The patient was diagnosed in 2004, at the age of 24 years, with gestational trophoblastic disease. This was three years after her last pregnancy. Initial treatment did not induce remission, and she developed lung and skin metastases in 2005. Treatment continued with chemotherapy (cisplatin, etoposide, and methotrexate) and an autologous bone marrow transplant. She also underwent a hysterectomy. After this treatment, there was some improvement, with regression of the lung nodules. However, her human chorionic gonadotropin (hCG) did not fall significantly at any point. She underwent a course of capecitabine chemotherapy, but at this point, symptom issues were becoming difficult to manage.The main problem came from painful skin metastases. These were raised hemangioma-type lesions widespread over the body, including thorax, scalp, and vulva, and were confirmed to be histologically similar to the primary malignancy. Toward the later stages of her disease, she developed lesions in her right nostril and her left lower eyelid. They were painful to touch and would bleed if traumatized. She was unable to brush her hair, and clothing/underwear caused discomfort.Several approaches were adopted to manage this pain. She was commenced on opioids, which were effective in the initial stages. Topical lidocaine and diamorphine were used for the vulval lesions, but with little effect. Radiotherapy to the lesions on the thorax was not helpful. Good pain relief was gained with gabapentin, but systemic disease was advanced by this point. Treatments, such as ketamine, were not used as the patient had a somewhat chaotic lifestyle and had difficulties managing medication.The patient deteriorated from the point of view of her lung disease. She became increasingly breathless, with an intractable cough and hemoptysis. She died earlier this year. CommentGestational trophoblastic disease with skin metastases is exceedingly rare. 3 It has been difficult to monitor trends of this disease due to the lack of a clear classification system and the absence of histological diagnosis in some cases. 1
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