Elevated Human Chorionic Gonadotropin Research Articles

Molecular and histopathological characterization of seminoma patients with highly elevated human chorionic gonadotropin levels in the serum

Approximately 30% of seminoma (SEM) patients present with moderately elevated human chorionic gonadotropin (hCG) levels at first diagnosis. In case of high hCG serum levels, the presence of a non-SEM component, i.e. choriocarcinoma (CC), may be assumed. To characterize cases described as pure seminoma with high serum hCG levels, tissue samples and DNA were analyzed. Patient files from an international registry were screened for patients with SEM and extraordinarily high hCG serum levels. IHC and qRT-PCR analysis was performed for markers of SEM, embryonal carcinoma (EC) and CC/trophoblast cells. The cell lines TCam-2 (SEM), 2102EP, NCCIT, NT2/D1 (EC) and JAR, JEG3 and BeWo (CC) were included for comparison. Of 1031 SEM patients screened, 39 patients (3.7%) showed hCG serum levels > 1000 U/l. Of these, tumor material for IHC and RNA for qRT-PCR was available from n = 7 patients and n = 3 patients, respectively. Median pre-orchiectomy serum hCG level was 5356 U/l (range: 1224–40909 U/L). Histopathologically, all investigated samples were classified as SEM with syncytiotrophoblast sub-populations. SEM cells were SALL4+ / OCT3/4+ / D2-40+, while syncytiotrophoblast cells were hCG+ / GATA3+ / p63+ and SOX2−/CDX2−. qRT-PCR analysis detected trophoblast stem cell markers CDX2, EOMES and TFAP2C as well as the trophectoderm-specifier TEAD4, but not GATA3. Additionally, SOX17 and PRAME, but not SOX2, were detected, confirming the pure SEM-like gene expression signature of the analyzed samples. In conclusion, excessively increased hCG serum levels can appear in patients with pure SEM. To explain detectable hCG serum levels, it is important to diagnose the subtype of a SEM with syncytiotrophoblasts.

Central precocious puberty secondary to peripheral precocious puberty due to a pineal germ cell tumor: a case and review of literature

BackgroundThe pineal lesion affecting melatonin is a rare cause of central precocious puberty by decreasing the inhibition of hypothalamic–pituitary–gonadal axis. Germ cell tumor secreting human chorionic gonadotropin is a rare cause of peripheral puberty.Case presentationA 5.8-year-old male presented facial hair and phallic growth, deepened voice, and accelerated growth velocity for 6 months. The elevated human chorionic gonadotropin level with undetectable gonadotropin levels indicated peripheral precocious puberty. Brain imaging revealed a pineal mass and further pathology indicated the diagnosis of teratoma. During chemoradiotherapy with operation, the elevated human chorionic gonadotropin level reduced to normal range, while the levels of gonadotropins and testosterone increased. Subsequently, progressing precocious puberty was arrested with gonadotrophin-releasing hormone analog therapy. Previous cases of transition from peripheral precocious puberty to central precocious puberty were reviewed. The transitions were caused by the suddenly reduced feedback inhibition of sex steroid hormones on gonadotropin releasing hormone and gonadotropins.ConclusionsFor patients with human chorionic gonadotropin-secreting tumors, gonadotropin levels increase prior to sex steroid decrease, seems a sign of melatonin-related central PP related to melatonin.

Abstract #1409027: Paraneoplastic Hyperthyroidism

Non-seminomatous germ cell tumors producing human chorionic gonadotropin (HCG) were first described in 1964. HCG is capable of inducing hyperthyroidism by stimulating the TSH receptor, due to its identical alpha subunit. We report a case of HCG-mediated hyperthyroidism in the setting of a choriocarcinoma. A 28-year-old man presented with a 3-week history of unintentional weight loss, cough, hemoptysis, palpitations, shortness of breath, nausea and vomiting. Chest x-ray showed a large pleural effusion and multifocal nodular opacities on lungs measuring up to 4 cm. CT abdomen/pelvis showed a 1.4 cm left renal mass concerning for metastasis, and hepatomegaly. CT chest demonstrated a 16 cm heterogeneous enhancing mass in the mediastinum, a large pericardial effusion, moderate left pleural effusion and metastatic pulmonary nodules. Laboratory results showed elevated HCG of 947,825 mIU/mL, AFP 25 ng/ml, LDH 1,394 U/L, TSH 0.011 mcIU/mL, FT4 2.0 ng/dL, Ferritin 2680 ng/mL, CRP 118 mg/L. Testicular ultrasound was unremarkable. Biopsy of mediastinal mass was consistent with choriocarcinoma. Endocrinology was consulted for evaluation of abnormal thyroid function. He was tachycardic, without other overt symptoms of hyperthyroidism and no clinical findings of Graves’ Disease. TRAB, TSI, TPO antibodies were negative. Propylthiouracil (PTU) 100mg every 8 hours and low dose propranolol were started. Chemotherapy with Etoposide, Ifosfamide, and Cisplatin was initiated. Thyroid function improved 5 days after initiation of therapy. After 3 cycles of chemotherapy, his TSH and Free T4 levels normalized and the HCG level decreased to 1,521 mIU/mL. His most recent thyroid function tests were TSH 5.8 mcIU/ml and Free T4 level 1.1 ng/dL and the decision was made to stop PTU. HCG is a heterodimer with an alpha subunit identical to that of TSH, LH and FSH. High HCG levels can stimulate the TSH receptor and cause hyperthyroidism. Hyperthyroidism has been reported in trophoblastic tumors when HCG levels are >200,000 mIU/mL. Initiation of chemotherapy produces rapid decline in HCG levels and improvement of Free T4 levels. Diagnosis of paraneoplastic hyperthyroidism is challenging, as symptoms of hyperthyroidism may overlap with those of metastatic disease. Symptomatic patients should be started on thianomide and beta blocker which improve well-being and tolerance to chemotherapy. We illustrated the challenge of diagnosing hyperthyroidism in HCG-secreting choriocarcinoma and the importance of initiating chemotherapy and anti-thyroidal medication in symptomatic patients to improve outcomes.

Precocious puberty due to intracranial germ cell tumors: a case–control study

Children with intracranial germ cell tumors may present premature sexual development via either gonadotrophin-releasing hormone (GnRH)-dependent cause or GnRH-independent cause. We conducted a single-center retrospective study on 37 precocious puberty (PP) patients with intracranial germ cell tumors and 25 age-matched prepubertal patients with elevated human chorionic gonadotropin (hCG) levels. Classification of PP was derived from hCG, gonadotropin and sex steroid levels and their changes. Five boys were assigned to GnRH-dependent group (G1). Thirty-one boys and one girl were assigned to GnRH-independent group (G2) with a median hCG of 76.75 (8.29-2747) IU/L. Seven boys and 18 girls were conducted as controls, with a median hCG of 17.12 (2.91-1062) IU/L. Patients in G1 had constant pubertal LH and testosterone levels after tumor complete response. Patients in G2 had hCG levels that decreased simultaneously with testosterone/estradiol levels, prior to tumor regression. The differences in hCG levels and the gender ratio were significant between G2 and controls (P = 0.006 and P < 0.001, separately). Among intracranial germ cell tumor patients with positive hCG, boys with significantly higher hCG levels more easily developed PP. Our results suggest that GnRH-independent PP commonly regresses together with tumor regression. In comparison, results were inconclusive in tying tumor regression to the regression of GnRH-dependent PP.

Misdiagnosis of epithelioid trophoblastic tumors: a case report and literature review

Background: The most common clinical types of gestational trophoblastic neoplasia are invasive hydatidiform mole and choriocarcinoma, which can be diagnosed without pathology, and be cured by chemotherapy. Epithelial trophoblastic tumor, a rare type of gestational trophoblastic neoplasia, does not exhibit precise clinical manifestations upon auxiliary examinations. Therefore, since epithelial trophoblastic tumors are prone to misdiagnoses and missed diagnoses, their diagnosis have to be confirmed through pathology and immunohistochemistry. Case: We describe a case of a 37-year-old woman that had been misdiagnosed at a local hospital after she had presented with irregular vaginal bleeding and elevated human chorionic gonadotropin. The initial diagnosis was ectopic pregnancy and she was subjected to left salpingectomy, however, after treatment, there was no significant drop in human chorionic gonadotropin. Later, she was diagnosed with gestational trophoblastic neoplasia and was treated with multiple chemotherapy and hysterectomy. However, after treatment, her human chorionic gonadotropin was found to repeatedly fluctuate. Eventually, pathological examination of a resected lung lesion confirmed the presence of epithelial trophoblastic tumors. Conclusions: Epithelial trophoblastic tumor is an intermediate trophoblastic tumor that is not sensitive to conventional chemotherapy. Surgical resection is the recommended therapeutic option. Gestational trophoblastic neoplasia patients presenting with persistently low levels of human chorionic gonadotropin and resistance to conventional chemotherapy should, therefore, be considered for early surgical resection, or tissue biopsy to pathologically confirm the diagnosis and inform treatment options.

False Positive Pregnancy Test Before Kidney Transplant: Case Report and Review of Literature

Pregnancy tests are routinely done before any surgery under general anesthesia including kidney transplantation. Positive test usually leads to more investigations to detect a possible pregnancy or malignancy and the surgery gets canceled or postponed. Because a kidney transplant from a deceased donor is not elective, it usually gets canceled in this scenario. Some groups have reported on normally elevated human chorionic gonadotrophin (hCG) levels in perimenopausal women and in patients with chronic kidney disease. This is thought to be from the pituitary. We present a highly sensitized prospective kidney transplant recipient with a positive pregnancy test with low levels of serum human chorionic gonadotrophin. She underwent additional preoperative testing after which we proceeded with the kidney transplant. Herein, we discuss the management of patients who have an unexpected positive pregnancy test before transplant.

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.

Search for morphological indicators that predict implantation by principal component analysis using images of blastocyst.

BackgroundAlthough the current evaluation of human blastocysts is based on the Gardner criteria, there may be other notable parameters. The purpose of our study was to clarify whether the morphology of blastocysts has notable indicators other than the Gardner criteria.MethodsTo find such indicators, we compared blastocysts that showed elevated human chorionic gonadotropin (hCG) levels after transplantation (hCG-positive group; n = 129) and those that did not (hCG-negative group; n = 105) using principal component analysis of pixel brightness of the images.ResultsThe comparison revealed that the hCG-positive group had grainy morphology and the hCG-negative group had non-grainy morphology. Classification of the blastocysts by this indicator did not make a difference in Gardner score. Interestingly, all embryos with ≥20% fragmentation were non-grainy. The visual classification based on this analysis was significantly more accurate than the prediction of implantation using the Gardner score ≥3BB. As graininess can be used in combination with the Gardner score, this indicator will enhance current reproductive technologies.

Pituitary Stalk Germ Cell Tumors: Retrospective Case Series and Literature Review.

Objective Intracranial germ cell tumors with isolated pituitary stalk involvement are rare. Early recognition and long-term monitoring deserve further exploration. Methods A retrospective study reviewing eleven intracranial germ cell tumor patients with isolated pituitary stalk involvement was performed. Results Seven boys and four girls who presented with a hyperintense pituitary stalk on postcontrast T1-weighted magnetic resonance imaging without a posterior pituitary signal were included. The average maximum width of the pituitary stalk was 5.2 ± 1.6 mm. Polydipsia and polyuria occurred in all patients, followed by growth retardation, fatigue, and amenorrhoea. Eight patients (72%) had concomitant partial anterior pituitary hormone deficiency. Seven patients initially had elevated human chorionic gonadotropin levels. After chemoradiotherapy, ten patients attended follow-up. Central diabetes insipidus remained in all survivors, and four (40%) of them had concomitant partial anterior pituitary hormone deficiency, primarily of growth hormone and insulin-like growth factor-1. The causes of the delayed diagnosis of previous studies were mainly negative tumor markers and the initial pathological diagnosis of autoimmune diseases. Conclusion Isolated pituitary stalk lesions could be a signal of intracranial germ cell tumors, especially coexisting with diabetes insipidus, hypopituitarism, and a worse response to glucocorticoid therapy. Negative results of tumor markers and pathology could not exclude the diagnosis. Chemoradiotherapy is an effective therapy, leaving mild-t-moderate hypothalamus-pituitary dysfunction. This rare neuroimaging feature may be used as a factor to predict long-term neuroendocrine outcomes.

Central Nervous System Tumors in Children.

Central Nervous System Tumors in Children.

Biotin induced elevation of Human Chorionic Gonadotropin

Biotin induced elevation of Human Chorionic Gonadotropin

Evaluating the Effect of Post-Operative Radiotherapy on Long Term Survival of Testicular Seminomas: A Population Based Study

Objectives: To assess the effect of post-operative radiotherapy (PORT) on long term survival in Testicular Seminoma (TS) patients and factors may effect the prognosis of PORT patients. Results: 12957 patients with a median age of 36.00 (13.00-107.00) years were pathologically diagnosed as primary TS. PORT was performed in 3407 patients. Patients with clinical stages I, II, and III testicular cancer accounted for 70.69% (n=9159), 8.30% (n=1075), and 5.72% (n=741) of all patients, respectively. According to results of multivariate Cox proportional hazard model, lower risk of cancer specific mortality was related with PORT in all patients (HR=0.40 95% CI=0.25-0.63 p&lt;0.0001). However, no benefit in survival (p&gt;0.05) was brought by PORT in either clinical stage. Aging, elevated human chorionic gonadotropin and lactate dehydrogenase level were related with higher risk of cancer specific mortality in PORT patients (p&gt;0.05). Furthermore, aging and elevated LDH were inversely related with the prognosis of CSI PORT patients. No significant risk factor was observed in CSII and III PORT patients. Conclusion: PORT can be benefit to the long term survival in TS patients, however, it did not show significant advantage in patients of either clinical stage based on the results of our study. Elevation of human chorionic gonadotropin and lactate dehydrogenase levels and elder age related with higher risk of CSM in PORT patients. Utilization of PORT in the management of TS should be considered comprehensively.

31. GENETIC CONTROL OF DECONVOLVED BRAIN CELL-TYPES

Choriocarcinoma germ cell tumors are rare and usually present with significantly elevated human chorionic gonadotropin (hCG) levels. When curable, it is felt to be largely a result of chemotherapy. We sought to determine the histologic characteristics for those undergoing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) and compare them with metastatic nonseminomatous germ cell tumor (NSGCT) patients with similarly elevated hCG levels.We reviewed medical records of men undergoing PC-RPLND between 1988 and 2017 with postorchiectomy, preinduction chemotherapy hCG levels greater than 50,000 mIU/ml. They were stratified by primary tumor histology: Pure choriocarcinoma and mixed NSGCT. Clinical, pathologic, and serologic data were reported and logistic regression was used to assess for predictors of necrosis in the PC-RPLND specimen.Our cohort consisted of 108 men. The mixed group (n = 91) had a median hCG of 165,177 mIU/ml, a postchemotherapy node size of 4.7 cm, of whom 19.8% also received salvage chemotherapy prior to RPLND. The pure choriocarcinoma group (n = 17) had a median hCG of 170,267 mIU/ml, a node size of 5.1 cm, of whom 17.6% received salvage chemotherapy. 88.2% of patients with choriocarcinoma had necrosis in the PC-RPLND specimen compared with 29.7% of the mixed NSGCT group (P = <0.0001). Controlling for salvage chemotherapy use, prechemotherapy hCG, node size and marker status, choriocarcinoma patients were 20 fold more likely to have necrosis on RPLND specimen (Odds ratio 20.68 [95% confidence interval 5.279–81.114]).While PC-RPLND is appropriate in patients with residual masses after chemotherapy, patients with pure choriocarcinoma presenting with significantly elevated hCG levels represent a unique patient population where necrosis is found more often than anticipated.

TU17. GENOME-WIDE ANALYSIS OF PSYCHOLOGICAL RESILIENCE

Choriocarcinoma germ cell tumors are rare and usually present with significantly elevated human chorionic gonadotropin (hCG) levels. When curable, it is felt to be largely a result of chemotherapy. We sought to determine the histologic characteristics for those undergoing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) and compare them with metastatic nonseminomatous germ cell tumor (NSGCT) patients with similarly elevated hCG levels.We reviewed medical records of men undergoing PC-RPLND between 1988 and 2017 with postorchiectomy, preinduction chemotherapy hCG levels greater than 50,000 mIU/ml. They were stratified by primary tumor histology: Pure choriocarcinoma and mixed NSGCT. Clinical, pathologic, and serologic data were reported and logistic regression was used to assess for predictors of necrosis in the PC-RPLND specimen.Our cohort consisted of 108 men. The mixed group (n = 91) had a median hCG of 165,177 mIU/ml, a postchemotherapy node size of 4.7 cm, of whom 19.8% also received salvage chemotherapy prior to RPLND. The pure choriocarcinoma group (n = 17) had a median hCG of 170,267 mIU/ml, a node size of 5.1 cm, of whom 17.6% received salvage chemotherapy. 88.2% of patients with choriocarcinoma had necrosis in the PC-RPLND specimen compared with 29.7% of the mixed NSGCT group (P = <0.0001). Controlling for salvage chemotherapy use, prechemotherapy hCG, node size and marker status, choriocarcinoma patients were 20 fold more likely to have necrosis on RPLND specimen (Odds ratio 20.68 [95% confidence interval 5.279–81.114]).While PC-RPLND is appropriate in patients with residual masses after chemotherapy, patients with pure choriocarcinoma presenting with significantly elevated hCG levels represent a unique patient population where necrosis is found more often than anticipated.

Disorders of Sex Development.

Disorders of Sex Development.

Effect of high levels of human chorionic gonadotropin and estradiol on degree of hyperemesis gravidarum

Hyperemesis gravidarum is a condition that affects pregnant women (HG),serum levels of human chorionic gonadotropin (hCG) and estradiol are increased than in pregnant women who are not influenced.Objective:This study's major goal was to learn moreabout how elevated human chorionic gonadotropin levels and estradiol affect the intensity of hyper emesis gravidarum during the first trimester.Methods: At El Hussein University Hospital, our prospective study was conducted from May 2020 to Nov. 2020; duration of the study was 7 months. The key sign of severe Hyper Emesis Gravidarum was a lengthy in the hospital (HG).The term extended hospital stay describedas ≥4 days, as this cut-off value demarcates the top quartilef orhospitalization timein our study population. Results: There was a highly significant difference between cases with hospital stay< 4 days and cases with hospital ≥ 4 days as regard HCG, cases with longer have higher median HCG (300637) compared to cases with

Abstract #1003958: Thyroid Storm Caused By Hyperemesis Gravidarum

Transient thyrotoxicosis has been documented in the setting of hyperemesis gravidarum (HG) as well as in gestational trophoblastic disease (GTD) with profoundly elevated human chorionic gonadotropin (hCG) levels. Thyroid storm in pregnancy is rare and typically associated with Graves disease. Here we describe thyroid storm in a patient with hCG elevation secondary to HG that spontaneously resolved in the second trimester of pregnancy.

An Unusual Cause of Thyrotoxicosis and Gynacomastia

We describe the case of a 24 year old man with metastatic non-seminomatous germ cell tumour who presented with hyperthyroidism and gynaecomastia associated with elevated human chorionic gonadotrophin(HCG). Following a 3 month history of gynaecomastia, flank pain, nausea and 7kg weight loss, the patient attended the emergency department with persistent vomiting. Initial laboratory investigations reported TSH <0.05mU/L (normal range 0.3-4.3) and free T4 29.5pmol/L (12-22), TPO antibodies negative, FSH <1 and LH 1 U/l, testosterone >52 nmol/L (9-29.0), bioactive prolactin 1048mU/L (63-245), SHBG 110.6 nmol/l (18.3-54.1), and oestradiol 3935pmol/L (<223). Clinical examination revealed bilateral tender gynaecomastia and supraclavicular lymphadenopathy. Testicular examination identified a left testis irregularity that was confirmed on ultrasound. Chest Radiograph revealed multiple bilateral opacities measuring up to 6 cm. Initial urine HCG was negative when tested on two occasions; however given suspicion for a HCG-secreting tumour, serum HCG was measured and reported as 503,944 IU/ml (<5) and AFP 17.6 IU/ml (0-5.0). The negative urine HCG is believed to be due to “hook effect”. CT revealed bulky retroperitoneal lymphadenopathy measuring 13 cm consistent with metastatic spread from the non-seminamatous germ cell tumour of testicular origin. Up front chemotherapy protocol with 4 cycles cisplatin based therapy was initiated given his disease burden and degree of symptoms. Radical orchidectomy was deferred until after chemotherapy - at which time germ cell tumour was only identified on immunohistochemistry staining. Over the 2 months following chemotherapy, all endocrinopathies resolved with corresponding reduction of HCG to 65.0 IU/ml. Symptoms of hyperthyroidism abated with treatment and his TFTs were biochemical normal. Oestrogen level also normalised with treatment. HCG-induced hyperthyroidism is a rare cause of hyperthyroidism. Endocrine manifestations occur in <5% germ cell tumour presentation but should be considered particularly when multiple endocrine abnormalities are present.

A Case of Pituitary Germinoma With Complete Recovery of Visual Field

Abstract Central nervous system germ cell tumours (GCTs) are rare, accounting for 0.1-3.4% of all primary brain malignancies. Intracranial GCTs (ICGCTs) usually arise within the pineal recess (50-65%), sellar-suprasellar region (25-35%) and rarely in the basal ganglia-thalamus (5-10%). A peakonset occurs during the second decade of life with a median age at diagnosis between10-12 years and a male predominance. Histologically, ICGCTs are classified into germinomas accounting for two thirds of cases and non-germinomatous GCTs. ICGCTs present with clinical features dependent on their location and tumour size. Symptoms most often arise from compressed optic structures, increased intracranial pressure and central endocrine abnormalities, particularly diabetes insipidus (DI). Clinical findings combined with elevated tumour marker levels within the serum and/or cerebrospinal fluid (CSF) can be diagnostic. Case: A 30-year-old lady who survived a childhood leukaemia presented as an emergency with a two-month history of headaches, dizziness and near-complete visual loss. Cranial MRI identified a large sellar mass with suprasellar extension compressing the optic chiasma and hypothalamus. Biochemical and endocrine profiles confirmed diabetes insipidus, hypocortisolaemia and hypothyroidism all requiring hormone replacement. Visual field examination revealed total left visual loss and a right temporal hemianopia. Cerebrospinal fluid analysis identified an elevated human chorionic gonadotropin (HCG) level at 16 IU/L (normal &amp;lt;2), with a normal alpha-fetoprotein (AFP) level. Both tumour markers were normal in the serum. Emergency Etoposide-Cisplatin (Em-EP) chemotherapy was initiated for a suprasellar GCT followed by the EPOMB-ITMTX regimen [Etoposide-Cisplatinwith intrathecal Methotrexate (ITMTX) alternating with Vincristine-Methotrexate-Bleomycin]. After four cycles EPOMB-ITMTX, the vision was fully restored, brain MRI demonstrated an excellent radiological response and the CSF HCG normalised. Our patient received volumetric-modulated arc cranial radiotherapy (VMAT) with a total 54 Gy in 16 fractions. She remains well without disease recurrence for 14 months. Tumour markers are normal with stable MRI brain and whole-spine. Endocrine follow-up confirms recovery in all pituitary axes except the gonadotrophins for which she remains on hormone replacement therapy. Conclusion: This case demonstrates an excellent outcome for a young adult diagnosed with a suprasellar GCT treated with chemotherapy followed by stereotactic radiotherapy. It highlights the importance in keeping a high clinical index of suspicion in young adults presenting with a midline intracranial tumour, visual dysfunction and an endocrinopathy. CSF analysis identified an elevated tumour marker level, which bypasses the need for a histological diagnosis.

Ultrasonographic technique to differentiate enhanced myometrial vascularity/arteriovenous malformation from retained products of conception.

To objective of this study is to discuss the ultrasonographic technique to diagnose uterine enhanced myometrial vascularity/arteriovenous malformation (EMV/AVM) and differentiate it from retained products of conception. The study also reviews the management and outcome of EMV/AVM. We present a series of three women who developed EMV after early pregnancy loss and a control case of incomplete abortion, where colour Doppler ultrasound was used to distinguish retained products of conception from features of EMV. Clinical status and imaging findings, including peak systolic velocity (PSV), were used for the initial risk stratification of the patients. All cases with EMV/AVM were managed expectantly with serial ultrasound imaging and trending human chorionic gonadotropin levels. The patient with retained products of conception was managed by hysteroscopy and curettage. In all cases, presentation was suggestive of incomplete abortion with retained products of conception. However, colour Doppler ultrasound demonstrated hypoechoic areas within the endometrium extending into the myometrium with a high maximum PSV. In the control case, colour Doppler ultrasound noted a heterogeneous area in the left uterine cavity; however, vascular flow in this area was distinct from the endometrium, suggesting retained products of conception. All three women with EMV were managed expectantly with close monitoring and good outcomes. In patients with early pregnancy loss and bleeding or persistently elevated human chorionic gonadotropin levels, clinical status and appropriate use of ultrasound imaging with colour Doppler, including PSV measurement, can assist in recognition of EMV/AVM. Expectant management with serial ultrasound evaluation is a safe treatment option for EMV/AVM with low PSV and can minimise complications such as need for blood transfusion, uterine artery embolization, and hysterectomy.