An unusual, poorly differentiated, neoplasm in a patient with an ASD closure device and bilateral adrenal involvement

We report a case of a 68-year old female patient, who initially presented with dyspnoea and bilateral lung nodules. While the symptoms were initially mild, the disease was clearly aggressive, and the patient passed away during workup. At autopsy, the disease was notable for involvement of multiple organs, with heavy intravascular tumour load. The patient's clinical history was notable for previous closure of an atrial septal defect (ASD), and, at autopsy, tumour thrombus was observed on the surface of the ASD closure device. The systemic tumour dissemination was attributed at least in part to the tumour laden thrombus in the atrium on the ASD closure device. Involvement of bilateral adrenal glands was noted at autopsy. The peri-mortem clinical history was notable for rapid deterioration, along with biochemical results consistent with an adrenal crisis. Histologically, the tumour was a high-grade, poorly differentiated neoplasm, and the exact origin of the neoplasm could not established, despite multiple rounds of immunohistochemistry workup. Thus, while the case remains a case of cancer of unknown primary (CUP), the autopsy highlighted a mechanism for wide tumour dissemination, as well as a mechanism that contributed to the peri-mortem clinical course