A 76-Year-Old Man With Anemia, Bone Pain, and Progressive Dyspnea Thitiporn Suwatanapongched, MD, Prapaporn Pornsuriyasak, MD, Wasana Kanoksil, MD, Thotsaporn Morasert, MD, Warapat Virayavanich, MD  CHEST  Volume 145, Issue 4, Pages 913-918 (April 2014) DOI: 10.1378/chest.13-1662 Copyright © 2014 The American College of Chest Physicians Terms and Conditions

Figure 1. A, B, Sagittal precontrast T1-weighted (A) and postgadolinium fat-suppressed T1-weighted (B) MRIs demonstrating multifocal gadolinium-enhanced hypointense lesions within the vertebral bodies and posterior elements of the sacrum and lumbar vertebrae. Note the presence of presacral, epidural, and posterior paraspinal soft-tissue masses (arrows). The intervertebral discs are spared. CHEST 2014 145, 913-918DOI: (10.1378/chest.13-1662) Copyright © 2014 The American College of Chest Physicians Terms and Conditions

Figure 2. Anteroposterior chest radiograph showing two vague opacities with partially sharp and unsharp margins at the right-sided mid hemithorax. Also note multiple lentiform-shaped masses having a convex medial margin, tapered superior and inferior edges, and obtuse angles at the pleural interfaces bilaterally. A small amount of bilateral pleural effusions is present. No skeletal abnormality is seen. CHEST 2014 145, 913-918DOI: (10.1378/chest.13-1662) Copyright © 2014 The American College of Chest Physicians Terms and Conditions

Figure 3. A, B, Axial chest CT scans with mediastinal window setting at the level of the main pulmonary artery (A) and T12 vertebral body (B) revealing moderate-sized bilateral pleural effusions with multiple noncalcified bilateral pleural masses and chest wall masses (white arrows), some of which wrap around the ribs and sternum. The masses show relatively homogeneous contrast enhancement, quite similar to the collapsed lungs (*), liver (L), and spleen (S). Extension into the right-sided intervertebral foramen and the spinal canal at the T12 level (black arrow) is also noted. All visualized thoracic bones are intact without alteration of their shape or attenuation. CHEST 2014 145, 913-918DOI: (10.1378/chest.13-1662) Copyright © 2014 The American College of Chest Physicians Terms and Conditions

Figure 4. Conventional preparation with Papanicolaou staining (original magnification ×400) of the pleural fluid revealing many medium to large single cells with convoluted nuclei and a minimal to moderate amount of cytoplasm. Note a histiocyte (arrow) in the center. CHEST 2014 145, 913-918DOI: (10.1378/chest.13-1662) Copyright © 2014 The American College of Chest Physicians Terms and Conditions

Figure 5. A, Cell block preparation of the pleural fluid with hematoxylin-eosin staining (original magnification ×400) revealing a loose cluster of multiple pleomorphic and immature plasma cells (seen on the right side of the image and outlined by arrowheads) having eccentric pleomorphic nuclei, amphophilic cytoplasm, and perinuclear hof admixed with RBCs. Note a mesothelial cell (large arrow) and a histiocyte (small arrow). B-D, Immunohistochemical staining (original magnification ×400) showing numerous neoplastic cells marked with CD-138 in their cytoplasmic membranes (B) and positive λ light-chain expression in their cytoplasm (C) compared with the negative immunoreactivity to κ light chain (D). CHEST 2014 145, 913-918DOI: (10.1378/chest.13-1662) Copyright © 2014 The American College of Chest Physicians Terms and Conditions