Pituitary hCG production and cerebral tuberculosis mimicking disease progression during chemotherapy for an advanced ovarian germ cell tumour

Abstract

Background: Ovarian germ cell tumours (OGCT) are rare but are usually curable with chemotherapy, even when presenting with advanced disease. The majority of OGCT produce the tumour markers, hCG and/or AFP which can be helpful in the diagnosis and monitoring the response to treatment.

Case presentation: In this case of a 36 year old woman, the elevated hCG level at presentation was helpful in making a clinical diagnosis of OGCT in a patient too unwell to permit a tissue diagnosis. Cisplatin based combination chemotherapy produced an initial normalisation of the hCG level, but later in treatment the patient developed new cerebral lesions and a rising serum hCG suggestive of disease progression. Further investigations suggested that the CNS lesions were cerebral TB and that the low levels of hCG elevations was likely to be pituitary in origin. Chemotherapy treatment was continued along with anti-tuberculous therapy and 24 months after successful completion of therapy the patient remains disease free.

Conclusions: In the treatment of cancer patients it may be helpful to consider the potential non-malignant causes of new CNS lesions and that low hCG elevations may result from physiology rather than pathology in selected cases.

Figure 1

CT scan of the abdomen on admission. This scan demonstrates a large necrotic, partially cystic tumour occupying most of the abdomen. The CT scan also demonstrated marked paraaortic lymphadenopathy but no visceral or CNS metastases.

Figure 2

MRI brain scan performed mid-treatment. The MRI brain scan performed shortly after readmission with acute neurological symptoms, demonstrates a number of ring-enhancing lesions with surrounding oedema which were thought likely to be metastases.

Figure 3

hCG treatment graph. This demonstrates the level of the serum hCG and the timing of chemotherapy treatment. After the initial elevation and fall to normal there was a 3 month low level hCG elevation. The solid line indicates the lower level of detection of the assay (1 IU/L) the dashed line the upper limit of the normal range (0-4 IU/L).

Figure 4

MRI brain scan performed 9 months post chemotherapy. The follow-up scan indicates that the previously noted oedema and the majority of the CNS lesions have resolved.