A Lesson from a Rare Cause of Pulmonary Embolism

A rare case of pulmonary artery embolism with choriocarcinoma: A case report and literature review

Pulmonary embolism (PE) caused by malignant tumor is not uncommon, but pulmonary artery with choriocarcinoma is rare and difficult to timely diagnose and effectively treat. To the best of our knowledge, there are only 15 cases reported at present in the literature that present variable clinical characteristics and prognosis. In the current study reports a 21-year-old female with a history of chest pain and slight fever for 4 months who was treated as a case of pneumonia. Owing to the recurrence of the symptoms, a contrast-enhanced chest computer tomography scan was performed on the patient, which revealed complete occlusion of the right pulmonary artery. The patient was diagnosed to have pulmonary embolism (PE). However, no abnormalities were observed in D-dimer value, tumor antigen testing or ultrasonography. Positron emission tomography/computed tomography (PET/CT) was performed, which revealed the abnormal hypermetabolic lesion of the right pulmonary artery. Following the laboratory report of a significantly elevated human chorionic gonadotropin β-subunit level combined with characteristic appearance of PET-CT, the diagnosis of primary pulmonary artery with choriocarcinoma was established based on guidelines of the European Society for Medical Oncology and the criteria formulated by the International Federation of Gynecology and Obstetrics. The patient underwent chemotherapy and responded well to the treatment. Although rare, choriocarcinoma should be considered for any fertile women who presents with a massive PE. These findings emphasize the importance of the early diagnosis and treatment of this disease.

Exploring the real cause of hemoptysis: A case of pulmonary tumor embolism in a young woman with accompanying pulmonary metastasis of gestational trophoblastic neoplasia

We report a case of pulmonary embolism caused by gestational trophoblastic neoplasia (GTN) accompanied by pulmonary metastasis to improve the recognition ability of the disease in young female patients with pulmonary embolism and hemoptysis.

Neoplastic embolization to systemic and pulmonary arteries

OBJECTIVE

Arterial neoplastic emboli are uncommon, accounting for <1% of thromboemboli in the current literature. Nonetheless, this event may be associated with significant morbidity and mortality. Herein, we report a series of 11 cases of arterial neoplastic emboli from a single tertiary care center along with a comprehensive review of the literature to date. The aim of this study was to document the incidence, clinical presentations, and complications of arterial neoplastic emboli as well as to highlight the importance of routine histologic examination of thrombectomy specimens.

METHODS

Pathology archives from a single tertiary care institution were queried to identify cases of surgically resected arterial emboli containing neoplasm (1998-2014). Histopathology was reviewed for confirmation of diagnosis. Patient demographics and oncologic history were abstracted from the medical record. Comprehensive literature review documented 332 patients in 275 reports (1930-2016).

RESULTS

Eleven patients (six men) with a median age of 63 years (interquartile range, 42-71 years) were identified through institutional archives. Embolism was the primary form of diagnosis in seven (64%) cases. Cardiac involvement (primary or metastasis) was present in more than half of the cohort. Comprehensive literature review revealed that pulmonary primaries were the most common anatomic origin of arterial neoplastic emboli, followed by gastrointestinal neoplasia. Cardiac involvement was present in 18% of patients, and sentinel identification of neoplasia occurred in 30% of cases. Postmortem evaluation was the primary means of diagnosis in 27%.

CONCLUSIONS

This study highlights the importance of routine histopathologic evaluation of embolectomy specimens in patients with and without documented neoplasia.

Role of chemotherapy and thrombolysis in treatment of choriocarcinoma accompanied with pulmonary embolism: A case report with literature review

RATIONALE

Choriocarcinoma accompanied with pulmonary embolism (PE) is rare and difficult to diagnose and treat. There are about 25 cases reported in literature, which presented variable clinical characteristics and prognosis.

PATIENT CONCERNS

We reported a case of choriocarcinoma presenting PE as the first manifestation in a 26-year-old Chinese female.

DIAGNOSES

Four months before her admission to our hospital, she presented to a local hospital with respiratory manifestations, and was first diagnosed as bronchitis and treated with antibiotics without improvement, and subsequently suspected of having pulmonary tuberculosis and receive anti-tuberculosis therapy, with no response. Upon admission to our hospital, spiral computed tomography-pulmonary angiography revealed complete occlusion of right pulmonary artery, leading to PE. She received thrombolysis and anticoagulant therapy, without improvement. Further interrogation of the patient revealed a history of irregular vaginal bleeding and multiple pregnancies and abortions. Following the laboratory report of a significantly elevated level of serum beta-human chorionic gonadotropin (β-HCG) combined with other clinical and laboratory findings, a diagnosis of choriocarcinoma accompanied with PE was established based on the criteria formulated by the International Federation of Gynecology and Obstetrics and guideline of European Society for Medical Oncology.

INTERVENTIONS

With 1 cycle of chemotherapy with etoposide-methotrexateactinomycin D-cyclophosphamide-vincristine (EMA-CO), her dyspnea and other symptoms improved, with a significant decrease in the serum β-HCG level and pulmonary artery pressure.

OUTCOMES

Unfortunately, she showed bone marrow inhibition, could not continue further chemotherapy, and finally died after discharging. We reviewed 25 similar cases in the literature, and found that all 17 cases receiving chemotherapy showed complete recovery while 6 of 8 cases without chemotherapy died during hospitalization.

LESSONS

This case report illustrates the challenges in diagnosis of choriocarcinoma presenting with respiratory manifestations, and highlights the importance of early diagnosis and timely appropriate chemotherapy in management of this disease.