PMC6526578_01
Chest X-ray: RUL infiltration and enlarged intercostal space in level T6-T7 on the same side.
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C-reactive protein level (5.43 mg/dl (normal < 0.5)). Chest X-ray demonstrated a large infiltration in the right upper lobe (Figure 1). Moreover, due to the increased intercostal space between T6-T7 on the right (Figure 1), the possibility of slow growing extrapleural mass was suggested.
Contrast enhanced computed tomography (CT): a large multicystic lesion in the right hemithorax with mediastinal shifting. The bronchus and azygous are not affected.
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Computed tomography (CT) (Figure 2) and magnetic resonance imaging (MRI) studies (Figure 3) demonstrated a large multilocular cystic lesion (6.6 x 4.2 x 5.8 cm) occupying most of the right hemithorax, mainly its posterior aspect.
Magnetic resonance imaging (MRI): insinuating multiloculated cystic lesion. (a) Small extrapleural extensions of the cystic mass superiorly and laterally. (b) The mass bulges in the posterior intercostal spaces, without neuroforaminal involvement. (c) Posterior intercostal bulging, with no neuroforaminal involvement, and hilar structures are not compressed.
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Computed tomography (CT) (Figure 2) and magnetic resonance imaging (MRI) studies (Figure 3) demonstrated a large multilocular cystic lesion (6.6 x 4.2 x 5.8 cm) occupying most of the right hemithorax, mainly its posterior aspect.
Perioperative picture showing intrathoracic cystic lymphangioma.
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A right thoracotomy was performed revealing a few large cysts placed in the intrapleural space as well as a few small extrapleural cysts (Figure 4).
Microscopic features of the cyst (H&E staining). (a) Panoramic view of the multicystic tumor (original magnification x12.5). (b) Proteinatious fluid and small lymphocytes in the lumen (original magnification x40).
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Histopathological examination revealed a multicystic tumor lined by a single layer of flat endothelial cells (Figure 5(a)), filled with proteinaceous fluid containing lymphocytes (Figure 5(b)).
Immunohistochemical findings. (a) The cells lining the inner surface of the cystic lesion are positive for D2-40 staining, expressed in lymphatic endothelium (original magnification x12.5). (b) The cells lining the outer surface of the cystic lesion are positive for calretinin staining, expressed in mesothelial cells (original magnification x12.5).
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The endothelial lining cells were found diffusely positive for D2-40, lymphatic endothelial marker (Figure 6(a)). The outer surface of the cyst was partially covered by mesothelium, as highlighted by immunostaining with calretinin (mesothelial marker, Figure 6(b)).