Gestational Trophoblastic Neoplasia With Severe Hyperthyroidism Associated With Markedly Elevated B-HCG And Persistent Disease After TAH-BSO: A Case Report

Abstract

Gestational Trophoblastic Neoplasia (GTN) is a malignant gestational disorder characterized by abnormal trophoblastic proliferation and elevated B-hCG levels. At markedly increased concentrations, B-hCG may exert thyrotropic activity through stimulation of the thyroid-stimulating hormone (TSH) receptor and contribute to clinically significant hyperthyroidism. GTN in perimenopausal women presents particular diagnostic and therapeutic challenges because its manifestations may overlap with common gastrointestinal complaints and physiological changes associated with the menopausal transition. This case report describes a 50-year-old P2A0 perimenopausal woman with GTN complicated by severe thyrotoxicosis and persistent disease following surgical management. The patient initially presented with progressive lower abdominal discomfort, nausea, recurrent vomiting, and mild vaginal spotting and was initially diagnosed with dyspepsia. Further evaluation revealed a uterine mass, serum B-hCG >50,000 mIU/mL, suppressed TSH, and markedly elevated FT4 >7.77 ng/dL, consistent with severe thyrotoxicosis. Preoperative treatment included propylthiouracil, Lugol’s iodine, dexamethasone, and propranolol to reduce the perioperative risk associated with severe thyrotoxicosis. The patient subsequently underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO). Histopathological examination demonstrated malignant trophoblastic proliferation with myometrial invasion. Following surgery, B-hCG levels initially declined substantially but subsequently showed a secondary rise and plateau, consistent with persistent GTN according to FIGO criteria. The patient was then treated with methotrexate-etoposide chemotherapy with leucovorin rescue, with subsequent clinical improvement. This case highlights the importance of considering GTN in perimenopausal women presenting with atypical gastrointestinal or gynecological symptoms, particularly in the presence of markedly elevated B-hCG. Evaluation of thyroid function is important in patients with high B-hCG levels because B-hCG-mediated stimulation of the TSH receptor may represent a likely mechanism of severe thyrotoxicosis. Serial postoperative B-hCG monitoring is also essential for early detection of persistent disease and timely initiation of further therapy.