Table1Laboratoryfindingsonadmission Hematology Serology LungFunctionTest WBC 7,410 /μl CRP 7.7mg/dl VC 3.12L(97.2%) Neut 66.4 % KL-6 777U/ml FEV1.0 2.35L(78.25%) Eosino 3.2 % PT (INR) 0.94 %DLCO 47.6 % Baso 0.9 % APTT 33.5sec Lym 24.1 % FDP 9.1μg/ml BloodGases(Room Air) Mono 4.2 % D dimer 0.6μg/ml PH 7.432 RBC 4.26 10 6 /μl TAT 11.2ng/ml PaO2 69.4Torr Hb 12.0g/dl CEA 6.0ng/ml PaCO2 35.6Torr Hb 36.5 % SCC 0.8ng/ml SaO2 93.2 % Plt 42.3 10 4 /μl CYFRA 2.9ng/ml A-aDO2 36.5Torr BloodChemistry PROGRP 23.3pg/ml TP 7.7g/dl Alb 5.0g/dl ANA 40 AST 19IU/l MPO-ANCA:(-) ALT 11IU/l Anti-GBM-Ab:(-) γgtp 26IU/l ACL-β2GPI:(-) LDH 214IU/l Anti-Cardiolipin BUN 16.4mg/dl (IgG):(-) Cr 1.1mg/dl Fig.1 Thechestradiographonadmissionshowsinfiltrativeshadowsinthesubpleuralregionoftheright upperlungfield,andapatchyshadow intheleftupperlungfield.
Fig.2 ThechestCT onadmissionshowsmultipleirregularlyshapedinfiltrativeshadowsinthesubpleuralregionsofbothlungfields(fig.2a,2b,2c).thechestct scanonjune18,3weeksafteradmission, showsmultipleinfiltrativeshadowsinthesubpleuralregionsofbothlungfields,includingnew lesionsin thebilaterallowerlungfields(fig.2d,2e,2f). Fig.3 (A)Microscopicfindingsofthespecimenfrom video-assistedthoracoscopicsurgery,showingtu- morcelsandthrombiinthepulmonaryvessels.(hestain)(b)(c)immunohistochemicalstainofthespeci- men(b)ca19-9ispositiveontumorcels.(c)cytokeratin7ispositiveontumorcels.
Fig.4 (A)Perfusionlungscanshowingmultiplesubsegmentalperipheraldefectsinbothlungs(B)Ventilationscanisnormal. Fig.5 Retrogradepyelography,showingmultipledefectsintherightpelvisandureter.
Fig.6 (A)(B)Microscopicfindingsofthespecimenfrom theurethroscopicexamination,showingurothelialcarcinoma.(he stain)(c)(d)immunohistochemicalstainofthespecimen(c)ca19-9ispositiveintumorcels.(d)cytokeratin7ispositiveintumorcels. Table2 Previousreportsregardingpulmonarytumorembolism thatwasdiagnosedwhenprimarylesionwasnot knownandthepatientwasalive Diagnosticprocedure OpenLungBiopsy OpenLungBiopsy Pulmonaryarterialwedgeaspirationcytology PulmonaryEmbolism togetherwithinvasionofprimary tumorintoivc OpenLungBiopsy PulmonaryEmbolism togetherwithinvasionofprimary tumorintoivc ThoracoscopicLungBiopsy Primarylesion Kidney Stomach Kidney Abdominalcavity Liver Kidney Lung Histology Renalcelcarcinoma 3) Adenocarcinoma 4) Adenocarcinoma 5) Renalcelcarcinoma 6) TrophoblasticMalignancy 7) Germ celtumor 8) Chorangio-carcinomasusp 9) Renalcelcarcinoma 10) Choriocarcinama 11) Poorlydiferentiatedsquamouscelcarcinoma 12) Choriocarcinama 13)