HEMOPTYSIS AS PRIMARY MANIFESTATION IN A WOMAN WITH CHORIOCARCINOMA WITH PULMONARY METASTASIS

SESSION TITLE: Systemic Diseases Causing Pulmonary Havoc SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Choriocarcinoma is the most common type of gestational trophoblastic neoplasm (GTN) and can occur in association with any pregnancy [1]. The main risk factors are advanced or very young maternal age, ethnicity, ectopic pregnancy, abortion, and prior molar pregnancy. The most common sites of choriocarcinoma metastasis are lungs, liver, and brain [2]. This case describes a patient with choriocarcinoma that presented with hemoptysis. CASE PRESENTATION: The patient is a 22 year-old G2P1 female presenting at 36 weeks-gestation with one week of hemoptysis. She denied any other symptoms. On presentation, she was tachycardic. Physical examination demonstrated bibasilar crackles. Admission chest x-ray revealed diffuse bilateral infiltrates (Fig 1). Hs-troponin was elevated to 144 ng/L;however, EKG did not show ischemic changes. Cultures were obtained prior to empirically initiating antibiotics. Despite antibiotic treatment, hemoptysis worsened over her course and oxygen requirements increased. Infectious workup was negative. CT obtained for pulmonary embolism revealed bilateral patchy airspace opacities in lungs, suspected due to multifocal pneumonia (Fig 2). AFB smear and quantiferon were negative. After an emergent C-section for increased oxygen requirements, bronchoscopy with BAL was obtained and demonstrated diffuse alveolar hemorrhage. BAL was only positive for mildly increased CD4:CD8 ratio. Transbronchial biopsy was aborted due to bleed risk. Subsequent right lobe wedge biopsy confirmed metastatic choriocarcinoma. Her serum human chorionic gonadotropin (ß-hCG) level was found to be 20,713 milli-international units/mL. DISCUSSION: The etiology of hemoptysis was initially thought to be secondary to pneumonia. Differential diagnoses also included an acute COVID infection, alveolar hemorrhage, tuberculosis in a recently-immigrated patient, myocarditis, autoimmune etiology, and malignancy. Patient's risk factors included a prior miscarriage. Rarely, bleeding can occur as a result of metastatic lesions and may result in abdominal pain, hemoptysis, melena, or evidence of increased intracranial pressure from intracerebral hemorrhage [2]. Patients, such as the one described in this case, can exhibit pulmonary symptoms of dyspnea, cough, and chest pain caused by lung metastases. Upon closer examination of the CT scans, several of the opacities are nodular and consistent with GTN. Patients treated with surgery, chemotherapy, or a combination of both demonstrated similar treatment outcomes;chemotherapy may still be the preferred option. The overall cure rate in treating these tumors is currently > 90% [2]. CONCLUSIONS: GTN, although rare, should be considered as a differential diagnosis in women with a pregnancy history and risk factors that present with the primary symptom of hemoptysis. High index of suspicion and awareness of these neoplasms are necessary for timely diagnosis. Reference #1: Savage P. Winter M. Parker V. et al. Demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma: a UK population study. BJOG. 2020;127: 1102-1107 Reference #2: Lurain, J., 2010. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. American Journal of Obstetrics and Gynecology, 203(6), pp.531-539. DISCLOSURES: No relevant relationships by Crystal Ajja No relevant relationships by Heba Osman No relevant relationships by James Rowley

Metastatic testicular choriocarcinoma presenting as eyelid swelling and ptosis.

A 34-year-old man presented with an 8-day history of swelling and ptosis affecting the right upper eyelid. An MRI scan showed right superior rectus enlargement. Histology of an incisional biopsy of the muscle demonstrated metastatic choriocarcinoma to the orbit, positive for pan-cytokeratins, beta-HCG and GATA3. Possible primary sites included testis. An ultrasound of the testes identified bilateral testicular masses, highly suspicious for primary testicular malignancy. A CT scan of the chest, abdomen and pelvis identified disseminated metastatic disease conferring a poor prognostic germ cell tumour. The overall interpretation was of disseminated testicular choriocarcinoma and the patient is currently undergoing intensive chemotherapy.

Pure testicular choriocarcinoma Cannonball metastases as a presenting imaging feature: A case report and a review of literature.

Pure testicular choriocarcinoma is an extremely rare subtype of nonseminomatous germ cell tumor, accounting for less than 1% of all germ cell tumors and only 0.19% of all testicular tumors. It is a highly aggressive malignant tumor with early multiorgan metastasis and poor prognosis. We present a case of 23-year-old male presented to the hospital with mild hemoptysis which was thought as a sequela of his past COVID-19 pneumonia infection, however; chest radiograph showed multiple rounded cannonball opacities seen throughout both lungs raising the suspicion of metastatic deposits to the lungs. During physical examination, left testicular painless swelling was noted leading to an ultrasound of the scrotum which revealed a left intratesticular infiltrative, heterogeneous mass. Tumor markers, including beta-human chorionic gonadotropin, lactate dehydrogenase and alpha fetoprotein were extremely high. Computed tomography scan of the brain, chest, abdomen, and pelvis showed hemorrhagic metastatic deposits to the brain, chest, and left para-aortic lymph nodes. The patient underwent radical orchiectomy and histopathology reports confirmed the diagnosis of pure testicular choriocarcinoma.