ABNORMAL PRESENTATION OF ADVANCED GESTATIONAL TROPHOBLASTIC NEOPLASM (GTN) WITH PULMONARY ARTERY OBSTRUCTIVE SYMPTOMS AND PROFOUND ANEMIA P Lowery MD, C Gregg, MD, M Modica MD, Department of Internal Medicine, LSU Health Sciences Center; New Orleans, LA CASE: A 42-year-old woman with a history of untreated Hepatitis C, Pre-diabetes, anxiety, and polysubstance abuse presented withbilateral lower extremity swelling andworseningdyspnea on exertion for 6 days. Initial chest radiographwas consistent with a large right sided pleural effusion. Her hemoglobin was 5.4, RDW was 24.8, and she had 11% nucleated RBCs on the differential. Other labs included LDH 946 and haptoglobin <1, however her direct antiglobulin test was negative. Her HbA1c was <2.9 which was thought to be due to an abnormally high RBC turnover. Her serum BhCG of 180,000 was at the upper limit of normal for a 6-8 week intrauterine pregnancy. Pelvic ultrasound did not reveal intra-uterine gestation. Computed tomographic scan of her chest revealed that the right sided pleural effusion as in fact a large mass incasing the R lung and invading into the mediastinum and abdomen. She also had multiple metastasis in both lungs and diffuse lymphadenopathy. Imaging findings along with such elevated BhCG was consistent with a GTN. DISCUSSION: Gestational Trophoblastic Neoplasm refers to a group of malignant neoplasms that consist of abnormal proliferation of trophoblastic tissue, and may follow a hydatidiform mole or a nonmolar pregnancy. Four histologic subtypes include invasive mole, choriocarcinoma (more aggressive, metastasize early, and secret high levels of BhCG), placental site trophoblastic tumor, and epithelioid trophoblastic tumor (less aggressive, generally remain localized, and do not secrete high levels of BhCG). Approximately 50 percent of cases of GTN arise from molar pregnancy, 25 percent from miscarriages or tubal pregnancy, and 25 percent from term or preterm pregnancy. Estimated incidence of GTN after a term pregnancy is 1 per 150,000 and after a spontaneous miscarriage is 1 in 15,000. Tissue diagnosis is not necessary and often avoided due to high risk of hemorrhage. Highly responsive to chemotherapy agents due to aggressive growth but also likely to develop resistance.
20
Made with FlippingBook Digital Publishing Software