Japanese Journal of Clinical Oncology 30:163-166 (2000)
© 2000 Foundation for Promotion of Cancer Research
Secretion of hCG/ß-hCG by Squamous Cell Carcinoma of the Lung in a 31-year-old Female Smoker
1Department of Thoracic Oncology and 2Pathology Laboratory, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
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ABSTRACT |
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We describe a rare case of pulmonary squamous cell carcinoma secreting human chorionic gonadotropin (hCG) and its ß-subunit (ß-hCG) in a young female smoker. A 31-year-old mother of one child had been suffering from dysfunctional uterine bleeding for about 1 year. Pelvic examinations and abdominal ultrasonography yielded no abnormal findings and no signs of pregnancy. She developed a pain in the right chest and a huge (12 x 10 cm) squamous cell carcinoma was diagnosed in the right lower lobe. The serum hCG and ß-hCG levels were high: hCG 5611 mIU/ml (normal upper limit 0.7 mIU/ml), ß-hCG 12 238 mIU/ml (normal upper limit 0.5 mIU/ml). The patient underwent right lower lobectomy and systematic lymph node dissection. Microscopic study showed a poorly differentiated squamous cell carcinoma. The pathological stage was T2N0M0, stage IB. Immunohistochemical staining of the tumor was strongly positive for hCG. The serum hCG level returned to normal 1 month after the operation, while an additional 2 months were necessary for the ß-hCG level to normalize. Dysfunctional uterine bleeding disappeared and the patient is doing well, with no signs of recurrence, 9 months after the resection.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentsREFERENCES |
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It is well known that squamous cell carcinoma (SCC) of the lung develops less frequently in the younger population, especially in women (1–4). Although pulmonary carcinoma secreting human chorionic gonadotropin (hCG) is not uncommon (5–8), the number of case reports on hCG-producing lung cancer, especially in women, is limited (9–14).
We describe here a rare case of pulmonary SCC secreting hCG and ß-hCG in a 31-year-old female smoker.
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CASE REPORT |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentsREFERENCES |
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A 31-year-old mother of one child had been suffering from dysfunctional uterine bleeding for about 1 year. She developed a pain in the right side of the chest on December 10, 1998. She visited a local clinic the next day and an abnormal shadow was detected on chest X-ray. She was then referred to a community hospital and underwent percutaneous needle biopsy, which revealed SCC.
On her first referral to our institute, she was in good condition except for chest pain and microcytic hypochromic anemia, which was attributable to the uterine bleeding. Pelvic examinations and abdominal ultrasonography yielded no abnormal findings and no signs of pregnancy. Chest X-ray showed a huge mass in the right lower lung field, measuring 12 x 10 cm (Fig. 1). Magnetic resonance imaging revealed a heterogeneous mass in the right lower lobe adjacent to the diaphragm and where diaphragm invasion was suspected (Fig. 2).
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She had a history of smoking seven cigarettes per day, starting from 17 years of age to the present. Her grandmother had a history of rectal cancer. Although she told us that she had been treated for hepatitis type B (HB) when she was 23 years old, the serological test was negative for HB viral infection on the present admission and there were no laboratory test results showing hepatic dysfunction. As pulmonary SCC in young women is rare and the tumor was large, serum hCG and ß-hCG levels were examined and extremely high levels were reported: hCG 5611 mIU/ml (normal upper limit 0.7 mIU/ml), ß-hCG 12 238 mIU/ml (normal upper limit 0.5 mIU/ml). We reviewed the biopsy specimen obtained at the community hospital and confirmed the diagnosis of SCC, but there were no findings suggestive of a germ cell tumor or trophoblasts.
She underwent right lower lobectomy and systematic lymph node dissection on January 13, 1999. The carcinoma had not invaded the diaphragm. The postoperative course was uneventful and she was discharged on the ninth postoperative day.
Grossly, the cut surface of the resected specimen revealed a well-circumscribed hard tumor, yellowish white in color, measuring 11.9 x 10.3 x 7.6 cm. More than half of the tumor was occupied by necrotic tissue, while about a quarter showed solid tumor growth. Microscopically, the majority of the tumor cells were poorly differentiated carcinoma with severe nuclear atypia. There were a limited number of carcinoma foci with squamoid differentiation with intercellular bridges but without keratinization, which was diagnosed to be poorly differentiated SCC (Fig. 3). We did not find multinucleated giant cells, cytotrophoblasts and syncytiotrophoblasts in the tumor. Venous invasion was found pathologically, but not lymphatic permeation. According to the UICC staging criteria (15), the pathological stage was T2N0M0, stage IB. Immunohistochemical staining of the tumor was strongly positive for hCG and approximately 30% of the tumor cells were stained positive (Fig. 4).
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The serum hCG level normalized 1 month after the operation, while the ß-hCG returned to normal a further 2 months later. Dysfunctional uterine bleeding disappeared. She is doing well, with no signs of recurrence, 9 months after the resection.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentsREFERENCES |
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It is known that most SCCs of the lung develop in elderly smokers. SCC accounts for 0–29% of lung cancers in the population younger than 40 years old (1–4). All the articles describing lung cancer in young patients concluded that fewer SCCs but more adenocarcinomas were found in this group of patients. This can be explained by the fact that pulmonary SCC usually develops after a long smoking history. The role of smoking in carcinogenesis in the younger generation remains unclear, although several authors concluded that women were more susceptible to smoking than men (16,17).
Szturmowicz and associates (5) reported that serum ß-hCG levels were elevated in 12% of non-small cell lung cancer (NSCLC) patients, while 3.5% of patients with benign lung diseases showed elevation. They also found that 28% of resected NSCLC specimens showed positive immunohistochemical staining for ß-hCG, although the positive results in previous reports differ widely, from 9% (6) to 84% (7). Positive staining was more common in adenocarcinoma (10/27, 37%) than in SCC (5/26, 19%) (5), which was consistent with another report (adenocarcinoma 60%, SCC 21%) (8).
Although hCG secretion by NSCLC does not seem to be very rare (5–8), the number of case reports on hCG-producing lung cancer is limited, especially in women (9–14). To our knowledge, there have been seven such cases reported in the literature that documented the female gender. There have been case reports of hCG-producing SCC in a 74-year-old patient (9), large cell carcinoma in a 24-year-old patient (10), adenocarcinoma in three patients aged 33 (11), 31 (12) and 49 (13) years and giant cell carcinoma in two 42-year-old patients (13,14).
Abnormal hCG secretion causes gynecomastia in men, which is a distinct clinical finding that may often lead to hormonal studies. On the other hand, amenorrhea and dysfunctional uterine bleeding, which can result from an elevated hCG level in women (18), are not very unusual findings and do not always lead to endocrine examinations or to chest roentgenograms, especially in women of childbearing age. This may explain why hCG-producing lung cancers in women have rarely been reported.
Historically, pulmonary carcinoma has occurred most frequently in men or postmenopausal women and the cause of elevated serum hCG level was not mistakenly ascribed to pregnancy (12). However, as the malignancy becomes more frequent in young women, there is a good chance of confusion in this group of patients. Physicians should take note that amenorrhea or dysfunctional uterine bleeding with an elevated hCG level in a young woman can suggest pulmonary carcinoma.
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Acknowledgments |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentsREFERENCES |
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The authors are indebted to Professor J. Patrick Barron and T. Kojima of the International Medical Communications Center of Tokyo Medical University, Japan, for their review of the manuscript. This work was supported in part by a Grant-in-Aid for Cancer Research from the Ministry of Health and Welfare, Japan.
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FOOTNOTES |
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+ For reprints and all correspondence: Junji Yoshida, Department of Thoracic Oncology, National Cancer Center Hospital East, 5–1, Kashiwanoha 6-chome, Kashiwa, Chiba, 277-8577, Japan. E-mail: jyoshida@east.ncc.go.jpAbbreviations: hCG, human chorionic gonadotropin; ß-hCG, ß-subunit of human chorionic gonadotropin; SCC, squamous cell carcinoma; HB, hepatitis type B; NSCLC, non-small cell lung cancer
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REFERENCES |
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Received August 13, 1999; accepted November 15, 1999.
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