ABSTRACT
TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: The Fontan procedure is a palliative surgical procedure performed in children ages 2-4 years old with hypoplastic right heart syndrome by relocating the inferior vena cava from the right atrium to the right pulmonary artery to complete the Fontan circuit[1][2]. This circuit allows for normalization of arterial saturation and abolishment of chronic volume overload at the cost of decreased cardiac output.[1] This adjustment allows for almost all venous blood to return to heart through the right pulmonary artery[3]. We present a case below in a patient with hypoplastic right heart treated with the Fontan procedure who was later diagnosed with testicular choriocarcinoma with hematogenous metastasis through the right pulmonary artery. CASE PRESENTATION: An 18-year-old male with a past medical history of heterotaxia, hypoplastic right heart treated with Fontan palliation and Kawashima surgery initially presented for persistent, worsening dyspnea. On further questioning the patient reported an active lifestyle but over the past several weeks had begun to develop dyspnea with limited ambulation and persistent cough. On presentation, the patient was found to be in acute hypoxic respiratory failure. Computed tomography (CT) imaging of the chest, abdomen and pelvis showed a new large right retroperitoneal mass causing hydronephrosis as well as innumerable right sided pulmonary nodules concerning for metastatic disease. Biopsy of the retroperitoneal mass revealed germ cell tumor, with choriocarcinoma heavily present in the tissue. The patient underwent MRI of the brain for staging, which subsequently revealed numerous embolic strokes. He was started on a chemotherapy regimen of etoposide, ifosfamide, and cisplatin;however, his course was complicated by COVID-19 infection which caused further deterioration in his respiratory status. He unfortunately passed away from respiratory failure. DISCUSSION: In this case, the Fontan procedure provided the patient with excellent oxygenation as the patient was able to exercise and live relatively unbound by his complex cardiovascular history. However, this procedure served as the conduit that allowed his testicular choriocarcinoma to hematogenously spread and predominately seed his right lung. Hospitalization was further complicated by active COVID-19 infection and in concert with his poor lung status, the patient passed. CONCLUSIONS: This case highlights the unique anatomy and physiology of patients treated with the Fontan circulation. This life saving surgery performed in early childhood unfortunately served as the conduit for hematogenously spread of choriocarcinoma. As a consequence of the surgery, the right pulmonary artery receives all the venous return which then allowed the malignancy to spread predominately to the right lung. REFERENCE #1: Gewillig M. The Fontan Circulation. Heart. 2005;91:839-846 REFERENCE #2: Kutty S, Jacobs M, Thompson R, Danford D. Fontan Circulation of Next Generation: Why It's Necessary, What It May Look Like. JAHA. 2020;9:e01 3691 REFERENCE #3: Cowgill LD. The Fontan Procedure: A Historical Review. Ann Thoracic Surgery. 1991;51:1026-30 DISCLOSURES: No relevant relationships by Arjan Ahluwalia, source=Web Response No relevant relationships by Martin Delatorre, source=Web Response No relevant relationships by Kaitlyn Musco, source=Web Response No relevant relationships by Alina Zhu, source=Web Response
ABSTRACT
Introduction: Early diagnosis of prostate cancer is challenging, especially in the homeless population, as many patients are asymptomatic. Prostate cancer is known to metastasize to the lungs in terminal patients. However, isolated lung metastasis without bone or lymph node involvement is quite rare, with minimal reports noted in the literature. Biopsy must be obtained to rule-out other etiologies. Case Report: A 57-year-old African American male with a history of homelessness, extensive substance abuse, and schizophrenia presented to the hospital with worsening auditory hallucinations. Plain films of the chest were obtained due to prior COVID-19 infection in April and the presence of a slight dry cough. Multiple new bilateral pulmonary nodules were noted. Computed tomography (CT) of the chest showed bilateral, spiculated, peripheral and centrally located masses, the largest measuring >1 cm. Upon admission, further work-up resulted in negative HIV, Hepatitis C and B, and tuberculosis testing, but UDS demonstrated cocaine and methadone. Testicular ultrasound and echocardiogram were unremarkable. CT of the abdomen and pelvis revealed a mildly enlarged prostate with a nodule projecting towards the bladder. There was no obvious lymphadenopathy or spinal lesions. A CT-guided biopsy of the largest nodule was performed after consultation with pulmonology. He was then discharged to inpatient psychiatry for treatment of his schizophrenia. Biopsy results demonstrated adenocarcinoma consistent with metastatic prostate disease (PSA+, PASP+, GATA3+). No serum PSA was able to obtained for baseline as the patient had left the psychiatric treatment facility prior to biopsy results returning. Discussion: Amongst malignant tumors in men, prostate cancer has the highest incidence and the second highest mortality. Incidence is largest amongst black men. Screening is often based on patient preference and family history of the cancer. The screening test of choice involves prostate-specific antigen (PSA), but this has a relatively low sensitivity and specificity. Symptomatology is not reliable, but in metastatic disease back pain is often the most common initial symptom. Rarely, metastatic prostate cancer manifests with isolated pulmonary involvement with either solitary or multiple pulmonary nodules. Upon discovery of bilateral nodules, biopsy should be performed promptly to rule out malignancy. In prostate cancer, biopsies will be PSA+ and often PSAP+. ' This case highlights the unfortunate reality of the social barriers of healthcare. Furthermore, this case highlights the importance of adhering to a specific and standardized approach when bilateral pulmonary nodules are present. Early biopsy is crucial in ruling out metastatic disease.