Abstract Introduction Lung adenocarcinoma, a subtype of non-small cell lung cancer, typically carries more favorable post-surgical outcomes in comparison to small cell carcinoma. We report a rare case of stage IV lung adenocarcinoma in a middle-aged woman whose disease rapidly progressed after video-assisted thoracoscopic surgery (VATS) with talc pleurodesis for treatment of complex pleural effusion, resulting in extensive chest wall invasion, pathologic rib fractures, and splenic metastasis—an atypical pattern for this cancer subtype. Case A 64-year-old woman with a 20 pack-year smoking history, quit 20 years ago, initially presented with chest pain that was attributed as musculoskeletal, but symptoms progressed leading to diagnosis of a left-sided pleural effusion on chest X-ray three months later. Thoracentesis drained 1.5 L of cloudy fluid, which was negative for malignant cells or infection. She returned to the emergency department two weeks later with shortness of breath and chest pain. CT chest demonstrated a complex, thick-walled, left-sided pleural effusion with extensive nodular thickening of the anterior inferior diaphragm and pleura, extensive mediastinal lymphadenopathy, and a 2.5 cm left upper lobe lung mass (A). Chest tube was inserted, and pleural fluid studies were again negative for malignant cells. Therapeutic drainage of the pleural effusion was not achieved, necessitating a VATS procedure with talc pleurodesis (B). Notable intraoperative findings included numerous chest wall nodules and dense pleural adhesions. Multiple tissue specimens were sent for pathology. The patient was discharged with pulmonology outpatient follow-up for endobronchial ultrasound but returned to the hospital one week later with uncontrollable chest pain. CT imaging demonstrated re-accumulation of left pleural effusion with new extensive left chest wall invasion, several pathologic rib fractures, numerous necrotic/malignant appearing mediastinal and periaortic lymph nodes, and loss of the intact fat plane along the superior splenic margin concerning malignant extension into the splenic capsule (C). Pathology from pleural biopsies taken during VATS demonstrated poorly differentiated lung adenocarcinoma. Attempted PleurX catheter placement was unsuccessful due to pleural thickening, requiring chest tube insertion. She was transferred for inpatient chemotherapy with carboplatin/pemetrexed by oncology with plans to initiate pembrolizumab on discharge. Discussion This case demonstrates an unusually aggressive progression of lung adenocarcinoma, marked by rapid local invasion and splenic metastasis following VATS. Poor differentiation and extensive local metastasis likely contributed to the fulminant progression. This case highlights the critical need for careful patient selection for VATS in advanced lung adenocarcinoma, as surgical intervention may inadvertently accelerate metastatic spread and worsen outcomes. This abstract is funded by: None
Martin et al. (Fri,) studied this question.