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INTRODUCTION: The most common cause for elevated beta-hCG in reproductive aged-women is pregnancy. Rarely, malignancy may cause persistent beta-hCG levels. We present a rare case of metastatic gastric adenocarcinoma masked as an ectopic pregnancy. METHODS: 34Y G2P2 healthy patient presented for intrauterine device removal where routine urine pregnancy test was positive. Beta-hCG was 287, which continued to plateau without sonographic evidence of intrauterine pregnancy. Methotrexate was given for suspected ectopic pregnancy. Beta-hCG fluctuated between 300-500. Ultrasound revealed solid mass in left adnexa and she underwent exploratory laparoscopy; however, intraoperative findings revealed normal fallopian tubes and bilateral corpus luteal cysts with no evidence of ectopic pregnancy. Second dose of methotrexate was given but beta-hCG continued to increase. She developed worsening abdominal pain, nausea, chest pain, dyspnea. CT chest/abdomen/pelvis revealed mediastinal, periaortic and upper abdominal lymphadenopathy, and bilateral lung nodules. AFP 111.9, CA 125 36, CA 19-9 649, CEA 11.9. Retroperitoneal lymph node biopsy and upper endoscopy revealed ulcerated, fungating gastric mass consistent with poorly differentiated adenocarcinoma. FOLFOX chemotherapy was started. Her worsening dyspnea called for CT angiography, revealing pericardial effusion, which required pericardiocentesis and a pericardial window. Pericardial fluid consisted of malignant cells and beta-hCG continued to increase, indicating worsening prognosis. She died from malignancy progression 7 weeks after diagnosis. CONCLUSION: Persistently elevated beta-hCG without response to methotrexate or surgical intervention may raise suspicion for rare presentations of malignancy. Our case demonstrates metastatic gastric adenocarcinoma can present with increasing beta-hCG serum levels without evidence of gynecologic disease.