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Mesothelioma in the azygos fissure

Case contributed by Ali Alsmair
Diagnosis certain


The patient presented with right sided pleural effusion. Investigations revealed pleural thickening and nodularity and pleural biopsy-proven mesothelioma. This examination is being done for evaluation and staging purposes.

Patient Data

Age: 55 years
Gender: Female


Nuclear medicine

There is evidence of a small amount of right-sided pleural effusion associated with nodular pleural thickening and irregularity and areas of calcifications [prominent in the lower posterior pleural surface], with prominent nodule within a major fissural nodule measuring 1 cm in maximum dimension with mild increased FDG uptake and the SUV maximum is exceeding 2.6 with ground-glass changes along the fissure and near the pleural fluid sides.

Also, there is an azygos fissure anatomic variant which shows significant thickening and appears as the most prominent hypermetabolic pathology with a thickness of 0.8 cm and SUV max reaching 8.7.

Also, a prominent hypermetabolic nodule is noted posterior at the same level measuring almost 1 cm with SUV max not exceeding 4.0.

No evidence of any suspicious hypermetabolic separate lung nodules within either lung field.
Hypermetabolic chest wall activity is noted within tracts at the site of a previous chest tube insertion with associated subcutaneous fat stranding. No evidence of any hypermetabolic left-sided pleural effusion. No evidence of any enlarged hilar or mediastinal lymph nodes [reference mediastinal SUV max = 2.6].

In the inferior mediastinum, incidental elongated hypermetabolic activity is noted along the most distal part of the esophagus reaching the gastroesophageal junction along almost 3 cm which could be due to changes of esophagitis.

Histopathology report

Case information: Received 2 paraffin blocks labeled P21-2053 corresponding pathology report.
Tissue origin: Right visceral and parietal pleura.

The tumor cells are positive for Calretinin. D20-40 and CK5/6 (rare cells) immunostatin. They are negative for TTF-1, BerEp4 and P40 immunostatins. WT-1 immunostatin is noncontributory. Tumor necrosis is present. Mitotic figures up to 7/2 mm2.

Right visceral and parietal pleura biopsy: Malignant high-grade peritoneal mesothelioma, solid pattern.

Case Discussion

Mesothelioma of the azygos fissure is a very rare entity, with only one case reported in the medical literature 1. Making this the second reported case of mesothelioma arising in the azygos fissure.

Many thanks to Dr Mais Al Halaseh for this case. 

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