Use of Urine Pregnancy Test for Rapid Diagnosis of Primary ...

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Figure 3. The histopathology of a transbronchial lung biopsy specimen shows a dimorphic population of malignant cells with hyperchromatic nuclei and multinucleated syncytiotrophoblasts scattered within fibrinoid deposits (hematoxylin-eosin stain, original 40). Figure 1. A chest radiograph performed at hospital admission shows airspace consolidation infiltrates involving the periphery of both lungs, with multiple pulmonary nodules of varying sizes in both lung fields. mainly as a gestational trophoblastic neoplasm, and rarely occurs in men as a nonseminomatous testicular tumor. Extragonadal nongestational primary pulmonary choriocarcinoma is exceedingly rare. 1–3 In the case presented, pulmonary choriocarcinoma was diagnosed on the basis of the following findings: obvious lesions were found only in Figure 2. A CT scan of the chest demonstrates multiple pulmonary nodules in both lungs with ground-glass opacities involving the periphery of both upper lobes, which is consistent with pulmonary hemorrhage. P posterior; R right. the lung; raised -HCG levels were found both in the serum and in the urine; and pathologic confirmation of the disease. Because the lung is a frequent site of metastatic choriocarcinoma, the diagnosis of the primary tumor should be made carefully. In this case, although multiple nodules were found in both lungs, we considered the patient to have primary choriocarcinoma because there was no apparent evidence of a primary genital tumor, and no lesions were found in midline structures or in other visceral organs by CT scan, abdominal echography, and gastroendoscopy. Nevertheless, the possibility of a metastasis from invisible lesions in other locations could not be ruled out completely because the request for an autopsy was denied. There are several possible theories explaining the development of primary pulmonary choriocarcinoma. Some authors 4 believe that the tumors arise from retained primordial germ cells that migrate abnormally during embryonic development. Others believe that the tumors represent metastasis from a primary gonadal (ie, testicular or ovarian) tumor that regressed spontaneously 1 or arose from a trophoblastic emboli related to molar pregnancy after long periods of latency. 5 In other reports, 6,7 the hypothesis of dedifferentiation or metaplasia to the trophoblast from a nongonadal tissue such as primary lung cancer is supported. This theory may help to resolve a semantic problem, namely, whether primary pulmonary choriocarcinoma is identical to HCG-producing giant cell carcinoma of the lung because the histopathologic similarity of choriocarcinoma with giant cell lung cancer has been reported. 2,3 Among the patients with primary pulmonary choriocarcinoma whose cases have been reported in the literature, most demonstrated solitary pulmonary nodules in the lung field. 3,5–7 However, in our patient, multiple nodular lesions were found on a chest radiograph. The presenting radiologic features in our patient would support the assertion CHEST / 121 /3/MARCH, 2002 997 Downloaded From: http://publications.chestnet.org/ on 05/16/2014
that the tumors may metastasize from a primary gonadal tumor undergoing spontaneous regression. However, as in the debate in the literature concerning the origin of the diffuse or multinodular form of bronchioloalveolar carcinoma of the lung, the tumors in our patient could be multicentric in origin or may merely represent a mode of extension within the lung of a tumor arising in the small foci of primordial germ cells. In contrast to gestational choriocarcinoma, the natural course of primary pulmonary choriocarcinoma is rapidly fatal in the great majority of cases. Prompt recognition of this unique disease is crucial because rapid intervention may be life-saving. However, treatment modalities such as chemotherapy, radiation, or surgical resection in patients with widespread, far-advanced malignant tumors have usually proven to be ineffective in providing better long-term survival, 3,8,9 as has been shown in this case. There have been only three reported cases 2 (Table 3) of survival for 1 year in male patients with primary pulmonary choriocarcinoma. The reason that nongestational choriocarcinoma behaves so differently from gestational cancers is unknown. A positive result of a -HCG test in patients with hemoptysis and progressive dyspnea should arouse suspicions of the presence of pulmonary choriocarcinoma, thus leading to an early diagnosis. In most of the reported cases, however, the patients had sought medical attention too late. In addition, because the radiologic findings of pulmonary hemorrhage may obscure the nodular lesions of choriocarcinoma, and because the -HCG test and the histologic processing of tissue specimens may take several days, the diagnosis may be delayed, particularly, in male patients. In the presented case, the patient was thought initially to have an infectious disease, germ cell tumors, or metastatic lung cancer, based on the findings of clinical entities, a chest radiograph, and CT scan. A positive urine pregnancy test result, which only takes a couple of minutes, rapidly gave us a very clear direction in the differential diagnosis of the lung lesions. In conclusion, the diagnosis of primary pulmonary choriocarcinoma must be considered in young male patients with hemoptysis, progressive dyspnea, and radiologic findings of airspace consolidation with solitary/multiple pulmonary nodules. The serum -HCG level should be examined as early as possible. Before this is done, the performance of a urine pregnancy test, a simple and convenient method, would be very useful in the rapid diagnosis of primary pulmonary choriocarcinoma. References 1 Hainsworth JD, Greco FA. Extragonadal germ cell tumors and unrecognized germ cell tumors. Semin Oncol 1992; 19:119–127 2 Ikura Y, Inoue T, Tsukuda H, et al. Primary choriocarcinoma and human chorionic gonadotrophin-producing giant cell carcinoma of the lung: are they independent entities Histopathology 2000; 36:17–25 3 Canver CC, Voytovich MC. Resection of an unsuspected primary pulmonary choriocarcinoma. Ann Thorac Surg 1996; 61:1249–1251 4 Fine G, Smith RW, Pachter MR. Primary extragenital choriocarcinoma in the male subject. Am J Med 1962; 32: 776–794 5 Tanimura A, Natsuyama H, Kawano M, et al. Primary choriocarcinoma of the lung. Hum Pathol 1985; 16:1281– 1284 6 Pushchak MJ, Farhi DC. Primary choriocarcinoma of the lung. Arch Pathol Lab Med 1987; 111:477–479 7 Sullivan LG. Primary choriocarcinoma of the lung in a man. Arch Pathol Lab Med 1989; 113:82–83 8 Benditt JO, Farber HW, Wright J, et al. Pulmonary hemorrhage with diffuse alveolar infiltrates in men with highvolume choriocarcinoma. Ann Intern Med 1988; 15:674–675 9 Aparcio J, Oltra A, Martinez-Moragon E, et al. Extragonadal nongestational choriocarcinoma involving the lung: a report of three cases. Respiration 1996; 63:251–223 Tracheal Compression by the Stomach Following Gastric Pull-Up* Diagnosis With CT and Treatment With Expandable Metallic Stent Placement Suil Kim, MD, PhD; Michael B. Gotway, MD; W. Richard Webb, MD; Roy L. Gordon, MD; and Jeffrey A. Golden, MD Surgical treatment of recurrent achalasia includes esophagectomy with gastric pull-up. A MEDLINE search yielded no articles describing an adverse effect of this surgery on pulmonary function. We report the first case of acute ventilatory failure caused by gastric pull-up. An evaluation by flexible bronchoscopy, spirometry with flow-volume loops, and dynamic CT scanning revealed extrinsic compression of the trachea by the stomach causing obstruction. Endotracheal placement of a selfexpanding stent resulted in the rapid extubation of the patient with normalization of the flow-volume loop and dramatic improvement in the FVC, FEV 1 , and peak expiratory flow. (CHEST 2002; 121:998–1001) Key words: bronchoscopy; dynamic CT; esophagectomy; spirometry; stent; tracheal obstruction; tracheomalacia Abbreviation: ETT endotracheal tube *From the Departments of Medicine (Drs. Kim and Golden) and Radiology (Drs. Gotway and Webb), Division of Pulmonary and Critical Care Medicine, and the Section of Interventional Radiology (Dr. Gordon), University of California, San Francisco, CA. Manuscript received May 16, 2001; revision accepted August 21, 2001. Correspondence to: Jeffrey A. Golden, MD, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, 400 Parnassus Ave, Box 0359, San Francisco, CA 94143-0359; e-mail: jgolden@itsa.ucsf.edu 998 Selected Reports Downloaded From: http://publications.chestnet.org/ on 05/16/2014
Page 1: 8 Muth CM, Shank ES. Gas embolism.

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