PMC10199323_01
Imaging findings of the patient. (a-d) PET/CT showed a mass in the mediastinal portion. (e and f) PET/CT showed nodules (red arrow) in lung. (g and h) MRI examination showed a 4.5 cm x 3.0 cm x 3.8 cm mass (red arrow) in the mediastinal portion. (i) MRI examination showed multiple nodules in the lung. The red arrow indicated a 1.9 cm x 1.8 cm nodule in the left lower lobe of the lung.
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Positron emission tomography (PET) and computed tomography (CT) indicated that the patient had soft-tissue density lesions with calcification in the left lower lobes of the thymus (Figure 1a-d) and multiple nodules of different sizes in bilateral lungs (Figure 1e and f). T1 and long T2 mixed signals with obvious heterogeneous enhancement (Figure 1g and h); (2) Multiple nodules with smooth margin were found in bilateral lungs. The largest one (19 mm x 18 mm) was located in the left lower lobe of lung, and displayed marked enhancement (Figure 1i).
(a) Histopathological result showed a type A thymoma pattern (hematoxylin and eosin staining; magnification: x100). (b) Microscopic view of thymoma type A in the anterior mediastinum. (c) Microscopic view of ectopic pulmonary thymomas type A in the left lower lung. Magnification: x40. (d) Serum CA724 and NSE expression levels in patients (normal level of CA724 is less than 6.9 U/mL and the normal value of NSE is less than 16.3 mug/L).
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T1 and long T2 mixed signals with obvious heterogeneous enhancement (Figure 1g and h); (2) Multiple nodules with smooth margin were found in bilateral lungs. The largest one (19 mm x 18 mm) was located in the left lower lobe of lung, and displayed marked enhancement (Figure 1i). A thymoma (Figure 2a), considering thymoma involving lung or ectopic pulmonary in the lung. At the end of December 2018, the patient underwent "thoracotomy exploration plus mediastinal lesion resection plus thoracoscopic wedge pneumonectomy" under general anesthesia. Postoperative pathology indicated type A anterior mediastinal thymoma (Figure 2b). Multiple type A thymoma presented in the lower left lung with ectopic thymoma in the lung (Figure 2c). The CA724 and NSE of the patients were high before operation, but the NSE decreased to normal after operation, and the CA724 maintained a slightly higher level until now (Figure 2d).
Imaging findings of the patient. CT examination showed masses (red arrows) in the multiple nodules in the lung.
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The pulmonary lesions of the patients have been stable (Figure 3).
Clone phylogenies and sample clone mixtures. A clone phylogeny is shown for the patient, with distinct clonal genotypes color-coded. The clonal composition of each sample was depicted as a schematic tumor, with the coloring of "cells" proportional to the prevalence of each clone. Samples were arrayed in a circle, with constituent clones from the overall clone phylogeny represented in an outer circle.
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To gain further insight into the accumulation of genetic alterations, we constructed phylogenetic trees of disease evolution taking all mutations in mediastinal thymoma and ectopic pulmonary thymoma (Figure 4).