed choriocarcinoma renal metastasis with high expression of beta human chorionic gonadotropin, cytokeratin 7, and Ki 67. Moreover, there were no malignant cells in the endometrial curettage specimens, and a corpus luteum cyst was found within the para-ovarian cyst. Further investigations revealed that the pleural effusion was free of malignant cells, and there was no evidence of metastatic lesions in the brain. As a result, the patient was referred to the oncology department to receive chemotherapy, and the beta human chorionic gonadotropin levels dropped to 5 mIU/mL after receiving courses of a standard regimen of etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine/oncovin over 3 weeks. Finally, monthly measurements of beta human chorionic gonadotropin levels for 6 months indicated that levels have constantly remained within normal ranges, showing no evidence of recurrence or new metastasis.
CONCLUSIONS: Urological symptoms such as hematuria or spontaneous renal hemorrhage might be the only presentation of post molar choriocarcinoma with renal involvement. Thus, it can be beneficial to measure serum beta human chorionic gonadotropin levels among females of childbearing age who present with unexplained urological symptoms, especially if there is a history of prior hydatiform mole.

BACKGROUND: Delayed postpartum hemorrhage is rare, with an incidence of 0.5% to 2.0% in all pregnancies. The most important causes are placental remnants, infections, and placental bed subinvolution. Postpartum choriocarcinoma, a highly malignant complication of pregnancy, is a rare condition that can be easily misdiagnosed as other common causes, such as gestational remnants, and delays the diagnosis.
METHODS: Four patients visited our clinic complaining of delayed postpartum hemorrhage, combined with respiratory and neurological symptoms in 2 cases. Two cases were confirmed by histopathological examination and in addition, medical history, elevated human chorionic gonadotropin (hCG) level, and imaging findings help confirm the diagnosis of delayed postpartum hemorrhage caused by postpartum choriocarcinoma in other cases. Individualized combination chemotherapies were prescribed. In the light of massive cerebral metastasis in case 2, intrathecal methotrexate injection combined with whole-brain radiotherapy was prescribed.
RESULTS: Due to the absence of routine monitoring of β-hCG following full-term delivery, there was widespread metastasis at the time of diagnosis. Three patients got complete remission and there is no sign of recurrence. One patient had relapse and widespread metastasis and died at home 6 months after the last chemotherapy.
CONCLUSIONS: It is important to be aware of the possibility of choriocarcinoma in patients with delayed postpartum hemorrhage. Clinicians should improve the recognition of choriocarcinoma following full-term delivery, emphasize the monitoring of β-hCG, comprehensively analyze the general condition of patients, and conduct standardized and individualized chemotherapy protocols.

UNASSIGNED: Choriocarcinoma is a rapidly progressive, widely metastatic, β-human chorionic gonadotropin (β-hCG)-secreting malignant tumor originating from trophoblast cells. Most choriocarcinomas are pregnancy-related. Choriocarcinoma of nonpregnant origin is very rare.
METHODS: A 60-year-old woman underwent abdominopelvic resection (APR) for low rectal cancer in May 2020. Postoperative pathological findings showed a poorly differentiated adenocarcinoma. Because of a post-operative recurrence, then she underwent chemotherapy for rectal adenocarcinoma. In February 2021, imaging finding showed metastases in her liver, both lungs and pelvis. Surprisingly, the β-hCG level was significantly elevated. A transvaginal pelvic tumor biopsy was performed and the pathology report was presented after discussions: choriocarcinoma differentiated carcinoma was considered, with no adenocarcinoma component detected. Then the patient underwent chemotherapy regimens for choriocarcinoma, which were initially effective but quickly became resistant. The patient died 8 months after the diagnosis of adenocarcinoma of the rectum transformed into choriocarcinoma.
UNASSIGNED: The dedifferentiation of adenocarcinoma to choriocarcinoma is rarely diagnosed and the disease is often overlooked, leading to delays in diagnosis and treatment, documenting cases and their clinical outcomes is important for future research and to improve patient prognosis. Perhaps genomic assessment using next-generation sequencing (NGS) technology could help in diagnosis and guide therapeutic strategies.
CONCLUSIONS: We report a very rare case of non-pregnant choriocarcinoma transformed from primary rectal adenocarcinoma. Awareness of secondary biopsies in special cases and genetic testing based on the dynamics of the disease should be raised in clinical practice to better develop precise treatment plans.

Choriocarcinoma (CC) is a malignant neoplasm of the trophoblastic tissue, with a potential to metastasise to distant organs. Limited case of gestational CC develops after a long latent period. We report a 52-year-old postmenopausal woman who developed metastatic choriocarcinoma presumably of gestational origin, 8 years after the last pregnancy and 2 years after the last menstrual period. The patient was brought to the emergency room of a tertiary care centre in Muscat, Oman, in 2022 and was diagnosed with CC metastatic to the brain, spleen, lung and the kidney. The β-human chorionic gonadotrophin level was found to be raised (1,292,867 mIU/mL). The International Federation of Gynecologic Oncology risk score was calculated to be 14 (very high risk). The patient was initially treated with whole-brain radiotherapy and splenic artery embolisation because of a hemoperitoneum. Afterwards the patient received systemic treatment using the standard EMA/CO regimen till complete serological remission.