PMC3618104_01
a PA view of chest X-ray showing numerous pulmonary nodules. b Lateral view of chest X-ray showing pulmonary nodules.
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F1
Her chest X-ray revealed multiple bilateral pulmonary modules (fig. 1a, b).
Chest CT with contrast showing pulmonary nodules and a moderate right-sided pleural effusion.
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F2
Multiple bilateral pulmonary nodules suspicious for metastatic disease and a moderate right-sided pleural effusion and a trace left-sided pleural effusion were also noted (fig. 2).
Transesophageal echocardiogram showing a large pedunculated mass attached to the TV.
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F3
It also showed a mild-to-moderate pulmonary artery (PA) dilatation with a large mass in the right PA (possibly thrombus) and a severe tricuspid regurgitation with a large pedunculated, very mobile mass attached to the TV leaflets that moved from the right atrium to the right ventricle during the cardiac cycle (fig. 3).
a Hematoxylin and eosin staining showing spindle cells with nuclear atypia on the right and necrosis on the left side. b Immunostaining for SMA of the mass resected from the TV showing myofibroblasts. c Immunostaining for desmin of the mass resected from the TV showing myofibroblasts with smooth muscle differentiation. d Immunostaining for ER of the mass resected from the TV indicating its likely uterine origin. e Immunostaining for PR of the mass resected from the TV indicating its likely uterine origin. f Immunostaining for cyclin-dependent kinase inhibitor 2A (p16) of the mass resected from the TV which helps distinguish it from leiomyoma.
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F4
Histology of the mass attached to the TV and the pulmonary nodule revealed spindle cells with marked nuclear atypia, frequent mitoses, extensive necrosis and vascular invasion consistent with leiomyosarcoma (fig. 4a). Immunohistochemistry was positive for smooth muscle actin (SMA), desmin, ER, PR and cyclin-dependent kinase inhibitor 2A (p16) (fig. 4b-f).