Tumors of the pulmonary arteries are often incorrectly diagnosed as pulmonary thromboembolism, and are thus seldom diagnosed during a patient’s lifetime. We report a patient with a choriocarcinoma mimicking pulmonary embolism, who required pulmonary embolectomy and had remission with chemotherapy thereafter.
A 27-year-old woman presented with exertional dyspnea and mild hemoptysis. She had one previous molar pregnancy. The initial chest radiographs was unremarkable. She was treated for bronchitis; however, her symptoms became worse. The subsequent chest radiographs showed a bilateral diffuse lower lobe infiltrative shadows. On admission, she was hypoxemic with resting O2 sat of 88%. The chest enhanced CT showed a filling defect at left pulmonary artery (LPA) [Fig 1]. After negative evaluation for the source for the pulmonary emboli and multiple ovarian varices, a choriocarcinoma was considered because her prior molar pregnancy. Pulmonary embolectomy was done. A whitish, thrombus was found occluding the MPA and extending into the LPA. The embolus was removed. Pulmonary arterial pressure dropped from 80 to 50 mm Hg immediately after the operation. However, the patient required ventilator support for subsequent respiratory failure. Microscopically, the specimens showed “syncytiotrophoblastic cells”. [Fig 2]. After a diagnosis of pulmonary artery choriocarcinoma was made, a serum HCG values was > 80,000 mIU/mL, and a gynecologic examination was performed. After a 6-month period of chemotherapy, the residual lung tumor decreased in size and lung fields of the chest radiographs became almost clear.DISCUSSION: Choriocarcinoma is a germ cell tumor containing syncytiotrophoblastic giant cells and often secreting a biological tumor marker. (β-HCG). It usually occurs in women. Development of pulmonary choriocarcinoma can come from retained primordial germ cells, metastasis from a primary gonadal tumor that regressed spontaneously, trophoblastic emboli related to molar pregnancy after long periods of latency or metaplasia to the trophoblast from a non-gonadal tissue, such as primary lung cancer. The natural history of untreated choriocarcinoma is characterized by the development of early hematogenous metastases. Some of the vagaries of this tumor have attracted attention, and failure to find a primary growth in the uterus, even on careful microscopic examination, is not infrequent. A few cases of primary choriocarcinoma have been reported1. However, this is the second patient who underwent pulmonary embolectomy and was treated with subsequent chemotherapy after a confirming pathologic diagnosis2. However, although rare, choriocarcinoma should be considered in the differential diagnosis of fertile women presenting with pulmonary embolism or pulmonary artery hypertension. Furthermore, Savage et al3 emphasized the importance of considering choriocarcinoma and measuring serum hCG in the investigation of fertile women presenting with pulmonary emboli or pulmonary artery hypertension. In our case, choriocarcinoma was not diagnosed in an early stage. However, chemotherapy was initiated as soon as the diagnosis was made and the patient responded positively, with serum β- HCG falling to within normal levels. Our results indicate that although rare, choriocarcinoma should be considered in the differential diagnosis of fertile women presenting with pulmonary embolism, because complete remission can be achieved with appropriate chemotherapy.
Choriocarcinoma should be considered in the differential diagnosis of fertile women presenting with pulmonary embolism. Due to their rarity, tumors of the pulmonary arteries are often incorrectly diagnosed as more common diseases, such as pulmonary thromboembolism, and are thus seldom diagnosed during a patient’s lifetime.
A. Pelaez, None.