Ovarian carcinoma producing parathyroid hormone-related protein causing hypercalcemia and metastatic calcification detected on 18F-FDG PET-CT
A 65-year-old female was diagnosed with carcinoma ovary 10 years ago. Laparoscopic cholecystectomy and ovarian cystectomy was performed in 2004. Histopathology revealed papillary serous cyst adenocarcinoma of ovary with metastatic deposits in serosa of the gallbladder. This was followed by ovarian laparotomy and peritoneal flush. Then, she was followed up with cancer antigen (CA)-125 level. A rising trend in CA-125 level from 250 mg/dl in February 2012 to 1194 mg/dl in November 2012 was noted. She was then referred to our department for 18F-FDG PET-CT study. 18F-FDG PET-CT scan revealed FDG-avid irregular soft tissue density mass lesion, measuring 5.1 × 7.7 cm, with calcification in left rectus abdominis (pelvic region). Another FDG-avid soft tissue density mass lesion in the subcutaneous region involving right rectus abdominis muscle, measuring 1.1 × 3.4 cm, in the region of epigastrium was also noted. FDG-avid enlarged lymph nodes with foci of calcification were noted in left inguinal, left external iliac, left obturator, and left common iliac regions []. In view of raised CA-125 levels, these lymph nodes were reported as metastatic lesions. The patient then underwent USG-guided aspiration from the left inguinal lymph node, which was positive for a metastatic lesion. Her serum calcium level was 16 mg/dl (normal 7.4-9.0 mg/dl). PTHrP level was estimated to look for a possible cause of hypercalcemia and was found to be markedly raised at 116 pmol/l (normal 17.6-61.2 pmol/l).