CONCURRENT PULMONARY AND JEJUNAL SARCOMATOID CARCINOMA WITH BRAIN METASTASES

Abstract

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary sarcomatoid carcinoma (SCA) is a poorly differentiated, aggressive type of non-small cell lung cancer accounting for 0.1-0.3% of all lung cancers1-3. It is commonly seen in male smokers in their sixties. We present a rare case of concurrent pulmonary and jejunal SCA with brain metastases. CASE PRESENTATION: 75-year-old male with 40-pack year smoking history presents to the hospital with two weeks of nausea, vomiting, weight loss and dyspnea. CXR revealed a 10.1 x 7.4 cm right perihilar mass. Subsequent chest CT showed a 7.8 x 6.6 x 8.7 cm mass involving the posterior segment of right upper lobe, right middle lobe, and right lower lobe. PET scan showed avid lesions involving jejunum, brain, and adrenal glands. Endobronchial biopsy of the lung mass obstructing the lumen of posterior segment of right upper lobe revealed SCA with focal pleomorphism. Immunohistochemical staining was positive for Keratin AE1/AE3 and vimentin. A subsequent jejunal mass biopsy was also consistent with SCA with staining positive for keratin CAM5.2 and ß-hCG. Patient underwent whole brain radiotherapy as well as palliative pembrolizumab therapy. DISCUSSION: SCA is an aggressive cancer with average survival of 8.8 months and 13 months when involving small intestine and lung respectively. 5,7 Immunohistochemical staining is crucial in differentiating metastases versus primary SCA. In our case, TTF-1, Napsin-A, and CK7 staining of the jejunal mass were negative, which contradicts lung derivation. 4 This is a rare case of primary pulmonary SCA and concurrent primary jejunal SCA with brain metastases. Most SCA tumors involving small intestine are polypoid with central ulceration and frequently necrotic and hemorrhagic. 6,7 In contrast, pulmonary SCA usually arises as a solitary central airway mass with an average size of 7 cm.3 Symptoms in pulmonary SCA are non-specific such as chest pain, dyspnea and weight loss.1,4 This makes early diagnosis challenging. Patients often present in advanced stages with extra-thoracic metastases.4 Findings of brain metastasis is rare due to aggressive course of disease with low survival time.3 Both pulmonary and jejunal SCA are resistant to traditional therapeutic methods. Novel therapies like immunotherapy appears promising. CONCLUSIONS: This case is unique as it has two concurrent primaries for SCA, lung and jejunum. It is imperative to perform a complete oncological evaluation to assess for metastases. Early diagnosis and proper adjuvant therapy could prolong survival and improve quality of life. Reference #1: Arshad, H., Dudekula, R., Niazi, M., Malik, S., and Khaja, M. (2017). A Rare Case of Sarcomatoid Carcinoma of the Lung with Spine Metastasis, Including a Literature Review. Am J Case Rep. 2017; 18: 760-765. Beasley, M., Brambilla, E., and Travis, W. (2005). The 2004 World Health Organization classification of lung tumors. Semin Roentgenol. 2005 Apr, 40 (2): 90-7. Reference #2: Oliveira MF, Watanabe SC, Andrade MP, Rotta JM, Pinto FC. Sarcomatoid carcinoma of the lung with brain metastases. J Bras Pneumol. 2013;39(6):753-756. doi:10.1590/S1806-37132013000600016 Jia J, Ren J, Gu J, Di L, Song G. Predominant sarcomatoid carcinoma of the lung concurrent with jejunal metastasis and leukocytosis. Rare Tumors. 2010;2(3):e44. Published 2010 Sep 30. doi:10.4081/rt.2010.e44 Reference #3: Huang, S., Shen, S., and Li, X. (2013). Pulmonary sarcomatoid carcinoma: a clinicopathologic study and prognostic analysis of 51 cases. World J Surg Oncol 2013; 11: 252. Kwok CM. Sarcomatoid carcinoma of the jejunum with gastric metastases: A case report and review of the literature. Int J Surg Case Rep. 2016;28:161-164. doi:10.1016/j.ijscr.2016.09.046 Zhang B, Cheng BO, Wang L, Zhao KE, Zhuo GZ, Ding JH. Primary sarcomatoid carcinoma of the jejunum with massive intra-abdominal hemorrhage: A case report and review of the literature. Mol Clin Oncol. 2016;4(5):811-816. doi:10.3892/mco.2016.809 DISCLOSURES: No relevant relationships by Kushagra Gupta, source=Web Response No relevant relationships by Anthony Loschner, source=Web Response No relevant relationships by Elizabeth McCaskey, source=Web Response No relevant relationships by Toribiong Uchel, source=Web Response