Case Presentation: A 54 year old African American female with a past medical history of significant tobacco use presented with worsening shortness of breath and increased cough. She reported having hemoptysis 2 months ago which resolved, unexplained weight loss (30 lbs over 6 months), orthopnea, and diaphoresis. Physical examination was positive for wheezing and rhonchi, diaphoresis, tachycardia, respiratory distress, and dampened lung sounds. Vital signs showed hypoxia improving with 2L of nasal cannula. Bloodwork demonstrated new anemia. Chest X-ray notable for a large right lower lobe lung mass of 18 cm with supraclavicular and mediastinal lymphadenopathy. A transesophageal echocardiogram demonstrated displacement of the heart, aorta, and compression of the left atrium. Differential diagnosis included lung adenocarcinoma, small cell carcinoma, or lymphoma. Elevated serum tumor markers β-hCG, CA-125, and LDH along with imaging were suggestive for a possible GCT. GCT, specifically choriocarcinoma, was confirmed with an endobronchial biopsy. VIP chemotherapy was initiated, consisting of VePesid (etoposide), ifosfamide, Platinol (cisplatin). She was also treated for suspected post-obstructive pneumonia. During her hospital admission she experienced multi-organ failure. Oliguric kidney injury indicated dialysis; however, the family opted for comfort care due to her guarded prognosis and wish to minimize invasive procedures. Patient was extubated and expired soon after.
Discussion: GCTs are typically associated with the gonads but can present extragonadal. This patient presented with a lung mass and elevated serum tumor markers β-hCG, CA-125, and/or LDH. Initially, GCTs seemed unlikely in our patient due to the absence of pelvic masses. Choriocarcinoma was considered but was discarded as the patient was status post hysterectomy with no pregnancy. Although rare, it is important to not discard GCTs due to hysterectomy or lack of pelvic mass. The prognosis of choriocarcinoma is poor and timely intervention is critical. Interestingly, choriocarcinomas containing a sarcomatoid component can be resistant to VIP chemotherapy and can lead to an even poorer prognosis. The current treatment regimen is based on gonadal GCTs. There is no data based on randomized trials to guide treatment in patients with mediastinal GCTs. More research is needed to further understand the etiology and develop better therapeutics against GCTs.
Conclusions: This case aims to highlight the rarity and the severity of GCTs and encourages more research to be conducted on GCTs to develop more targeted therapeutics.