PMC8415542_01
(A) The patient's chest CT examination conducted in 2009 showed multiple nodular shadows in the right lung. (B) The 2013 chest CT examination showed larger, multiple shadows in the right lung. (C) In 2019, the patient had worse chest tightness and his chest CT scan showed a large irregular mass in the right lung, multiple nodules of varying sizes in the surrounding lung and invasion of the superior vena cava, right pulmonary artery and vein.
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F1
In July 2009, the patient presented in a local hospital due to "fatigue" and chest Computed Tomography (CT) showed a shadow of multiple masses in the right lung, as shown in Figure 1A, but he was never treated. In March 2013, due to physical examination, the patient underwent a second chest CT (Figure 1B) which revealed a larger shadow of masses in the right lung, compared to the one seen 4 years before. Re-examination through chest CT (Figures 1C, 2) revealed a large irregular mass in the right lung, with calcification and some low-density areas.
The 2019 chest CT examination showed an irregular large mass in the right lung, about 226 x 145 x 143 mm in size, with calcification and some low-density areas. The scan showed uneven enhancement, after injection of the contrast medium. Multiple nodules of varying sizes were also seen in the lungs surrounding the mass (A). The superior vena cava, some branches of the right pulmonary artery and the right pulmonary vein were also all invaded (B). In addition, bronchial stenosis in the upper, middle, and lower lobes of the right lung was observed (C). The mediastinum was shifted to the left due to compression and multiple enlarged lymph nodes were seen in the mediastinum (D).
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Re-examination through chest CT (Figures 1C, 2) revealed a large irregular mass in the right lung, with calcification and some low-density areas.
HE staining (x400) showing that the papillary area was composed of many cuboidal surface cells and rounded cells (A), the solid area was mainly composed of rounded cells of similar size (B), focal hyperplasia could be found around the vascular wall in the sclerosing area (C), and a large number of red blood cells could be observed filling the lung interstitium and alveolar cavity in the hemorrhagic area (shown by the arrow in D); Histochemistry (x400) shows that the cuboidal surface cells of the tissue are positive for Pan-cytokeratin (Pan-CK) (shown by the arrow in E), while the rounded cells are negative for Pan-CK (F), positive for Epithelial Membrane Antigen (EMA) (G) and Thyroid Transcription Factor-1 (TTF-1) (H). The pathological manifestations are consistent with the diagnosis of PSP.
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F3
Subsequently, a CT-guided lung biopsy was performed, where the tumor tissue was punctured multiple times at different tumor sites and the pathological diagnosis was confirmed to be PSP (Figure 3).
(A) The 18F-FDG PET/CT examination showed a huge irregular mass in the right lung with uneven density and increased FDG uptake. The SUVmax was 8.21. (B) Multiple enlarged lymph nodes were seen in the 2R, 2L, 4R, 4L, 5, 7, 8, and 10R areas of the mediastinum, their FDG intake had unevenly increased and the SUVmax was 10.39. (C) Round low-density nodules were present in the lateral segment of the left lobe of the liver and the posterior lower segment of the right lobe of the liver, respectively. Round low-density nodules were also present in the left and right lobes of the liver, respectively, with unclear borders and increased FDG uptake. The SUVmax was 4.48. (D) Multiple enlarged lymph nodes were present in the abdominal cavity, there was an increase in FDG uptake and the SUVmax was 6.79. (E,F) Low-density lesions were seen in the lumbar 1 and sacral 1 vertebral bodies, FDG uptake had increased and the SUVmax was 4.58. Examination through 18F-FDG PET/CT showed a malignant tumor in the right lung with multiple metastases in the hilar and mediastinal lymph nodes, several bones, liver, and intra-abdominal lymph nodes.
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