Primary pulmonary leiomyosarcoma in a patient with disseminated pulmonary tuberculosis and constrictive pericarditis

Figures

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  Fig. 1. Serial imaging demonstrating disease progression 6 months apart. Initial contrast-enhanced CT (3 mm reconstructions): 1A: Axial reconstruction showing circumferential visceral and parietal pericardial thickening with associated pericardial effusion (white arrow). Right-sided pleural effusion with adjacent passive atelectasis (yellow arrow). Filling defects within the pulmonary arteries consistent with pulmonary emboli (blue arrow). 1B: Coronal reconstruction showing well-circumscribed right upper lobe apical nodule (2.1 cm × 1.4 cm × 1.3 cm) (white arrow). Calcified hilar and paratracheal lymph nodes suggesting prior granulomatous disease. 1C (axial) and 1D (coronal): 3 mm axial reconstruction clear of active pulmonary TB.

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  Fig. 2. Interval imaging at six months: 2A: PA chest radiograph showing progression to right upper lobe apical mass (5.1 cm × 4.9 cm) (white arrow). Interval reduction in cardiac silhouette size. No new parenchymal features of pulmonary TB. 2B: 3 mm coronal soft tissue reconstructed contrast-enhanced CT showing right apical soft tissue mass (white arrow) with bilateral hilar and paratracheal calcified lymph nodes. 2C (axial) and 2D (coronal): 3 mm axial lung reconstructed contrast-enhanced CT showing no CT evidence of active TB.

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  Fig. 3. Cardiac MRI findings and the adapted flow diagram protocol. 3A: Cardiac MRI, 4-chamber view, T1-weighted late gadolinium enhancement (slice thickness: 8 mm; orientation: axial-oblique, cardiac 4-chamber plane) demonstrates circumferential thickening and enhancement of both visceral and parietal pericardium (arrow) on late gadolinium phase imaging. A complex pericardial effusion is present. 3B: Cardiac MRI, 4-chamber view, STIR sequence (slice thickness: 8 mm; orientation: axial-oblique, cardiac 4-chamber plane) shows circumferential pericardial thickening (arrow) with a large, complex pericardial effusion appearing hyperintense on STIR. 3C: Diagram adapted from Imaging-Guided Therapies for Pericardial Diseases with permission from authors.

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  Fig. 4. A: PA chest radiograph showing marked interval increase in size of the right upper lobe mass (black arrow). Leftward tracheal deviation indicates mass effect. Post-sternotomy wires are present following pericardiectomy. B: 3 mm coronal soft tissue reconstructed contrast-enhanced CT showing large heterogeneous right upper lobe mass with central areas of low attenuation compatible with tumour necrosis (white arrow) and tracheal deviation.

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  Fig. 5. Surgical specimen following right upper lobectomy demonstrating the large (>15 cm) heterogeneous tumour mass.

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  Fig. 6. Histopathology of right upper lobectomy specimen. A: Smooth muscle actin (×100). B: Desmin (×100). C: Negative cytokeratin MNF-116 (×200). D: H&E showing highly pleomorphic spindle cells with multinucleated tumour giant cells (×400), confirming PPL.