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EGFR-Mutated Pulmonary Choriocarcinoma Combined With Adenocarcinoma

  • Yasuyuki Shigematsu
    Affiliations
    Department of Pathology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research (JFCR), Tokyo, Japan

    Division of Pathology, The Cancer Institute, Japanese Foundation for Cancer Research (JFCR), Tokyo, Japan
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  • Kaoru Nakano
    Affiliations
    Department of Pathology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research (JFCR), Tokyo, Japan

    Division of Pathology, The Cancer Institute, Japanese Foundation for Cancer Research (JFCR), Tokyo, Japan
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  • Ken Uchibori
    Affiliations
    Division of Thoracic Medical Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research (JFCR), Tokyo, Japan
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  • Kentaro Inamura
    Correspondence
    Corresponding author. Address for correspondence: Kentaro Inamura, MD, PhD, Division of Pathology, The Cancer Institute, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan.
    Affiliations
    Department of Pathology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research (JFCR), Tokyo, Japan

    Division of Pathology, The Cancer Institute, Japanese Foundation for Cancer Research (JFCR), Tokyo, Japan
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Published:August 09, 2022DOI:https://doi.org/10.1016/j.jtho.2022.07.1146
      A 78-year-old woman with no history of smoking presented to our hospital with complaints of wet cough and exertional dyspnea that had worsened progressively in 1 week. Physical examination result revealed reduced air entry into the right side of the chest. Imaging result by computed tomography revealed an 8.6 cm-sized mass in the right middle-to-lower lobes and multiple nodules in the bilateral lobes of the lung (Fig. 1). Subsequently, multiple masses in the liver, vertebrae, and uterus were detected. The patient could not undergo a pathologic examination owing to poor general condition and died 11 days after presentation. Autopsy result revealed the largest tumor mass, which occupied the right middle-to-lower lobes of the lung, to have “black” and “white” components, and diffuse alveolar injury was identified as the direct cause of death. Pathologic examination result further revealed that the “black” and “white” areas represented choriocarcinoma and adenocarcinoma, respectively (Fig. 2). Microscopically, the choriocarcinoma component was composed of mononucleated and multinucleated trophoblastic cells and exhibited marked hemorrhage, which is characteristic of choriocarcinoma and caused the “black” macroscopic appearance. Immunostaining result revealed that this tumor component was positive for germ cell markers SALL4 and human chorionic gonadotropin (hCG) but negative for pneumocyte markers TTF-1 (also known as NKX2-1) and Napsin A. In contrast, the adenocarcinoma component of the tumor exhibited papillary morphology and immunostained positive for TTF-1 and Napsin A but not for SALL4 or hCG. The “black” choriocarcinoma had metastasized throughout the body, resulting in the formation of malignant foci in the bilateral lungs, liver, vertebrae, and uterus, whereas the “white” adenocarcinoma was localized within the lung and mediastinal lymph node. The spatial localization of the two components with distinct “black” and “white” phenotypes raised the question of whether the tumor was a collision carcinoma originating from different clones or a single carcinoma originating from an identical clone.
      Figure thumbnail gr1
      Figure 1Contrast-enhanced computed tomography images. (A) Coronal view. A heterogeneous contrast-enhancing tumor can be identified in the right middle-to-lower lobes of the lung. The tumor metastasized to the bilateral lungs and liver. (B) Axial view. The primary lung tumor localized at the right middle-to-lower lobes of the lung. Multiple metastatic foci can be found in the bilateral lobes in the upper pulmonary window setting image. A mediastinal lymph node metastasis is clearly observed in the lower mediastinal window setting image.
      Figure thumbnail gr2
      Figure 2Macroscopic and microscopic images revealing pathologic features of the pulmonary tumor. The left panel illustrates the gross appearance and an illustrative representation. In the illustration, the black and white areas represent the choriocarcinoma and adenocarcinoma, respectively. The shaded area indicates the necrotic region. The righthand panels reveal micrographs of HE and immunostained samples of the adenocarcinoma (upper panels) and choriocarcinoma (lower panels). Prominent hemorrhage observed in the choriocarcinoma component was responsible for its “black” macroscopic appearance. Black bars on the right-side images, 100 μm. hCG, human chorionic gonadotropin; HE, hematoxylin and eosin.
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