GESTATIONAL TROPHOBLASTIC NEOPLASIA–THE GREAT MASQUERADER

Objective: To report 4 cases of gestational trophoblastic neoplasia (GTN) with varied interesting presentations who were admitted in our hospital between 2011 and 2014. Methodology: Medical records of these 4 patients with high risk GTN were examined. All 4 patients were treated with combination chemotherapy-EMACO. Conclusion: GTN can have varied presentations depending upon the site of metastasis. A high index of suspicion and close follow up with serum β hCG is necessary for early diagnosis and treatment. Introduction: Most cases of Gestational trophoblastic neoplasia (GTN) are diagnosed with plateauing or rising serum β hCG levels following evacuation of hydatidiform mole. We report 4 interesting cases of GTN with varied presentations depending on the site of metastasis, months or even years after the causative pregnancy. Early diagnosis of gestational trophoblastic neoplasia increases the chances of cure with chemotherapy. Hence a high index of suspicion and close follow up with β hCG is necessary for early diagnosis and treatment. Case 1: Haemothorax A 24 year old multipara presented to emergency department with complaints of sudden onset left sided chest pain and breathing difficulty for a day, 2 months following term delivery. Prior obstetric historyObstetric score: P2L2VM1 (Para2 live2 vesicular mole1) 1st pregnancy: She had lower segment caesarean section for non-reassuring fetal status and delivered a term baby girl 3.12 kg in June 2009. 2nd pregnancy: She was diagnosed to have partial mole when she presented with bleeding per vaginum at 18 weeks and 1 day of gestation in April 2011.Her serum β hCG pre evacuation was 10,000 mIU/ml. Suction evacuation was done, but she was lost for further follow up. 3rd pregnancy: She delivered a term baby boy by lower segment caesarean section done in August 2012.Serum β hCG was not checked at 6 weeks post-delivery. Following 2 months of lactational amenorrhea, postpartum, she presented to our emergency department with chest pain and breathlessness. She was anaemic, tachycardic, tachypnoeic, and had decreased air entry on the left side of chest. Her Chest X-ray showed left sided pleural effusion .CT scan showed left pleural effusion with partial lung collapse and multiple lung nodules {Figure1}. Liver and brain imaging was normal. Her serum β hCG was found to be 156,400 mIU/ml. She was stabilised with blood transfusion followed by insertion of intercostal drainage tube and 1.5 litres of hemorrhagic pleural fluid was drained. She was diagnosed as GTN Stage III: FIGO score 11 and was started on combination chemotherapy with EMACO (Etoposide, Methotrexate, Actinomycin-D, Cyclophosphamide, Vincristine). She received 12 cycles of EMACO totally; the 11th cycle was delayed by 2 weeks as she developed neutropenia which responded to granulocyte colony stimulating factor. She received 2 cycles of chemotherapy after normalisation of serum β hCG and was on monthly follow up. After the last cycle of EMACO, her 3 consecutive monthly β hCG reports were normal. In the fourth and fifth month after completion of chemotherapy, her β hCG values were 14 and 400 mIU/ml respectively. She was advised metastatic work up and the need for further chemotherapy, but she refused treatment. Two months later, she presented to the emergency de-