S3141 A Case of Gastropleural Fistula from Spindle Cell Sarcoma

Introduction: Gastropleural fistulas are rare and often represent a challenging clinical case. They usually occur following trauma, iatrogenic interventions (esophageal, bariatric or thoracic surgery) or malignancy. We present a case of malignancy associated gastropleural fistula. Case Description/Methods: Our patient is an 82-year-old female who was transferred to our hospital for evaluation of suspected gastropleural fistula. The patient presented to her local hospital 3 weeks prior to transfer with shortness of breath and was found to have a complex empyema. Further work up with bronchoscopy was negative for malignancy. A surgical chest tube was placed, and fluid cultures grew serratia marcescens and candida albicans. A CT of the chest with contrast was performed with findings concerning for a gastropleural fistula secondary to a gastric perforation at the fundus. Imaging also revealed a lobulated soft tissue mass measuring 4.6 x 3.1 x 5.1 cm adjacent to the stomach along the greater curvature, left lobe of the liver and anterior hemidiaphragm. Upon transfer to our facility, EGD revealed a 3 cm ulceration in the gastric fundus with surrounding friable mucosa and suspected gastropleural fistula (Figure 1). Biopsies of the ulceration revealed numerous yeast, but no tumor cells were seen. The patient was taken to the operating room for repair of the fistula. Upon entry, there was diffuse peritoneal carcinomatosis at the site of the gastropleural fistula. Attempt at resection of the fistula was determined to be too high risk and unlikely to heal. There was also a large left upper quadrant mass with rock-hard adhesions to the stomach, spleen and omental tissue that limited access to repair the area of gastric perforation. A gastrostomy and jejunostomy tube were placed for palliation of symptoms. Pathology from the omental nodule and peritoneum revealed spindle cell sarcoma, consistent with dedifferentiated liposarcoma. Given patient’s significant co-morbidities and extensive spread of disease, patient decided to pursue hospice care and was discharged home. Discussion: Our case discusses a rare disease of spindle cell sarcoma presenting with a gastropleural fistula. Spindle cell sarcoma is one of the least reported primary tumors and usually involves the skin and soft tissue. Surgical resection is the mainstay of treatment. Early diagnosis and treatment is key to success in this patient population. Patients who present late with significant co-morbidities have a high mortality, as evidenced by our case.Figure 1.: 20X Magnification of Histopathology Slides A: Signet ring cell carcinoma in rectal mucosa H&E B: Signet ring cell carcinoma in gastric mucosa H&E C: Positive staining for CK7 in tumor cells D: Negative staining for CK20 in tumor. Overlying rectal mucosa is positive E: Immunostain for GATA3 positive in tumor cells F: Mucicarmine stain positive in tumor cells.