A 59 years old man complaining of hemoptysis and chest pain presented to our hospital. Four months prior to admission, Chest computed tomography (CT) revealed a 43×26 mm parenchymal nodule in the posterior right upper lung lobe accompanied by emphysema, while no treatment was performed. The patient had hemoptysis without obvious inducement, accompanied by progressive shortness of breath, chest pain, intermittent fever, drenching night sweats, diminished appetite and a 5-kg weight loss over 3 months. The patient a smoking history for 30 years with one pack per day and a drinking history for 40 years with 200g per day.
There were no abnormalities on physical examination, including genital examination. Chest x-ray was significant for bilateral pulmonary nodules. Doppler ultrasound of the testes and mammography of breasts were negative for malignancy. To determine whether the tumor occurred primarily within the lung systemic screenings were performed by positron emission tomography-computed tomography (PET-CT). The results showed that multiple high metabolic nodules throughout the body (Fig 1), multiple bilateral pulmonary nodules (Fig 2), especially large mass in the upper lobe of the right lung (Fig 3), a 22 mm metastatic lesion in the pancreas (Fig 4), and multiple bone metastases (Fig 5). The patient underwent single-port thoracoscopic wedge resection of the right lung upper lobe. Extensive metastases in the right lung were observed during the operation, with tumor diameters ranging from 2-6 cm. Histopathologic workup of excised tumor showed poorly differentiated carcinoma and hemorrhage, with the few viable islands demonstrating syncytiotrophoblastic and cytotrophoblastic like cells (Fig 6). Immunohistochemical phenotype of pathological sections was that CK7(+), TTF-1(-), CK(+), CD34(-), CD117(-), OCT3/4(-), SALL4(+), HCGα(+), Ki67(+90%), Vimentin(-). Thus, we performed the serum β-HCG levels examination and the result was >10000.00(mlU/ml). The abnormal increase of tumor markers were ferritin >320.00 μg/L, lung tumor antigen (LTA) 136.20 ng/L and tissue polypeptide specific antigen (TPS)>4500.00 U/L. The results of sex hormone were testosterone 0.83 ng/mL, estradiol 716.10 pg/mL, follicle stimulating hormone (FSH) 0.26 mIU/mL. The pathological and hormone levels evidence met the diagnostic criteria for PPC.
Three days after the operation, the patient suddenly appeared consciousness disorder, sweating profusely and pinpoint pupils. Subsequently, hemodynamic instability and acute respiratory failure appeared. The patient was admitted to the ICU with tracheal intubation for respiratory support. A large amount of bloody fluid was sucked out of the bilateral main bronchus using bronchoscopy. The chest radiograph showed that multiple cluster and nodular shadows scattered in both lungs. Laboratory data was significant for white blood cell 13.85 900/mm which prompt the pneumonia. Subsequently, the patient developed cardiac dysfunction, manifested by increased myocardial markers. Cardiac color doppler ultrasound revealed that ventricular wall motion is not coordinated; left ventricular diastolic function decreased; ejection fraction was 60%. Simultaneously, the patient suffered acute renal failure, the endogenous creatinine clearance rate continued to decrease, to a minimum of 10.01 (ml/min/1.73m2), and urea and creatinine continued to rise. Despite supportive treatment, the patient’s condition continued to deteriorate. Due to multiple organ failure, the patient has no indications for chemotherapy and eventually died. Diagnosis of death: 1. Pulmonary choriocarcinoma with metastasis to the lung, brain, bone, pancreas, and lymph nodes 2. Severe pneumonia and respiratory failure 3. Acute renal failure; 4. Acute coronary syndrome.