A 59-year-old man complaining of haemoptysis 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, although no treatment was performed. The patient had haemoptysis 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 had a smoking history for 30 years of one pack per day and a drinking history for 40 years of 200 g 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 tumour occurred primarily within the lung, systemic screening was performed by positron emission tomography-computed tomography (PET-CT). The results showed multiple highly metabolic nodules throughout the body (Fig. 1); multiple bilateral pulmonary nodules (Fig. 2), especially a 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 tumour diameters ranging from 2–6 cm. A histopathologic workup of the excised tumour showed a poorly differentiated carcinoma and haemorrhage, with the few viable islands demonstrating syncytiotrophoblastic and cytotrophoblast-like cells (Fig. 6). The immunohistochemical phenotype of the pathological sections was CK7(+), TTF-1(-), CK(+), CD34(-), CD117(-), OCT3/4(-), SALL4(+), HCGα(+), Ki67(+ 90%), and vimentin(-). Thus, we measured serum β-HCG levels, and the result was > 10000.00 mlU/ml. Tumour markers showing abnormal increases were ferritin > 320.00 µg/L, lung tumour antigen (LTA) 136.20 ng/L and tissue polypeptide specific antigen (TPS) > 4500.00 U/L. The measured concentrations of the sex hormones were testosterone 0.83 ng/mL, oestradiol 716.10 pg/mL, and follicle-stimulating hormone (FSH) 0.26 mIU/mL. The pathological and hormone level evidence met the diagnostic criteria for PPC.
Three days after the operation, the patient suddenly exhibited consciousness disorder, profuse sweating and pinpoint pupils. Subsequently, haemodynamic instability and acute respiratory failure manifested. The patient was admitted to the ICU with tracheal intubation for respiratory support. A large volume of bloody fluid was sucked out of the bilateral main bronchus using bronchoscopy. The chest radiograph showed multiple clusters and nodular shadows scattered in both lungs. Laboratory data were significant for white blood cells 13.85 × 109 cells/liter, which was prompted by the pneumonia. Subsequently, the patient developed cardiac dysfunction, manifested as increased myocardial markers. Cardiac colour Doppler ultrasound revealed that ventricular wall motion was not coordinated, left ventricular diastolic function decreased, and the 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/1.73 m2), and serum urea and creatinine continued to rise. Despite supportive treatment, the patient’s condition continued to deteriorate. Due to multiple organ failure, the patient had no indications for chemotherapy and eventually died. Cause of death was diagnosed as 1. pulmonary choriocarcinoma with metastasis to the lung, brain, bone, pancreas, and lymph nodes, 2. severe pneumonia and respiratory failure, 3. acute renal failure and 4. acute coronary syndrome.