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case_images: The initial imaging and pathological examinations of the patient. (A and B): CT indicates a mass in the upper lobe of the right lung (A), and no evident lymphadenopathy can be seen in the mediastinal window (B and C) HE demonstrates that the lung tissue exhibits interstitial fibrosis and scattered infiltration of lymphocytes and plasma cells, with some epithelioid cells visible, indicative of granulomatous inflammation at 100x magnification.
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case_images: A computed tomography (CT) scan of the chest showed a circular, low-density shadow of 1.5x1.0 cm without discernible borders in the upper lobe of the right lung (Figure 1A and B). A CT-guided biopsy of the upper right lung tubercle was performed to clarify the nature of the tumor, and the pathology report indicated granulomatous inflammation (Figure 1C).
case_images: The second CT imaging examinations and pathological findings of the tumor mass in the right lung lobe. (A and B) CT indicates that the mass in the right lung has enlarged compared to that before (A), along with an enlargement of multiple mediastinal lymph nodes (B and C): The HE staining indicates that the tumor is predominantly composed of spindle cells. (D-H): Immunohistochemistry shows that the tumor cells are negative for expression of P40 (D) and positive for expression of SMA (E), Cam5.2 (F), CK7 (G), and Ki-67 (H) at the magnification of x200.
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case_images: Moderate bilateral pleural and pericardial effusion was observed, with the possibility of pericardial metastasis (Figure 2A and B). The pathological examination of the biopsies from the right upper lung and mediastinum indicated a malignant spindle cell tumor, with a tendency towards primary lung origin (Figure 2C-H). The histopathological features were as follows: Hematoxylin and eosin staining showed that the tumor cells were entirely composed of spindle cells in diffuse or storiform patterns (Figure 2C). The immunohistochemical analysis revealed negative staining for P40 (Figure 2D), whereas it revealed positive staining for SMA, Cam5.2, and CK7 (lesion area) (Figure 2E-G). Ki67 indicated a high tumor proliferation index (about 60%+) (Figure 2H).
case_images: The radiation therapy plan and the diagnosis and treatment flow chart. (A-D): Radiation treatment plan for VMAT (volumetric modulated arc radiotherapy) targeting the right upper lobe tumor and multiple metastatic lymph nodes with a total dose of 60 Gy in 30 fractions. (A and B): Axial mediastinal window; (C) Coronal lung window; (D) Sagittal lung window. Color areas are the radiation isodose curves, yellow represents 60 Gy, red 63 Gy, and blue 57 Gy. (E). The diagnosis and treatment flow chart.
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case_images: Detailed delineation of the target area is presented in Figure 3A-D. The diagnosis and treatment flow chart is shown in Figure 3E.