Role of chemotherapy and thrombolysis in treatment of choriocarcinoma accompanied with pulmonary embolism A case report with literature review

Rationale: Choriocarcinoma accompanied with pulmonary embolism (PE) is rare and difficult to diagnose and treat. There are about 25 cases reported in literature, which presented variable clinical characteristics and prognosis. Patient concerns: We reported a case of choriocarcinoma presenting PE as the first manifestation in a 26-year-old Chinese female. Diagnoses: Four months before her admission to our hospital, she presented to a local hospital with respiratory manifestations, and was first diagnosed as bronchitis and treated with antibiotics without improvement, and subsequently suspected of having pulmonary tuberculosis and receive anti-tuberculosis therapy, with no response. Upon admission to our hospital, spiral computed tomography-pulmonary angiography revealed complete occlusion of right pulmonary artery, leading to PE. She received thrombolysis and anticoagulant therapy, without improvement. Further interrogation of the patient revealed a history of irregular vaginal bleeding and multiple pregnancies and abortions. Following the laboratory report of a significantly elevated level of serum beta-human chorionic gonadotropin (b-HCG) combined with other clinical and laboratory findings, a diagnosis of choriocarcinoma accompanied with PE was established based on the criteria formulated by the International Federation of Gynecology and Obstetrics and guideline of European Society for Medical Oncology. Interventions: With 1 cycle of chemotherapy with etoposide-methotrexateactinomycin D-cyclophosphamide-vincristine (EMACO), her dyspnea and other symptoms improved, with a significant decrease in the serum b-HCG level and pulmonary artery pressure. Outcomes: Unfortunately, she showed bone marrow inhibition, could not continue further chemotherapy, and finally died after discharging. We reviewed 25 similar cases in the literature, and found that all 17 cases receiving chemotherapy showed complete recovery while 6 of 8 cases without chemotherapy died during hospitalization. Lessons: This case report illustrates the challenges in diagnosis of choriocarcinoma presenting with respiratory manifestations, and highlights the importance of early diagnosis and timely appropriate chemotherapy in management of this disease.