LAUSR

CASE PRESENTATION: 71 y/o prior smoker presents to an outside hospital with worsening dyspnea for 2weeks and noted to be hypoxic on arrival. He has a PMH of COPD, HTN, DM, bladder cancer s/p resection and CKD. CXR on admission was suggestive of a large left sided pleural effusion for which a chest tube was placed for symptomatic relief after drainage of 1.5L. Subsequently, chest CT was done which showed left main stem bronchus endobronchial lesion and a pneumothorax ex-vacuo. Patient had a bronchoscopy with endobronchial biopsy which showed inflammatory squamous epithelial cells and negative for malignancy. He was transferred to our hospital where he underwent a rigid bronchoscopy with jet ventilation. Complete obstruction of the left main stem bronchus was noted with a mass that was adherent to the wall with thick secretions proximal to the mass. Tumor debulking was attempted with grasper forceps, hot diathermy forceps and argon plasma coagulation but we were unable to remove the mass en bloc. Tumor was noted to have a gritty consistency and resistant to debulking. The patient had a repeat bronchoscopy 3 days later and debulking was attempted again with Nd: YAG laser and dilation with a Fogarty balloon because of which small recanalization was possible. Due to the extent of tumor, proximity to the pulmonary artery and adherence to the bronchus wall complete recanalization and debulking was not possible. Surgical pathology was consistent with sarcomatoid malignant neoplasm with osteosarcomatous features. Patient had a PET scan and a bone scan which was negative for extra pulmonary spread. Due to extensive nature of the malignancy and failure to wean from the ventilator, the patient opted for palliative care and expired shortly after.