Fulminant Thoracic Sarcoma Masked by Hemothorax

Abstract

A 15-year-old female was admitted to the hospital with dyspnea and thoracic pain 1 month after trauma caused by a snowboarding accident. The patient was hit by another snowboarder and landed on the left hemithorax. She suffered immediate pain. The pain decreased gradually, but increasing dyspnea developed 2 weeks prior to admission. No evidence of other illness symptoms was recorded. Chest x-ray (Fig. 1) revealed left pleural effusion. Blood tests revealed a hemoglobin level of 9.9 gm/dl but were otherwise normal. Pleural drainage was performed based on clinical suspicion of traumatic hemothorax, and 2700 ml of blood-stained fluid was drained, with subsequent satisfactory radiological examination (Fig. 1) and immediate patient recovery. One month later, the patient was readmitted to the hospital with low hemoglobin (10.5 g/dl) and weight loss (7% of body mass). Except for a slight contusion to the left hemithorax at home, no other anamnestic event or new symptoms were recorded. After chest x-ray and CT scan (Fig. 2), the patient was operated on with the intention of performing hematoma debridement and lung decortication because of hemothorax. During thoracotomy, a cauliflower-like tumor filling the whole thoracic cavity and infiltrating the chest wall was found. There was minimal blood content in the thoracic cavity. Intraoperative biopsy diagnosis indicated “highly malignant neoplasm of unknown origin.” Taking into account extensive infiltration of the thoracic wall, the decision to abandon curative resection was made, and additional biopsies were taken before the thoracotomy was closed. The patient received four units of red blood cell concentrates after the operation. Histological examination revealed primitive neuroendocrine tumor, which belongs to the Ewing sarcoma family.1–3 The patient was subsequently treated with chemotherapy (ifosfamid, vincristin, doxorubicin, and cyclofosfamid) and died 8 months later from progressive disease. REFERENCES 1. Hadithi M, van Boxem TJ, Giaccone G, et al. Exercise-induced spontaneous hemothorax insinuates trauma; yet unmasks a lament disorder. Neth J Med. 2001;59:292–294. 2. Varsano S, Edelstein E, Gendel B, et al. Bilateral and unilateral spontaneous massive hemothorax as a presenting manifestation of rare tumors. Respiration. 2003;70:214–218. 3. Eroglu A, Kurkcuoglu IC, Karaoglanoglu N, et al. Extraskeletal Ewing sarcoma of the diaphragm presenting with hemothorax. Ann Thorac Surg. 2004;78:715–717.