SARCOMA METASTASIS CAUSING ATRIAL FIBRILLATION AND REFRACTORY PLEURAL EFFUSION

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Lungs are a primary site for metastasis of sarcomas, however malignant pleural effusion, which indicates a more widespread disease, are much rarer representing only 1-6% of all malignant effusions. We describe a case of a young man with a low-grade pelvic sarcoma that had progressive metastatic lung disease who went on to develop a refractory pleural effusion and new-onset atrial fibrillation CASE PRESENTATION: A 43-year-old male diagnosed with low-grade sarcoma in the pelvis had undergone a left hemipelvectomy. Nine months later he developed metastatic disease and underwent radiation/chemotherapy and eventually Nivolumab trial with no improvement of the disease. The patient then presented three months later with respiratory distress and atrial fibrillation (Afib). A Computed Tomography Scan(CT) of the chest showed increased muscular, bone, lung, and now pleural/ possible pericardial metastases. The CT also showed a large right-sided pleural effusion. The patient underwent thoracentesis with pleural fluid analysis demonstrating an exudative effusion, with cytology showing rare atypical large cells with high nuclear/cytoplasmic ratio consistent with malignant pleural effusion. Echocardiogram showed a new pericardial space mass likely a metastatic deposit. It was felt that mass contributes to persistent Afib. Due to recurrent pleural effusions, the patient received a PleurX catheter. This PleurX catheter initially drained well but later failed to continue to drain fluid and was removed. He later required admission to ICU due to acute hypoxic and hypercapnic respiratory failure. The patient failed to improve with non-invasive ventilation. The family declined intubation and the patient passed away on comfort measures. DISCUSSION: Metastatic pulmonary metastases arise most commonly in patients with malignant fibrous histiocytoma, synovial sarcoma, liposarcoma, & leiomyosarcoma, especially if histology is high grade. Lower grade sarcomas are considered more indolent and lung metastatic rate is lower. In our case, the patient had low-grade sarcoma which makes it more unusual. Complete resection of metastasis, when feasible, is the most important factor in determining post-metastasis survival, with the median survival of 33 months vs median survival of 11 months if resection is not done. This was not able to be done in our patient. When metastasis to the pericardium occurs it is common to see arrhythmias on ECG; the most common being PAC’s, PVC’s, and SVT's such as Afib as in our patient CONCLUSIONS: Metastatic progression of sarcoma to the lung can be managed surgically and with chemotherapy in select patients but prognosis remains poor. Pleural involvement, especially with malignant effusion, portends a very poor prognosis Reference #1: Cates CU, Virmani R, Vaughn WK, et al. Electrocardiographic markers of cardiac metastasis. Am Heart J 1986;112:1297–303. Reference #2: Marulli G, Mammana M, Comacchio G, Rea F. Survival and prognostic factors following pulmonary metastasectomy for sarcoma. J Thorac Dis. 2017;9(Suppl 12):S1305-S1315. Reference #3: Yildirim H1, Metintaş M, Ak G, Dündar E, Erginel S. Soft tissue sarcoma metastatic to pleura. Tuberk Toraks. 2008;56(2):197-200 DISCLOSURES: No relevant relationships by Edward Conuel, source=Web Response No relevant relationships by Lezah McCarthy, source=Web Response No relevant relationships by Kristoffer Neu, source=Web Response No relevant relationships by Raina Patel, source=Web Response No relevant relationships by Muhammad Salick, source=Web Response No relevant relationships by Ali Wazir, source=Web Response No relevant relationships by Robert Wilcott, source=Web Response