CHEST Guidelines-A-73-Year-Old-Man-With-Right-Sided-Chest-Pain-and-

A-73-Year-Old-Man-With-Right-Sided-Chest-Pain-and-

Pdf Summary

A 73-year-old man with a history of hypertension and diabetes presented with a two-week history of right-sided chest pain, cough, and worsening dyspnea. He also experienced weight loss and appetite changes. A construction worker for 50 years, he does not smoke. His daughter died of lung cancer. Physical examination showed he was afebrile and stable, but had reduced breath sounds and dullness on his right hemithorax, as well as hepatomegaly. Blood tests revealed anemia, and imaging showed large right pleural effusion and a diaphragm mass. A thoracocentesis yielded serosanguinous fluid with 500 mL removed, partially alleviating his symptoms.<br /><br />A CT scan confirmed a massive pleural effusion with a diaphragm mass invading the liver. Histological examination from a thoracoscopy biopsy identified a malignant spindle cell tumor with rhabdomyosarcoma features. This type of soft tissue sarcoma, arising from mesenchymal cells, is rare, particularly in adults where the prognosis is generally worse compared to children. The tumor demonstrated skeletal muscle differentiation with myogenic markers on immunohistochemistry.<br /><br />Rhabdomyosarcomas have four recognized subtypes; spindle cell variants are particularly rare in adults but have a more aggressive course compared to the pediatric cases. Treatment typically involves a combination of surgery, chemotherapy, and possibly radiotherapy. In this case, the patient was started on chemotherapy using vincristine, doxorubicin, and cyclophosphamide.<br /><br />The condition presents challenges due to its rarity and lack of specific treatment protocols. Diaphragmatic rhabdomyosarcomas often present asymptomatically or through mass effect, but in this patient, the symptoms reflected tumor invasion affecting surrounding structures. The patient remains alive three months after initial presentation, reflecting a particularly aggressive management approach given the severity of metastasis at diagnosis.

Keywords

rhabdomyosarcoma

spindle cell tumor

pleural effusion

diaphragm mass

chemotherapy

soft tissue sarcoma

immunohistochemistry

mesenchymal cells

vincristine

doxorubicin