PMC9663986_01
Abbreviated timeline of clinical course demonstrating the time of symptom onset to the time of remission.
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A 76-year-old male former smoker with a significant history of hypertension presented to his outpatient primary care office for a dry cough (Fig. 1). The patient was started on combination chemoimmunotherapy with cyclophosphamide, dexamethasone, and rituximab (Fig. 1). This ultimately led to 26 therapeutic thoracenteses leading to weight loss and malnutrition (Fig. 1).
Pleural fluid from initial thoracentesis appearing milky-orange in color. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)
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Two liters (L) of pleural fluid appearing milky-orange was drained (Fig. 2).
(A) Contrasted CT of the chest demonstrating a periaortic mass (white arrow). (B) Initial PET demonstrating abnormal FDG-avidity of the soft mass encasing the descending thoracic aorta. (C) PET mid-chemoimmunotherapy demonstrating interval decrease in size and FDG uptake of the soft tissue in the posterior mediastinum. (D) PET post-chemoimmunotherapy demonstrating no evidence of disease or FDG-avidity of the soft mass encasing the descending thoracic aorta. CT of the chest post pleurectomy demonstrating resolved pleural effusion; (E) lung enhanced view and (F) mediastinal view.
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Additional contrasted CT of the chest showed an ill-defined soft tissue mass encasing the descending thoracic aorta (Fig. 3). Follow up positron emission tomography (PET) demonstrated abnormal FDG avidity of the soft tissue mass (Fig. 3). Despite excellent radiologic response to chemoimmunotherapy (Fig. 3), he continued requiring high volume therapeutic thoracentesis (2.0-2.5 L per week). Follow-up pleural ultrasound four weeks post procedure demonstrated <50 ml of pleural fluid indicating excellent response to surgical intervention (Fig. 3). Patient completed chemoimmunotherapy without evidence of disease or FDG avidity on repeat PET (Fig. 3), and is currently in remission for his WM.