Gestational trophoblastic neoplasia (GTN) is primarily treated with chemotherapy, but surgery plays a key role at different steps in disease management, including initial diagnosis, primary therapy, and salvage options. Initial diagnosis is usually made by electric or manual vacuum aspiration for molar pregancy or uterine curettage for other forms of GTN. Excisional procedures of localized disease, whether second curettage or hysterectomy, can obviate chemotherapy, but patients still require monitoring for relapse. Resection remains a useful adjunct for either the management of isolated foci of chemoresistant disease or the management of bleeding complications.

Complete and partial molar pregnancies arise from abnormal fertilization with marked proliferation of syncytiotrophoblasts. Earlier diagnosis has reduced the frequency of severe medical complications at presentation; however, the risk of progression to gestational trophoblastic neoplasia (GTN) has remained unchanged. Initial assessment should include serum hCG measurement after physical examination, laboratory testing for organ dysfunction, and Doppler ultrasound. Following uterine evacuation, pathologic assessment can distinguish complete from partial moles or non-molar gestations. Close surveillance is essential for the timely diagnosis of GTN. Cure rates and subsequent obstetrics outcomes are excellent, but all patients should be referred for psychologic support and expert level care.

Background: Metastatic vulvar choriocarcinoma, a rare ectopic gestational trophoblastic neoplasia (GTN), often presents a diagnostic challenge due to its mimicry of other conditions, particularly in resource-limited settings. Its primary symptom is abnormal vaginal bleeding without a clear cause. Consequently, diagnosing and managing it poses difficulties for many low-resource health facilities, as evidenced by the current case. Case Presentation: We present the case of a 25-year-old, P2+2+2L2, who had a large painless, bleeding vulva mass for nearly 5 months. This followed a spontaneous abortion the month prior. The mass gradually increased in size and was accompanied by fever, pus discharge, and weight loss. Despite being treated at multiple health facilities for a vulvar abscess, there was no improvement. A diagnosis was finally made at a tertiary facility where elevated quantitative serum beta-human chorionic gonadotropin (hCG) (β-hCG) was noted. Due to uncontrollable vulva bleeding, she was referred to another tertiary facility for emergency radiotherapy. Following stabilization, chemotherapy was administered using the EMA-CO protocol. Conclusion: The report highlights the difficulty in diagnosing vulvar choriocarcinoma, underscoring the importance of a high index of suspicion. Clinical tests such as serum (β-hCG) and imaging studies are crucial for diagnosis. In resource-limited settings, a simple strip-based urine pregnancy test with serial dilutions can be sufficient for diagnosing and managing vulvar choriocarcinoma.

Majority of gestational trophoblastic neoplasia (GTN) follows molar pregnancies where diagnosis is mostly based on persistent or rising serum human chorionic gonadotrophin (hCG). Diagnosis of GTN could be based on clinical presentation, serum hCG measurement, imaging, histology, and genotyping. A high index of suspicion in women of reproductive age presenting with abnormal vaginal bleeding or unusual systematic presentation is important. An accurate staging and classification system for GTN is crucial to evaluate the risk and the prognosis of patients, and to optimize treatment. GTN is staged using the International Federation of Gynecology and Obstetrics 2000 staging and the modified World Health Organization prognostic scoring system.

OBJECTIVE: To elucidate the clinicopathological characteristics and oncological outcomes of a special group of patients with gestational trophoblastic neoplasia (GTN) initially presenting with isolated lung lesions, elevated human chorionic gonadotropin (hCG) levels, and unobserved pelvic lesions.
METHODS: Overall, 2358 patients with GTN treated at our hospital between 2000 and 2023 were retrospectively reviewed, and 40 patients were evaluated. The demographic characteristics, clinicopathological features, treatment data, and follow-up information of each patient were collected. The primary outcome was progression free survival. Kaplan-Meier analysis and univariate and multivariate Cox proportional hazard analyses were used to identify the risk factors.
RESULTS: Among the 40 patients, 95.0 % had solitary lung lesions, with a median size of 1.9 cm. Moreover, 72.5 % of patients were pathologically confirmed as epithelioid trophoblastic tumors (ETT). During a median follow-up period of 53.5 months (range, 2-143), 11 patients experienced recurrence, including all patients who received chemotherapy alone as the initial treatment, and no death was observed. Relapse treatment involved lung segmentectomy and lobectomy combined with chemotherapy and immunotherapy. Univariate and multivariate Cox analyses identified comparing with surgery±chemotherapy, chemotherapy alone as the initial treatment (hazard ratio [HR] =7.738, 95 % confidence interval [CI] 1.698-35.269, P = 0.008) as independent risk factor for recurrence.
CONCLUSIONS: In patients with a history of pregnancy exhibiting isolated pulmonary lesions, elevated hCG levels (mostly <1000 mIU/mL), and unobserved pelvic lesions, ETT should be considered first. Surgical resection of lung lesion is crucial for optimal management. When chemotherapy is considered, multidrug regimen is recommended.

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.

UNASSIGNED: In addressing Gestational Trophoblastic Neoplasia (GTN), it is imperative to acknowledge the evolving landscape of treatment options, especially in light of the challenges posed by traditional methods. While historically, surgical interventions, radiation therapy, and chemotherapeutic agents have been the mainstays, the emergence of resistance and high-risk scenarios necessitates a reevaluation of our therapeutic approaches. Our review highlights the promising advancements in immunotherapy and molecular targeted therapy as viable alternatives for GTN management. The introduction of immune checkpoint inhibitors and kinase inhibitors offers a paradigm shift, particularly for patients resistant to conventional chemotherapy regimens. These novel therapies not only exhibit efficacy but also demonstrate manageable toxicity profiles, particularly in high-risk cases. However, integrating these innovative treatments into established international guidelines presents a formidable task. As we move forward, it is imperative that future research not only prioritizes fertility preservation but also rigorously evaluates long-term toxicity implications. International collaboration becomes pivotal in addressing the nuances of this rare and complex disease. In conclusion, our review underscores the need for a nuanced approach to GTN treatment, one that prioritizes reduced toxicity and improved quality of life. By embracing the advancements in immunotherapy and molecular targeted therapy, we can pave the way for more effective and patient-centered care in the management of GTN.

UNASSIGNED: This study aimed to determine the clinical outcomes of ultra high-risk gestational trophoblastic neoplasia (GTN) patients managed with and without induction chemotherapy in the Division of Trophoblastic Diseases, Department of Obstetrics and Gynecology, Philippine General Hospital.
UNASSIGNED: Clinical and demographic data were collected retrospectively from ultra high-risk GTN patients admitted in the Division of Trophoblastic Diseases, Department of Obstetrics and Gynecology, Philippine General Hospital from January 2015 to December 2021. Rate of remission and early death of those who received induction chemotherapy were compared to those who did not.
UNASSIGNED: A total of 21 patients with ultra high-risk GTN were included in the study, nine of whom underwent induction chemotherapy while 12 had no induction chemotherapy and was given the standard EMACO regimen. There was no significant difference in the rate of early death as well as the rate and time to achieve remission between those who received induction chemotherapy compared to those who were immediately started on EMACO.
CONCLUSIONS: A firm conclusion cannot be drawn from the results considering the small population included in the study. Further studies with larger sample size and prospective study design are recommended.

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.

The present study reports a rare case of an exaggerated placental site (EPS) in a caesarean scar that was misdiagnosed as gestational trophoblastic neoplasia (GTN) by imaging, resulting in unnecessary surgical treatment. A 38-year-old woman underwent hysteroscopic resection of a cesarean scar pregnancy (CSP). The patient\'s serum β-human chorionic gonadotropin (β-hCG) level was elevated (76,196 mIU/ml) at the 24-day postoperative follow-up visit. On postoperative day 51, the patient experienced vaginal bleeding for three days and β-hCG levels were 2,799 mIU/ml. Ultrasonography and MRI revealed a heterogeneous mass and hypervascularity. The patient was diagnosed with a GTN in a cesarean scar and treated with methotrexate (MTX). β-hCG levels decreased after 3 MTX doses, but the mass did not change in size and was still hypervascular on imaging. Total hysterectomy was performed due to the serious side effects of chemotherapy and the lack of desire to preserve fertility. The histological findings supported the diagnosis of an EPS reaction. The present case is unique because of the rare intrauterine mass and possibility of retained trophoblastic changes causing EPS. EPS differs from GTN both clinically and pathologically and should be considered a possible diagnosis in any woman who has irregular bleeding following CSP resection.