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8 Muth CM, Shank ES. Gas embolism. N Engl J Med 2000;<br />

342:476–482<br />

9 Coulter TD, Wiedemann HP. Gas embolism [letter]. N Engl<br />

J Med 2000; 342:2000–2002<br />

10 Leach RM, Rees PJ, Wilmshurst P. ABC <strong>of</strong> oxygen: hyperbaric<br />

oxygen therapy. BMJ 1998; 317:1140–1143<br />

11 Worth ER, Burton Jr, Landreneau RJ, et al. Left atrial air<br />

embolism during intraoperative needle biopsy <strong>of</strong> a deep<br />

pulmonary lesion. Anesthesiology 1990; 73:342–345<br />

12 Kodama F, Ogawa T, Hashimoto M, et al. Fatal air embolism<br />

as a complication <strong>of</strong> CT-guided needle biopsy <strong>of</strong> the lung.<br />

J Comput Assist Tomogr 1999; 23:949–951<br />

13 Baker BK, Awwad EE. Computed tomography <strong>of</strong> fatal cerebral<br />

air embolism following percutaneous aspiration biopsy <strong>of</strong><br />

the lung. J Comput Assist Tomogr 1988; 12:1082–1083<br />

<strong>Use</strong> <strong>of</strong> <strong>Urine</strong> <strong>Pregnancy</strong> <strong>Test</strong><br />

<strong>for</strong> <strong>Rapid</strong> <strong>Diagnosis</strong> <strong>of</strong> <strong>Primary</strong><br />

Pulmonary Choriocarcinoma in<br />

a Man*<br />

Jong-Rung Tsai, MD; Inn-Wen Chong, MD, FCCP;<br />

Jen-Yu Hung, MD; and Kun-Bow Tsai, MD<br />

<strong>Primary</strong> pulmonary choriocarcinoma is an extremely<br />

rare tumor in men, with 13 cases reported in the<br />

literature. Due to its rarity, primary choriocarcinoma<br />

<strong>of</strong> the lung in men is <strong>of</strong>ten incorrectly diagnosed<br />

as more common diseases, such as primary or<br />

metastatic lung cancer, and there<strong>for</strong>e potentially<br />

curative chemotherapy or surgery may be withheld<br />

from the patient. In this report, we present the case<br />

<strong>of</strong> a 23-year-old man with hemoptysis and progressive<br />

dyspnea. Airspace consolidation with multiple<br />

nodules <strong>of</strong> varying sizes was found on a chest radiograph.<br />

The results <strong>of</strong> a urine pregnancy test were<br />

positive, and the -human chorionic gonadotropin<br />

level was markedly elevated both in the serum and<br />

the urine. Subsequently, testing <strong>of</strong> a bronchoscopic<br />

biopsy specimen proved these tumors to be choriocarcinoma.<br />

We conclude that the urine pregnancy<br />

test, a simple and convenient method, would be very<br />

useful in the rapid diagnosis <strong>of</strong> primary pulmonary<br />

choriocarcinoma in men.<br />

(CHEST 2002; 121:996–998)<br />

Key words: human chorionic gonadotropin; primary pulmonary<br />

choriocarcinoma; urine pregnancy test<br />

Abbreviation: HCG human chorionic gonadotropin<br />

*From the Departments <strong>of</strong> Internal Medicine (Drs. Tsai, Chong,<br />

and Hung) and Pathology (Dr. Tsai), Kaohsiung Medical University,<br />

Kaohsiung, Taiwan.<br />

Manuscript received March 15, 2001; revision accepted August<br />

20, 2001.<br />

Correspondence to: Inn-Wen Chong, MD, FCCP, Department <strong>of</strong><br />

Internal Medicine, Kaohsiung Medical University, Kaohsiung,<br />

807, Taiwan; e-mail: chong@cc.kmu.edu.tw<br />

Choriocarcinoma, a representative neoplasm producing<br />

human chorionic gonadotropin (HCG), is an extremely<br />

malignant tumor originating from anaplastic trophoblastic<br />

tissue. It is usually intrauterine and arises most<br />

commonly from molar pregnancy, but may also follow a<br />

term or ectopic pregnancy and spontaneous abortions.<br />

Extragonadal, nongestational choriocarcinoma is uncommon<br />

with a striking predominance in young men between<br />

20 and 35 years <strong>of</strong> age. Most cases arise in midline<br />

structures, such as the retroperitoneum, the mediastinum,<br />

and the vicinity <strong>of</strong> the pineal body but also have been<br />

reported in other visceral organs such as the stomach,<br />

esophagus, small bowel, prostate, and urinary bladder. 1 To<br />

our knowledge, there have been only 22 cases <strong>of</strong> primary<br />

pulmonary choriocarcinoma reported in the literature. Of<br />

those cases, 13 developed in men. 2 Extragonadal choriocarcinoma<br />

arising in the lung is thought to be unresponsive<br />

to treatment and is associated with a poor prognosis.<br />

We report a young male patient with extragonadal, nongestational<br />

choriocarcinoma apparently arising in the lung.<br />

A positive urine pregnancy test result and an elevated<br />

serum -HCG level are compatible with the presence <strong>of</strong><br />

this neoplasm, and the diagnosis was confirmed histologically<br />

by bronchoscopy examination.<br />

Case Report<br />

A 23-year-old man was admitted to the hospital with a 3-week<br />

history <strong>of</strong> hemoptysis and progressive dyspnea. A chest radiograph<br />

on hospital admission revealed airspace consolidation in<br />

the periphery <strong>of</strong> the upper portion <strong>of</strong> both lungs with multiple<br />

nodules <strong>of</strong> variable sizes in both lung fields (Fig 1). A CT scan <strong>of</strong><br />

the chest confirmed the presence <strong>of</strong> pulmonary nodules with<br />

ground-glass opacities in both lungs, which is consistent with the<br />

presence <strong>of</strong> pulmonary hemorrhage (Fig 2). On physical examination,<br />

no gynecomastia was noted. The abdomen was s<strong>of</strong>t with<br />

no abnormal findings. A genital examination revealed no evidence<br />

<strong>of</strong> any scrotal masses. The remainder <strong>of</strong> the physical<br />

examination was unremarkable except <strong>for</strong> diffuse crackles in both<br />

lung fields. Under the impression <strong>of</strong> suspected germ cell tumors,<br />

a biological tumor marker study was per<strong>for</strong>med. The result <strong>of</strong> a<br />

urine pregnancy test was positive, and the levels <strong>of</strong> -HCG were<br />

very high at 1,600,000 IU/L in the serum (normal, 5 IU/L) and<br />

3,464,000 IU/L in the urine. However, the serum -fetoprotein<br />

level was within normal limits (ie, 3.8 ng/mL). A transbronchial<br />

lung biopsy in the right lower lobe showed intense hemorrhage<br />

and fibrinoid deposits in the alveoli with a dimorphic population<br />

<strong>of</strong> malignant cells with hyperchromatic nuclei and multinucleated<br />

syncytiotrophoblasts, which is consistent with choriocarcinoma<br />

(Fig 3), although a weak positive result <strong>of</strong> a -HCG immunohistochemical<br />

stain was found to be due to limited lesions (data not<br />

shown). Based on the findings, a diagnosis <strong>of</strong> choriocarcinoma<br />

was made. The patient was given chemotherapy, which consisted<br />

<strong>of</strong> actinomycin-D, methotrexate, and cyclophosphamide. Despite<br />

aggressive chemotherapy and management in the ICUs, the<br />

patient’s condition deteriorated rapidly, and he died <strong>of</strong> acute<br />

respiratory failure 8 days after hospital admission. A request <strong>for</strong><br />

an autopsy was denied.<br />

Discussion<br />

Choriocarcinoma is a germ cell tumor containing syncytiotrophoblastic<br />

giant cells and <strong>of</strong>ten secreting a biological<br />

tumor marker (-HCG). It usually occurs in women,<br />

996 Selected Reports<br />

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Figure 3. The histopathology <strong>of</strong> a transbronchial lung biopsy<br />

specimen shows a dimorphic population <strong>of</strong> malignant cells with<br />

hyperchromatic nuclei and multinucleated syncytiotrophoblasts<br />

scattered within fibrinoid deposits (hematoxylin-eosin stain,<br />

original 40).<br />

Figure 1. A chest radiograph per<strong>for</strong>med at hospital admission<br />

shows airspace consolidation infiltrates involving the periphery <strong>of</strong><br />

both lungs, with multiple pulmonary nodules <strong>of</strong> varying sizes in<br />

both lung fields.<br />

mainly as a gestational trophoblastic neoplasm, and rarely<br />

occurs in men as a nonseminomatous testicular tumor.<br />

Extragonadal nongestational primary pulmonary choriocarcinoma<br />

is exceedingly rare. 1–3 In the case presented,<br />

pulmonary choriocarcinoma was diagnosed on the basis <strong>of</strong><br />

the following findings: obvious lesions were found only in<br />

Figure 2. A CT scan <strong>of</strong> the chest demonstrates multiple<br />

pulmonary nodules in both lungs with ground-glass opacities<br />

involving the periphery <strong>of</strong> both upper lobes, which is consistent<br />

with pulmonary hemorrhage. P posterior; R right.<br />

the lung; raised -HCG levels were found both in the<br />

serum and in the urine; and pathologic confirmation <strong>of</strong> the<br />

disease.<br />

Because the lung is a frequent site <strong>of</strong> metastatic choriocarcinoma,<br />

the diagnosis <strong>of</strong> the primary tumor should<br />

be made carefully. In this case, although multiple nodules<br />

were found in both lungs, we considered the patient to<br />

have primary choriocarcinoma because there was no apparent<br />

evidence <strong>of</strong> a primary genital tumor, and no lesions<br />

were found in midline structures or in other visceral<br />

organs by CT scan, abdominal echography, and gastroendoscopy.<br />

Nevertheless, the possibility <strong>of</strong> a metastasis from<br />

invisible lesions in other locations could not be ruled out<br />

completely because the request <strong>for</strong> an autopsy was denied.<br />

There are several possible theories explaining the development<br />

<strong>of</strong> primary pulmonary choriocarcinoma. Some<br />

authors 4 believe that the tumors arise from retained<br />

primordial germ cells that migrate abnormally during<br />

embryonic development. Others believe that the tumors<br />

represent metastasis from a primary gonadal (ie, testicular<br />

or ovarian) tumor that regressed spontaneously 1 or arose<br />

from a trophoblastic emboli related to molar pregnancy<br />

after long periods <strong>of</strong> latency. 5 In other reports, 6,7 the<br />

hypothesis <strong>of</strong> dedifferentiation or metaplasia to the trophoblast<br />

from a nongonadal tissue such as primary lung<br />

cancer is supported. This theory may help to resolve a<br />

semantic problem, namely, whether primary pulmonary<br />

choriocarcinoma is identical to HCG-producing giant cell<br />

carcinoma <strong>of</strong> the lung because the histopathologic similarity<br />

<strong>of</strong> choriocarcinoma with giant cell lung cancer has<br />

been reported. 2,3<br />

Among the patients with primary pulmonary choriocarcinoma<br />

whose cases have been reported in the literature,<br />

most demonstrated solitary pulmonary nodules in the lung<br />

field. 3,5–7 However, in our patient, multiple nodular lesions<br />

were found on a chest radiograph. The presenting radiologic<br />

features in our patient would support the assertion<br />

CHEST / 121 /3/MARCH, 2002 997<br />

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that the tumors may metastasize from a primary gonadal<br />

tumor undergoing spontaneous regression. However, as in<br />

the debate in the literature concerning the origin <strong>of</strong> the<br />

diffuse or multinodular <strong>for</strong>m <strong>of</strong> bronchioloalveolar carcinoma<br />

<strong>of</strong> the lung, the tumors in our patient could be<br />

multicentric in origin or may merely represent a mode <strong>of</strong><br />

extension within the lung <strong>of</strong> a tumor arising in the small<br />

foci <strong>of</strong> primordial germ cells.<br />

In contrast to gestational choriocarcinoma, the natural<br />

course <strong>of</strong> primary pulmonary choriocarcinoma is rapidly<br />

fatal in the great majority <strong>of</strong> cases. Prompt recognition <strong>of</strong><br />

this unique disease is crucial because rapid intervention<br />

may be life-saving. However, treatment modalities such as<br />

chemotherapy, radiation, or surgical resection in patients<br />

with widespread, far-advanced malignant tumors have<br />

usually proven to be ineffective in providing better long-term<br />

survival, 3,8,9 as has been shown in this case. There have been<br />

only three reported cases 2 (Table 3) <strong>of</strong> survival <strong>for</strong> 1 year in<br />

male patients with primary pulmonary choriocarcinoma. The<br />

reason that nongestational choriocarcinoma behaves so differently<br />

from gestational cancers is unknown.<br />

A positive result <strong>of</strong> a -HCG test in patients with<br />

hemoptysis and progressive dyspnea should arouse suspicions<br />

<strong>of</strong> the presence <strong>of</strong> pulmonary choriocarcinoma, thus<br />

leading to an early diagnosis. In most <strong>of</strong> the reported<br />

cases, however, the patients had sought medical attention<br />

too late. In addition, because the radiologic findings <strong>of</strong><br />

pulmonary hemorrhage may obscure the nodular lesions<br />

<strong>of</strong> choriocarcinoma, and because the -HCG test and the<br />

histologic processing <strong>of</strong> tissue specimens may take several<br />

days, the diagnosis may be delayed, particularly, in male<br />

patients. In the presented case, the patient was thought<br />

initially to have an infectious disease, germ cell tumors, or<br />

metastatic lung cancer, based on the findings <strong>of</strong> clinical<br />

entities, a chest radiograph, and CT scan. A positive urine<br />

pregnancy test result, which only takes a couple <strong>of</strong> minutes,<br />

rapidly gave us a very clear direction in the differential<br />

diagnosis <strong>of</strong> the lung lesions.<br />

In conclusion, the diagnosis <strong>of</strong> primary pulmonary<br />

choriocarcinoma must be considered in young male patients<br />

with hemoptysis, progressive dyspnea, and radiologic<br />

findings <strong>of</strong> airspace consolidation with solitary/multiple<br />

pulmonary nodules. The serum -HCG level should<br />

be examined as early as possible. Be<strong>for</strong>e this is done, the<br />

per<strong>for</strong>mance <strong>of</strong> a urine pregnancy test, a simple and<br />

convenient method, would be very useful in the rapid<br />

diagnosis <strong>of</strong> primary pulmonary choriocarcinoma.<br />

References<br />

1 Hainsworth JD, Greco FA. Extragonadal germ cell tumors<br />

and unrecognized germ cell tumors. Semin Oncol 1992;<br />

19:119–127<br />

2 Ikura Y, Inoue T, Tsukuda H, et al. <strong>Primary</strong> choriocarcinoma<br />

and human chorionic gonadotrophin-producing giant cell<br />

carcinoma <strong>of</strong> the lung: are they independent entities Histopathology<br />

2000; 36:17–25<br />

3 Canver CC, Voytovich MC. Resection <strong>of</strong> an unsuspected<br />

primary pulmonary choriocarcinoma. Ann Thorac Surg 1996;<br />

61:1249–1251<br />

4 Fine G, Smith RW, Pachter MR. <strong>Primary</strong> extragenital choriocarcinoma<br />

in the male subject. Am J Med 1962; 32:<br />

776–794<br />

5 Tanimura A, Natsuyama H, Kawano M, et al. <strong>Primary</strong><br />

choriocarcinoma <strong>of</strong> the lung. Hum Pathol 1985; 16:1281–<br />

1284<br />

6 Pushchak MJ, Farhi DC. <strong>Primary</strong> choriocarcinoma <strong>of</strong> the<br />

lung. Arch Pathol Lab Med 1987; 111:477–479<br />

7 Sullivan LG. <strong>Primary</strong> choriocarcinoma <strong>of</strong> the lung in a man.<br />

Arch Pathol Lab Med 1989; 113:82–83<br />

8 Benditt JO, Farber HW, Wright J, et al. Pulmonary hemorrhage<br />

with diffuse alveolar infiltrates in men with highvolume<br />

choriocarcinoma. Ann Intern Med 1988; 15:674–675<br />

9 Aparcio J, Oltra A, Martinez-Moragon E, et al. Extragonadal<br />

nongestational choriocarcinoma involving the lung: a report<br />

<strong>of</strong> three cases. Respiration 1996; 63:251–223<br />

Tracheal Compression by the<br />

Stomach Following Gastric<br />

Pull-Up*<br />

<strong>Diagnosis</strong> With CT and Treatment<br />

With Expandable Metallic Stent<br />

Placement<br />

Suil Kim, MD, PhD; Michael B. Gotway, MD;<br />

W. Richard Webb, MD; Roy L. Gordon, MD; and<br />

Jeffrey A. Golden, MD<br />

Surgical treatment <strong>of</strong> recurrent achalasia includes<br />

esophagectomy with gastric pull-up. A MEDLINE<br />

search yielded no articles describing an adverse<br />

effect <strong>of</strong> this surgery on pulmonary function. We<br />

report the first case <strong>of</strong> acute ventilatory failure<br />

caused by gastric pull-up. An evaluation by flexible<br />

bronchoscopy, spirometry with flow-volume loops,<br />

and dynamic CT scanning revealed extrinsic compression<br />

<strong>of</strong> the trachea by the stomach causing<br />

obstruction. Endotracheal placement <strong>of</strong> a selfexpanding<br />

stent resulted in the rapid extubation <strong>of</strong><br />

the patient with normalization <strong>of</strong> the flow-volume<br />

loop and dramatic improvement in the FVC, FEV 1 ,<br />

and peak expiratory flow.<br />

(CHEST 2002; 121:998–1001)<br />

Key words: bronchoscopy; dynamic CT; esophagectomy; spirometry;<br />

stent; tracheal obstruction; tracheomalacia<br />

Abbreviation: ETT endotracheal tube<br />

*From the Departments <strong>of</strong> Medicine (Drs. Kim and Golden) and<br />

Radiology (Drs. Gotway and Webb), Division <strong>of</strong> Pulmonary and<br />

Critical Care Medicine, and the Section <strong>of</strong> Interventional Radiology<br />

(Dr. Gordon), University <strong>of</strong> Cali<strong>for</strong>nia, San Francisco, CA.<br />

Manuscript received May 16, 2001; revision accepted August 21,<br />

2001.<br />

Correspondence to: Jeffrey A. Golden, MD, Division <strong>of</strong> Pulmonary<br />

and Critical Care Medicine, University <strong>of</strong> Cali<strong>for</strong>nia, San<br />

Francisco, 400 Parnassus Ave, Box 0359, San Francisco, CA<br />

94143-0359; e-mail: jgolden@itsa.ucsf.edu<br />

998 Selected Reports<br />

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