PMC10131125_01
Chest Xray demonstrating right pleural effusion on presentation.
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Chest x-ray (CXR) performed in the emergency department demonstrated a right pleural effusion (Fig. 1).
Computed Tomography Angiogram of the chest revealing post right upper lobe wedge resection with increased soft tissue nodularity along the surgical sutures measuring up to 1.4 x 0.9 cm (A) and moderate right pleural effusion (B).
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A computed tomography (CT) angiogram of the chest confirmed moderately sized partially loculated right pleural effusion with associated right lower lobe compressive atelectasis as well as a new soft tissue nodularity noted along the right upper lobe wedge resection site (Fig. 2).
Chest Xray demonstrating interval decrease in right pleural effusion post thoracentesis.
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Post-thoracentesis chest x-ray demonstrated interval decrease of right sided effusion (Fig. 3).
Chest Xray revealing of stable right pleural effusion and Interval right indwelling pleural catheter placement.
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The patient subsequently underwent placement of a right indwelling pleural catheter (IPC) for management of recurrent and symptomatic pleural effusion (Fig. 4).
PET scan demonstrating pathologic FDG uptake suspicious for biologic tumor activity including diffuse heterogeneous uptake in thickened right pleura, right paratracheal and supra hilar, right hilar, and subcarinal adenopathy.
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Upon follow up in the pulmonary clinic, a positron emission tomography (PET) scan was performed which demonstrated new sites of pathologic fludeoxyglucose (FDG) uptake suspicious for biologic tumor activity including diffuse heterogeneous uptake in thickened right pleura with a standard uptake value (SUV) up to 4.4, right paratracheal and supra hilar (SUV 4.1), right hilar (SUV 4.2), and subcarinal adenopathy (SUV 4.1) (Fig. 5).
Cell block of pleural fluid demonstrate the large metastatic adenocarcinoma cells admixture with many lymphocytes, H&E (A). The carcinoma cells are positive for BerEP4(B) and TTF-1 (C). Calretinin stains some scattered mesothelial cells (D).
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Further immunohistochemical stains (Fig. 6) were performed and revealed the malignant cells to be positive for Ber-EP4 and thyroid transcription factor- 1 (TTF-1), negative for CK7, CK20, PAX-8, CDX-2, Gata3; calretinin stain highlights the mesothelial cells.
Cell block of pleural fluid demonstrates large metastatic adenocarcinoma cells admixture with many atypical lymphocytes, H&E (A). The atypical lymphocytes are monotypic B-cells, (12% of cells) detected by flow cytometry. CD20 highlights the B-cells (B).
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After further review of the cell block, it was noted that there were small to medium sized lymphocytes (Fig. 7).