Case Presentation
In 2017, a 53-year-old female presented with a calcified mass in the left upper lobe of the lung, diagnosed as a carcinoid tumor. She underwent a video-assisted thoracoscopic surgery (VATS) upper lobectomy in 2018 with a final pathological staging of pT2aN0, stage II. Four years later, she was diagnosed with stage 1B HPV-negative squamous cell carcinoma of the left labia majora and underwent a left radical hemivulvectomy and sentinel lymph node biopsy.
The patient presented with a new anal lesion in June 2022. Biopsy revealed a poorly differentiated squamous cell cancer undifferentiated with sarcomatoid features (Images 1 and 2). This lesion was staged as IIIA (cT2, cN0 vs. cN1, cM0) SCC of the anus (Images 1 and 2). Pre-treatment testing demonstrated a positive urine pregnancy test and serum beta-HCG of 87.5 mlU/mL. The patient was postmenopausal by history and had a prior uterine ablation. The ultrasound did not identify intrauterine pregnancy. Given these results, the patient was treated with standard chemo-radiation.
The immunohistochemistry from the biopsy was positive for beta-hCG (Image 3). Beta-hCG was monitored via weekly urine pregnancy tests. The patient completed chemotherapy and radiation treatment in late August. Urine beta-hCG was negative. Six weeks after completing treatment, testing of urine beta-hCG was found, once again, to be elevated. A positron emission tomography (PET) scan in October 2022 revealed a persistent hypermetabolic mass with a maximum standardized uptake value (SUVmax) of 17.6 (not felt to be substantially changed from the previous scan). There was no evidence of metastatic disease. Given the persistent disease, robotic-assisted abdominoperineal resection with a colostomy was performed post-treatment. Imaging seven months later demonstrated disease recurrence and progression. Subsequently, the patient started palliative pembrolizumab.