So, I'm Kashka Goyle. I am a third-year fellow at Ohio State, and I have nothing to disclose. Briefly, the things that we'll review today are the etiologies of lung tumors in young patients, and what that differential looks like, and specifically considerations we should have in terms of resecting large masses that have potential impacts on the mediastinum. Our presentation starts with a 31-year-old female who has a history of hypertension. She presents with acute dyspnea, and notably in frank respiratory distress, and also hypoxic. She was intubated on arrival to outside hospital, and initial testing was notable for a positive PCR for influenza A. She was started on oseltamivir, and then a CT chest was obtained. Here is her CT imaging, and there's an obvious large right-sided mass. The mass measures 12 by 15 by 13 centimeters, and notably has extensive contact with the pleura, extending all the way to the lung apex. For the portion of the right lung that is visualized, there's atelectasis that is appreciated, total collapse of the right upper lobe, and here you can see severe narrowing at that distal trachea. Additionally, it's important to note that there's a leftward shift of those cardiomediastinal structures. And additionally, the left lung looked relatively clear. Notably, there's no mediastinal or hyaler adenopathy that were present. What's interesting is that this patient actually had a CT scan from the year prior that demonstrated this large mass, although there had been a few centimeters of growth in that interim. Unfortunately, she had previously been lost to follow-up. She was transferred to our institution for ongoing care and underwent bronchoscopy and biopsy, which we'll talk about. The bronchoscopy was completed on hospital day one, and notably she had erythematous airways and total collapse of the right upper lobe takeoff. There was also distal trachea narrowing from extrinsic compression that had complete dynamic collapse noted with respiration. She had a CT-guided biopsy of that large primary mass that was completed on hospital day three that was concerning for a spindle cell tumor. And given this large mass, thoracic surgery was consulted to think about a surgical excision. But ultimately, the decision in terms of how to move forward with excision most successfully was going to be guided by the underlying pathology. So here's her initial pathology slides, both at five times and 20 times magnification. This demonstrates that spindle cell neoplasm that I mentioned. And specifically, we see mostly antony type A areas. There is some focal hemorrhage that you can see in the five-time slide. But importantly, there's no necrosis and no mitosis that's appreciated. At this point, the differential remained pretty broad, including things like a solitary fibrous tumor or even an inflammatory fibroblastic tumor. So we'll pause briefly for our pathology. We're thinking about spindle cell neoplasms. And so that differential includes things like schwannoma, which would be notable if they had a SOX10 or S100 staining. Potentially a solitary fibrous tumor, given the radiographic appearance, but would be looking for CD34 positivity in STAT6. There was additionally a concern for a melanoma. Because in rare cases, there's been bland pathology reported. And it was really this potential differential that made our surgeons pause. And then less likely but still on the differential was the possibility of a malignant peripheral nerve sheath tumor. Although like I mentioned, there was no mitosis appreciated. So really highlighting that the immunohistochemistry was of utmost importance. While that was pending, the patient underwent a PET scan, which is shown here. You see the avidity of that large right-sided mass with areas of focal hemorrhage extending all the way to the mediastinum. Notably, there was two contralateral cervical lymph nodes with mild avidity that were unclear significance, as well as some tonsillar adenopathy. And on hospital day seven, her final pathology returned. And that's shown here. So notably here is the SOX10 staining. So the staining in conjunction with the initial pathology was confirmatory for a schwannoma at this point. With a diagnosis in mind, surgical planning moved forward. The patient notably remained intubated during this, both in the setting of her persistent hypoxemia, but the concern for hemodynamic and respiratory decompensation with possible extubation. Surgical planning also included IR evaluation. And she had two branches of the intercostal bronchial arteries that were embolized that were noted to be feeding the tumor. And there was an ongoing discussion about mitigation strategies for how we could best support this patient through the potential risk for significant hemodynamic and respiratory compromise due to the extent of her mass effect. So in order to do that, the patient was actually placed on VV ECMO intraoperatively in a joint surgery with our cardiac and thoracic surgeons. She underwent on hospital day 10 a hemichel thoracotomy, an extensive dissection and mobilization of this mass. It was densely adherent to surrounding structures, as well as dissection down to the neural stock. She underwent a right upper lobe resection. And here's actually the gross pathology of her schwannoma. So you can see this characteristic yellow material. It's a well-encapsulated tumor. And you can see the areas, cystic changes, and hemorrhage, which we saw both on imaging and pathology. Impressively, this patient had an uneventful postoperative course, and she was discharged on room air. We have one postoperative image. So this is on postoperative day one. And she was still intubated here. But you can see that there's re-expansion in that right lower lobe, although she still has dense consolidated findings in the right upper lobe. And the left side remains spared. This case importantly highlights a case of a giant intrathoracic schwannoma. And schwannomas are rare tumors. And they arise in the mediastinum. They can come from the vagal nerve or the, in rare cases, the pulmonary parenchyma. It's actually the most common peripheral nerve tumor that's found in the posterior mediastinum and should be on your differential for spindle cell malignancies and tumors. This case also highlights that the CT findings are not diagnostic. That symptoms are often associated with large tumors and when there is a mass effect. But what we really needed was immunohistochemical staining, that S100 and SOX10 to confirm the diagnosis. I think this case also highlights the importance of surgical considerations. Our patient's safer section was facilitated both with a vessel embolization. And I think also raises a concern or a question that should these patients be best served in institutions that can facilitate ECMO to mitigate some of those risks of both hemodynamic and respiratory compromise. Thank you. Any questions from the audience? All right. Thank you. All right. Next up is Dr. Chang, a case of mistaken identity, persistent PE symptoms, prompt, and secondary investigation. If you press escape, it will go and then try again. I'm not sure how to do this. Even now I keep breaking it. Yeah. It's not the second investigation. Thank you. All right. Thank you. All right. Well, thank you. My name is Lily Chen. I'm the director of the Center for Infectious Diseases at the University of Michigan. And I'm here to talk to you about a case of mistaken identity, persistent PE symptoms, prompt, and secondary investigation. If you press escape, it will go and then try again. I'm not sure how to do this. Even now I keep breaking it. Well, thank you. My name is Lily Cheng. I'm a second year pulmonary critical care fellow at Emory. And today I'm going to be discussing a case of mistaken identity. I have no financial disclosures. So this all started off with a 53-year-old female that presented to the emergency department for having some chest pain that had been going on for the last two weeks. She said it was a gradual onset, predominantly on the right side, had a sharp sensation. And sometimes when she would exert herself, she would get some shortness of breath. Her only past medical history was asthma and fibromyalgia. She had no surgical history, wasn't taking any significant medications, didn't have any significant allergies, and was a never smoker. So in the ER, they did a basic workup, including some basic labs that included a BNP intraponin that were normal. EKG was also normal. SC segments were normal without any evidence of right heart strain. And her physical exam was largely unremarkable. What you may see on the right side is that they did check a dimer for concerns for her having a PE. And what they found was having a large, right main PA clot. So this was her diagnosis. She was diagnosed with an acute, unprovoked PE, discharged on a DOAC, and sent home. So case is closed, and we are done with this lecture. Oh, well, we thought so. And then over the last few months, she still had the symptoms. So she actually presented to the pulmonary clinic and, again, to the emergency department. She was still having that right side of chest pain. And now she was having more worsening symptoms, including shortness of breath. She was having near-sinkable episodes and was really feeling pretty crummy. So at this point, when she came back to the emergency department, they repeated the CAT scan. And on this repeat CAT scan, they showed that she still had the filling defect in her right PA. And at this point, she had some ground glass opacities in her right middle lobe, right lower lobe. That was concerning for a long infarct. So at this point, this has been two months that she's been adherent to her DOAC, taking it every day. So the question came to palm as to why she's still having a persistent filling defect and, even with that, an evolving infarct. So this prompted a secondary investigation. At this point, over the next few months, she started undergoing a series of tests. So this included PFTs that had normal spirometry, normal lung volumes, but did show a mildly reduced diffusion capacity. Her VQ scan showed an age-indeterminate filling defect in her right lower lobe and right middle lobe. Her echo was normal, so normal biventricular function. She underwent a right heart cath with a pulmonary angiogram. With the right heart cath, her mean PA pressures were normal. Her wedge pressure was also normal. But the angiogram did show a complete cutoff of her right lower lobe with the angiogram. And they also completed a left heart cath for completeness, and she had normal coronaries. So with all this extensive workup, this became her new diagnosis, that she had CTED, so chronic thromboembolism disease. Now we've got a good diagnosis, so she gets referred to a new hospital, to the thoracic surgeons, for evaluation for a thromboendarterectomy. As part of their workup, they actually repeated the CAT scan as part of their pre-op evaluation, only this time, that previous filling defect now has extraluminal extension into a soft tissue mass. They obtained a PET scan that shows as highly PET avid and underwent a bronch, and the transbronchial biopsies actually showed a remnant sarcoma. So at this point, it's been two years since she first presented to the emergency department with her first symptoms, and she underwent a right pneumonectomy with pericardial resection and reconstruction. And so her final, ultimate diagnosis ended up being an intimal sarcoma of the right pulmonary artery. So I want to talk a little bit more about primary pulmonary artery sarcoma. It's a very rare malignancy that's only reported in medical literature as case reports. Oftentimes, it's misdiagnosed as a PE or some other pathophysiology, and it's often diagnosed in postmortem autopsies. The tumor origins are from stromal cells and the intimal and sometimes the medial layers of large vessels. It often includes the pulmonary arteries, pulmonary veins, and the right ventricular outflow tract. One thing that can distinguish it on a CT from CTED is that it often will have a lobulated heterogeneous component to it within the artery versus CTED, which has a more smooth contour to it. Because of its slow growing, patients often present with subacute symptoms. They'll just have maybe a little bit of shortness of breath, a little bit of chest pain, and some fever. However, pulmonary artery sarcoma has a high, a poor prognosis and a high mortality. The median survival is between two to three years after complete resection. Risk factors that drive mortality includes delays in diagnosis, local reoccurrence, and distant metastasis. Unfortunately, right now, the true management for now is for complete surgical resection. So that means either pulmonary endarterectomy, full thickness resection, or pneumonectomy. There's not enough clinical significance in regards to specific chemo or radiation options right now, but in some case reports, they are using pembrolizumab. So I'll go back to our case. So after she had her right pneumonectomy, she still had some residual disease afterwards. They started her on radiation therapy and she started getting pembrolizumab. And as of now, her recent scan shows complete resolution of PET-AVID disease. So in conclusion, I think it's always good to step away from anchoring bias to some extent. And if a patient is coming in with persistent symptoms, especially in a presumed PE, that's a good time to take a step back and have a secondary investigation if there's another pathophysiology that's occurring or if there's an underlying malignancy. So after this case, these are some of the questions I ask myself and maybe you may ask yourself and if that's going to change your clinical practice, is that is there any clinical features in some of these patients that have a PE that may prompt you to have a secondary thought if they have another malignancy or is there any role in repeating CAT scans in patients who have been diagnosed with a PE? All right, and these are some of my attendings that helped with her and her two-year progress. That's it. Any questions from the audience? Did you get any answers to your questions? I think it all comes down to anchoring bias. You can't scan everyone that has a PE and repeat a CT scan. That would be overuse of resources. But I think you have to listen to a lot of the patients and if they're still having similar symptoms or complaining of something, then you have to take a step back. All right. Yeah. Yeah, that's definitely good to consider. All right. Okay. Thank you. All right. Thank you. Yeah. Next up is Dr. Mustafa Al-Jaloudi, Primary Malignancy Melanoma of the Lung, a Case Series. Okay. Thank you guys for attending my session. I'm going to be talking about primary malignant lung melanoma. It's a case series of two. My name is Mustafa. I'm a third-year IM resident at Beaumont Royal Oak. I have nothing to disclose. So really the learning objectives of this case series is just to recognize that primary malignant lung melanoma, it can be a primary lung cancer, how to diagnose it, what's the prognosis, and what's the treatment. So case number one, we have a 65-year-old gentleman with really no significant past medical history. He had a routine chest X-ray in one of his annual physical that showed some right lower lobe parenchymal changes. He had a follow-up CT that showed this speculated nodule that was 1.8 times 1.7 centimeter in his right lower lobe. And this is the CT scan that showed the nodule speculated. He had subsequently a PET scan that showed that this lesion is FDG AVID. There was absolutely no other lesions that was FDG AVID. Bronchoscopy with biopsy revealed that there was a sparse cellular specimen containing discohesive large malignant cells in a background of small lymphocytes. He had a histochemistry evaluation that showed SOX10 and S100 positivity with negative staining for cytokeratin. There was way more stains, but I didn't want to list everything, but there was a lot of staining that was negative for anything that is suggest epithelial origin or mesenchymal origin, and all the markers were suggestive of melanoma. The patient had a full dermatologic and ophthalmologic evaluation. There was no cutaneous or mucosal lesion that was identified. They even went further and got a brain MRI that was also negative. He was treated surgically followed by postoperative immunotherapy. Case number two, we have a 79-year-old gentleman with a history of prostate cancer in remission, two-pack year smoking history. He had incidentally found tiny pulmonary nodule in his right middle lobe. I think the CT was ordered for a TAVR workup. He had a follow-up CT just to follow up on these two tiny pulmonary nodule, and they found a new 2-centimeter pulmonary nodule in his right lower lobe, and the tiny ones were still stable. He went a PET, and it showed that this new nodule, the two centimeter one, is FDG-AVID again. And it was in the right lower lobe. This is the nodule. It was about two by two centimeter in size. Subsequent CT guided biopsy revealed malignant melanoma. The immunohistochemical profile, again, was S100 positive, HMB45 positive, and negative for any epithelial or mesenchymal staining. He had the dermatologic and ophthalmologic evaluation with no suspicious lesion. He was treated surgically, and post-operative diagnosis confirmed that this is a malignant melanoma. Follow-up PET scan showed that there was no FDG-AVID activity in any of the remaining nodules. So discussion, malignant melanoma, as the name applies, it happens where you would expect to see melanocytes, like skin, eyes, meninges, oropharynx. Primary malignant melanoma of the lung is extremely rare, and it only accounts for 0.01% of all primary lung tumor. In 2019, they did a study about all the case reports of lung melanoma, and only 45 of primary malignant lung melanoma were reported. The pathogenesis is still controversial, but we have two hypotheses. Number one is during embryonic development, there might be some melanocytes that migrate not only into the dermis and the epidermis, but also into deeper organs, like esophagus, throat, brain, or even the lungs. And the second hypothesis is that we have some stem cells in the right part of the lower respiratory tract, and these can differentiate into melanocyte, and subsequently they can develop into malignant melanoma. Currently, we have guideline, a pathological criteria to how to diagnose a primary malignant melanoma of the lung, and it's issued by the Armed Forces Institute of Pathology. You need a solitary pulmonary nodule, you need a malignant melanoma confirmed by immunohistochemistry, no past history of excision or fulguration of a cutaneous mucosal or an ocular lesion, and at the time of diagnosis, no observable tumor elsewhere at the time of diagnosis. Unfortunately, the prognosis is poor, with a five-year survival being 10%. The prognosis does differ based on what's the treatment strategy. People who get surgical resection tend to have a more favorable prognosis compared to people who get treated in different ways. So the treatment approach, really generally speaking, you need aggressive surgical approach combined with radiation therapy, chemo, and immunotherapy. The incision should be at least five centimeter from the margin to avoid recurrence. Post-operative adjuvant chemotherapy proposed agents are either IL-2, interferon, and dacarbazine. Radiation is usually only for locally advanced melanoma or as part of palliation treatment. Immunotherapy with checkpoint inhibitor like pimbrolizumab is only for advanced melanoma cases with distant metastases. Primary, in conclusion, a primary melanoma of the lung is extremely rare, highly malignant neoplasm with unfavorable prognosis. The gold standard is histopathologic examination being the gold standard. Prognosis is poor, and it's really based on what's the treatment strategy. Treatment is aggressive surgical approach combined with radiation therapy, chemotherapy, and immunotherapy. Those are my resources, and thank you. Thank you. Any questions? Okay. Thank you. Our next speaker is Dr. Raina Patel, a rare case of post-radiation angiosarcoma with pluromeths. Good afternoon. So today I'll be talking about a rare case of post-radiation angiosarcoma complicated by pleural metastasis. My name is Raina Patel. I'm from the University of Toledo. I'm a second-year internal medicine resident, and I have nothing to disclose. These are the other authors that also helped participate in this case as well. So here are some of the objectives of and the goals of this oral presentation. So let's just get right into the case. So we have a 77-year-old female. She presents with dyspnea ongoing for the last two days. At home, or she came from a nursing home. So at the nursing home, for the last two days, she was actually saturating in the mid to low 80s, even while on four liters of nasal cannula. So she came to the ED and was immediately placed on BiPAP and then admitted to the team. She does have a pretty extensive past medical history, but her past medical history is significant for heart failure with preserved ejection fraction and then end-stage renal disease. And she had recently been placed on hemodialysis. And then of note, in 2014, she was diagnosed with breast cancer, the left breast. And at that time, she was treated with radiation and a lumpectomy. And then for five years after that, she continued with chemotherapy with anastrozole. In 2021, she actually, on surveillance imaging, had another mass, again, in the left side of her breast. And that was significant for radiation-induced angiosarcoma. At that time, it was treated with chemotherapy. She did have two prior recent hospital admissions before this third hospital admission within the last few months. Usually at baseline, she's able to saturate on room air well, and she's able to ambulate without any assistance. On those previous admissions, she did have bilateral pleural effusions, and she was requiring increased oxygen, up to two liters during those admissions. And at that time, she did have thoracentesis performed, and she was discharged with the diagnosis, or the presumed diagnosis, of acute hypoxic hypercapnic respiratory failure, secondary to heart failure exacerbation. So this is her chest x-ray that she presented to the ED with, clearly, like a bilateral pleural effusions, and then right-sided, just white out of the lung. Additionally, they did do a CT as well, and that did show on the right side of her chest wall a small subcutaneous nodule. And that was actually consistent with a PET scan that was done about two months prior, showing a right subcutaneous nodule on her chest wall. So during the hospital course, we had the pulmonology team consulted. They did a thoracentesis, both diagnostic and therapeutic, and cytology was sent. Even though, originally, she started to feel better, she did have recurrent pleural effusions and dyspnea, and so she had multiple thoracentesis. At the time of discharge, it was collectively decided that she would benefit from having a catheter placed, so she was discharged with a right-sided pleurex catheter. So in terms of the diagnosis, eventually, the cytology did come back, and the pH was 7.35. LDH was elevated, and the protein was elevated. And then she had increased lymphocytes in the fluid cell count, very consistent with malignant pleural effusions. And then the cytopathology confirmed that it was abnormal cells with enlarged nuclei and this irregular chromatin and nucleoli in clusters. So eventually, she was diagnosed with this metastatic angiocarcinoma with pleural involvements and malignant pleural effusions. So let's talk a little bit more about angiosarcoma. So a brief overview, soft-tissue sarcomas make up about 1% of all malignancies. Angiosarcoma is a subtype of the soft-tissue sarcomas, and they compromise about 2% of that. Usually, angiosarcomas are vascular or lymphatic in origin, and they commonly affect the head, the neck, and the breast. Post-radiation angiosarcoma with pleural involvement, like this case, is very rare, and it's estimated that even less than 1% of all angiosarcomas are post-radiation with pleural involvement. So some of the risk factors to develop angiosarcoma are prior radiation therapy, like as in our patient here, and exposure to vinyl chloride and arsenic. Generally, if they are treated with radiation, the average latency of angiosarcoma is about five to seven years, and it's most strongly associated with previous breast cancer. In one of the data studies that was performed, it showed that women who were treated for breast cancer ended up developing angiosarcoma and had a 16-fold increase of risk for angiosarcoma. And in that population, they had a two-fold increase in risk for other sarcomas. Now, although there is an increased risk for developing angiosarcoma or other sarcomas, it is important to note that the overall magnitude of that risk is still very small. It's still less than 1%. So in terms of clinical presentation, it varies greatly based off of location and the size of the tumor. Oftentimes, they can be asymptomatic, but they could present with the common B symptoms of the night sweats, the chills, the weight loss. Or they could have more of the physical exam changes involving changes over the breast or purple or red skin lesions. In this case, this lady in 2021, when she was originally diagnosed with that post-radiation angiosarcoma, she did have that painless mass that was found on imaging at that time as well. In terms of diagnosis and treatment, the diagnosis primarily can be first from clinical findings and then imaging and biopsy to confirm the diagnosis. In our case, she originally had that angiosarcoma that was diagnosed with biopsy. But then for the metastasis, that was diagnosed via the cytology and the cytopathology of the thoracentesis. Treatment generally would involve surgery and then chemotherapy. In terms of the prognosis, unfortunately, the prognosis for angiosarcoma is very poor. The five-year survival rate is up to 60%, but generally it's not 60%. And then with metastatic disease, the median survival is about three to 10 months. As I said before, this case of post-radiation angiosarcoma with the plural involvement compromises less than 1% of all cases. So there are very few data points. But in general, for that with the plural involvement, the median survival time is less than one year. So in conclusion, angiosarcoma of the breast is one of the rarest forms of soft tissue neuroplasms, and the prognosis is unfortunately generally very poor. In this case today, I've presented a very unique patient who presented with the plural metastasis two years after the initial diagnosis of post-radiation angiosarcoma. Thank you. Any questions? Thank you. All right, excellent. Thank you. All right. Next up is Dr. Labib Debian. A long, long title. I'll let you say it. Hi, everyone. My name is Labib Debian. I'm presenting this case of post-radiation angiosarcoma of the breast. This is a very rare case of post-radiation angiosarcoma of the breast. today. I have no disclosures. So the objective of today's presentation will be to outline a very rare case of uracle carcinoma that metastasized to the airway and maybe highlight some key features to metastatic uracle carcinoma, adenocarcinoma, and discuss a little bit palliative treatment for this rare condition. So uracle carcinoma in about 80% of the time is actually in the form of an adenocarcinoma. It's obviously a very rare malignancy of the bladder. The incidence is probably less than 1% of all bladder tumors. And it constitutes in total like 0.01% of all adult malignancies. So quite rare to see it in your lifetime of practice. Usually associated with a poor prognosis. So our patient is 68-year-old. And he actually has no past medical history with the exception of stage 3 uracle adenocarcinoma that was diagnosed actually in 2017. And he underwent a few months later a partial cystectomy and was told to be with no evidence of disease at that point in time. And then a few years later started developing a nonspecific, nonproductive cough that his primary care physician thought would be just a chronic cough. And the most common etiologies for chronic cough would be acid reflux disease and upper airway cough syndrome. Both of which he got treated for with obviously no resolution of this nagging cough. It was only until later, probably a year later, that he started developing additional symptoms. Shortness of breath, wheezing that did not add up with his absence of any history of lung disease in the past. So he underwent an x-ray followed by a CAT scan that demonstrated complete atelectasis or collapse of the right upper lobe with a filling defect noted in the proximal and mid right main stem bronchus. Raising the concern of a malignant appearing lesion that required bronchoscopy and biopsy. The biopsy revealed urethral carcinoma consistent with his original diagnosis years before. We're talking about five years before his presentation. So he was taken to the operating room and underwent a rigid bronchoscopy. The indication of that is that those tumors tend to bleed and they're vascular. And so this is the best approach for that kind of tumor. Not to mention that the intervention required to recanalize the area would require that kind of procedure or that kind of bronchoscopy. And what was visible is this necrotic appearing mass on the surface but honestly quite fleshy and vascular further deep inside and with near complete obstruction of that right main stem bronchus. And there was also evidence of retention of secretion distally. So he underwent extensive mechanical tumor debulking of the airway and that involved electrocautery snare as well as debulking with rigid forceps. Eventually to be able to control the bleeding and also further ablate the tumor he underwent ablation with argon plasma coagulation and the objective was to try to move that tumor as far away from the right main stem knowing that potentially it will grow back since it's a metastatic cancer with not much treatment available. So basically quote unquote buying time. And due to the high suspicion of recurrence of this illness we decided to proceed with placement of a fully covered endobronchial metal stent so that we can protect the airway from this reobstruction. So what happened, patient was sent for a treatment with chemotherapy which would have been his second line at that time. Unfortunately the stent has migrated and he coughed it out which didn't come to a surprise to us because the airway was quite re-canalized I should say. Migration in this situation is actually expected. This being said he had required multiple procedures thereafter and this is one of the learning point I guess from that case is that with an incurable disease that puts high threat on patient's pulmonary status those patients tend to come back a lot requiring the same procedure. Unfortunately the disease has progressed and he was no longer responding to treatment and during his last procedure we attempted a second stent placement which so far has been in proper position with no known complications thus far. And finally he's been enrolled currently in a clinical trial with the hope that we can at least halt the progression of that disease. So uricle adenocarcinoma tends to recur locally and metastasize late during actually the clinical course. Although it's rare when it happens lung is actually the most common location for that metastatic disease 40 to 50%. And so it's very important that a patient with that kind of cancer gets initial imaging sooner than later and then especially if respiratory symptoms are present in this situation it would have been cough. So to our knowledge it's really the first case of late metastatic uricle adenocarcinoma causing malignant central airway obstruction. We were not able to find any other cases in the literature so we're going to assume I guess it would be like a first case. There has been case reports of metastatic disease in the form of lung nodules but not in the form of endobronchial disease. Obviously quite rare and we don't really have any standard treatment or protocols that we can follow so we have to use our personal judgment which consists basically of continuous palliative involvement in recanalization of the airway and allowing the patient as much as possible to be symptom free and able to engage in therapy if there are any. And palliative airway recanalization allows the patient to improve quality of life or performance status and the patient himself has voiced this numerously. He's able after every procedure to do the activities of daily living that he enjoys. So take home points from today's presentation. Although uricle adenocarcinoma is rare when it's metastasized lung is one of the most common sites. Usually if it metastasizes it's in the form of a lung nodule. In our case it was an endobronchial lesion. And there should be a low degree of suspicion with early imaging in any patient with this cancer. Easier said than done in retrospect but moving forward something to think about. And symptom palliation is really the most important goal and it provides a bridge for the patient to be able to undergo any experimental therapy that could be available or that could come up in the future. Thank you. Excellent. Thank you. Thank you for all our presenters.

rare lung tumors

spindle cell tumor

melanoma

pneumonectomy

post-radiation angiosarcoma

thoracentesis

urethral adenocarcinoma

bronchoscopy