Pleural-based Mass Research Articles

Localized type tenosynovial giant cell tumor with metastases to lungs and pleura: a case report and literature review

BackgroundTenosynovial giant cell tumor is a rare soft tissue tumor of the synovium of joint, bursae, or tendon sheath. It is divided into localized or diffuse types on the basis of the growth pattern. Localized tenosynovial giant cell tumors are usually benign and treated successfully by excision. Diffuse tenosynovial giant cell tumors, in contrast to localized type, can destroy bone and cartilage and are associated with frequent local recurrences and distant metastasis. Localized type tenosynovial giant cell tumors rarely metastasize to distant organs. Here, we report a case of localized tenosynovial giant cell tumor presenting with lung metastases and systematically review literature.Case presentationA 55-year-old Asian male presented with a dry cough, right-sided chest pain and progressive dyspnea for 1 month. At 18 months before this presentation, he had undergone excision of a painless swelling on his right index finger. The swelling recurred within 3 months of excision, and a biopsy was then suggestive of a giant cell tumor. Given the suspicion of a giant cell tumor, a wide excision of the lesion was performed and the excisional biopsy was consistent with a diagnosis of tenosynovial giant cell tumor, localized type. At admission to our hospital, the patient had tachypnoea and absent breath sounds on the right side. A chest radiograph showed a right-sided pleural effusion with a homogenous opacity in the left mid-zone. A contrast-enhanced computed tomography of the chest and abdomen showed right massive pleural effusion and bilateral multiple lobulated heterogeneously enhancing pleural-based masses with areas of internal calcification. Pleural fluid analysis revealed an exudate with no malignant cells on cytology. A lung biopsy showed osteoclast-like giant cells and mononuclear spindle cells with areas of hemorrhage and necrosis, suggesting tenosynovial giant cell tumor metastasis. A final diagnosis of localized type tenosynovial giant cell tumor of the right index finger with metastases to the lungs and pleura was made. The patient passed away after receiving three cycles of denosumab injection owing to progressive disease.ConclusionLung metastasis is extremely rare in patients with localized tenosynovial giant cell tumor. The survival is usually poor in patients with lung metastasis. A close follow-up of patients with localized type tenosynovial giant cell tumor is necessary for early detection of pleuropulmonary complications.

Primary extraskeletal osteosarcomas of the pleura: A clinicopathological, immunohistochemical, and molecular analysis of 4 cases

Four primary extraskeletal osteosarcomas of the pleura are presented. The patients were men between the ages of 63 and 78 years (average: 70.5 years) who presented with symptoms of chest pain, cough, and shortness of breath. Diagnostic imaging showed variably calcified, pleural-based masses and/or diffuse pleural thickening, clinically mimicking mesothelioma. Thoracoscopic surgical material was obtained for histopathological diagnosis. Histological findings showed the presence of a neoplastic spindle cell proliferation composed of fusiform cells with scant cytoplasm, elongated nuclei and inconspicuous nucleoli. Mitotic activity was easily identified. Additionally, all tumors showed extensive osseous differentiation in the form of osteoid matrix production; one tumor demonstrated additional chondrosarcomatous elements and another showed focal myxoid changes. Immunohistochemical analysis revealed that the tumor cells were uniformly negative for a wide variety of antibodies, including keratin AE1/AE3, keratin 5/6, D2-40, EMA, calretinin, WT-1, BerEP4, and HEG1; BAP1 was retained in all cases. In addition, fluorescence in situ hybridization for CDKN2A (p16) was negative for homozygous deletion in all tumors. Clinical follow-up showed that one patient had died 8 months after diagnosis and one had remained alive with short post-diagnostic follow-up. The tumors herein described highlight a challenging issue in the separation of mesothelioma with heterologous elements from true osteosarcomas of pleural origin. We propose that a diagnosis of extraskeletal osteosarcoma of the pleura is rendered for tumors with malignant osseous and/or cartilaginous differentiation in which comprehensive immunohistochemical studies and FISH analysis have failed to provide support for a diagnosis of mesothelioma with heterologous elements.

Paradoxical development of pleural-based masses in patients with pleural tuberculosis during treatment: a clinical observational study in China

BackgroundTo explored the clinical, pathological, and bacteriological characteristics of pleural-based masses occurred during anti-tuberculosis (TB) treatment in patients with pleural TB.MethodsPatients referred with newly diagnosed pleural TB were prospectively enrolled into the study. Patients were followed up throughout the treatment, and clinical data were recorded. Percutaneous biopsy and surgical tissues from pleural-based masses were examined histologically and samples sent for PCR. Cytokines in the pleural effusions and clinical factors were collected and compared between different patients.ResultsA total of 122 patients with pleural TB were enrolled, and 34.4% (42/122) displayed newly observed pleural-based mass during the treatment. Twelve cases underwent surgical resection at the 12 ± 0.5 months during the treatment course. Based on the surgical observation, 58.3% (7 /12) were located in pleura, 41.7% (5/12) were located in the lung parenchyma. Pathological observations showed that the pleural-based masses were typed as granulomatous inflammation, fibrous hyperplasia and necrosis. Mycobacterium tuberculosis PCR was positive in 57.1% of the cases (24/42). Any first-line anti-TB drug resistance gene mutations were positive in only 9.5% (4/42). Aside from 12 cases who underwent the surgical operation, 86.7% of the patients (26/30) still had a pleural-based mass at the end of 12 months treatment course. Patients with a pleural-based mass were younger, had a thicker pleural, a higher proportion of pleural adhesive, loculated pleural effusion and residual pleural effusion, and a higher level of LDH, ADA and lower glucose in pleural effusion than those without a pleural-based mass occurrence during the treatment (all Pcorr < 0.05).ConclusionsPleural-based masses were observed in about one-third of patients with pleural TB. The masses were in the lung or pleura and were divided into three pathological types.

Primary follicular dendritic cell sarcoma of the pleura: A clinicopathological and immunohistochemical study of two cases

Two cases of primary follicular dendritic cell sarcoma (FDCS) of the pleura are presented. The patients are a woman 76-years-old and a man 64-years-old who presented with nonspecific symptoms including chest pain, dyspnea, and cough. Clinical history did not disclose any pertinent history of previous malignancy. Diagnostic imaging showed the presence of a pleural-based mass in both patients and a thoracotomy with resection of the pleural mass was performed. Both tumors were described as solid, light tan, and with ill-defined borders. Histologically, both tumors showed similar histological features, namely the presence of a spindle cellular proliferation composed of elongated cells with fibrillary cytoplasm, oval nuclei, and conspicuous nucleoli. Mild to moderate cellular atypia was present, while mitotic figures ranged from 3 to 4 per 10 high power fields. Mature lymphocytes and plasma cells were also present dispersed throughout the tumor. Immunohistochemical stains in both cases show positive staining for CD21 and CD35 while focal staining was present for D2-40 and clusterin, while negative for other markers including keratin, desmin, S-100 protein, calretinin, and STAT-6. Clinical follow up shows that both patients have remained alive 12 and 14 months after initial diagnosis. The cases herein described represent an unusual occurrence of FDCS arising in the pleural surface and one that must be kept in mind when dealing with spindle cell tumors of the pleura.

Multidetector CT findings of primary pleural angiosarcoma : a systematic review, an additional cases report

BackgroundTo demonstrate and analyze the relatively common imaging findings in this rare primary pleural angiosarcoma (PPA).Case presentationThree cases of PPA, proven by video-assisted thoracic surgery biopsies are retrospectively reviewed. Patients were all male. Age ranges from 65 to 75 years old age (mean; 69). Major chief complaints were dyspnea and chest pain. One has a history of colon cancer, the other has a tuberculosis history and the other has no known history. Multidetector chest CT and PET CT were all done. Immunohistochemical studies were performed including CD31, CD34, or factor VIII-related antigen, vimentin, and cytokeratin. We also review the literatures on recently published PPA. All masses were from 1 to 10 cm. All three patients had multiple pleural based masses, which were ovoid in shape with relatively sharp margin in unilateral hemithorax. Multiple small circumscribed pleural masses are limited in the pleural space in two patients, whereas two, huge lobulated masses about up to 10 cm were present with pleural and extrapleural involvement in one patient. In two patients with pleural mass only, multiple pleural masses were only seen in parietal pleura in one patient and were in both visceral and parietal pleura in one patient. Pleural effusion were found in one side in one patient and in both sides in one patient. One angiosarcoma was arised from chronic tuberculotic pleurisy sequelae. All pleural masses are heterogenous with irregular internal low densities in all patients. Hematogenous metastases were found in liver, vertebra, rib in one patient, and were in lungs with mediastinal lymph node metastases in the other patient. Three patients survived for longer than 3months after diagnosis, but continued to deteriorate rapidly. Two patients underwent chemotherapy after surgical excision, and the other one with multiple metastases treated chemotherapy after CT-guided biopsy, but eventually all died. As a result of comparative analysis of a total of 13 patients’ images including 10 cases previously published, there was pleural effusion in all except 2 cases.ConclusionsPPA were all necrotic without any vascularized enhancing nature, and manifested as unilateral circumscribed or localized pleural-based masses.

Shear Wave Ultrasound Elastography and Diffusion-Weighted Magnetic Resonance Imaging Findings of Pleural-Based Masses with Histopathologic Correlation

Objective: The study aims to evaluate the usefulness of non-invasive diagnostic methods, shear wave elastography (SWE), and diffusion-weighted magnetic resonance imaging (DWI) to differentiate benign and malignant lesions in the thoracic pleural based masses by comparing them with histopathological findings.Materials and Methods: Sixty-three patients having a pleural-based peripheral mass on CT, admitted to the interventional radiology department for transthoracic biopsy, were included in the study. All patients underwent DWI, and ADC values of the groups were measured. Transthoracic biopsy was performed with the guidance of US from the area where the highest shear wave velocity (SWV) value was calculated. ADC and SWV values of histopathologically proven benign and malignant lesions were statistically compared.Results: Fifty-six patients were male, and seven were female. The mean age was 64.68±10.13 years (41-85 years). Fourty-four patients were malignant, and 19 were benign. The maximum SWV was found to be 4.13±0.59 m/s in malignant cases and 3.55±0.71 m/s in benign cases, and the difference was significant (p = 0.001). Mean ADC value was measured as 1.04±0.30 x 10-3 mm2/s in malignant cases and 1.32±0.33 x 10-3 mm2/s in benign cases on DWI and the difference was significant (p = 0.002). In malignant cases, the minimum ADC was 0.73±0.29 x 10-3 mm2/s, and 0.99±0.44 x 10-3 mm2/s in benign cases, the difference was significant (p = 0.024). ROC analysis revealed a cut-off value of ≥4.08 m/s for SWVmax, ≤1.01x10-3 mm2/s for mean ADC, and ≤0.8x10-3 mm2/s for minimum ADC showed a significant performance in distinguishing malignant and benign lesions. Conclusions: Transthoracic US elastography and DWI are useful in differentiating malignant and benign lesions in appropriate cases. Both SWE and DWI are useful in routine use because they are non-invasive and do not contain radiation. In particular, SWE is suitable for biopsy guidance and may prevent the possibility of insufficient material.

OLEOTHORAX: PULMONARY PLOMBAGE

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Plombage (extra-pleural pneumonolysis) is a surgical treatment method used to treat cavitary lesions of the lung in patients with pulmonary tuberculosis (TB) during 1930–50s before the introduction of anti-TB chemotherapy by creating a cavity surgically under the ribs in the chest wall and filling the space with inert material [1]. The materials used in this procedure are acrylic balls, fat, wax, rubber, and mineral oil (Oleothorax). Rarely, Plombage is used to seal a large bronchopleural fistula that causes refractory pneumothorax, with only one reported case in the literature [2]. We present another case of Pulmonary Plombage (Oleothorax) used in successfully treating refractory pneumothorax. CASE PRESENTATION: A 62-year-old man with a history of hypertension and symptomatic bradycardia requiring a permanent pacemaker came in with worsening shortness of breath associated with decreased exercise tolerance and orthopnea. The examination was remarkable for pan systolic murmur at the apex, jugular venous distention, and decreased breath sounds in the right lung base. Chest radiograph (Image 1) revealed cardiomegaly and a pleural-based rounded mass in the right pleural space inferiorly. Computed tomography (Image 2) showed a loculated cystic mass (label A) (13x9x10 cm) measuring slightly above water density and apical bullae. An echocardiogram revealed severe left atrial and left ventricular dilation with an ejection fraction of 55% and prolapse of the anterior leaflet of the mitral valve (MV) with severe mitral regurgitation (MR). Pulmonary service was consulted for loculated cystic mass in the lung, upon further questioning, the patient mentioned he had lung surgery in 1993 due to recurrent pneumothorax, which was found to be Pulmonary Plombage. He was started on intravenous loop diuretics for congestive heart failure secondary to MR with improvement in symptoms. DISCUSSION: We presented the modern imaging description of a Plombage thoracoplasty performed to treat refractory pneumothorax with an uncomplicated outcome 28 years after surgery. A new method to treat pneumothorax due to a large cavity with a bronchopleural fistula. The utility of Pulmonary Plombage to seal a large bronchopleural fistula causing refractory pneumothorax has not been studied, with only one case report [2] in the literature where they used pericardial fat pad as Plombage to successfully treat refractory pneumothorax without complications after 48 years. This technique involves complications like hemorrhage, infection, fistulization to the skin. Radiographic characters depend on the material used in the Plombage treatment. The cystic mass measuring slightly above water density seen in our patient was filled with mineral oil (Oleothorax). CONCLUSIONS: Pulmonary Plombage, a historical treatment used to treat cavitary lesions in tuberculosis patients, can be used effectively in treating refractory pneumothorax. REFERENCE #1: Namana V, Gupta SS, Sarasam R, Mathur P: Historical TB treatment—Plombage. QJM An Int J Med. 2017, 110:191. 10.1093/qjmed/hcw213 REFERENCE #2: Nakano T, Tsubochi H, Minegishi K, Endo S: Pericardial fat pad plombage for pulmonary cavity causing massive air leakage. Surg Case Reports. 2020, 6:156. 10.1186/s40792-020-00917-7 DISCLOSURES: No relevant relationships by Akshay Avula, source=Web Response No relevant relationships by Elias Chuki, source=Web Response No relevant relationships by Raja Jadav, source=Web Response No relevant relationships by Harry Sequeira gross, source=Web Response

Pleuropulmonary Aspergillosis in an Immunocompetent Patient Presenting as Pleural-Based Peripheral Lung Mass

The importance of knowledge about pulmonary aspergillosis has increased immensely in the era of COVID-19 as a significant number of post-COVID patients develop lung infection with aspergillosis, an entity called COVID-associated pulmonary aspergillosis producing increasing morbidity and mortality. In this case report, we describe an immunocompetent elderly man presenting with a peripheral lung mass, suspected to have lung malignancy which turned out later to be pleuropulmonary aspergillosis.

Dyspnoea from a rapidly growing intrathoracic mass

A 54-year-old man presented with progressive dyspnoea and non-productive cough for 2 months. A physical examination revealed diminished breath sounds and dullness to percussion on the right side. A preoperative...

PLEURAL SPINDLE CELL NEOPLASM IN A PATIENT WITH NEUROFIBROMATOSIS TYPE I

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: A twenty-two year old male with NF1 presented with multiple pleural masses, consistent with spindle cell neoplasm. Given his history, malignant peripheral nerve sheath tumor is suspected and a rare presentation of this disease. CASE PRESENTATION: A twenty-two-year-old male with Neurofibromatosis Type 1 (NF1) presented to the Emergency Department with abdominal pain. Past medical history included malignant peripheral nerve sheath tumor (MPNST) of the left leg. Despite resection, there was local recurrence within one month and the patient subsequently received chemotherapy with ifosphamide and etoposide, radiation, and surgical resection with a below-knee amputation. A one-cm right lower lobe pulmonary nodule with mild FDG avidity was found on surveillance PET scan. An attempted biopsy was unsuccessful due to the location of the nodule. Unfortunately, the patient was lost to followup. He presented six months later with abdominal pain and dyspnea and was found to have a large right pleural effusion with pleural masses causing mediastinal shift (Figure 1). Tube thoracostomy was performed. Pleural fluid analysis showed a lymphocyte-predominant, exudative effusion. Infectious workup, including bacterial and fungal cultures and adenosine deaminase level, was negative. Cytology demonstrated only reactive mesothelial cells. Pleuroscopy was performed, and multiple pleural-based masses (Figure 2) were biopsied and found to be consistent with spindle cell neoplasm. Immunostaining was negative for neurofilament, CD34, STAT6, Bcl-2, SMA and desmin, CD117, Dog-1, Sox-10, ALK-1, beta-catenin. There was rare staining of S100 and WT-1 positivity, with further histopathological workup pending. DISCUSSION: NF1 is an autosomal dominant disorder with variable organ involvement. Mutation in the NF1 gene results in loss of function of the neurofibromin tumor suppressor protein and upregulation of RAS activity leading to increased tumorigenesis. While a benign disorder, the incidence of malignancy in patients with NF1 is increased and is estimated to be around 2-4.1% per lifetime. Malignant transformation in young adults is most often MPNST, a type of spindle cell sarcoma. Pleural involvement, while rare, is often from metastases as suspected in this case. Accurate and early diagnosis has implications for therapy but can be difficult to distinguish from other soft tissue sarcomas as there is no specific molecular signature. Immunohistochemical staining may show weak staining for S-100 protein in 50% of cases. Surgical resection is preferred in localized disease. Metastatic disease is associated with a poor prognosis, with fewer than 40% of patients surviving past one year after diagnosis. CONCLUSIONS: While a benign disease, NF1 is associated with an increased risk of malignant transformation; pleural involvement is rare but should be on the differential diagnosis of a pleural mass associated with NF1. Reference #1: Zhang Y, Chao J, Qin S. Type I neurofibromatosis with spindle cell sarcoma: A case report. World Journal of Clinical Cases 2019;7:3104-3110. Reference #2: Bethany C. Prudner Tyler Ball , Richa Rathore , and Angela C. Hirbe. Diagnosis and management of malignant peripheral nerve sheath tumors: Current practice and future perspectives. Neuro-Oncology Advances 2019; 20: 1–10 Reference #3: Evans DG, B. M., McGaughran J, Sharif S, Howard E, Moran A: Malignant peripheral nerve sheath tumours in neurofibromatosis 1. J Med Genet, 39((5)): 311-4, 2002 DISCLOSURES: No relevant relationships by Edward Bergin, source=Web Response No relevant relationships by Arista Chand, source=Web Response No relevant relationships by Joshua Malo, source=Web Response

Cytopathology of myxofibrosarcoma: a study of 66 cases and literature review

Myxofibrosarcoma is one of the more common sarcomas encountered in adults. A search was made of our cytopathology and surgical pathology databases for cases diagnosed as myxofibrosarcoma (MyxoFS). FNA biopsy smears and cell block were performed and examined using standard techniques. Sixty-six cases were retrieved from patients aged 40 to 94 years (mean: 67 years), with a male:female ratio of 1.4:1. Forty-seven (71%) were primary neoplasms, 13 (20%) locally recurrent, and 6 (9%) metastasis. Lower extremity was the most common site 38 (58%) cases, followed by upper extremity and trunk (each 13 [20%] cases), 1 head/neck, and 1 pleural-based mass. Forty-two (64%) cases were specifically/correctly diagnosed as MyxoFS. Thirteen (20%) were diagnosed as undifferentiated pleomorphic sarcoma (UPS), 3 (4.5%) as myxoid neoplasm, 2 (3%) as myxoid sarcoma, and 1 (1.5%) sarcoma, not otherwise specified. As most were examples of high-grade (HG) MyxoFS, cytomorphology contained pleomorphic and spindled cells set in a variable amount of myxoid stroma. Arborizing capillaries were common, and pseudolipoblasts were uncommon. All cases interpreted as UPS were HG MyxoFS histologically. Five (7.5%) cases-pleomorphic liposarcoma (3), solitary fibrous tumor (1), and atypical lipoma (1)-were mistakenly diagnosed. Ancillary immunohistochemistry played a minor role in diagnostic assessment. MyxoFS was accurately interpreted using FNA biopsy in about two thirds of cases. One fifth were misinterpreted as UPS due to the absence/near absence of myxoid stroma, which varies considerably in the definition of this neoplasm.

Should We Perform Transthoracic Trucut Lung Biopsies of Pleural-Based Lung Masses Under Ultrasound Guidance or Computed Tomography Guidance?

We aimed to emphasize which method should be prioritized by comparing the ultrasound and computed tomography (CT) guidance for percutaneous transthoracic biopsy of pleural-based lung lesions in terms of comorbidity, diagnostic success, time, and costs.Approximately 700 biopsy procedures performed between 2014 and 2018 were retrospectively reviewed. The files of these patients and picture archiving and communication system were scanned.Size and localization of the lesion, pathological diagnosis, comorbidity status, pneumothorax complications at the end of the procedure, and whether or not a thoracic tube was placed due to pneumothorax were recorded. Fisher exact test and Pearson χ test were used for statistical analysis.A total of 181 patients who underwent the pleural-based biopsy procedure, the subject of study, were included in the study. One hundred (55.2%) of the biopsy procedures of these patients were performed under the guidance of tomography, and 81 (44.8%) were performed under the guidance of ultrasound (US). Median size of the lesions is 38 mm (25%-75%, 33-55 mm). Pneumothorax complications were observed in 6 patients (6%) who had CT-guided procedures and 4 patients (4.9%) who had US-guided procedures. Of the patients who developed pneumothorax, 2.8% were inserted thoracic tubes owing to the complication. Diagnostic efficacy of our procedures is 99.8% in US-guided procedures and 97% in CT-guided transthoracic biopsy. The average duration of US-guided transthoracic biopsy procedures is 17 minutes, and the average duration of CT-guided biopsy procedures is 35 minutes.

A Case of Small Cell Carcinoma of Lung Presenting as Opaque Hemithorax

The most common cause of an Opaque Hemithorax is Pleural Effusion. It is a rare occurrence to find patients with extensive mass leading to an opaque hemithorax. Thorough search of literature did not yield any case with such a large lung mass leading to opaque hemithorax, without the presence of pleural effusion. Lung cancer is the most common cancer diagnosed worldwide and has predominantly been attributed to tobacco smoke exposure. Of the several types, small cell lung cancer differs from others by its early spread and extensive dissemination leading to metastatic classification at the time of diagnosis. Here, is a case of a 50-year-old female patient who presented to the outpatient department with dry cough, weight loss and appetite loss since five months. Her chest radiograph revealed a right-sided homogeneous opacity involving the entire right hemithorax and left-sided pleural-based homogenous mass. Contrast Enhanced Computed Tomography (CECT) thorax revealed an enlarged hemithorax with evidence of large, ill-defined heterogeneously enhancing multilobulated soft-tissue density mass lesion occupying the entire right hemithorax. Biopsy was suggestive of Small Cell Carcinoma of Lung (SCLC), chemotherapy was given and patient is under regular follow-up.

AIUM Practice Parameter for the Performance of Point-of-Care Ultrasound Examinations.

AIUM Practice Parameter for the Performance of Point-of-Care Ultrasound Examinations.

Safety and diagnostic yield of thoracic ultrasound-assisted transthoracic biopsy performed by a pulmonologist

BackgroundTransthoracic ultrasonography (US) is still not utilized to its full potential by respiratory physicians, despite being a well-established and validated imaging modality. It allows for an immediate and mobile assessment that can potentially augment the physical examination of the chest. This work aims to assess safety and diagnostic yield of thoracic US-assisted transthoracic biopsy performed by a pulmonologist . Patients and methods The present study was conducted upon 75 patients who are referred to the Pulmonary Medicine Department, Ain Shams University Hospitals with radiological assessment that reveals pleural-based mass with or without pleural effusion, anterior mediastinal mass, peripheral lung lesions or chest wall lesions. The present study was conducted upon 75 (67 male and 8 female) patients with mean±SD age 58.8±15.64.ResultsThis study showed that 31 cases were presented by peripheral pulmonary mass, 29 pleural lesions, nine mediastinal and six chest wall lesions, 57 of them diagnosed by sonar guided biopsy, 51 of them were malignant and the remaining six were benign.ConclusionTransthoracic US-assisted cutting-needle biopsy is an excellent first-line diagnostic tool for pleural-based lesions of at least 3 cm in diameter. It is a quick, low-cost, safe and well-tolerated tool in the hands of pulmonologists and has a high sensitivity for pleural-based malignancies.

Extramedullary Hematopoiesis in the Absence of Myeloproliferative Neoplasm: Mayo Clinic Case Series of 309 Patients

Background:Extramedullary hematopoiesis (EMH) implies the production of erythroid and myeloid progenitor cells outside of the bone marrow. EMH in adults is typically seen in patients with myeloproliferative neoplasms (MPN). The current study examines the Mayo Clinic experience with EMH cited in the absence of MPN. The objectives were to describe associated conditions and involved sites and identify “idiopathic” cases and review their management and long-term outcome.Methods:After approval by the Mayo Clinic institutional review board, institutional databases were screened through the Mayo Clinic Advanced Cohort Explorer (ACE) Tool, in order to identify patients with EMH. We performed a retrospective database review of all identified patients between 1975 and 2018. Demographic, biochemical, genetic, radiological and pathological data were collected and reviewed.Results:ACE identified 1,933 cases of “EMH”. Extensive review confirmed the absence of associated MPN in 336 cases. Among these, 27 cases involved pathology remarks during tissue biopsy for liver transplant and were excluded from further analysis. The most frequent associated conditions in the remaining 309 cases included myelodysplastic syndromes (n=41; 13%), acute myeloid leukemia (n=28; 9%), hemolytic anemia (n=24; 8%), thalassemia (n=22; 7%), non-Hodgkin's lymphoma (n=19; 6%), immune thrombocytopenic purpura (n=17; 6%), metastatic cancer (n=17; 6%), plasma cell neoplasms (n=12; 4%) and a spectrum of other hematologic and non-hematologic conditions, including chronic lymphocytic leukemia, natural killer cell disorders, Hodgkin's lymphoma and Hemophagocytic lymphohistiocytosis. in 12 (4%) cases, no overt associated condition was evident and the cases were accordingly assigned “idiopathic”. The most frequent involved sites included spleen (n=162), liver (n=78) and lymph nodes (n=20).A diagnosis of “idiopathic” EMH was established in 12 (4%) patients (median age 71 years, range 23-78; 50% females). Most of these cases presented with non-specific symptoms including abdominal and back pain and the EMH was an incidental discovery (Table 1). Involved sites included 4 pre-sacral, 3 para-spinal, 2 spleen and one each retroperitoneal, pleural-based chest mass and right upper lobe lung mass. All cases were evaluated with imaging studies and diagnosis was subsequently confirmed by pathology review. Past medical history was non-contributory. Complete blood counts were normal in 7 cases, showed anemia in 4 cases and were not available in one case (Table 1). The median follow-up time since the discovery of EMH was 7 years (range 2-20). None of the patients showed evidence of any malignancy, including MPN or other hematologic disorders, either at presentation or during follow-up. Nine (75%) of the 12 patients were managed conservatively; the two patients with splenic EMH underwent splenectomy and one patient had surgical excision of the EMH mass in order to prevent compression of the ureter. The FUO in the patient with splenic EMH resolved with splenectomy.Conclusions:We present the largest experience in EMH without associated MPN, in adults. We describe associated conditions and elaborate further on “idiopathic” EMH (n=12), which often represented an incidental discovery during evaluation of unrelated symptoms. None of the patients with idiopathic EMH harbored occult malignancies or subsequently developed MPN or other myeloid malignancies. Our observations do not support undertaking extensive investigations targeting MPN or other malignancies in idiopathic EMH and simple monitoring might be adequate. DisclosuresNo relevant conflicts of interest to declare.

Cytologic examination of ascitic fluid in a patient with pleural-based mass: A unique presentation of a rare tumor.

Body fluids may be the only available sample for diagnosis of tumors affecting the serous cavities. Hence, detailed cytologic examination carries utmost importance in spite of morphologic overlaps. Peritoneal mesotheliomas need to be distinguished from advanced intra-abdominal serous adenocarcinomas especially in women with the help of immunohistochemical stains pancytokeratin and calretinin. Dual site mesothelioma is a rare possibility which may be encountered.

Pleural mass imaging - A quick primer

A 35-year-old female patient with no comorbidities and no history of addictions presented with a 2 week history of intermittent right-sided chest pain without any associated symptoms. On local examination, there was dullness over the right infrascapular and right infra-axillary area along with decreased breath sounds over the corresponding areas. Computed tomography scan revealed a well-defined lobulated heterogeneously enhancing pleural-based mass. What is the most likely diagnosis?

Thymoma with pleural metastasis

Case summary A previously healthy 46-year-old male presented with right-sided pleuritic chest pain for 2 weeks. He had no other symptoms such as febrile, cough, hemoptysis or dyspnea. He had no underlying disease and no history of cancer in his family. He reported no smoking and no alcohol drinking. On physical examination revealed normal heart and lung sounds. His vital signs showed body temperature of 36.6°C, blood pressure of 128/83 mmHg, pulse rate of 90/minute, respiratory rate of 24/minute and 98% oxygen saturation. Laboratory tests showed normal hemoglobin level, normal renal function and unremarkable liver function. White blood cell count was normal. Chest radiography and enhanced chest computerized tomography (CT) scan showed a large pleural-based mass in the right side of the chest. The patient underwent pleural biopsy via transthoracic needle biopsy (TTNB) on 11 January, 2018. Pathological findings for pleural specimens were consistent with thymoma. Bone scan was done on 16 January, 2018 showing no evidence of bone metastasis.Anutida Limsuknirun, M.D.From The Department of Radiology,Faculty of Medicine, Prince of Songkla University, Songkhla, ThailandAddress correspondence to A.L. (e-mail: anutida.limsuknirun@gmail.com)

Infliximab Therapy Leading to Pulmonary Tuberculosis in a Patient With Negative Interferon γ Release Assay (IGRA)-Based QuantiFERON Gold Test.

Infliximab therapy is associated with higher rates of active tuberculosis (TB), particularly extrapulmonary and disseminated forms with unusual symptoms. We report the case of a 66-year-old man with Crohn’s disease who developed TB mimicking lung cancer on imaging. He presented with cough and fever of 2 weeks’ duration shortly after starting infliximab. Computed tomography of the chest revealed a 7.0 × 3.2 cm2 pleural-based mass, highly suspicious for malignancy. Histopathological examination confirmed the diagnosis of TB. The mass disappeared after antitubercular treatment, and the patient recovered completely. A review of the literature suggests that TB masquerades as lung cancer clinically and radiologically. The classical lesions of TB are cavitatory with calcifications. Mass lesions without cavity or calcifications are rare and are mostly reported from regions endemic for TB. The majority of patients on infliximab therapy required biopsy for accurate diagnosis of TB because of its unusual presentation.