Summary
A 27 year young lady with recent history of molar pregnancy referred from outside as a case of suspected astrocytoma of brain and was finally diagnosed as a case of ultrahigh risk Gestational Trophoblastic Neoplasia (GTN) stage IV (brain, liver, lung metastasis) with risk Score 14.Patient received whole brain radiotherapy (WBRT) + Triple intra thecal (IT) therapy followed by 2 cycles of Etoposide and Cisplatin (EP), 9 cycles of EMA-CO, 4cycles of EP-EMA. Again patient had risen of β hCG for which she received 6 cycles of VeIP. Patient is having persistently low β hCG for last 2 years. Multiple regimens of chemotherapy and multidisciplinary team effort were the key factor for success of this ultrahigh risk patient GTN patient management.
Key words: FIGO -The International Federation of Gynecology and Obstetrics, VeIP- vinblastine, ifosfamide, cisplatin, hCG – Human Chorionic Gonadotropin, CSF- Cerebrospinal fluid.

Introduction
GTN is described as “God’s first cancer and man’s first cure”, refers to spectrum of malignant trophoblastic disease comprising invasive mole, Choriocarcinoma, Placental site trophoblastic tumor (PSTT) and epitheloid trophoblastic tumor (ETT). GTN patient with the FIGO score <7 is low risk, score ≥7 is high risk and ≥12 is defined as ultrahigh-risk GTN and it carries poor prognosis.1 There is a high likelihood of resistance to first line chemotherapy, hence optimal therapy is controversial.2 Here, we have selected the case as it gave us the insight to confront the different challenges, complications and learning we came across related to ultrahigh stage GTN with multi organ metastasis.

Case Report
A 27 years lady para 1 live 1 with 1 abortion 6 months back presented with astrocytoma of brain on June 2017 in our institute. At admission complaint was vomiting, headache and paraplegia. On past obstetric history and scrutiny of old documents revealed that she had suction and evacuation for molar pregnancy abortion and she was followed up with serum β hCG outside but it never touched the normal level. CT scan shows multiple brain metastatic lesion in left occipital region (largest 2.2 cm) with peri-lesional oedema, 2 lung metastasis and liver metastasis. At admission her serum β hCG was 5,17694 IU/L, CSF β hCG- 2855.0 IU/L. On evaluation WHO prognostic score was 14 and FIGO stage IV. Initially she was treated in ICU with mannitol, phenytoin, blood transfusion, electrolyte correction and other supportive measures. Multi-disciplinary tumor board was conducted and started with whole brain radio therapy (WBRT) 30 Gray 10 fractions followed by intra thecal (IT), triple chemotherapy (MTX, cytarabine, hydrocortisone). As etoposide, methotrexate, actinomycin, cyclophosphamide, vincristine (EMACO) cannot be given with WBRT and etoposide, cisplatin (EP) will be toxic with RT hence, interim biweekly triple IT was given in view of WBRT induced initial rise of β hCG.

Thereafter 9 cycles of EMACO and 2 cycles of EP(low dose) received through internal jugular vein chemo port till 29th November 2017. At the completion her serum β hCG came down to 7.8 IU/L. Patient required intermittent G-CSF injection for neutropenia. Due to rise in hCG 4 cycles of EMA- EP was given till 14th February 2018. Patient developed herpes labialis, low ANC. Due to poor tolerance of chemo dense therapy and stable β hCG(plateau at 5.5 IU/L) in near complete remission range decision was made to no further chemotherapy and closely observe the patient with every week serum β hCG monitoring. On 25th April 2018 there was rise in serum β hCG from 10.47 IU/L (previous) to 131.0 IU/L within a week. On 1st May serum β hCG came 461.0 IU/L. PET CT showed 3.5x3.2 lesion in posterior wall of uterus, multiple well defined opacities in the both lung field, 1.3x1 cm hypo dense lesion with peripheral enhancement in left occipital region with no appreciable uptake. Vinblastine, ifosphamide, cisplatin (VeIP) chemotherapy started. After 3rd cycle VeIP β hCG normalized and thereafter 3 more cycles of VeIP continued till 10th October 2018.

Following 6th cycle of VeIP CT scan was done which revealed 1.3 cm hypo dense lesion in posterior wall of uterus, 0.9 cm soft tissue opacities in bilateral lung field- suggestive of responding of disease. Clinical examination was normal except bulky uterus. Patient is in follow up in stable condition with persistently normal serum β hCG of 0.1 IU/L for last 2 years.