Volume 139, Issue 2, Pages 464-468 (February 2011) Chest Pain and Progressive Shortness of Breath in a 60-Year-Old Woman Following Liver Transplantation  Nelson Jennifer S. , MD, Jackson Autumn L. , MD, Darling Jama M. , MD, Gerber David A. , MD  CHEST  Volume 139, Issue 2, Pages 464-468 (February 2011) DOI: 10.1378/chest.09-2438 Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 1 A, Anterior/posterior chest radiograph (CXR) showing large right pleural effusion with loculated fluid along the minor fissure and an irregular pleural process anteriorly and laterally in the right hemithorax (arrow). Mediastinal contour on the right is abnormal, although this may be the result of a tortuous ascending aorta. Left lung is grossly normal. B, Right lateral decubitus CXR with arrow demonstrating loculated pleural effusion. CHEST 2011 139, 464-468DOI: (10.1378/chest.09-2438) Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 2 Axial chest CT image demonstrating large right pleural effusion. White arrows indicate right-sided anterolateral and anteromedial loculated fluid collections. Black arrow indicates filling defect in the right atrium (RA). CHEST 2011 139, 464-468DOI: (10.1378/chest.09-2438) Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 3 Apical four-chamber view on transthoracic echocardiography showing mildly dilated RA containing a large, highly reflective mass (arrow). See Figure 2 legend for expansion of the other abbreviation. CHEST 2011 139, 464-468DOI: (10.1378/chest.09-2438) Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 4 Cardiac MRI using a gated, true fast imaging with steady-state precession technique showing a large mass expanding but not obstructing the inferior vena cava (arrow). The mass extends into the RA and demonstrates soft-tissue signal intensity consistent with that of a tumor. See Figure 2 legend for expansion of the abbreviation. CHEST 2011 139, 464-468DOI: (10.1378/chest.09-2438) Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 5 Fine needle aspirate of the patient's RA mass. Smears of the aspiration show a cellular neoplasm with epithelioid features. There is evidence of cellular discohesion and cytologic atypia (hematoxylin-eosin, original magnification × 400). See Figure 2 legend for expansion of the abbreviation. CHEST 2011 139, 464-468DOI: (10.1378/chest.09-2438) Copyright © 2011 The American College of Chest Physicians Terms and Conditions

Figure 6 Core biopsy specimen of the patient's RA mass. Section shows a monomorphic epithelial neoplasm with a macrotrabecular architecture characteristic of hepatocellular carcinoma (hematoxylin-eosin, original magnification × 400). See Figure 2 legend for expansion of the abbreviation. CHEST 2011 139, 464-468DOI: (10.1378/chest.09-2438) Copyright © 2011 The American College of Chest Physicians Terms and Conditions