case_images: PMC10917883_01
case_images: Bone Marrow Biopsies from 2018 and 2020. (A) Bone marrow biopsy from 2018 showing trabecular thickening and increased cellularity. (B) Bone marrow biopsy from 2020 also showing increased cellularity and increased numbers of atypical spindle cells (inset). (C) A reticulin stain showing extensive fibrosis. A negative CD34 immunostain in the atypical spindle cells (inset).
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case_images: IHC stains were positive for tryptase, CD117, and CD34 ( Figure 1A ). Reticulin stain showed severe grade 3 myelofibrosis (MF3) ( Figures 1B, C ).
case_images: Lung Biopsy. (A) Lung biopsy from 2021 showing focal, well-circumscribed nodules comprised of atypical spindle cells. (B) Plump spindle cells showing slit-like vasoformative channels (arrows). Lung biopsy also showing ERG positive cells (inset) and CD31 (not pictured).
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case_images: In June 2021, video-assisted thoracoscopic (VATS) lung biopsy of the right upper and middle lung lobes was performed due to worsened innumerable lung nodules first seen in December 2020 ( Figure 2A ). IHC stains were positive for CD31, CD34, ERG, FLI-1, collagen IV, and D2-40 ( Figure 2B ).
case_images: CT scans without contrast and MRI of the tumor lesions. (A, B) Upper left and right images of a CT scan of the abdomen and pelvis showing hypodense tumor lesions in the liver (A) and spleen (B). (C) Lower left image showing a chest CT scan of the lung with innumerable pulmonary nodules seen throughout the lungs. (D) MRI of the brain showing five supratentorial lesions with minimal enhancement within bilateral cerebral hemispheres. The largest lesion found within the superior left parietal lobe measured 2.4 cm in maximal dimension. Findings consistent with multiple intracranial hemorrhagic metastases with surrounding vasogenic edema.
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case_images: In addition, restaging CT scans and MRI were compatible with disease progression and new brain metastases accompanied by both motor and cognitive dysfunction, as well as worsening dyspnea on exertion ( Figure 3 ).