Ovarian carcinoma producing parathyroid hormone-related protein causing hypercalcemia and metastatic calcification detected on 18F-FDG PET-CT
A 47-year-old female presented with amenorrhea and pain in lower abdomen since 2 months. On pelvic ultrasound examination, lobulated soft tissue lesions showing mildly echogenic center and peripheral hypoechoic soft tissue rim with moderate internal vascularity were noted in the pouch of Douglas [31.7 × 31.9 × 34.0 mm (volume 18 cc)] and left adnexa [32.9 × 24.6 × 17.7 mm (volume 7.5 cc)]. On contrast-enhanced computed tomography (CECT) whole abdomen examination, there were extensive retroperitoneal, retrocrural, and pelvic lymphadenopathies. Majority of the nodes revealed tiny punctuate calcific foci. Both ovaries were bulky and cystic. Her CA-125 level was markedly elevated (4969 mg/dl). A CT-guided fine needle aspiration cytology (FNAC) from retroperitoneal lymph node revealed features of metastatic adenocarcinoma. The patient was advised a trucut biopsy, but biopsy could not be done as the treating gynecologist declined to perform trucut biopsy because of the risk of spread of disease. She was classified as stage IIIC (FIGO staging), as the retroperitoneal lymph nodes were involved with no distant metastasis. She was then referred to our department for 18F-FDG PET-CT study.18F-FDG PET-CT scan revealed serosal deposit in the sigmoid colon and pararectal mesentery, with mildly increased FDG uptake and foci of calcification. The scan also revealed multiple enlarged FDG-avid left external iliac, left internal iliac, left common iliac, retroperitoneal, and multiple mesenteric lymph nodes with foci of calcification []. So, a final impression of metastatic disease involving multiple lymph nodes, serosal and mesenteric deposits was reported. The patient later underwent CT-guided FNAC from retroperitoneal lymph node. FNAC smear was found to be cellular with small clusters and cell balls. The cells were found to be crowded with enlarged nuclei with prominent nucleoli in a background of blood, lymphocyte, few mesothelial cells, and adipose tissue fragments []. Her serum calcium level was 15 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 108 pmol/l (normal 17.6-61.2 pmol/l).