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Thoracolithiasis: a unique autopsy finding
Petr Hejna Jan Laco
Accepted: 7 February 2014
ÓSpringer Science+Business Media New York 2014
Case report
A 68-year-old man was found dead by his relatives at his
apartment with signs of advanced putrefaction. The coroner
who performed the postmortem examination at the scene of
the death requested a medicolegal autopsy because the
cause of death was uncertain. The man’s medical history
was unremarkable.
External examination revealed a well-nourished, well-
developed male body with greenish discoloration of the
skin and marbling over the trunk and both arms and thighs.
There was leakage of brownish fluid from the nose and
mouth and bloating of the abdomen. There was no evi-
dence of trauma.
On internal examination, there were signs of advanced
putrefaction involving all internal organs. Cardiac
autopsy revealed enlarged and hypertrophied ventricles
and scarring of the anterior wall of the left ventricle. The
coronary arteries were calcified; the left anterior
descending artery was almost completely occluded by
atherosclerotic plaques. Atherosclerosis was present in
the aorta with calcification and ulceration of its wall. The
most surprising finding was observed in the right thoracic
cavity after removal of the internal organs; there was a
bizarre oval, tumor-like object loosely lodged onto the
posterior parietal pleura (Fig. 1). The lesion was 3 cm in
diameter, circular, beige-brown in color, and firm. Mul-
tiple finger-like protrusions were present on the surface
of the lesion; thus, it resembled a small sea urchin
(Fig. 2). At dissection, the lesion showed a smooth,
slightly circulated cut surface that was pale yellow in
color. There were neither gross areas of necrosis nor
signs of hemorrhage.
Microscopically, the lesion was well circumscribed
and arborized and had no fibrous capsule (Fig. 3a). It
contained abundant hyalinized collagenous tissue arran-
ged into a micronodular or whorled pattern (Fig. 3b),
which stained with van Gieson’s method and blue and
green trichrome (Fig. 3c). Elastic fibers were not present.
Dusty violet granules of initial dystrophic calcification
were dispersed throughout the lesion. A partially calci-
fied, necrotic, presumably fatty, core, was present in the
center (Fig. 3d). The calcifications herein were irregu-
larly shaped, without the laminated appearance typical of
psammoma bodies. The lesion was completely devoid of
any recognizable (viable) cells, either within the mass or
on the surface. No inflammatory infiltration was
observed. Detection of amyloid using Sirius red was
negative. Immunohistochemical detection of a large panel
of antibodies (anaplastic lymphoma kinase, bcl-2, calre-
tinin, CD34, CD99, cytokeratins, desmin, epithelial
membrane antigen, S-100 protein, smooth muscle actin,
vimentin, and Wilms’ tumor-1) was repeatedly negative.
The microscopic findings were consistent with a diag-
nosis of thoracolithiasis.
Toxicology showed that no alcohol or common drugs
were present in the blood or urine. Death was attributed to
heart failure and was classified as natural.
P. Hejna (&)
Department of Forensic Medicine, Charles University in Prague,
Faculty of Medicine and University Hospital Hradec Kra
´love
´,
Sokolska
´581, 500 05 Hradec Kralove, Czech Republic
e-mail: hejnap@lfhk.cuni.cz; dr.petrhejna@gmail.com
J. Laco
The Fingerland Department of Pathology, Charles University in
Prague, Faculty of Medicine and University Hospital Hradec
Kra
´love
´, Sokolska
´581, 500 05 Hradec Kralove, Czech Republic
123
Forensic Sci Med Pathol
DOI 10.1007/s12024-014-9542-y
Discussion
Thoracolithiasis (also known as pleurolith, pleural stone,
intrathoracic calculus, or corpus liberum intrathoracicum)
is a unique finding at autopsy, radiology, or surgery. It is
characterized by the presence of one or more free bodies
with or without calcification in the thoracic cavity, with no
previous trauma, intervention, or pleurisy. Nevertheless, a
precise definition of thoracolithiasis is still missing from
relevant medical textbooks. The first case of thoracolithi-
asis was reported by Dias et al. [1].
To date, only about 20 reports of thoracolithiasis have
been presented in the literature, none of which were pub-
lished in the medicolegal literature [16]. The majority of
these cases were from Japan [2,3], whereas only several
reports were published in other countries [46]. Almost all
published cases described a solitary occurrence of tho-
racolithiasis. Rawstorne et al. [5] reported the incidental
detection of two pleural stones. The largest case series was
reported by Kinoshita et al., who described 11 cases of
thoracolithiasis among 12,835 patients using multidetector-
row computed tomography [3].
Most pleuroliths are discovered in the left hemithorax
[13,5]. The lesion is usually situated inferiorly in the
thoracic cavity, probably because of gravity, which means
that the thoracolith can migrate and change its position
within the thoracic cavity as has been repeatedly demon-
strated by computed tomography in living patients [3]. The
lesion is usually calcified, but pleuroliths without calcifi-
cation have also been reported [2]. The lesion is typically
oval and pearl-like with a smooth surface [16]. In con-
trast, the pleural stone presented herein showed multiple
thorn-like protrusions on its surface.
Histologically, thoracolithiasis generally comprises
central fatty tissue with necrosis surrounded by almost
a-cellular fibrous tissue. Calcification may be present
within the core. Other histologic findings may include
calcification surrounded by cellular fibrous tissue, central
caseous necrosis covered by fibrous tissue, fibrous tissue
with dust and calcification, and fatty tissue with calcifica-
tion. Microscopic differential diagnosis includes mainly
calcified tuberculous granuloma, calcifying fibrous tumor,
inflammatory myofibroblastic tumor, and solitary fibrous
tumor [1,2,5,6].
The etiology of thoracolithiasis remains unclear, and
various authors have suggested several explanations
including a focus of old tuberculosis, aggregation of con-
iophages, an infarcted lipoma, and pericardial or pleural fat
entering the thoracic cavity [46]. Iwasaki et al. [2]
hypothesized that the association between pericardial fat
and thoracolithiasis is highly likely, and this idea is further
supported by the predominant occurrence of thoracolithi-
asis in the left hemithorax.
A number of questions may arise when such a bizarre
finding is incidentally revealed at autopsy. The pleurolith
may be mistaken for an encapsulated foreign body that
remained in the thorax after a penetrating chest trauma
(e.g., gunshot injury, sharp force trauma, or impalement
[7]). In addition, the pleurolith may mimic an unintentional
consequence of thoracic surgery, such as an instrument left
behind. The immobile lesion may be also mistaken for a
pleural or pulmonary neoplasm [8]. The free lesion may be
considered to be part of an intrathoracic neoplasm that
became detached from its primary localization either
spontaneously or during autopsy procedures (e.g., pul-
monary hamartoma or pericardial lipoma [9]). Finally, the
pleural stone may be mistaken for a parasitic body or as a
consequence of a granulomatous process [10].
Diagnosis of pleuroliths may also be challenging from
a clinical point of view. Such lesions are usually identi-
fied incidentally as an actual pulmonary nodule during
imaging examinations. The first clinical possibility that is
Fig. 1 Loosely lodged pleural stone incidentally discovered in the
right pleural cavity during the removal of intrathoracic organs (blue
arrow). The yellowish mass in the left thoracic cavity is fat
accumulation secondary to putrefaction (the body was stored in the
mortuary refrigerator before autopsy)
Fig. 2 Calcified pleural stone removed from the right pleural cavity
with multiple finger-like protrusions on the surface
Forensic Sci Med Pathol
123
generally taken into consideration is a localized intra-
thoracic neoplasm. The pleurolith may be distinguished
from other lesions by its mobility and calcification. In
most cases, the thoracolithiasis is completely asymptom-
atic and does not require any specific treatment. Tho-
racolithiasis will probably be detected more frequently in
the future as modern imaging methods become more
readily available for both clinical examinations and digital
autopsies [3,6].
In conclusion, we have reported an uncommon benign
abnormality: a free pleural stone that was incidentally
revealed in the right pleural cavity after removal of intra-
thoracic organs during autopsy. The lesion in this case was
remarkable with respect to its large size and unusual
external appearance characterized by multiple thorn-like
protrusions. Both forensic pathologists and radiologists
should always bear in mind the possibility of the incidental
discovery of thoracoliths.
Acknowledgments This work was supported by the program
PRVOUK P37/11 and by project LM2010004.
References
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Fig. 3 a Arborized shape of the lesion. Note the calcified core
(hematoxylin-eosin [HE], original magnification 910). bWhorled
pattern of the hyalinized collagenous tissue, with violet dust as foci of
calcification (HE, original magnification 9200). cCollagen fibers
stained with blue trichrome (original magnification 9100). dCalcified
central core (HE, original magnification 950)
Forensic Sci Med Pathol
123
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C. Incidental occult gunshot wound detected by postmortem
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incidental finding at autopsy. Am J Forensic Med Pathol.
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Forensic Sci Med Pathol
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