Elevated Beta-human Chorionic Gonadotropin Research Articles

Presentation Invasive Mole After Normal Pregnancy: A Very Rare Case Report

Gestational trophoblastic neoplasia (GTN) is a rare neoplasm and is a spectrum of proliferative disorders of placenta. Invasive mole is a subtype of GTN that almost always arises after molar pregnancy. This report presents a 35-year-old woman with an atypical presentation of invasive mole after a normal pregnancy. The patient presented with a complaint of vaginal bleeding after normal vaginal delivery. Invasive mole was diagnosed based on findings of imaging and elevated beta human chorionic gonadotropin (ß-hCG) levels. Hysterectomy was finally decided upon due to severe vaginal bleeding and the patient’s request. Although GTN occurs after normal delivery, the patient recovered without receiving chemotherapy. It is important to consider all subtypes of GTN as a differential diagnosis of patients with abnormal postpartum bleeding and elevated ß-hCG levels even after a normal pregnancy.

Primary Hepatic Choriocarcinoma with Pregnancy: A Diagnostic and Therapeutic Challenge

Choriocarcinoma occurs mainly in the gonads, but an extragonadal origin has been reported, albeit infrequently. Primary hepatic choriocarcinoma (PHC) is a rare malignancy, with only 11 cases reported. Most cases reported were in males, with none reported in pregnant females. A 23-year-old primigravida presented with a large liver lesion involving the right lobe of the liver at 28 weeks of pregnancy. Preoperative imaging was suggestive of hepatocellular carcinoma. She underwent a non-anatomical resection of the liver lesion. Surprisingly, her postoperative histopathology revealed a diagnosis of PHC. Her blood workup showed elevated beta human chorionic gonadotrophin. She underwent a termination of her pregnancy at 32 weeks. Before initiating adjuvant chemotherapy four weeks after surgery, a whole-body PET scan revealed multiple bi-lobar liver and pelvic deposits. After a multidisciplinary team discussion, she was started on adjuvant chemotherapy. She is currently under regular follow-up, seven months post-surgery. PHC, one of the vascular lesions of the liver, poses a diagnostic and therapeutic challenge, warranting a multidisciplinary approach.

Epithelioid trophoblastic tumor: A case series.

An epithelioid trophoblastic tumor (ETT) is an extremely rare gestational trophoblastic tumor. Cases of ETT present with abnormal vaginal bleeding in women of reproductive age group with marginally elevated beta human chorionic gonadotrophin (B-hCG) levels. Here, we describe a series of four patients (all were females) including histomorphology, immunoprofiles, and diagnostic difficulty of this rare entity. All cases were in their reproductive age group. The mean pre-treatment hCG level was 665.24 (mIU/mL). Microscopically, all cases had a tumor showing an epithelioid appearance arranged in large nests and sheets. Individual tumor cells were round to polygonal with abundant eosinophilic cytoplasm, with central vesicular nuclei and prominent nucleoli. Areas of hemorrhage, necrosis, and intercellular hyaline-like material deposition were identified in all cases (100%). Immunohistochemically, tumor cells in all cases showed diffuse positivity for AE1/AE3 and p63 (100%). GATA3 was available in one case (25%), which was positive in the tumor cells. In one case (25%), hPL was focally positive, and in one case (25%), it was negative. SALL4 was performed in two cases (50%) and was negative in tumor cells. The mean Ki67 labeling index was 19.2 (range 10-30%). All four patients underwent surgical intervention and were treated with hysterectomy. The mean follow-up in this series was 39.4 months (range 6-70), and all patients are alive to date with a mean survival of 32.8 months (range, 4-67).

A Rare Case of Non-Gestational Ovarian Mixed Intermediate Trophoblastic Tumor Associated with a Mature Cystic Teratoma

Abstract Introduction/Objective Ovarian non-gestational trophoblastic tumors are rare with only a few documented cases. We report a case of a 22-year-old non-sexually active woman who presented to the emergency department with ongoing left lower quadrant abdominal pain. Workup showed elevated Beta-human chorionic gonadotropin levels (152 mIU/mL) and a left ovarian mass. This was initially thought to be an ectopic pregnancy, however patient was non- sexually active. Patient underwent a left oophorectomy and the specimen was sent to pathology. Methods/Case Report Microscopic examination of the ovary revealed a mature cystic teratoma with intimately associated foci of loosely cohesive pleomorphic atypical cells. The atypical cells also replaced some of the blood vessel walls and infiltrated the residual ovarian parenchyma. Mitoses were present at (2/10hpf). No necrosis or chorionic villi were identified. Immunohistochemical stains were performed, and the atypical cells were positive for GATA3, inhibin, and human placental lactogen. These cells also showed an elevated ki67 proliferative index (15%). All these findings supported a diagnosis of a placental site trophoblastic tumor. Focally, well-defined cystic structures composed of large epithelioid cells were also noted. These epithelioid cells were positive for GATA3, inhibin, and p63. These cells were negative for human placental lactogen and showed an elevated ki67 proliferative index (12%), findings consistent with an epithelioid trophoblastic tumor component. Ovarian intermediate trophoblastic tumors are rare and could be of gestational or non-gestational origin. To confirm a non-gestational origin, DNA genotyping was performed. Results showed identical genetic profiles in the teratoma, the intermediate trophoblastic tumor, and in the patient’s benign ovarian tissue. This finding confirmed the diagnosis of a non-gestational mixed intermediate trophoblastic tumor associated with a mature cystic teratoma. This tumor is exceedingly rare with only a few reported cases in literature. Results (if a Case Study enter NA) NA Conclusion The diagnosis of a non-gestational mixed intermediate trophoblastic tumor is exceedingly rare with only a few reported cases in literature. The combination of immunohistochemistry and dna genotyping confirmed our suspicion and yielded the correct diagnosis.

Persistently elevated β-human chorionic gonadotropin level after vacuum-assisted uterine aspiration: a case report

BackgroundUrothelial carcinoma of the bladder accounts for nearly 90% of all bladder cancers. Risk factors include cigarette smoke, chronic cystitis, and human papilloma virus infection. It is commonly diagnosed by hematuria, obstructive voiding, and irritative symptoms. Despite the prevalence of urothelial carcinoma, elevation of β-human chorionic gonadotropin in the setting of these malignancies is not common. This case report informs gynecologic practitioners to consider urologic causes of β-human chorionic gonadotropin elevation even in the setting of recent spontaneous abortion and details comprehensive review of diagnostic testing in the setting of β-human chorionic gonadotropin elevation.Case presentationA 49-year-old, non-Hispanic Caucasian woman, former smoker, with a history of polycystic ovary syndrome, high-risk human chorionic gonadotropin infection, and hypertension, underwent vacuum-assisted aspiration for significant vaginal bleeding in the setting of incomplete abortion. Fetal tissue was confirmed pathologically. Human chorionic gonadotropin levels decreased to 12.5 mU/mL and were no longer followed due to resumption of menses. Five months later during routine preoperative evaluation for orthopedic surgery, her human chorionic gonadotropin level was found to be elevated. She was also noted to have persistent asymptomatic hematuria. She completed an extensive gynecologic and urologic work-up, including hysteroscopy, dilation and curettage, methotrexate therapy, computerized tomographic imaging, and cystoscopy to finally arrive at the diagnosis of urothelial carcinoma.ConclusionsOnly a rare subset of urothelial carcinomas secretes β-human chorionic gonadotropin. Therefore, diagnosis of urothelial carcinoma is typically achieved by urine cytology with cystoscopic biopsy. Although rare, urothelial carcinoma should be considered in patients with risk factors presenting with persistently elevated beta-human chorionic gonadotropin.

Ovarian dysgerminoma in a 14-year-old presenting with an adnexal mass and elevated beta-human chorionic gonadotropin (beta-hCG)

Introduction: Ovarian germ cell tumors most commonly affect young women in the second and third decades of life. Dysgerminomas account for 30–50% of malignant ovarian germ cell tumors and are classically associated with elevated lactate dehydrogenase (LDH). Elevated human chorionic gonadotropin (hCG) in the setting of an adnexal mass in this age group may raise concern for ectopic pregnancy. It is critical to maintain a high index of suspicion for possible germ cell tumor in young women with adnexal masses to avoid unnecessary surgical spillage that might upstage a malignancy. We present a case of a 14-year-old female with adnexal mass and elevated hCG who was ultimately diagnosed with ovarian dysgerminoma. Case Report: A 14-year-old female presented to the emergency room with vaginal bleeding and altered mental status and was found to have a markedly elevated beta-hCG, normal LDH, and an 8 cm complex adnexal mass. She underwent minimally invasive surgery and was ultimately diagnosed with stage 1A dysgerminoma with abundant synctiotrophoblast giant cells. Patient remained in remission for four years until she began experiencing new irregular periods. This time she was found to have an elevated LDH, normal B-hCG, and a 10 cm pelvic mass. She underwent exploratory laparotomy, removal of pelvic mass, right salpingo-oophorectomy, pelvic lymph node debulking, and adjuvant chemotherapy with bleomycin, etoposide, and cisplatin (BEP). Conclusion: Dysgerminoma, the most common malignant ovarian germ cell tumor, may present with the uncommon profile of markedly elevated hCG and otherwise normal tumor markers. While ectopic pregnancy must be considered in this scenario, keeping dysgerminoma in the differential diagnosis of a young woman with a solid adnexal mass and elevated hCG may allow for intact removal of the mass, possibly helping to avoid adjuvant chemotherapy.

Subsequent left distal tubal pregnancy following laparoscopic tubal sterilization: a case report

Background: Post-sterilization pregnancies are rare and many postulations were made for its mechanism. Abdominal pain in women with retained uterus mandates a pregnancy test, regardless of previous tubal surgery or sterilization surgery to exclude the possibility of ectopic pregnancy. Prevention via surgical approach not only prevents future occurrence but also confer prophylaxis measure against ovarian cancer. Case: A 39-year-old woman who had undergone open right salpingectomy due to tubal pregnancy presented with abdominal pain, a positive pregnancy test, and elevated beta-human chorionic gonadotropin (β-hCG) level. Furthermore, an ultrasound exam revealed the absence of a gestational sac in the uterine cavity but the presence of a left adnexal mass; hence ectopic pregnancy was suspected. Laparoscopy revealed a 3 × 4 cm bulging ectopic pregnancy at the left distal end of the remnant stump in the ampulla. The histopathological assessment confirmed ectopic pregnancy in the left distal tubal stump. Post-operation, β-hCG levels decreased. The patient fully recovered postoperatively. Discussion: Ectopic pregnancies after tubal sterilization are caused by fistula formation and intraperitoneal sperm transmigration. To avoid this possibility, surgical techniques should be used to obliterate the residual canal, including the precise location and depth of electrocautery to prevent fistula formation. Total salpingectomy is the recommended treatment approach for effective permanent sterilization and a prophylaxis measure against ovarian cancer.

Elevated Beta-Human Chorionic Gonadotropin in a Non-pregnant Female With Altered Kidney Function

Elevated beta-human chorionic gonadotropin (beta-hCG) levels in postmenopausal women is a finding known in the literature; however, it still commonly leads to unnecessary and extensive diagnostic workup. We present the case of a 48-year-old African-American postmenopausal female with acute kidney injury on chronic kidney disease (CKD) stage 5 and an incidental finding of elevated serum beta-hCG. Abdominal and transvaginal ultrasound showed no evidence of intrauterine or ectopic pregnancy or gestational trophoblastic disease. Menopausal status was confirmed with follicle-stimulating hormone (FSH) measurement, and following the improvement of renal status, beta-hCG levels were normalized to expected values for the patient’s age group. The etiology of elevated beta-hCG was suspected to be from the pituitary as previous literature has shown decreasing beta-hCG levels in postmenopausal women following the administration of gonadotropin-releasing hormone (GnRH) antagonist.

Incomplete abortion with elevated beta-human chorionic gonadotropin levels mimicking a molar pregnancy

Abstract Rationale: Incomplete abortion often causes a lot of bleeding and may lead to severe anemia. The elevated beta-human chorionic gonadotropin (beta-hCG) level is often associated with a molar pregnancy. We report a case of incomplete abortion with elevated beta-hCG levels mimicking a molar pregnancy. Patient concerns: A 29-year-old woman experienced prolonged vaginal bleeding for several months. She had an artificial abortion one year before, however, vaginal bleeding was noted, and the local clinic prescribed progesterone and transamine to stop the bleeding. The amount of bleeding decreased after medication, but persistent bleeding was noted. Diagnosis: She visited our hospital where the urine pregnancy test was positive. Ultrasound and computed tomography showed a hematometra (4.5 cm × 4.3 cm), thickened endometrium, and mild ascites. An elevated serum beta-hCG level of 32980.4 mIU/mL was observed along with a hemoglobin level of 7.2 g/dL. Incomplete abortion or molar pregnancy was suspected. Interventions: Endometrial curettage was performed. Outcomes: Pathology showed the gestational product and chromosome analysis showed normal karyotyping. Incomplete abortion was diagnosed. Postoperative follow-up was uneventful and the beta-hCG level returned to normal after 3 months. Lessons: Incomplete abortion with elevated beta-hCG levels is a rare condition that mimics a molar pregnancy. Transvaginal ultrasound, quantitative serum hCG evaluation, and other laboratory tests (e.g., complete blood count) are essential preoperative investigations.

A series of missing primaries: Pulmonary metastasis in Gestational Trophoblastic Neoplasia in the absence of uterine tumors

Gestational trophoblastic neoplasias (GTN) are extremely aggressive tumors derived from placental trophoblasts. These tumors are always the sequalae of a pregnancy. Choriocarcinoma, which is the most common of these, is typically characterized by early extra-pelvic hematogenous spread. Since the progression of illness is rapid, timely diagnosis and treatment will favor improved chances for cure, whereas late commencement of therapy will make resolution difficult. The diagnosis of GTN is straightforward with an elevated beta-human chorionic gonadotropin (β-hCG) and distinct sonographic features of the tumor inside the uterus. However, very rarely, this disease may occur in the absence of uterine tumors. Practicing physicians must be mindful that GTN may initially manifest with pulmonary symptoms and/or radiographic evidence of metastatic lung lesions. In this series, the features pertaining to the clinical course of three patients are described, all of whom presented with pulmonary masses, elevated β-hCG, and normal transvaginal sonograms.

Induction Chemotherapy Reduces Radiation Therapy Dose and Volume in the Treatment of Intracranial Germinoma: Results of the SMC-G13 Trial

We performed a prospective single-arm trial (NCT02782754) to explore the feasibility of reducing radiation therapy (RT) dose when induction chemotherapy is combined in the treatment of intracranial germinoma with beta-human chorionic gonadotropin levels <200 mIU/mL. All patients aged 3 to 35 years from November 2012 to June 2018 were eligible for this study. Four cycles of induction chemotherapy were given before RT. Carboplatin/etoposide and cyclophosphamide/etoposide regimens were used in alternation every 3 weeks. A dose of 18 Gy of craniospinal RT for metastatic tumors, whole brain RT for basal ganglia tumors, or otherwise whole ventricular RT followed by 12.6 Gy of boost RT to the primary tumor bed was administered after induction chemotherapy. The primary endpoint of this study was progression-free survival. A total of 41 consecutive patients were enrolled (location: suprasellar in 12, pineal in 12, both suprasellar and pineal in 11, and basal ganglia in 6 patients). Eleven patients had leptomeningeal seeding. Toxicity during chemotherapy was mild, except for bone marrow suppression. Tumor status after induction chemotherapy was complete response in 33 patients and partial response in 8. All but 2 patients completed the scheduled treatment. All patients but 1 remained event free during a median follow-up of 3.4 (range, 0.3-7.0) years from diagnosis. The 1 patient experienced relapse and died of tumor bleeding. Late effects were not significant except for neuroendocrine dysfunction already present at diagnosis. Vertical growth and cognitive function were not significantly disturbed by treatment. This study showed the feasibility of reducing RT dose/volume with induction chemotherapy in pathologically pure germinoma with elevated beta-human chorionic gonadotropin levels up to 200 mIU/mL.

An uncommon spontaneous right distal tubal pregnancy post bilateral laparoscopic sterilization

Rationale:Tubal sterilization as a contraception method has a high success rate; however, it also carries a low risk of incidental pregnancy. A majority of these pregnancies are ectopic. In this study, we report a rare case of spontaneous right distal tubal pregnancy after bilateral laparoscopic tubal sterilization.Patient concerns:A 36-year-old woman who had undergone bilateral laparoscopic tubal sterilization presented with abdominal pain and a positive test for pregnancy.Diagnosis:Ectopic pregnancy was suspected based on absence of gestational sac in the uterine cavity on ultrasound and elevated beta-human chorionic gonadotropin (β-hCG) level.Intervention:Since the patient had unstable vitals, emergency laparoscopic surgery was performed, which revealed a right distal fallopian tube pregnancy. We performed a complete bilateral residual tubal stump excision.Outcomes:The patient recovered well after surgery, with a reduction in β-hCG level, and was discharged after 3 days.Lessons:To ensure complete sterilization, the gap at the excised end needs to be adequately widened and enhanced with electro-destruction to prevent formation of a fistula.

Ultrasound diagnosis of a molar pregnancy

We describe a case of a middle-aged female presenting with vaginal bleeding and elevated beta-human chorionic gonadotropin. Transvaginal ultrasound images were consistent with a molar pregnancy. This example highlights the benefit of including emergency ultrasound in the clinical management of suspected gestational trophoblastic disease. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Schreiber S, Wallace L, Boulger CT, Bahner DP. Bedside sonography primer: Ultrasound diagnosis of a molar pregnancy. OPUS 12 Scientist 2013;7(1):1-2.

An Unusual Case of Acquired Uterine Arteriovenous Malformation With Persistent Scar Ectopic Pregnancy Successfully Managed With Uterine Artery Embolization

Uterine arteriovenous malformation (AVM) is a rare entity in gynecology, with fewer than 100 cases reported in the literature. AVM is an abnormal arteriovenous connection lacking an intervening capillary network on histopathological examination. We report an unusual case of acquired AVM after dilatation and curettage of cesarean scar ectopic pregnancy managed with uterine artery embolization and concurrent methotrexate administration for persistently elevated beta-human chorionic gonadotropin levels. J Med Cases. 2016;7(4):143-147 doi: http://dx.doi.org/10.14740/jmc2458w

Unusual Presentation of Hypothyroidism in a Pregnant Woman, Mimicking Gestational Trophoblastic Neoplasm.

Hypothyroidism is a common health issue worldwide with varying clinical manifestations. We report a woman who experienced an incomplete abortion and undiagnosed hypothyroidism who was referred to the oncologist with the suspicion of metastatic gestational trophoblastic neoplasm (GTN). A 29-year-old woman with incomplete abortion was referred to an oncologist for possible GTN due to persistent active vaginal bleeding, an elevated beta human chorionic gonadotropin (hCG), abnormal cervical inspection exam, abnormal liver function tests, ovarian enlargement, ascites, and a pleural effusion. She was found to have hypothyroidism in further work-up. She was managed with thyroid hormone replacement therapy and her condition improved after 6 weeks. Complete resolution of the ovarian mass and pericardial and pleural effusion was achieved. This case describes an important experience; hypothyroidism should be considered in the differential diagnosis of any woman with an incomplete abortion presenting with an ovarian mass. Evaluation and correct diagnosis are important to prevent mismanagement.

Ovarian Dysgerminoma

Dysgerminomas are rare ovarian malignancies that primarily affect young women and can occur during pregnancy. Clinically, these tumors present with lower quadrant pain and adnexal mass, and laboratory values may include elevated beta human chorionic gonadotropin (β-hCG) and lactate dehydrogenase (LDH). These symptoms, along with the sonographic findings of a large, solid lobulated adnexal mass in young women, strongly suggest an ovarian dysgerminoma in the differential diagnosis. The majority of these tumors will be diagnosed at Stage IA and will respond well to fertility-sparing surgery. This case report demonstrates both the clinical and sonographic findings unique to this rare type of ovarian malignancy.

Management of dual intracranial germinoma by radiotherapy alone

Synchronous intracranial germ cell tumor in the pineal and suprasellar region is rare. They represent only 5–10% of all intracranial germinomas. They are also known by the entity “double midline atypical teratoma” and are common in the second decade of life. We report a case of an 11-year-old girl having dual midline intracranial lesions with obstructive hydrocephalus treated by ventriculo-peritoneal shunt. Diagnosis of germinoma was made on the basis of imaging and elevated beta-human chorionic gonadotropin in cerebrospinal fluid. Radiotherapy was instituted, which resulted in the total disappearance of both the lesions. Clinical expression, diagnosis and management strategies are discussed.

Intensive chemotherapy followed by reduced-dose radiotherapy for biopsy-proven CNS germinoma with elevated beta-human chorionic gonadotropin

In this study, 10 patients with biopsy-proven germinoma with a beta-human chorionic gonadotropin (β-HCG) level >50 mIU/ml received intensive chemotherapy followed by reduced-dose radiotherapy (RT) to reduce late effects from RT. CSF β-HCG levels were >200 mIU/ml in five patients. After endoscopic or stereotactic biopsy, four cycles of induction chemotherapy were administered prior to RT. A CEB regimen (carboplatin+etoposide+bleomycin) and a CyEB regimen (cyclophosphamide+etoposide+bleomycin) were alternated. No residual tumor remained after induction chemotherapy in six patients, only cystic lesions were present at the primary tumor site in three, and a small solid residual tumor was observed in the remaining patient; however, all these patients had normal β-HCG levels. If complete response was achieved before initiation of RT, 19.5Gy craniospinal RT (CSRT)+10.8Gy local RT was administered to the tumor bed. If residual lesion was suspected, the dose of RT was selected according to the presence/absence of tumor dissemination at diagnosis (19.5Gy CSRT+19.8Gy local RT for localized tumors and 24.0Gy CSRT+16.2Gy local RT for disseminated tumors). Eight patients, including four patients with a β-HCG level >200mIU/ml, received 19.5Gy CSRT. All patients remain disease free at a median follow-up of 58 (range 35-94) months from diagnosis. Our data suggest that pathologically pure germinoma with a significantly elevated β-HCG level might be cured with reduced-dose RT if intensive chemotherapy is provided.

Paraparesis and pleural effusion in a young patient: A road less travelled

Intrapulmonary teratoma is a rare tumor of the lung, which is scarcely reported to have metastasis at presentation. Here, we report a case of a 14-year-old patient admitted with paraparesis and heaviness of the right side of the chest and was found to have compressive myelopathy along with pleural effusion. He had elevated alpha fetoprotein and beta human chorionic gonadotropin. Imaging revealed a heterogeneous, massive space lesion occupying the right hemithorax and collapse of D12 vertebra with altered marrow signal causing extradural spinal compression. Cytopathology from the tumor revealed immature teratoma cells. The patient was diagnosed as a case of intrapulmonary teratoma with vertebral metastasis. He was started on bleomycin, etoposide, cyclophosphamide chemotherapy and spinal irradiation, which was unsuccessful.

HCG 産生を伴う卵黄嚢腫瘍および成熟奇形腫からなる卵巣混合型胚細胞腫瘍の 1 例

hCG 産生を伴う卵黄嚢腫瘍および成熟奇形腫からなる卵巣混合型胚細胞腫瘍の 1 例