Extragonadal nongestational choriocarcinoma involving the lung: a report of three cases

A Case Report on Primary Pulmonary Choriocarcinoma

Primary choriocarcinoma originating in the lung is a rare entity. These are highly malignant intrapulmonary tumors with a notoriously poor prognosis. The pathogenesis is unclear. A 34-year-old lady, with a history of abortion six months back, presented with left-sided chest pain for one month, dyspnea on exertion, weight loss, and loss of appetite. Computed tomography (CT) of the thorax was suggestive of a mass lesion 4 x 5 cm at the left upper lobe, which was invading the chest wall, and pleural effusion, histopathologically defined as adenocarcinoma. A positron emission tomography-computed tomography (PET-CT) scan showed a fluorodeoxyglucose (FDG) avid lesion in the left upper lobe of size 4 x 5 with invasion to the chest wall with no evidence of distant metastases. Urine pregnancy test (UPT) was negative for this patient. Thus, the patient was initially diagnosed with stage cT3N0M0 adenocarcinoma of left lung cancer. The sample was sent for the lung next-generation sequencing (NGS) panel. Meanwhile, the patient was empirically started on gefitinib. Tumor markers revealed raised beta-human chorionic gonadotropin (β-hCG) to 1,79,000 IU/ml. A review biopsy was done, which was suggestive of choriocarcinoma. Genetic testing of lung biopsy suggestive of XX chromosome, confirming the diagnosis of primary pulmonary choriocarcinoma (PPC). The patient was planned for chemotherapy with etoposide and cisplatin. The patient underwent embolization of the left internal mammary artery (IMA) and branches of the left subclavian vein. There was a gradual fall in β-hCG after the second dose of chemotherapy on day 7. For the diagnosis of PPC, immunohistochemistry (IHC) staining, β-hCG measurement, and examination to exclude primary gonadal malignancies are essential. A combination of surgery and chemotherapy is a favorable treatment. As it's a highly vascular tumor, selective arterial embolization can be life-saving in case of bleeding.

Analysis of clinical characteristics and prognosis of 68 patients with primary pulmonary choriocarcinoma

BACKGROUND

Primary pulmonary choriocarcinoma (PPC) is a highly malignant intrapulmonary tumor with a notorious prognosis. Few clinical studies have been undertaken to investigate the clinical characteristics and prognosis of PPC.

MATERIAL AND METHODS

We systematically conducted a retrospective analysis of patients with PPC in the literature published in PubMed and CNKI databases until March 31, 2022. The primary outcome was all-cause mortality. Survival curves were depicted using the Kaplan‒Meier method and compared using the stratified log-rank test. A Cox proportional hazards model was used to estimate the prognostic factors.

RESULTS

A total of 68 patients were included, which consisted of 32 females and 36 males, with an average age of (44.5 ± 16.8) years old, ranging from 19 to 77 years. The clinical characteristics were mostly cough (49.2%), dyspnea (22.2%), hemoptysis (39.7%) and chest pain (39.7%). Kaplan‒Meier analysis showed that sex, age, hemoptysis, metastasis and treatment combining surgery with chemotherapy had a significant effect on survival. There were no effects on other outcomes. Furthermore, univariate and multivariable Cox regression analyses showed that the impact of the treatment combining surgery with chemotherapy on OS showed independent prognostic significance.

CONCLUSION

PPC is a rare disease that lacks specific clinical features. Early diagnosis with optimal management is a significant goal. Surgery followed by adjuvant chemotherapy may be the best treatment for PPC.

Pulmonary metastasis as a primary manifestation of gestational choriocarcinoma in a third trimester pregnancy

•

Choriocarcinomas can follow molar, ectopic, or normal pregnancies.

•

The early diagnosis and treatment of choriocarcinomas is imperative.

•

Atypical symptoms in pregnancy should raise suspicion for choriocarcinoma.

•

Choriocarcinoma must always be in the differential in uncomplicated term pregnancies.

Primary pulmonary choriocarcinoma

Background

The aim of the study was to establish whether there are different clinical entities of primary pulmonary choriocarcinoma (PPC) that deserve different diagnostic approach and the most optimal treatment.

Patients and methods

A systematic review with PubMed search was conducted to identify studies that reported cases of PPC. The eligibility criteria were histological diagnosis of pulmonary choriocarcinoma and thorough examination of the reproductive organs to exclude potential primary choriocarcinoma in the gonads. Furthermore, to illustrate the review we additionally present a patient referred at our institution.

Results

55 cases (17 men) were included in the review with a median age of 34 years. Women with the history of gestational event showed better survival outcome than women without the history of gestational event. Patients treated with combined modality treatment (surgery and chemotherapy) survived longer than the patients without combined modality treatment. Furthermore, multivariate analysis of prognostic factors showed that the combined modality treatment had independent prognostic significance. Size of the tumour showed significant prognostic influence in univariate and multivariate analysis.

Conclusions

PPC is an extreme rarity with variable clinical characteristics and outcome. It is important to capture and treat patients in the early stages of the disease. Women with the history of gestational event may show better survival, therefore genetic examination could help us to predict patient’s prognosis. Surgery followed by adjuvant chemotherapy appears to represent the best treatment for PPC.

Primary pulmonary choriocarcinoma: case report and review of the literature

Primary pulmonary choriocarcinoma is a rare disease with only 31 reported cases in the literature so far. Here, we summarize all published cases, including a recent case of our own clinic. Patients usually presented with symptoms like dyspnea, cough, chest pain, weight loss or hemoptysis. In some cases, the nodule in the lung was found in a routine check-up in asymptomatic patients. In the present case, the patient presented to our clinic because of a positive urine pregnancy test despite taking oral contraceptives. Patients in the analyzed cases were either treated with surgery, chemotherapy, radiotherapy or best supportive care. In the present case, a complete resection of the tumor was possible and the patient has not had any signs of recurrence so far. When looking at the published cases and corresponding outcomes, a slight tendency toward a complete resection followed by chemotherapy or close follow-up examinations seems to give the patients the best survival chances. Nevertheless, the overall prognosis of primary pulmonary choriocarinoma is poor and the 5-year survival rate is below 5%.

[Choriocarcinoma with pulmonary metastasis: diagnosis and treatment]

INTRODUCTION

Choriocarcinoma is a rare tumour which results from the anarchic proliferation of a gonadic or extra gonadic germinal cell.

CASE REPORT

A 45 year old pre menopausal woman of African origin presented with a persistent cough and deterioration of general status. The chest X-ray revealed a cavitated mass of the right upper lobe. Other lesions were associated (liver, kidney and scalp). Choriocarcinoma, suspected in the presence of an elevated ssHCG without a gravid uterus, was confirmed by biopsy excision of a haemorrhagic cutaneous lesion of the scalp. Despite the poor prognosis methotrexate based chemotherapy resulted in control of the disease and a good remission.

Primary pulmonary choriocarcinoma presenting with a hemothorax

Primary pulmonary choriocarcinoma is an extremely rare condition that is difficult to diagnose. In this report, we describe a case of primary pulmonary choriocarcinoma that presented with a hemothorax, initially diagnosed as an ectopic pregnancy. The patient was treated successfully with surgery followed by combination chemotherapy. In rare instances such as this, choriocarcinoma can originate in sites outside the genital tract; a thorough and thoughtful evaluation will ensure an accurate diagnosis and prompt treatment.

Pulmonary pleomorphic carcinoma producing hCG

An 80-year-old woman with a pleomorphic carcinoma (PC) producing hCG was admitted to Nippon Steel Hirohata Hospital because of an abnormal shadow on CT seen during a follow-up examination after surgery for breast cancer. A right upper lobectomy was performed due to rapid growth of the shadow 3 months later. Macroscopically the tumor was a 4.8 x 4.0 cm well-circumscribed grayish-white mass. On histology the tumor consisted mostly of intermingled spindle and polygonal cells, while evidence of poorly differentiated adenocarcinoma was seen in a few areas. A diagnosis of PC was made due to hCG expression in approximately 20% of the spindle and polygonal cells on immunohistology. Six months after the operation metastasis to the liver and adrenal gland was seen on CT. The patient died due to metastases 1 year after the operation, even though the patient had been at stage 1B at the time of the operation and appropriate chemotherapy had been given. PC patients with immunohistochemical hCG expression have elevated risk of local recurrence and metastasis.

Primary pulmonary choriocarcinoma combined with adenocarcinoma

An extremely rare autopsy case of primary pulmonary choriocarcinoma combined with adenocarcinomatous components in a 77-year-old Japanese man is described. The patient died of rapidly progressive respiratory dysfunction without ante-mortem diagnosis. Autopsy revealed necro-hemorrhagic areas of the primary lung tumor with a typical biphasic pattern of choriocarcinoma. Topographical analysis suggested that moderately to poorly differentiated adenocarcinoma components partially surrounded the choriocarcinomatous components. Moreover, dedifferentiated carcinomatous components were scattered next to both adenocarcinomatous and choriocarcinomatous areas, and a few cells of the dedifferentiated carcinomatous components had a similar immunoreaction to conventional adenocarcinomatous or choriocarcinomatous components, such as surfactant apoprotein A, placental alkaline phosphatase or beta-human chorionic gonadotropin. Additionally, epithelial membrane antigen-positive cytotrophoblastic cells were rarely found in choriocarcinomatous areas. The present case suggests that primary lung choriocarcinoma can occur closely related to conventional pulmonary adenocarcinoma, although collision tumor was not completely ruled out.

Combined choriocarcinoma and adenocarcinoma of the lung occurring in a man: case report and review of the literature

BACKGROUND

Human chorionic gonadotropin (hCG)-producing large or giant cell carcinoma of the lung is not uncommon, but primary pulmonary choriocarcinoma is an extremely rare entity. Even rarer are cases occurring in males; to date the authors have found only 12 reported cases in the English literature.

METHODS

The clinical record of a 61-year-old man who presented with hemoptysis is described. A review of the literature regarding patients with primary pulmonary choriocarcinoma also is reported.

RESULTS

Computed tomography scan of the chest demonstrated an expanding thickness of the bullous wall within areas of emphysematous change in the lower lobe of the right lung. Moreover, a new, round tumor near the thickness appeared and rapidly expanded evenly into the surrounding lung tissue. Exploratory thoracotomy revealed the previous tumor to be adenocarcinoma with a small foci of choriocarcinoma, and the new tumor to be a hemorrhage with choriocarcinoma. Because of the pleural dissemination, the patient was treated with chemotherapy. At last follow-up he was alive and well with a gradually increasing serum hCG-beta level in spite of chemotherapy.

CONCLUSIONS

Primary pulmonary choriocarcinoma occurring in men is an extremely rare entity with a fatal prognosis. Of the 12 cases reported to date in the English literature, 3 cases of choriocarcinoma with the coexistence of another type of pulmonary carcinoma were reported. To the authors' knowledge the clinical relation between these two types of carcinoma are unknown because all cases to date have been detected at the time of autopsy. Only in the current study case could the clinical course of the disease be followed and pathologic confirmation achieved, although the pathogenesis of the two types of carcinoma could not be determined.

Primary choriocarcinoma and human chorionic gonadotrophin-producing giant cell carcinoma of the lung: are they independent entities?

AIMS

Human chorionic gonadotrophin (hCG) is a useful marker for chorionic proliferative disorders, such as choriocarcinoma. Although hCG synthesis in lung cancers is frequent, primary pulmonary choriocarcinoma (PCC) is rare. To clarify the differences between primary choriocarcinoma and hCG-producing giant cell carcinoma (GCC) of the lung, we compared the clinicopathological and immunohistochemical findings of these tumours.

METHODS AND RESULTS

Three patients, one with PCC and two with hCG-producing GCC, were included in this study. They were all middle-aged men and habitual smokers. The growth of these tumours and the progression of the clinical courses were extremely rapid, and the patients all died within 8 months after the pulmonary tumours were found. Haemorrhagic appearance was a common macroscopic feature of the specimens obtained. Microscopically, both types of tumours mainly consisted of atypical polygonal cells. While PCC contained many syncytial trophoblast-like multinucleated cells that had strong immunoreactivity for anti-hCG, such cells were relatively few in hCG-producing GCC. These histological and immunohistochemical findings reflected the serum test result for hCG, which was higher in the case of PCC.

CONCLUSIONS

There are a few differences between PCC and hCG-producing GCC, as described above. Reliable distinction between them seems to be difficult for pathologists and worthless for clinicians.