case_images: PMC9807439_01
case_images: (a) Frontal image of enhanced computed tomography (CT) from chest to trunk. (b) Serial transverse images of enhanced CT of chest showing massive right pleural effusion, tumor with low density area in the right lower lobe and no pathological enlargement of the mediastinal lymph nodes. (c) Fluorodeoxyglucose (FDG)-positron emission tomography (PET) image of body showing FDG uptake by multiple lesions.
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case_images: The patient was diagnosed with right pleural effusion and a tumor in her right lung (Figure 1a-c).
case_images: List of biopsy sites and dates along the clinical course. Each mentioned biopsy date is in accordance with consideration of the first visit as day 1. Cytopathological examination of the right pleural effusion specimen was performed after collecting samples from the previous physician on the day of visit, the day of first visit at our hospital, and the day of thoracoscopy on day 12, respectively. (a) Transbronchial biopsy (TBB) was performed on day 5, and rapid on-site evaluation (ROSE) showed malignant cells with enlarged atypical nuclei and tracheal epithelial cells (x 400). (b) Hematoxylin and eosin (HE) staining of TBB specimens showed clusters of malignant cells in only one of five collected samples (x 100). (c) An enlarged view is shown. (x 200). (d) ROSE of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) specimen performed on day 9 showed malignant cells and evidence of necrosis. (e) HE staining showed few clusters of malignant cells in large areas of necrosis. (f) Thoracoscopy performed on day 12 showed numerous white nodules on the pleura including the diaphragm. (g) Stamp cytology of the specimen showed malignant cells and necrosis, and (h) HE staining showed numerous malignant cells.
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case_images: The course of these biopsies is summarized in Figure 2.
case_images: Specimens collected with transbronchial biopsy (TBB) were stained with specific antibody against EGFR L858R, and malignant cells were stained (x 400).
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case_images: Immunohistochemistry was performed on bronchoscopy biopsy specimens, wherein the tissue samples were stained with a specific antibody against EGFR L858R, which confirmed the presence of tumor cells (Figure 3).