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Sarcomatoid Carcinoma of the Lung
Mimicking a Thromboembolic Disease
Mona Mlika, 1,2 Selma Chaieb, 1,2 Sonia Baccari, 3 Tarek Kilani, 3 Faouzi Mezni 1,2
1. Department of Pathology, Abderrahman Mami Hospital, Université de Médecine, Tunis El Manar; 2. Research Unit: RU12/SP16, Public
Health Ministry, Tunis, Tunisia; 3. Department of Thoarcic Surgery, Abderrahman Mami Hospital, Tunis, Tunisia
B ackground: Sarcomatoid carcinoma of the lung is a rare tumour with a poor prognosis. Observation: We present a case report
of sarcomatoid carcinoma and its mode of presentation with a complete illustration. In this case, the tumour, which is generally
peripheral, was proximal and was revealed by non-specific symptoms and radiological features suggesting a thromboembolic
disease. Conclusion: This observation is interesting because it highlights the necessity of evoking the diagnosis of lung carcinoma when
dealing with radiologic features related to a thromboembolic disease.
Keywords Sarcomatoid carcinoma, thromboembolic
Disclosure: Mona Mlika, Selma Chaieb, Sonia Baccari,
Tarek Kilani and Faouzi Mezni have nothing to disclose
in relation to this article. No funding was received for the
publication of this article.
Compliance with Ethics: All procedures were followed
in accordance with the responsible committee on human
experimentation and with the Helsinki Declaration of
1975 and subsequent revisions, and informed consent
was received from the patient involved in this case study.
Open Access: This article is published under the
Creative Commons Attribution Noncommercial License,
which permits any non-commercial use, distribution,
adaptation and reproduction provided the original
author(s) and source are given appropriate credit.
Received: 11 June 2016
Accepted: 10 August 2016
Citation: European Respiratory & Pulmonary Diseases,
2016;12(2):58–9 Corresponding Author: Mona Mlika, Department
of Pathology, Abderrahman Mami Hospital,
Université de Médecine, Tunis El Manar.
Primary lung carcinoma spreading to pulmonary vessels and presenting as a thromboembolic
disease is quite rare and only few individual cases have been reported in the English literature. 1-3
The prognostic significance of pulmonary vessel invasion by lung carcinoma is unclear and the
treatment is challenging. We aim to describe an unusual case of sarcomatoid carcinoma of the
lung characterised by its hilar localization. 1,2
A 68-year-old man, 80 pack-year smoker, consulted for a 4-month-lasting effort dyspnea of New
York Heart Association (NYHA) functional class II and dry cough. Physical examination revealed
a grade III/IV ejection systolic murmur in the aortic area. Chest X-ray showed a heterogeneous
poorly defined opacity of the right hilius without cardiomegaly (Figure 1). Electrocardiogram
showed a regular sinusoidal rhythm and a tachycardia at 100 beats/min without signs of left
ventricular hypertrophy. A two-dimensional (2D) transthoracic echocardiography (TTE) showed
a severe aortic stenosis. The left ventricular ejection fraction was estimated to 70%. There was
no pulmonary arterial hypertension. The pulmonary artery systolic pressure was estimated to
30 mm Hg. A computed tomography (CT) scan revealed a thrombus in the lower branch of the
right pulmonary artery of tumoural appearance extending to the right lower lobe artery (Figure 2).
Bronchial fibroscopy was normal. No distant metastasis was revealed by the cerebral CT scan
or the abdominal CT scan. The lung function was within normal values. Surgical resection of the
arterial process and aortic replacement was decided.
Surgical resection was performed through a median vertical sternotomy. The procedure consisted
of a right intra pericardial pneumonectomy with aortic valve replacement by a mechanical
valve. A mediastinal lymph node dissection was also performed. Postoperative macroscopic
examination of the resected specimen showed a 2 cm tumour encompassing the pulmonary
artery and developing into the sub-intima without endoluminal component (Figure 3A). The
extemporaneous exam concluded to a sarcomatous tumour. Definitive microscopic findings
consisted in a malignant proliferation with wide necrosis composed of tumour cells of variable size
with abundant eosinophilic cytoplasm and atypical nuclei. Some tumour cells were multinucleated
(Figure 3B). Immunohistochemical study revealed the co-expression of cytokeratin and vimentin
antibodies by the tumour cells (Figure 3C and D). Other antibodies including anti-smooth muscle
actin and desmin weren’t expressed, ruling out the diagnosis of a muscle differentiated tumour.
The mediastinal lymph nodes dissected were benign.
These morphological and immunohistochemical features were consistent with a primary
sarcomatoid carcinoma of the lung invading the pulmonary artery classified as a pT1N0M0
tumour. Molecular studies highlighted no epidermal growth factor receptor (EGFR), Her mutations,
anaplastic lymphoma kinase (ALK) translocation or c-met amplification.
There were no postoperative serious complications except for an atelectasis with oxygen
dependency. This complication was managed by a non-invasive ventilation and chest physiotherapy
with a good outcome. The patient was discharged 18 days after the surgical resection. He is still
58 TOU C H ME D ICA L ME D IA