Fine Needle Aspiration Cytology Findings of Primary Pulmonary Choriocarcinoma in a Male Patient

Abstract

Extragonadal germ cell tumors (EGCT) account for 2-5% of all germ cell tumors.1 Choriocarcinoma in male subjects is one of the non-seminomatous EGCT that occurs in relatively young individuals. Primary (extragonadal) choriocarcinoma (PCC) commonly arises in the retro peritoneum, mediastinum and brain.2 Metastasis to the lung is common, but PCC originating in the lung is extremely rare. Cytological features of PCC have been described only occasionally. 3,4Here we describe a case of a 26 years old male where the differential diagnosis of PCC was offered after FNAC (fine needle aspiration cytology) and subsequently it was confirmed histologically and immunohistochemically. The prognosis of pulmonary PCC, especially in males is very poor as compared to its testicular counterpart because hematogenous spread is usually common at the time of diagnosis. 2,5,6 Often the entity is misdiagnosed as more common diseases such as primary or secondary lung tumors, tuberculosis, pneumonia or lymphoma and thus potentially curative chemotherapy or surgery may be delayed. [5][6][7] Considering its rarity, prognosis and diagnostic difficulties FNAC definitely has a role in such cases! A 26 year-old non-smoker male with no significant medical or surgical history presented with the complaints of progressive shortness of breath, productive cough, night sweats, diminished appetite and unexplained weight loss for 4 weeks. Sputum for AFB (Acid-Fast Bacilli) was negative.Mantoux test was negative. No history of hemoptysis, chest pain, fever or chills was present. The patient did not respond to routine antibiotics. Chest examination revealed diffuse coarse inspiratory crackles. Genital exam did not reveal any scrotal mass. Laboratory data revealed raised ESR, neutrophilic leucocytosis, normal liver function tests and alpha-fetoprotein level. HIV 1 and 2 were nonreactive. Chest x-ray showed bilateral pulmonary cannon-ball nodules. Computed tomography (CT) demonstrated multiple cannonball lesions of variable sizes in both lung fields largest one measuring 8x7x5cm without enlargement of intrapulmonary or mediastinal lymph nodes ( Figure 1A) that first raised the suspicion of a germ cell tumor.FNAC under CT-guidance ( Figure 1B) was suggestive of nonsmall cell carcinoma possibly squamous cell carcinoma with extensive necrosis ( Figures 1C & 1D). The cellularity was poor and the fields were predominated by hemorrhage and large areas of coagulative necrosis and ghost cells resembling anucleate squames ( Figures 1C & 1D). Many apoptotic and degenerated cells and cells with cytoplasmic orangeophilia were identified (Figure 1d) but practically no inflammatory cells! The tumor cells were large, undifferentiated, highly pleomorphic with clumped chromatin, indistinct nucleoli and multivacuolated abundant cytoplasm (Figures 2A-2C). Bi and multinucleated cells were present. Screening for additional mass including CT scan of the retroperitoneum, abdomen, scrotum, brain and spine showed no abnormality. Serum levels of Human chorionic gonadotrophin (β-HCG)...