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case_images: Pulmonary Computed Tomography Angiography| (A-F) Sequential PCTA Scans Demonstrate PAS Progression: (A, B) October 2022 - Low-density defects fill and expand both pulmonary trunks, eclipsing artery walls (red triangle) and causing left-sided pleural effusion; trunk diameter reaches 35 mm. (C, D) December 20-2 - Defects in pulmonary trunks enlarge, extending into the right ventricular outflow tract with progression beyond the left artery. (E, F) February 20-3 - Delayed-phase imaging reveals unevenly enhanced, irregular PAS lesions (red start), (F) the lesion within the branches of the left lower lobe arteries is markedly enlarged with inhomogeneous enhancement. (A, C) The red triangle marks the special PAS characteristics: complete arterial lumen filling with an "eclipsing vessel sign" and vessel expansion.
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case_images: Figures 1A, B ), which initially suggested a misdiagnosis of pulmonary embolism with pulmonary hypertension:a common interpretation under these circumstances. Furthermore, a Doppler ultrasound of the lower limb found no thrombi, indicating a need for additional explorations for other thrombosis sources or causes. A follow-up CTPA two months later revealed further enlargement of the pulmonary artery trunk and a progressive increase in pulmonary artery pressure ( Figures 1C, D ). In the delayed phase of repeated CTPA, the lesions displayed inhomogeneous enhancement: a detail previously missed ( Figures 1E, F ).
case_images: Cranial Magnetic Resonance Imaging (CMRI) of suspected brain metastases: CMRI T1WI (A), T2WI (B), DWI (C), Enhanced T1WI (D) axial images demonstrating a suspicious metastatic lesion: a subcortical roundish nodule located in the left frontal lobe, with low signal in T1WI and slightly hyperintense concentric ring pattern and uneven signal in T2WI, with peripheral circumferential ring-like enhancement, surrounded by a large area of edema, no apparent diffusion restriction.
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case_images: Figures 2A-D ) delineated the lesion as solid tissue with irregular ring enhancement and significant surrounding edema, indicative of an intracranial metastatic tumor. Following these findings, he was urgently transferred to the neurosurgery department of a cancer hospital for emergency surgical intervention.
case_images: 18F-FDG Positron Emission Tomography-Computed Tomography (PET-CT) images (A) The anteroposterior 3-dimensional maximum intensity projection image (MIP) demonstrated a hypermetabolic lesion in the left and right artery trunks, while abnormal FDG metabolic nodules were found in the right deltoid muscle and left transversus abdominis muscle; (B, C) irregular PAS lesion in the pulmonary artery wall, with increased FDG uptake (SUV max=12.7).
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case_images: An 18F-FDG Positron Emission Tomography - Computed Tomography (PET-CT) scan revealed significant radiotracer uptake in the irregular lesion located in the pulmonary artery trunk ( Figures 3B, C ), with a maximum standardized uptake value (SUV) of 12.7. Additionally, abnormal FDG metabolic nodules were detected in the right lower lobe of the lung, right deltoid, and left transverse abdominis ( Figure 3A ).
case_images: Histopathological Findings (A) Irregular tumor cell morphology, spindle-shaped and pleomorphic, with large, deeply stained nuclei showing obvious atypia, frequent nuclear division, and no specific arrangement pattern (x100 for cell morphology). (B) Tumor immunohistochemical markers reveal diffusely only positive staining for Vimentin (x100 for immunohistochemistry).
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case_images: Figure 4A ). Furthermore, multiple immunohistochemical tests failed to show differentiation ( Figure 4B ), raising the possibility of an undifferentiated sarcoma or meningioma.