Metastatic gastric adenocarcinoma first discovered through a malignant pleural effusion

What happened, in summary

A 73-year-old man came to the emergency department with worsening shortness of breath, cough, solid-food swallowing difficulty and a 10-pound weight loss. Imaging found a pulmonary embolism and bilateral pleural effusions. Fluid drained from the right chest contained metastatic adenocarcinoma, and immunostaining pointed to a gastrointestinal origin. Endoscopy during the admission showed abnormal stomach and duodenal tissue, and biopsies confirmed invasive diffuse gastric adenocarcinoma.

He was discharged on supplemental oxygen, but a PET/CT 2 weeks later showed disease involving both lungs, the diaphragmatic surfaces and bone. His breathing worsened and he returned to the hospital with recurrent malignant pleural effusion and acute hypoxic respiratory failure. Oncology considered chemotherapy inappropriate because of his rapidly declining condition, and palliative care became involved.

During the second hospitalization he required intensive care, mechanical ventilation and chest tubes. Renal failure, shock and worsening acute respiratory distress followed. Despite escalating supportive treatment, his condition continued to deteriorate. Life-support measures were withdrawn and he was terminally extubated soon after the diagnosis of metastatic gastric cancer.