,microscope.JPG 
Indiana Association 
of Pathologists, Inc.
Histology Laboratory, Indiana Medical History Museum 

September 2017

A 79 year-old female with recurrent left pleural effusion

Contributed by:

 


 Kristen Partyka, MD

 Resident Physician, PGY-4, Department of Pathology and Laboratory Medicine

 Indiana University School of Medicine  

 

and 



 Shaoxiong Chen, MD, PhD

 Assistant Professor, Department of Pathology and Laboratory Medicine

 Indiana University School of Medicine.


Clinical History:

The patient is a 79 year-old female with a past history of congestive heart failure, hypertension, and tobacco use. She presented with left-sided chest pain, acute on chronic anemia, and a recent history of significant weight loss. Imaging revealed a new loculated left pleural effusion and multiple bilateral pulmonary nodules.

Bloody exudative fluid was obtained by thoracentesis, and cytology showed mixed inflammation. Repeat fluids were non-diagnostic, demonstrating blood and mixed inflammatory cells. Follow-up CT imaging showed an interval increase in the left pleural effusion, now almost completely filling the left hemithorax with near complete atelectasis of the left lung.

A video-assisted thoracoscopy was performed, and a liter of fluid was initially drained. There was pleural debris and multiple loculated pockets of fluid observed. A portion of the left lower lobe was adhesed to the posterior wall. A sample of the parietal pleura from the posterior wall was obtained for evaluation.

Gross Examination:

The specimen was received in two parts, consisting of aggregates of pink/tan irregular soft tissue, having dimensions of 8 x 5 x 2 cm and 4 x 2.5 x 1.1 cm. Step sectioning did not reveal any mass lesions. Representative sections were taken.

Microscopic Examination and Immunohistochemistry:

Microscopic examination shows fibrin and fibrous tissue with small nodules composed of highly atypical cells. These cells have large, pleomorphic nuclei with open chromatin and prominent nucleoli. There is hemorrhage in association with the tumor cells. Poorly formed vascular spaces are present, and some appear to be lined by atypical nuclei (Figs. 1-2).

Epithelial membrane antigen, MOC31, cytokeratin 7, cytokeratin 5/6, and calretinin are negative in the cells of interest. Thrombomodulin and CD34 show patchy positive staining. CD31 and ERG are strongly positive (Figs. 3-4).

(Windows users: Right click on image and open in new window. Zoom to enlarge)                       

Fig. 1 and 2: The neoplasm is hypercellular with markedly atypical cells lining poorly formed vascular spaces and associated hemorrhage.


Fig. 3: CD31


Fig. 4: ERG


Final diagnosis and Discussion


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