PORCELAIN PLEURA: A RARE CASE OF METASTATIC CHONDROSARCOMA WITH EXTENSIVE PLEURAL CALCIFICATION

Abstract

TOPIC: Disorders of the Pleura TYPE: Fellow Case Reports INTRODUCTION: Calcified pleural lesions have both benign and malignant etiologies. Benign lesions can originate from previous trauma, prior pleural infections, hemothorax, or asbestos exposures, and are often focal and limited1,2. Malignant lesions often involve metastatic disease from mesenchymal tumor origin, such as osteosarcoma, chondrosarcoma, or mesothelioma1,3. We describe a case of a patient with metastatic chondrosarcoma manifesting with extensive calcification of the parietal and visceral pleura. CASE PRESENTATION: A 67 year old man was referred to pulmonary for a new subcarinal soft tissue mass on chest CT. He had been previously diagnosed with chondrosarcoma in 2016 and underwent treatment via a radical right proximal humerus excision and shoulder arthroplasty, with final pathology revealing grade 2 conventional chondrosarcoma, mixed hyaline and myxoid, without metastatic foci.Screening chest CT in 2020 noted a new, partially calcified subcarinal soft tissue mass and adjacent lymphadenopathy with moderate hypermetabolism on a positron emission tomography scan (PET/CT). Bronchoscopy with endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) subcarinal lymph node and adjacent posterior mass confirmed metastatic disease.He subsequently developed rapidly progressive dyspnea on exertion over the following month. Repeat chest CT revealed extensive development of circumferential nodularity and calcification of the right visceral and parietal pleura with a large pleural effusion. Thoracentesis improved dyspnea despite limited reexpansion of the lung and noted loculation of the effusion. Pleuroscopic evaluation of the complicated space was undertaken to remove loculations and optimize placement of an indwelling pleural catheter (IPC) for his malignant effusion. Despite difficulty with trocar insertion into the calcified pleural space, placement of the IPC was successful with improvement in his dyspnea. DISCUSSION: Metastatic pleural involvement of chondrosarcoma is rare, and can occur in the setting of direct extension in locoregional disease or hematogenous spread from other sites of primary involvement. Metastatic disease has been noted to be more prevalent in the dedifferentiated and mesenchymal subtypes4. Manifestations of metastatic pleural involvement are typically pleural calcifications that can be profound in the rapid evolution and extent of calcified involvement. Management is often palliative, as in this case, with drainage of any associated pleural effusions and attempts to mitigate accompanying dyspnea. CONCLUSIONS: This case of metastatic chondrosarcoma with extensive visceral and parietal pleural involvement is rare and infrequently noted in the literature. Palliative management with thoracentesis and IPC placement was complicated by the pervasive pleural calcification that prevented ultrasound imaging and made access to the pleural space difficult and dangerous. REFERENCE #1: Sureka B, Thukral BB, Mittal MK, Mittal A, Sinha M. Radiological review of pleural tumors. Indian J Radiol Imaging. 2013;23(4):313-320 DISCLOSURES: No relevant relationships by Robert Browning, source=Web Response, value=Grant/Research Support Removed 04/29/2021 by Robert Browning, source=Web Response No relevant relationships by Robert Browning, source=Web Response, value=Consulting fee Removed 04/29/2021 by Robert Browning, source=Web Response No relevant relationships by Robert Browning, source=Web Response, value=Consulting fee Removed 04/29/2021 by Robert Browning, source=Web Response No relevant relationships by Sean McKay, source=Web Response No relevant relationships by Philip Mullenix, source=Web Response No relevant relationships by Caitlin Nickens, source=Web Response No relevant relationships by John Shumar, source=Web Response