Snapshot A 28-year-old woman presents to the emergency department after coughing blood. Her symptom is associated with progressively worsening shortness of breath. She has a past medical history of bilateral theca-lutein ovarian cysts. A radiagraph of the chest demonstrates multiple radiopaque pulmonary lesions. Laboratory studies are remarkable for highly elevated β-hCG. Introduction Overview a type of gestational trophoblastic neoplasia made up of cytotrophoblasts and syncytiotrophoblasts without villi most commonly of placental origin most commonly spreads to the lungs, leading to shortness of breath and hemoptysis can follow a molar pregnancy or can arise from the ovaries and testes as a germ cell tumor Epidemiology incidence extremely rare (<1% of ovarian tumors) Associated conditions theca-lutein ovarian cysts molar pregnancy (more common after a complete than a partial mole) Presentation Symptoms shortness of breath and hemoptysis suggests metastasis to the lung Physical exam pelvic mass Imaging Radiography of the chest indication to evaluate cause of shortness of breath or hemoptysis findings "cannonball" metastases Studies Serum labs ↑ β-hCG Histology trophoblasts and cytotrophoblasts with syncytiotrophoblast central hemorrhage with necrosis cytologic atypia Differential Dysgerminoma differentiating factors associated with elevated lactic acid dehydrogenase (LDH) Treatment Medical chemotherapy indication mainstay of treatment highly sensitive to chemotherapy medications methotrexate Complications Hemorrhage secondary to its high vascularity