- Email: [email protected]
Use of Urine Pregnancy Test for Rapid Diagnosis of Primary Pulmonary Choriocarcinoma in a Man
8 Muth CM, Shank ES. Gas embolism. N Engl J Med 2000; 342:476 – 482 9 Coulter TD, Wiedemann HP. Gas embolism [letter]. N Engl J Med 2000; 342:2000 –2002 10 Leach RM, Rees PJ, Wilmshurst P. ABC of oxygen: hyperbaric oxygen therapy. BMJ 1998; 317:1140 –1143 11 Worth ER, Burton Jr, Landreneau RJ, et al. Left atrial air embolism during intraoperative needle biopsy of a deep pulmonary lesion. Anesthesiology 1990; 73:342–345 12 Kodama F, Ogawa T, Hashimoto M, et al. Fatal air embolism as a complication of CT-guided needle biopsy of the lung. J Comput Assist Tomogr 1999; 23:949 –951 13 Baker BK, Awwad EE. Computed tomography of fatal cerebral air embolism following percutaneous aspiration biopsy of the lung. J Comput Assist Tomogr 1988; 12:1082–1083
Use of Urine Pregnancy Test for Rapid Diagnosis of Primary Pulmonary Choriocarcinoma in a Man* Jong-Rung Tsai, MD; Inn-Wen Chong, MD, FCCP; Jen-Yu Hung, MD; and Kun-Bow Tsai, MD
Primary pulmonary choriocarcinoma is an extremely rare tumor in men, with 13 cases reported in the literature. Due to its rarity, primary choriocarcinoma of the lung in men is often incorrectly diagnosed as more common diseases, such as primary or metastatic lung cancer, and therefore potentially curative chemotherapy or surgery may be withheld from the patient. In this report, we present the case of a 23-year-old man with hemoptysis and progressive dyspnea. Airspace consolidation with multiple nodules of varying sizes was found on a chest radiograph. The results of a urine pregnancy test were positive, and the -human chorionic gonadotropin level was markedly elevated both in the serum and the urine. Subsequently, testing of a bronchoscopic biopsy specimen proved these tumors to be choriocarcinoma. We conclude that the urine pregnancy test, a simple and convenient method, would be very useful in the rapid diagnosis of primary pulmonary choriocarcinoma in men. (CHEST 2002; 121:996 –998) Key words: human chorionic gonadotropin; primary pulmonary choriocarcinoma; urine pregnancy test Abbreviation: HCG ⫽ human chorionic gonadotropin *From the Departments of Internal Medicine (Drs. Tsai, Chong, and Hung) and Pathology (Dr. Tsai), Kaohsiung Medical University, Kaohsiung, Taiwan. Manuscript received March 15, 2001; revision accepted August 20, 2001. Correspondence to: Inn-Wen Chong, MD, FCCP, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, 807, Taiwan; e-mail: [email protected] 996
a representative neoplasm producing C horiocarcinoma, human chorionic gonadotropin (HCG), is an ex-
tremely malignant tumor originating from anaplastic trophoblastic tissue. It is usually intrauterine and arises most commonly from molar pregnancy, but may also follow a term or ectopic pregnancy and spontaneous abortions. Extragonadal, nongestational choriocarcinoma is uncommon with a striking predominance in young men between 20 and 35 years of age. Most cases arise in midline structures, such as the retroperitoneum, the mediastinum, and the vicinity of the pineal body but also have been reported in other visceral organs such as the stomach, esophagus, small bowel, prostate, and urinary bladder.1 To our knowledge, there have been only 22 cases of primary pulmonary choriocarcinoma reported in the literature. Of those cases, 13 developed in men.2 Extragonadal choriocarcinoma arising in the lung is thought to be unresponsive to treatment and is associated with a poor prognosis. We report a young male patient with extragonadal, nongestational choriocarcinoma apparently arising in the lung. A positive urine pregnancy test result and an elevated serum -HCG level are compatible with the presence of this neoplasm, and the diagnosis was confirmed histologically by bronchoscopy examination.
Case Report A 23-year-old man was admitted to the hospital with a 3-week history of hemoptysis and progressive dyspnea. A chest radiograph on hospital admission revealed airspace consolidation in the periphery of the upper portion of both lungs with multiple nodules of variable sizes in both lung fields (Fig 1). A CT scan of the chest confirmed the presence of pulmonary nodules with ground-glass opacities in both lungs, which is consistent with the presence of pulmonary hemorrhage (Fig 2). On physical examination, no gynecomastia was noted. The abdomen was soft with no abnormal findings. A genital examination revealed no evidence of any scrotal masses. The remainder of the physical examination was unremarkable except for diffuse crackles in both lung fields. Under the impression of suspected germ cell tumors, a biological tumor marker study was performed. The result of a urine pregnancy test was positive, and the levels of -HCG were very high at 1,600,000 IU/L in the serum (normal, ⬍ 5 IU/L) and 3,464,000 IU/L in the urine. However, the serum ␣-fetoprotein level was within normal limits (ie, 3.8 ng/mL). A transbronchial lung biopsy in the right lower lobe showed intense hemorrhage and fibrinoid deposits in the alveoli with a dimorphic population of malignant cells with hyperchromatic nuclei and multinucleated syncytiotrophoblasts, which is consistent with choriocarcinoma (Fig 3), although a weak positive result of a -HCG immunohistochemical stain was found to be due to limited lesions (data not shown). Based on the findings, a diagnosis of choriocarcinoma was made. The patient was given chemotherapy, which consisted of actinomycin-D, methotrexate, and cyclophosphamide. Despite aggressive chemotherapy and management in the ICUs, the patient’s condition deteriorated rapidly, and he died of acute respiratory failure 8 days after hospital admission. A request for an autopsy was denied.
Discussion Choriocarcinoma is a germ cell tumor containing syncytiotrophoblastic giant cells and often secreting a biological tumor marker (-HCG). It usually occurs in women, Selected Reports
Figure 3. The histopathology of a transbronchial lung biopsy specimen shows a dimorphic population of malignant cells with hyperchromatic nuclei and multinucleated syncytiotrophoblasts scattered within fibrinoid deposits (hematoxylin-eosin stain, original ⫻ 40).
Figure 1. A chest radiograph performed at hospital admission shows airspace consolidation infiltrates involving the periphery of both lungs, with multiple pulmonary nodules of varying sizes in both lung fields.
mainly as a gestational trophoblastic neoplasm, and rarely occurs in men as a nonseminomatous testicular tumor. Extragonadal nongestational primary pulmonary choriocarcinoma is exceedingly rare.1–3 In the case presented, pulmonary choriocarcinoma was diagnosed on the basis of the following findings: obvious lesions were found only in
Figure 2. A CT scan of the chest demonstrates multiple pulmonary nodules in both lungs with ground-glass opacities involving the periphery of both upper lobes, which is consistent with pulmonary hemorrhage. P ⫽ posterior; R ⫽ right.
the lung; raised -HCG levels were found both in the serum and in the urine; and pathologic confirmation of the disease. Because the lung is a frequent site of metastatic choriocarcinoma, the diagnosis of the primary tumor should be made carefully. In this case, although multiple nodules were found in both lungs, we considered the patient to have primary choriocarcinoma because there was no apparent evidence of a primary genital tumor, and no lesions were found in midline structures or in other visceral organs by CT scan, abdominal echography, and gastroendoscopy. Nevertheless, the possibility of a metastasis from invisible lesions in other locations could not be ruled out completely because the request for an autopsy was denied. There are several possible theories explaining the development of primary pulmonary choriocarcinoma. Some authors4 believe that the tumors arise from retained primordial germ cells that migrate abnormally during embryonic development. Others believe that the tumors represent metastasis from a primary gonadal (ie, testicular or ovarian) tumor that regressed spontaneously1 or arose from a trophoblastic emboli related to molar pregnancy after long periods of latency.5 In other reports,6,7 the hypothesis of dedifferentiation or metaplasia to the trophoblast from a nongonadal tissue such as primary lung cancer is supported. This theory may help to resolve a semantic problem, namely, whether primary pulmonary choriocarcinoma is identical to HCG-producing giant cell carcinoma of the lung because the histopathologic similarity of choriocarcinoma with giant cell lung cancer has been reported.2,3 Among the patients with primary pulmonary choriocarcinoma whose cases have been reported in the literature, most demonstrated solitary pulmonary nodules in the lung field.3,5–7 However, in our patient, multiple nodular lesions were found on a chest radiograph. The presenting radiologic features in our patient would support the assertion CHEST / 121 / 3 / MARCH, 2002
997
that the tumors may metastasize from a primary gonadal tumor undergoing spontaneous regression. However, as in the debate in the literature concerning the origin of the diffuse or multinodular form of bronchioloalveolar carcinoma of the lung, the tumors in our patient could be multicentric in origin or may merely represent a mode of extension within the lung of a tumor arising in the small foci of primordial germ cells. In contrast to gestational choriocarcinoma, the natural course of primary pulmonary choriocarcinoma is rapidly fatal in the great majority of cases. Prompt recognition of this unique disease is crucial because rapid intervention may be life-saving. However, treatment modalities such as chemotherapy, radiation, or surgical resection in patients with widespread, far-advanced malignant tumors have usually proven to be ineffective in providing better long-term survival,3,8,9 as has been shown in this case. There have been only three reported cases2 (Table 3) of survival for ⬎ 1 year in male patients with primary pulmonary choriocarcinoma. The reason that nongestational choriocarcinoma behaves so differently from gestational cancers is unknown. A positive result of a -HCG test in patients with hemoptysis and progressive dyspnea should arouse suspicions of the presence of pulmonary choriocarcinoma, thus leading to an early diagnosis. In most of the reported cases, however, the patients had sought medical attention too late. In addition, because the radiologic findings of pulmonary hemorrhage may obscure the nodular lesions of choriocarcinoma, and because the -HCG test and the histologic processing of tissue specimens may take several days, the diagnosis may be delayed, particularly, in male patients. In the presented case, the patient was thought initially to have an infectious disease, germ cell tumors, or metastatic lung cancer, based on the findings of clinical entities, a chest radiograph, and CT scan. A positive urine pregnancy test result, which only takes a couple of minutes, rapidly gave us a very clear direction in the differential diagnosis of the lung lesions. In conclusion, the diagnosis of primary pulmonary choriocarcinoma must be considered in young male patients with hemoptysis, progressive dyspnea, and radiologic findings of airspace consolidation with solitary/multiple pulmonary nodules. The serum -HCG level should be examined as early as possible. Before this is done, the performance of a urine pregnancy test, a simple and convenient method, would be very useful in the rapid diagnosis of primary pulmonary choriocarcinoma.
References 1 Hainsworth JD, Greco FA. Extragonadal germ cell tumors and unrecognized germ cell tumors. Semin Oncol 1992; 19:119 –127 2 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 3 Canver CC, Voytovich MC. Resection of an unsuspected primary pulmonary choriocarcinoma. Ann Thorac Surg 1996; 61:1249 –1251 4 Fine G, Smith RW, Pachter MR. Primary extragenital cho998
5 6 7 8 9
riocarcinoma in the male subject. Am J Med 1962; 32: 776 –794 Tanimura A, Natsuyama H, Kawano M, et al. Primary choriocarcinoma of the lung. Hum Pathol 1985; 16:1281– 1284 Pushchak MJ, Farhi DC. Primary choriocarcinoma of the lung. Arch Pathol Lab Med 1987; 111:477– 479 Sullivan LG. Primary choriocarcinoma of the lung in a man. Arch Pathol Lab Med 1989; 113:82– 83 Benditt JO, Farber HW, Wright J, et al. Pulmonary hemorrhage with diffuse alveolar infiltrates in men with highvolume choriocarcinoma. Ann Intern Med 1988; 15:674 – 675 Aparcio J, Oltra A, Martinez-Moragon E, et al. Extragonadal nongestational choriocarcinoma involving the lung: a report of three cases. Respiration 1996; 63:251–223
Tracheal Compression by the Stomach Following Gastric Pull-Up* Diagnosis With CT and Treatment With Expandable Metallic Stent Placement Suil Kim, MD, PhD; Michael B. Gotway, MD; W. Richard Webb, MD; Roy L. Gordon, MD; and Jeffrey A. Golden, MD
Surgical treatment of recurrent achalasia includes esophagectomy with gastric pull-up. A MEDLINE search yielded no articles describing an adverse effect of this surgery on pulmonary function. We report the first case of acute ventilatory failure caused by gastric pull-up. An evaluation by flexible bronchoscopy, spirometry with flow-volume loops, and dynamic CT scanning revealed extrinsic compression of the trachea by the stomach causing obstruction. Endotracheal placement of a selfexpanding stent resulted in the rapid extubation of the patient with normalization of the flow-volume loop and dramatic improvement in the FVC, FEV1, and peak expiratory flow. (CHEST 2002; 121:998 –1001) Key words: bronchoscopy; dynamic CT; esophagectomy; spirometry; stent; tracheal obstruction; tracheomalacia Abbreviation: ETT ⫽ endotracheal tube
*From the Departments of Medicine (Drs. Kim and Golden) and Radiology (Drs. Gotway and Webb), Division of Pulmonary and Critical Care Medicine, and the Section of Interventional Radiology (Dr. Gordon), University of California, San Francisco, CA. Manuscript received May 16, 2001; revision accepted August 21, 2001. Correspondence to: Jeffrey A. Golden, MD, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, 400 Parnassus Ave, Box 0359, San Francisco, CA 94143-0359; e-mail: [email protected] Selected Reports
Use of Urine Pregnancy Test for Rapid Diagnosis of Primary Pulmonary Choriocarcinoma in a Man* Jong-Rung Tsai, MD; Inn-Wen Chong, MD, FCCP; Jen-Yu Hung, MD; and Kun-Bow Tsai, MD
Primary pulmonary choriocarcinoma is an extremely rare tumor in men, with 13 cases reported in the literature. Due to its rarity, primary choriocarcinoma of the lung in men is often incorrectly diagnosed as more common diseases, such as primary or metastatic lung cancer, and therefore potentially curative chemotherapy or surgery may be withheld from the patient. In this report, we present the case of a 23-year-old man with hemoptysis and progressive dyspnea. Airspace consolidation with multiple nodules of varying sizes was found on a chest radiograph. The results of a urine pregnancy test were positive, and the -human chorionic gonadotropin level was markedly elevated both in the serum and the urine. Subsequently, testing of a bronchoscopic biopsy specimen proved these tumors to be choriocarcinoma. We conclude that the urine pregnancy test, a simple and convenient method, would be very useful in the rapid diagnosis of primary pulmonary choriocarcinoma in men. (CHEST 2002; 121:996 –998) Key words: human chorionic gonadotropin; primary pulmonary choriocarcinoma; urine pregnancy test Abbreviation: HCG ⫽ human chorionic gonadotropin *From the Departments of Internal Medicine (Drs. Tsai, Chong, and Hung) and Pathology (Dr. Tsai), Kaohsiung Medical University, Kaohsiung, Taiwan. Manuscript received March 15, 2001; revision accepted August 20, 2001. Correspondence to: Inn-Wen Chong, MD, FCCP, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, 807, Taiwan; e-mail: [email protected] 996
a representative neoplasm producing C horiocarcinoma, human chorionic gonadotropin (HCG), is an ex-
tremely malignant tumor originating from anaplastic trophoblastic tissue. It is usually intrauterine and arises most commonly from molar pregnancy, but may also follow a term or ectopic pregnancy and spontaneous abortions. Extragonadal, nongestational choriocarcinoma is uncommon with a striking predominance in young men between 20 and 35 years of age. Most cases arise in midline structures, such as the retroperitoneum, the mediastinum, and the vicinity of the pineal body but also have been reported in other visceral organs such as the stomach, esophagus, small bowel, prostate, and urinary bladder.1 To our knowledge, there have been only 22 cases of primary pulmonary choriocarcinoma reported in the literature. Of those cases, 13 developed in men.2 Extragonadal choriocarcinoma arising in the lung is thought to be unresponsive to treatment and is associated with a poor prognosis. We report a young male patient with extragonadal, nongestational choriocarcinoma apparently arising in the lung. A positive urine pregnancy test result and an elevated serum -HCG level are compatible with the presence of this neoplasm, and the diagnosis was confirmed histologically by bronchoscopy examination.
Case Report A 23-year-old man was admitted to the hospital with a 3-week history of hemoptysis and progressive dyspnea. A chest radiograph on hospital admission revealed airspace consolidation in the periphery of the upper portion of both lungs with multiple nodules of variable sizes in both lung fields (Fig 1). A CT scan of the chest confirmed the presence of pulmonary nodules with ground-glass opacities in both lungs, which is consistent with the presence of pulmonary hemorrhage (Fig 2). On physical examination, no gynecomastia was noted. The abdomen was soft with no abnormal findings. A genital examination revealed no evidence of any scrotal masses. The remainder of the physical examination was unremarkable except for diffuse crackles in both lung fields. Under the impression of suspected germ cell tumors, a biological tumor marker study was performed. The result of a urine pregnancy test was positive, and the levels of -HCG were very high at 1,600,000 IU/L in the serum (normal, ⬍ 5 IU/L) and 3,464,000 IU/L in the urine. However, the serum ␣-fetoprotein level was within normal limits (ie, 3.8 ng/mL). A transbronchial lung biopsy in the right lower lobe showed intense hemorrhage and fibrinoid deposits in the alveoli with a dimorphic population of malignant cells with hyperchromatic nuclei and multinucleated syncytiotrophoblasts, which is consistent with choriocarcinoma (Fig 3), although a weak positive result of a -HCG immunohistochemical stain was found to be due to limited lesions (data not shown). Based on the findings, a diagnosis of choriocarcinoma was made. The patient was given chemotherapy, which consisted of actinomycin-D, methotrexate, and cyclophosphamide. Despite aggressive chemotherapy and management in the ICUs, the patient’s condition deteriorated rapidly, and he died of acute respiratory failure 8 days after hospital admission. A request for an autopsy was denied.
Discussion Choriocarcinoma is a germ cell tumor containing syncytiotrophoblastic giant cells and often secreting a biological tumor marker (-HCG). It usually occurs in women, Selected Reports
Figure 3. The histopathology of a transbronchial lung biopsy specimen shows a dimorphic population of malignant cells with hyperchromatic nuclei and multinucleated syncytiotrophoblasts scattered within fibrinoid deposits (hematoxylin-eosin stain, original ⫻ 40).
Figure 1. A chest radiograph performed at hospital admission shows airspace consolidation infiltrates involving the periphery of both lungs, with multiple pulmonary nodules of varying sizes in both lung fields.
mainly as a gestational trophoblastic neoplasm, and rarely occurs in men as a nonseminomatous testicular tumor. Extragonadal nongestational primary pulmonary choriocarcinoma is exceedingly rare.1–3 In the case presented, pulmonary choriocarcinoma was diagnosed on the basis of the following findings: obvious lesions were found only in
Figure 2. A CT scan of the chest demonstrates multiple pulmonary nodules in both lungs with ground-glass opacities involving the periphery of both upper lobes, which is consistent with pulmonary hemorrhage. P ⫽ posterior; R ⫽ right.
the lung; raised -HCG levels were found both in the serum and in the urine; and pathologic confirmation of the disease. Because the lung is a frequent site of metastatic choriocarcinoma, the diagnosis of the primary tumor should be made carefully. In this case, although multiple nodules were found in both lungs, we considered the patient to have primary choriocarcinoma because there was no apparent evidence of a primary genital tumor, and no lesions were found in midline structures or in other visceral organs by CT scan, abdominal echography, and gastroendoscopy. Nevertheless, the possibility of a metastasis from invisible lesions in other locations could not be ruled out completely because the request for an autopsy was denied. There are several possible theories explaining the development of primary pulmonary choriocarcinoma. Some authors4 believe that the tumors arise from retained primordial germ cells that migrate abnormally during embryonic development. Others believe that the tumors represent metastasis from a primary gonadal (ie, testicular or ovarian) tumor that regressed spontaneously1 or arose from a trophoblastic emboli related to molar pregnancy after long periods of latency.5 In other reports,6,7 the hypothesis of dedifferentiation or metaplasia to the trophoblast from a nongonadal tissue such as primary lung cancer is supported. This theory may help to resolve a semantic problem, namely, whether primary pulmonary choriocarcinoma is identical to HCG-producing giant cell carcinoma of the lung because the histopathologic similarity of choriocarcinoma with giant cell lung cancer has been reported.2,3 Among the patients with primary pulmonary choriocarcinoma whose cases have been reported in the literature, most demonstrated solitary pulmonary nodules in the lung field.3,5–7 However, in our patient, multiple nodular lesions were found on a chest radiograph. The presenting radiologic features in our patient would support the assertion CHEST / 121 / 3 / MARCH, 2002
997
that the tumors may metastasize from a primary gonadal tumor undergoing spontaneous regression. However, as in the debate in the literature concerning the origin of the diffuse or multinodular form of bronchioloalveolar carcinoma of the lung, the tumors in our patient could be multicentric in origin or may merely represent a mode of extension within the lung of a tumor arising in the small foci of primordial germ cells. In contrast to gestational choriocarcinoma, the natural course of primary pulmonary choriocarcinoma is rapidly fatal in the great majority of cases. Prompt recognition of this unique disease is crucial because rapid intervention may be life-saving. However, treatment modalities such as chemotherapy, radiation, or surgical resection in patients with widespread, far-advanced malignant tumors have usually proven to be ineffective in providing better long-term survival,3,8,9 as has been shown in this case. There have been only three reported cases2 (Table 3) of survival for ⬎ 1 year in male patients with primary pulmonary choriocarcinoma. The reason that nongestational choriocarcinoma behaves so differently from gestational cancers is unknown. A positive result of a -HCG test in patients with hemoptysis and progressive dyspnea should arouse suspicions of the presence of pulmonary choriocarcinoma, thus leading to an early diagnosis. In most of the reported cases, however, the patients had sought medical attention too late. In addition, because the radiologic findings of pulmonary hemorrhage may obscure the nodular lesions of choriocarcinoma, and because the -HCG test and the histologic processing of tissue specimens may take several days, the diagnosis may be delayed, particularly, in male patients. In the presented case, the patient was thought initially to have an infectious disease, germ cell tumors, or metastatic lung cancer, based on the findings of clinical entities, a chest radiograph, and CT scan. A positive urine pregnancy test result, which only takes a couple of minutes, rapidly gave us a very clear direction in the differential diagnosis of the lung lesions. In conclusion, the diagnosis of primary pulmonary choriocarcinoma must be considered in young male patients with hemoptysis, progressive dyspnea, and radiologic findings of airspace consolidation with solitary/multiple pulmonary nodules. The serum -HCG level should be examined as early as possible. Before this is done, the performance of a urine pregnancy test, a simple and convenient method, would be very useful in the rapid diagnosis of primary pulmonary choriocarcinoma.
References 1 Hainsworth JD, Greco FA. Extragonadal germ cell tumors and unrecognized germ cell tumors. Semin Oncol 1992; 19:119 –127 2 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 3 Canver CC, Voytovich MC. Resection of an unsuspected primary pulmonary choriocarcinoma. Ann Thorac Surg 1996; 61:1249 –1251 4 Fine G, Smith RW, Pachter MR. Primary extragenital cho998
5 6 7 8 9
riocarcinoma in the male subject. Am J Med 1962; 32: 776 –794 Tanimura A, Natsuyama H, Kawano M, et al. Primary choriocarcinoma of the lung. Hum Pathol 1985; 16:1281– 1284 Pushchak MJ, Farhi DC. Primary choriocarcinoma of the lung. Arch Pathol Lab Med 1987; 111:477– 479 Sullivan LG. Primary choriocarcinoma of the lung in a man. Arch Pathol Lab Med 1989; 113:82– 83 Benditt JO, Farber HW, Wright J, et al. Pulmonary hemorrhage with diffuse alveolar infiltrates in men with highvolume choriocarcinoma. Ann Intern Med 1988; 15:674 – 675 Aparcio J, Oltra A, Martinez-Moragon E, et al. Extragonadal nongestational choriocarcinoma involving the lung: a report of three cases. Respiration 1996; 63:251–223
Tracheal Compression by the Stomach Following Gastric Pull-Up* Diagnosis With CT and Treatment With Expandable Metallic Stent Placement Suil Kim, MD, PhD; Michael B. Gotway, MD; W. Richard Webb, MD; Roy L. Gordon, MD; and Jeffrey A. Golden, MD
Surgical treatment of recurrent achalasia includes esophagectomy with gastric pull-up. A MEDLINE search yielded no articles describing an adverse effect of this surgery on pulmonary function. We report the first case of acute ventilatory failure caused by gastric pull-up. An evaluation by flexible bronchoscopy, spirometry with flow-volume loops, and dynamic CT scanning revealed extrinsic compression of the trachea by the stomach causing obstruction. Endotracheal placement of a selfexpanding stent resulted in the rapid extubation of the patient with normalization of the flow-volume loop and dramatic improvement in the FVC, FEV1, and peak expiratory flow. (CHEST 2002; 121:998 –1001) Key words: bronchoscopy; dynamic CT; esophagectomy; spirometry; stent; tracheal obstruction; tracheomalacia Abbreviation: ETT ⫽ endotracheal tube
*From the Departments of Medicine (Drs. Kim and Golden) and Radiology (Drs. Gotway and Webb), Division of Pulmonary and Critical Care Medicine, and the Section of Interventional Radiology (Dr. Gordon), University of California, San Francisco, CA. Manuscript received May 16, 2001; revision accepted August 21, 2001. Correspondence to: Jeffrey A. Golden, MD, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, 400 Parnassus Ave, Box 0359, San Francisco, CA 94143-0359; e-mail: [email protected] Selected Reports