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Washington University Experience | NEOPLASMS (METASTASES) | Gross Pathology | 23A0 Case 23 History
Case 23 History ---- The decedent was a 36-year-old man with a left thigh soft tissue CIC-DUX4 Sarcoma diagnosed in April 2026, with known pulmonary metastases. He was transferred from an outside hospital to BJH on August 24th for intractable nausea and vomiting. Head CT performed at the OSH demonstrated bilateral rim-enhancing brain masses with surrounding edema. Brain MRI on August 25th demonstrated numerous large supratentorial intracranial metastases with intralesional hemorrhage, marked surrounding vasogenic edema, persistent 5 mm left-to-right midline shift, and possible papilledema. CT chest/abdomen/pelvis showed multiple pulmonary nodules without metastatic disease in the abdomen or pelvis. He was treated with dexamethasone and Keppra. Radiation oncology was consulted, with simulation planned for whole-brain radiation therapy. On August 26th, he developed a prolonged generalized tonic-clonic seizure, treated with Versed. Keppra was loaded and the maintenance dose increased. He subsequently became unresponsive with anisocoria and posturing and was transferred to the intensive care unit. Repeat CT imaging showed multiple bilateral hemorrhagic intracranial metastases without significant interval change. In the ICU, he received high-dose steroids and hypertonic saline for cerebral edema and hemorrhagic metastases. Following multidisciplinary discussions among medical oncology, radiation oncology, neurosurgery, neurology, and critical care teams, his neurologic injury was considered catastrophic, with no anticipated recovery to his previously expressed level of independence. The family elected comfort-focused care, and he was transitioned to inpatient hospice. He died on August 29th.
