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A series of missing primaries: Pulmonary metastasis in Gestational Trophoblastic Neoplasia in the absence of uterine tumors

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.