Pulmonary Synovial Sarcoma Presenting as Empyema

SESSION TITLE: Metastatic and Other Primary Lung Tumors SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Sarcomas are rare group of malignant tumors of mesenchymal origin. These mesenchymal cells have the capability to mature into striated skeletal and smooth muscles, adipose and fibrous tissue, bone, and cartilage. Therefore, histopathology of a sarcoma can widely vary. We report a patient who presented with acute empyema and pulmonary synovial sarcoma. CASE PRESENTATION: A 79-year-old man with history of hypertension, hyperlipidemia, diabetes mellitus, and right lower leg sarcoma status post resection about 20 years ago, presented with worsening right-sided pleuritic chest pain for duration of 3 days, dry cough and dyspnea on exertion. He was subsequently intubated for acute hypoxic respiratory failure and concurrent shock requiring vasopressors. The patient was started on vancomycin and piperacillin-tazobactam empirically. A computed tomography of the chest revealed a multiloculated right-sided pleural effusion with large area of collapsed lung with calcifications. An ultrasound of the thorax revealed a moderate sized pleural effusion with multiple septations, and this was followed by thoracentesis with drainage of 400 mL of yellow turbid fluid with gelatinous material. The pleural fluid analysis was consistent with empyema, but cultures were negative. Two surgical chest tubes were placed targeting an apical anterior and diaphragmatic posterior pleural effusion. An inspection bronchoscopy was performed and an endobronchial lesion was noted to be obstructing the right lower lobe bronchus, which was biopsied. Once the patient was titrated off vasopressors, he underwent open thoracotomy, total pulmonary decortication and right lower lobe pleural-based mass biopsy. The pathological examination of both the endobronchial and pleural-based biopsy revealed spindle cell neoplasm. Immunohistochemically, the neoplasm was positive for TLE1 and CD99 expression yielding a final diagnosis of pulmonary synovial sarcoma. DISCUSSION: Synovial sarcoma is an extremely rare tumor comprising 5-10% of all soft tissue sarcomas. Even rarer is the incidence of lung cancer associated empyema which is < 0.3%. The exact mechanism of pathogenesis is unclear but factors associated with infection and pulmonary sarcoma include obstructive pneumonia with progression to pulmonary abscess and empyema; tissue necrosis and cavitations from tumor burden leading to empyema. Mainstay treatment of empyema is chest drainage along with antibiotics. The treatment for pulmonary synovial sarcoma consists of surgical resection followed by radiation therapy and chemotherapy. CONCLUSIONS: To the best of our knowledge, this is the first reported case of pulmonary synovial sarcoma presenting with empyema. Our patient was treated with open thoracotomy with pulmonary decortication along with broad spectrum antibiotics. Further management of his newly diagnosed sarcoma is being planned as outpatient. Reference #1: Thoracic Cancer 7 (2016), 684-688 Reference #2: J Formos Med Assoc | 2006, Vol 105, No 9, 760-764 DISCLOSURE: The following authors have nothing to disclose: Bahishta Yaqubi, Ivan Wong, Zoheb Shaikh, Anthony Saleh, MD No Product/Research Disclosure Information