A 71 year old man experienced a 40 lb weight loss and was fo | Figure 1

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A 71 year old man experienced a 40 lb weight loss and was found to be anemic with a hemoglobin of 10.6. PSA was normal. EGD showed gastritis, colonoscopy was normal. He developed back pain and a CT showed a T3 vertebral lesion with extraosseous extension. A corpectomy was performed and a post op PET CT showed hypermetabolic adrenal masses, right acetabular and pubic symphasis lesions.

Initial pathology from the corpectomy showed sarcomatoid carcinoma. Radiation was administered to the bone lesions. He was given gemcitabine and paclitaxel by an outside oncologist and tolerated it poorly. He was monitored for over a year and had enlargement of his adrenal masses.

A biopsy was performed and the pathology is attached, demonstrating a sarcomatoid carcinoma. Genomic studies showed a FLT1, DNMT3A, SETD2 mutations and was microsatellite stable. Radiation was given to the adrenal lesion and he now presents with progression in those lesions and enlarging intraabdominal lymphadenopathy.

Where is his primary cancer? What would you do for diagnostics, treatments next?

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