PMC10265368_01
Chest x-ray showing right-sided pleural effusion.
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CXR showed a large right-sided pleural effusion (Figure 1). Computed tomography (CT) angiogram of the chest showed multiple right-sided extra-pleural versus pleural-based masses with an associated large right pleural effusion, with masses eroding adjacent ribs, lateral margin of the T6 vertebral body, possibly involving the adjacent neural foramen, and partially extending through intercostal spaces.
(A) CT angiogram of the chest showing multiple right-sided extra-pleural versus pleural-based masses eroding adjacent ribs (red arrow), with an associated large right pleural effusion (green arrow), a large part of the mass-like process indenting the heart and displacing it to the left (blue arrow). (B) CT angiogram of the chest showing mass eroding lateral margin of the T6 vertebral body.. Abbreviation: CT, computed tomography.
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A large part of the mass-like process was indenting the heart and displacing it to the left; some elements of cardiac invasion could not be excluded (Figure 2A and B).
Magnetic resonance imaging of the thoracic spine showing right paraspinal soft tissue mass with direct invasion of the right side of the T6 vertebral body (red and white arrows).
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The MRI of the thoracic spine showed a right paraspinal soft tissue mass with direct invasion of the right side of the T6 vertebral body (Figure 3).
Computed tomography and pelvis with intravenous and oral contrast with liver protocol showing porta hepatis lymphadenopathy, measuring 31 x 19 mm.
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Computed tomography and pelvis with intravenous and oral contrast with liver protocol showed porta hepatis lymphadenopathy, measuring 3.1 cm (Figure 4).
Histopathology shows the carcinoma as poorly differentiated with a partially discohesive growth pattern. The neoplastic cells are polymorphisms with a prominent nucleolus. Some of the neoplastic cells demonstrate the rhabdoid and plasmacytoid features. The neoplastic cells are immunoreactive to carcinoma marker AE1/AE3 (hematoxylin-eosin, original magnifications x40).
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The pathology (Figure 5) showed invasive poorly differentiated carcinoma and a high grade of uncertain histogenesis.
(A) Immunohistochemical (IHC) stain demonstrating loss of SMARCA4/BRG1, original magnification x20. (B) IHC stain demonstrating loss of SMARCA2/BRM 1, original magnification x20. (C) Positive controls of lung tissue.
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Tumor cells showed complete loss of BRM (SMARCA2) and BRG-1 (SMARCA4) expression (Figure 6A and B) with control as lung tissue (Figure 6C).
(A) CT of the chest repeated after the third cycle of chemotherapy and one cycle of pembrolizumab shows that the previously described right-sided pleural-based metastases resolved, resolving right-sided pleural effusion (red arrow), and soft tissue mass in subcarinal space extending to the mediastinal side of pleura significantly decreased in size (yellow arrow). (B) CT scan repeated after the third cycle of chemotherapy and one cycle of pembrolizumab shows that the upper abdominal lymph node significantly decreased in size (21 x 10 mm) from the prior CT scan (prior size ~31 x 19 mm).. Abbreviation: CT, computed tomography.
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The CT of the chest repeated after the third cycle of chemotherapy showed previously described right-sided pleural-based metastases resolved, soft tissue mass in subcarinal space extending to the mediastinal side of pleura significantly decreased in size (Figure 7A), and enlarged upper abdominal lymph node significantly decreased in size (21 x 10 mm) from the prior CT scan (prior size ~31 x 19 mm) (Figure 7B). The patient was stable and alive at the time of this paper writing and was actively pursuing treatment in different hospitals due to insurance issues.