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Gestational Trophoblastic Disease and Choriocarcinoma.

CLINICAL HISTORY A 33-year-old G5P2032 female patient with gynecologic history notable for complete hydatidiform mole in 2011 was successfully treated with suction curettage and subsequent completed 8 weeks of methotrexate therapy with normalization of hCG. The patient became pregnant and underwent a spontaneous first trimester miscarriage in April 2012 treated with dilation and curettage (D & C), followed by a new pregnancy and normal vaginal delivery in January 2013. In July 2013, the patient was noted to have persistently elevated hCG while breast-feeding and on reliable contraception. At the time, it was uncertain if this elevation of hCG was related to a new pregnancy or demonstrated persistent elevation since her delivery. Patient underwent a repeat D &C with pathology negative for molar pregnancy. The patient continued with persistent elevation of hCG and was treated with several doses of methotrexate, followed by weekly methotrexate in another state facility. Patient also received actinomycin D/dactinomycin at the completion of methotrexate administration. The patient continued having vaginal discharge and irregular bleeding with elevated hCG up to 14,000 mIU/mL. Imaging performed at an outside institution revealed 2-cmmass in the uterus. Findings were consistent with gestational trophoblastic disease (GTD) with invasive mole or choriocarcinoma on the differential. Patient presented to our institution for discussion of therapeutic options consisting of etoposide, methotrexate, actinomycin D/cyclophosphamide, vincristine (EMA/CO) chemotherapy versus hysterectomy. Patient underwent a total vaginal hysterectomy, and a pathological diagnosis of choriocarcinoma was made.