A BONE TOO TOUGH TO PICK

SESSION TITLE: Lung Cancer SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/23/2019 8:45 AM - 9:45 AM INTRODUCTION: Primary thoracic sarcomas are rare with angiosarcoma, leiomyosarcoma and rhabdomyosarcoma being the major constituents. Diagnosis is confirmed only after metastatic disease has been excluded. We present a rare case of a 71 year old gentleman with an endobronchial presentation of primary sarcomatoid pulmonary carcinoma. CASE PRESENTATION: 71 y/o prior smoker presents to an outside hospital with worsening dyspnea for 2weeks and noted to be hypoxic on arrival. He has a PMH of COPD, HTN, DM, bladder cancer s/p resection and CKD. CXR on admission was suggestive of a large left sided pleural effusion for which a chest tube was placed for symptomatic relief after drainage of 1.5L. Subsequently, chest CT was done which showed left main stem bronchus endobronchial lesion and a pneumothorax ex-vacuo. Patient had a bronchoscopy with endobronchial biopsy which showed inflammatory squamous epithelial cells and negative for malignancy. He was transferred to our hospital where he underwent a rigid bronchoscopy with jet ventilation. Complete obstruction of the left main stem bronchus was noted with a mass that was adherent to the wall with thick secretions proximal to the mass. Tumor debulking was attempted with grasper forceps, hot diathermy forceps and argon plasma coagulation but we were unable to remove the mass en bloc. Tumor was noted to have a gritty consistency and resistant to debulking. The patient had a repeat bronchoscopy 3 days later and debulking was attempted again with Nd: YAG laser and dilation with a Fogarty balloon because of which small recanalization was possible. Due to the extent of tumor, proximity to the pulmonary artery and adherence to the bronchus wall complete recanalization and debulking was not possible. Surgical pathology was consistent with sarcomatoid malignant neoplasm with osteosarcomatous features. Patient had a PET scan and a bone scan which was negative for extra pulmonary spread. Due to extensive nature of the malignancy and failure to wean from the ventilator, the patient opted for palliative care and expired shortly after. DISCUSSION: Carcinosarcoma is defined as a malignant tumor having a mixture of carcinoma and sarcoma-containing heterologous elements such as malignant cartilage, bone, or skeletal muscle. Squamous cell carcinoma is the most common histologic type of carcinoma followed by adenocarcinoma. The sarcomatous component can consist of various patterns including pure components or mixtures of rhabdomyosarcoma, chondrosarcoma, or osteosarcoma. They are usually treated with preoperative chemotherapy followed by resection. Survival is poor, with a 5-year survival rate of about 15% compared with 60%–70% in extremity osteosarcomas treated with resection and chemotherapy. CONCLUSIONS: Primary thoracic sarcomas are extremely rare and carry a poor prognosis and survival. They can be resistant to debulking even with skilled interventionalist at the helm. Reference #1: Gladish, G, et al. Primary Thoracic Sarcomas. Radiographics. 2002 May-Jun;22(3):621-37 Reference #2: Trawis, WD. Sarcomatoid neoplasms of the lung and pleura. Arch Pathol Lab Med. 2010 Nov;134(11):1645-58 DISCLOSURES: No relevant relationships by Erica Altschul, source=Web Response No relevant relationships by Nader Ishak Gabra, source=Web Response No relevant relationships by Oki Ishikawa, source=Web Response no disclosure on file for Viera Lakticova; No relevant relationships by Omar Mahmoud, source=Web Response No relevant relationships by Maly Oron, source=Web Response No relevant relationships by Varun Shah, source=Web Response