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Does Primary Pulmonary Choriocarcinoma Really Exist?
15 Svanborg E, Larsson H. Development of nocturnal respiratory disturbance in untreated patients with obstructive sleep apnea syndrome. Chest 1993; 104:340 –343 16 Lindberg E, Elmasry A, Gislason T, et al. Evolution of sleep apnea syndrome in sleepy snorers: a population-based study. Am J Respir Crit Care Med 1999; 159:2024 –2027 17 Krakow B, Lowry C, Germain A, et al. A retrospective study on improvements in nightmares and posttraumatic stress disorder following treatment for co-morbid sleep-disordered breathing. J Psychosom Res 2000; 49:291–298 18 Melendrez D, Krakow B, Johnston L, et al. A prospective study on the treatment of “complex insomnia”—insomnia plus sleep disordered breathing—in a small series of crime victims with PTSD [abstract]. Sleep 2001; 24(suppl):A120 19 Krakow B, Melendrez D, Warner TD, et al. To breathe, perchance to sleep: sleep-disordered breathing and chronic insomnia among trauma survivors. Sleep Breath 2002; 6:189 –202
Does Primary Pulmonary Choriocarcinoma Really Exist? To the Editor: We read with interest the article by Tsai et al (March 2002),1 but several points make us doubtful about the diagnosis of primary pulmonary choriocarcinoma, as follows: 1. There is no comment concerning the technique (physical examination? ultrasonography? CT scan? MRI? other?) adopted to exclude for certain that the patient had no testicular lesion. Moreover, it is well known that the “burnt-out” phenomenon occurs in germinal tumors in general, and in choriocarcinoma in particular. Choriocarcinoma is likely to metastasize greatly prior to detection of the primary lesion, leaving only zones of scarring and hemosiderin-laden macrophages in the testis.2 2. Chest radiographs and CT scanning displayed bilateral pulmonary involvement by ground-glass opacities and nodules, showing many clinicoradiologic similarities with the previously report by McGowan et al,3 who described a testicular choriocarcinoma with pulmonary metastases presenting as ARDS. These authors correctly underlined that only at autoptic examination, “the right testicle was essentially replaced by choriocarcinoma but was the same size as the uninvolved left one.” 3. We have investigated two solitary pulmonary nodules in adult men (one of whom presented with gynecomastia) showing a dimorphic neoplasms characterized by polygonal mononuclear cells closely admixed with multinucleated syncytiotrophoblastlike cells in a hemorrhagic and necrotic background, thus sharing many morphologic features with a choriocarcinoma. Both tumors displayed a nuclear immunoreactivity for thyroid transcription factor (TTF)-1, the best immunohistochemical marker of pulmonary origin. Although a weak cytoplasmic immunostaining for -human chorionic gonadotrophin was noted, such tumors have been classified as pleomorphic carcinomas with choriocarcinomalike features in accordance to the 1999 World Health Organization classification of lung tumors,4 but not as primary choriocarcinomas of the lung. Besides, cyto- and syncytiotrophoblast cells are completely negative for TTF-1. 4. Finally, it is well documented that many nontrophoblastic malignancies may produce and/or express ectopic placental hormones, including primary conventional lung carcinomas.5 Granted the diagnosis of pulmonary choriocarcinoma is debatable and far from being clarified,6 the authors recommended the use of a urine pregnancy test as a rapid diagnostic method of primary pulmonary choriocarcinoma. We retain that a more www.chestjournal.org
detailed and rigorous clinicopathologic analysis should be preferred before one can establish such a diagnosis. Giulio Rossi, MD Riccardo Valli, MD Francesco Rivasi, MD Department of Morphologic Sciences, Section of Pathology University of Modena and Reggio Emilia Modena, Italy Lucia Longo, MD Division of Oncology, Hospital of Faenza Faenza, Italy Correspondence to: Giulio Rossi, MD, Department of Morphologic Sciences, Section of Pathology, University of Modena and Reggio Emilia, Policlinico, Via del Pozzo, 71– 41100 Modena, Italy; e-mail: [email protected]
References 1 Tsai J-R, Chong I-W, Hung J-Y, et al. Use of urine pregnancy test for rapid diagnosis of primary pulmonary choriocarcinoma in a man. Chest 2002; 121:996 –998 2 Burt ME, Javadpour N. Germ-cell tumors in patients with apparently normal testes. Cancer 1981; 47:1911–1915 3 McGowan MP, Pratter MR, Nash G. Primary testicular choriocarcinoma with pulmonary metastases presenting as ARDS. Chest 1990; 97:1258 –1259 4 Brambilla E, Travis WD, Colby TV, et al. The new World Health Organization classification of lung tumours. Eur Respir J 2001; 18:1059 –1068 5 Marcillac I, Troalen F, Ghillani P, et al. Free human chorionic gonadotropin  subunit in gonadal and nongonadal neoplasms. Cancer Res 1992; 52:3901–3907 6 Ikura Y, Inoue T, Tsukuda H, et al. Primary choriocarcinoma and human chorionic gonadotrophin-producing giant cell carcinoma of the lung: are they independent entities? Histopathology 2000; 36:17–25
Observation-Only Management of Inoperable Lung Cancer Do Not Do That: A Loud and Clear Radiographic Point of View! To the Editor: We have read with interest the recent article in CHEST by McGarry et al (April 2002)1 on three different treatment options in 128 patients with early stage non-small cell lung cancer (NSCLC). Although the authors acknowledge the limitations of their retrospective study, which showed no advantage for radiation therapy (RT) over observation only, we believe that additional aspects need to be brought to the attention of the readership of the journal, so as to leave no doubts regarding treatment choice in this patient population. These aspects are as follows: 1. More information about differences between the treatment groups regarding various pretreatment characteristics should have been disclosed, principally regarding patients’ refusal to surgery (14 refusals in the observation-only group vs no refusal in RT group; reason for radiotherapy referral not specified in 7 patients in the RT group). This may have seriously imbalanced prognosis, since it was shown that patients’ refusals inversely correlate with the incidence of intercurrent deaths,2– 4 which, on the other side, directly correlate with increasing age and pre-existing comorbidCHEST / 123 / 1 / JANUARY, 2003
313
Does Primary Pulmonary Choriocarcinoma Really Exist? To the Editor: We read with interest the article by Tsai et al (March 2002),1 but several points make us doubtful about the diagnosis of primary pulmonary choriocarcinoma, as follows: 1. There is no comment concerning the technique (physical examination? ultrasonography? CT scan? MRI? other?) adopted to exclude for certain that the patient had no testicular lesion. Moreover, it is well known that the “burnt-out” phenomenon occurs in germinal tumors in general, and in choriocarcinoma in particular. Choriocarcinoma is likely to metastasize greatly prior to detection of the primary lesion, leaving only zones of scarring and hemosiderin-laden macrophages in the testis.2 2. Chest radiographs and CT scanning displayed bilateral pulmonary involvement by ground-glass opacities and nodules, showing many clinicoradiologic similarities with the previously report by McGowan et al,3 who described a testicular choriocarcinoma with pulmonary metastases presenting as ARDS. These authors correctly underlined that only at autoptic examination, “the right testicle was essentially replaced by choriocarcinoma but was the same size as the uninvolved left one.” 3. We have investigated two solitary pulmonary nodules in adult men (one of whom presented with gynecomastia) showing a dimorphic neoplasms characterized by polygonal mononuclear cells closely admixed with multinucleated syncytiotrophoblastlike cells in a hemorrhagic and necrotic background, thus sharing many morphologic features with a choriocarcinoma. Both tumors displayed a nuclear immunoreactivity for thyroid transcription factor (TTF)-1, the best immunohistochemical marker of pulmonary origin. Although a weak cytoplasmic immunostaining for -human chorionic gonadotrophin was noted, such tumors have been classified as pleomorphic carcinomas with choriocarcinomalike features in accordance to the 1999 World Health Organization classification of lung tumors,4 but not as primary choriocarcinomas of the lung. Besides, cyto- and syncytiotrophoblast cells are completely negative for TTF-1. 4. Finally, it is well documented that many nontrophoblastic malignancies may produce and/or express ectopic placental hormones, including primary conventional lung carcinomas.5 Granted the diagnosis of pulmonary choriocarcinoma is debatable and far from being clarified,6 the authors recommended the use of a urine pregnancy test as a rapid diagnostic method of primary pulmonary choriocarcinoma. We retain that a more www.chestjournal.org
detailed and rigorous clinicopathologic analysis should be preferred before one can establish such a diagnosis. Giulio Rossi, MD Riccardo Valli, MD Francesco Rivasi, MD Department of Morphologic Sciences, Section of Pathology University of Modena and Reggio Emilia Modena, Italy Lucia Longo, MD Division of Oncology, Hospital of Faenza Faenza, Italy Correspondence to: Giulio Rossi, MD, Department of Morphologic Sciences, Section of Pathology, University of Modena and Reggio Emilia, Policlinico, Via del Pozzo, 71– 41100 Modena, Italy; e-mail: [email protected]
References 1 Tsai J-R, Chong I-W, Hung J-Y, et al. Use of urine pregnancy test for rapid diagnosis of primary pulmonary choriocarcinoma in a man. Chest 2002; 121:996 –998 2 Burt ME, Javadpour N. Germ-cell tumors in patients with apparently normal testes. Cancer 1981; 47:1911–1915 3 McGowan MP, Pratter MR, Nash G. Primary testicular choriocarcinoma with pulmonary metastases presenting as ARDS. Chest 1990; 97:1258 –1259 4 Brambilla E, Travis WD, Colby TV, et al. The new World Health Organization classification of lung tumours. Eur Respir J 2001; 18:1059 –1068 5 Marcillac I, Troalen F, Ghillani P, et al. Free human chorionic gonadotropin  subunit in gonadal and nongonadal neoplasms. Cancer Res 1992; 52:3901–3907 6 Ikura Y, Inoue T, Tsukuda H, et al. Primary choriocarcinoma and human chorionic gonadotrophin-producing giant cell carcinoma of the lung: are they independent entities? Histopathology 2000; 36:17–25
Observation-Only Management of Inoperable Lung Cancer Do Not Do That: A Loud and Clear Radiographic Point of View! To the Editor: We have read with interest the recent article in CHEST by McGarry et al (April 2002)1 on three different treatment options in 128 patients with early stage non-small cell lung cancer (NSCLC). Although the authors acknowledge the limitations of their retrospective study, which showed no advantage for radiation therapy (RT) over observation only, we believe that additional aspects need to be brought to the attention of the readership of the journal, so as to leave no doubts regarding treatment choice in this patient population. These aspects are as follows: 1. More information about differences between the treatment groups regarding various pretreatment characteristics should have been disclosed, principally regarding patients’ refusal to surgery (14 refusals in the observation-only group vs no refusal in RT group; reason for radiotherapy referral not specified in 7 patients in the RT group). This may have seriously imbalanced prognosis, since it was shown that patients’ refusals inversely correlate with the incidence of intercurrent deaths,2– 4 which, on the other side, directly correlate with increasing age and pre-existing comorbidCHEST / 123 / 1 / JANUARY, 2003
313