Introduction: Mediastinal tumors are however a very uncommon cause of syncope. Mediastinal sarcoma is a very rare pathology which is more common in people younger than 40 years old. In case of complete surgical resection the rate of recurrence is high, over 60%, with a low 3-year survival rate (30%). We presents a complex case of a female with chronic atrial fibrillation on oral anticoagulation admitted to emergency depart-ment for syncope, dyspnea and upper gastrointestinal hemorrhage(UGH), which in the end proved to be an extensive mediastinal sarcoma, with an important extrinsic compression of the heart and esophageal inva-sion, inferior vena cava and bushing of thoracic aorta.

Case presentation: A 69-year old patient, known with high blood pressure, renal tumor with radical nephrectomy 7 years ago, permanent atrial fibrillation with ineffectiveness of oral anticoagulation treatment admitted for frequent episodes of lipothymia, a sin-gle episode of syncope, progressively aggravated effort dyspnea and fatigue, associated with hematemesis and melena. At the admittance, the patient with altered general condition, sclero-tegumentar pallor, profuse sweating, afebrile, conscious, SO2= 92%, RR= 28/min, basal dullness and abolished vesicular murmur in the right hemithorax, right posterior latero-thoracic firm formation fixed to the costal arch, BP= 100/60 mmHg, HR= 98 b.p.m, ECG: atrial fibrillation with an average HR, without ischemic changes. Biological: microcytic hypochromic anemia, iron deficiency, moderate infla-mmatory syndrome, intermediate growth of D-dimer. Chest X-ray shows a stretched latero-thoracic opacity on the right lung, medium right pleurisy. Acid-base balance: hypoxemia, hypocapnia, respiratory alkalosis (SaO2= 92%, PaO2= 60mmHg, pCO2= 29mmHg, Ph= 7.5). The clinical appearance required the elimination of the diagnosis of pulmonary embolism (PE) in a patient with evidence suggestive of upper gastrointestinal ble-eding. Transthoracic echocardiography (TTE) revealed a left atrium (LA) with significant extrinsic compres-sion (> 60%), determined by the presence of a tumor mass in the mediastinum, preserved LVEF, moderate to severe tricuspid regurgitation, probable PHTN, TAP-SE= 21mm, no intracardiac mass. Thoracoabdominal CT scan contrast-enhanced showed a bulky, extensive, intensely vascularized tissue formation with central areas of necrosis in the posterior mediastinum, no intracardiac invasion, but no demarcation of the LA to the right, right pulmonary veins, IVC, descending aor-ta on a length of 10 cm. The esophagus shows left lateral deviation and tumor infiltration. Multiple secondary determinations of large costal, cost-vertebral, peritone-al dimensions. The EGD performed in the emergency room revealed the source of bleeding: esophageal varices grade II-III, 1/3 upper and middle, with adherent clot, requiring their band ligation with 3 rubber bands. Histopathological examination performed on one of the latero-thoracic formations establishes the diagnosis of sarcoma.

Conclusions: The multidisciplinary team, thoracic surgeon, cardiologist, oncologist decided on radiotherapy, anti-inflammatory treatment, chemotherapy, tem-porary discontinuation of anticoagulation. Although surgical resection is the gold standard in mediastinal sarcoma, the tumor’s extension required conservati-ve approach. We considered major hemorrhagic risk (UGH, tumor with significant vascularization in contact with major vascular structures), also with a high thrombotic risk (malignancy, contact with IVC). We presented the case of a patient with extensive mediastinal sarcoma with multiple metastases, diagnosed after syncope and UGH. The etiology of syncope can be: LA compression and UGH, with exclusion of PE. The peculiarity of the case derives from the late diagnosis of this extensive rare tumor.