We report the case of a 55-year-old postmenopausal Syrian woman who presented to the emergency department at our hospital with a history of massive vaginal bleeding for 10 days accompanied by constant abdominal pain with diarrhea and vomiting. Her obstetrical history reported natural menopause 15 months earlier and a history of 14 normal vaginal deliveries (G14P14A0), with the last delivery being 13 years before the current presentation. She had no history of spontaneous abortions, contraceptive drug use or molar pregnancies. Medical and family history were unremarkable. Physical examination revealed a palpable pelvic mass extending up to approximately 3 cm above the umbilicus. The serum beta-human chorionic gonadotropin (b-HCG) level was determined to be 542.250 mU/mL. Pelvic ultrasonography demonstrated an enlarged uterus the size of 24-week gestation, with a heterogeneous mass obliterating the endometrial cavity, with a vesicular appearance and normal ovaries. Computed tomography (CT) scan of the abdominopelvic region confirmed the presence of a well-demarcated mass measuring 25 × 20 × 13 cm with very high-density central cystic content. Thus the primary differential diagnosis included a metastatic endometrial leiomyosarcoma, a choriocarcinoma and an invasive mole. Chest and cranial CT scans were also performed to detect possible metastases, demonstrating mild bilateral pleural effusion with multiple nodular lesions in the basal lung segments, whereas no lesions were detected elsewhere. As the patient was a postmenopausal woman with massive vaginal bleeding, the surgical decision was to perform total hysterectomy with bilateral salpingo-oophorectomy. Gross examination revealed an enlarged uterus measuring 25 × 20 × 13 cm and weighing 3350 g,, with normal bilateral fallopian tubes and ovaries. The endometrial cavity was highly enlarged, and filled with hemorrhagic villi and edematous grape-like vesicles measuring up to 1.5 cm in diameter. Microscopic examination demonstrated a circumferential proliferation of abnormal hyperchromatic trophoblastic cells surrounding edematous hydropic villi invading the myometrium, with a few scattered trophoblastic cells within blood vessels. Based on detailed observation of morphological features accompanied by clinical and radiological correlation, the diagnosis was confirmed as an invasive mole with pulmonary metastases and classified as high risk (stage III: score 14) according to the International Federation of Gynecology and Obstetrics staging system and World Health Organization (WHO) prognostic scoring system: Following surgical resection, the patient was scheduled for combination chemotherapy including methotrexate, etoposide and actinomycin with monitoring of b-HCG levels. However, 2 weeks later the patient was readmitted to the emergency department due to severe dyspnea and hemoptysis. Later the patient developed cardiac arrest and unfortunately she died despite resuscitation efforts. A timeline of the patient's case can be seen in Fig.. Written informed consent was obtained from the patient's legal guardian.