PMC10031536_01
Stained samples of the core needle biopsy for amyloid typing (400x magnification). (A) Hematoxylin and Eosin (H&E) Stain of the Amyloidoma. (B) Congo Red Stain staining the amyloid. Amyloid deposition can be seen around the blood vessel. (C) CD138 Immunohistochemistry (IHC) shows CD138 positive plasma cells. (D) Kappa In Situ Hybridization (ISH) is positive in the plasma cells proving monoclonality. (E) Lambda ISH negative in the plasma cells proving clonality. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
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The biopsy had abundant eosinophilic amorphous material with associated dystrophic calcifications, histiocytic reaction, and multinucleated giant cells (Fig. 1A). A Congo red stain was performed on paraffin sections of the specimen and Congo red-positive amyloid deposits were present, characterized by pink amorphous material with apple green birefringence under polarized microscopy (Fig. 1B). Few groups of intact plasma cells were identified by CD138 stain (Fig. 1C). The plasma cells were kappa light chain restricted and negative for lambda light chain (Fig. 1D and E).
Positron emission tomography/Computed Tomography (PET/CT) in the coronal and axial view. Initial PET/CT scan demonstrates a metabolically active 14.3 x 13.7 x 12.9 cm partially calcified right posterior thoracic mass originating from the right ninth rib and invading into the thoracic wall and T9/T10 vertebral bodies. Maximum standardized uptake value (SUV) was 5.1.
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Positron emission tomography (PET) imaging (Fig. 2) showed a metabolically active mass with minimal cord compression.
T1 weighted magnetic resonance imaging (MRI) of the thoracic spine in the sagittal view (A) and axial view (B). 14.5 cm lesion involving the right posterior chest wall with peripherally enhancing extension into the right T9 and T10 vertebral bodies with slight extraosseous extension into the right lateral extradural canal at T9 and T10 with minimal cord displacement.
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Magnetic resonance imaging (MRI) of the whole spine (Fig. 3) revealed some extension into the canal at T9/T10; however, the patient had not experienced any radicular symptoms.
Positron emission tomography/Computed Tomography (PET/CT) in the coronal and axial view. PET/CT scan two years later showed the mass was stable in size but contained several regions of increased calcifications. The mass continued to extend through the thoracic cage into the right lateral subcutaneous tissues. SUV was 5.3 and the large size of the mass caused adjacent compressive atelectasis.
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The following year, imaging revealed that the right chest wall mass continued to grow larger towards the anterior chest (Fig. 4).
Computed tomography (CT) imaging of the chest with contrast in the axial and coronal view. (A) 21.0 cm x 12.7 cm x 10.9 cm peripherally calcified soft tissue mass extending through the thoracic cage into the right lateral subcutaneous soft tissue and involvement of the T9 and T10 vertebral bodies with epidural extension. (B) After 3 months, size increased to a 21 x 13 cm peripherally calcified right thoracic soft tissue mass exerting regional mass effect with resultant compression of the right lower lobe bronchus. (C) After 6 months, CT demonstrated growth in the AP dimension to 13.9 cm as well as progressive narrowing of the right mainstem bronchus and bronchus intermedius with new complete occlusion of the right upper and right middle lobe segmental bronchi causing collapse of the right middle and upper lobe.
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Given that the tumor continued to grow even on radiation therapy (Fig. 5A-C), the patient was no longer a candidate for further spinal irradiation. Despite these lab changes, the mass continued to grow aggressively and eventually caused complete occlusion of the right upper and middle lobe segmental bronchi causing collapse of the right middle and upper lobe of the lung (Fig. 5C).