{
  "abstract": "A male in his 20s who had never smoked presented with complaints of left-sided pleuritic chest pain of 2 months’ duration. It was associated with a cough with scanty mucopurulent expectoration, breathlessness on exertion (Modified Medical Research Council (mmRC) Gd I) and anorexia. On respiratory system examination, the patient had stony dull percussion and absent breath sounds over the left infrascapula and infra-axillary areas. His chest radiograph revealed a left-sided massive pleural effusion with mediastinal and tracheal shifts to the right ( figure 1). He underwent diagnostic pleurocentesis, which was serosanguinous, exudative by Light’s criteria and lymphocyte-predominant (65%) with low adenosine deaminase (ADA) (23 U/L). Pleural fluid showed no evidence of atypia and malignancy. CT of the chest (figure 2) revealed focal expansion of the lateral and anterolateral aspects of the left 6th rib with fine linear calcific strands perpendicular to the long axis of the rib (sunburst appearance) (spiculated periosteal reaction)1 and an associated ill-defined heterogeneously hyperdense soft tissue lesion (14×6 cm) abutting the costal pleural surface of the anterior and lateral aspects of the 6th and 7th ribs on the left side, with gross left-sided pleural effusion with near-complete collapse of the left lung. He underwent whole-body positron emission tomography and CT (figure 3), which showed a large expansile lesion arising from the lateral and anterolateral aspects of the left 6th rib with multiple calcific strands arising from the inner cortex of the rib, giving rise to a sunburst appearance associated with a large heterogeneously fluorodeoxyglucose (FDG)-avid (standardised uptake value (SUVmax) 6.13) soft tissue component measuring 14×8×12 cm, invading the pleura, multiple FDG-avid left-sided pleural deposits and left-sided pleural effusion. Patient underwent ultrasonography (USG)-guided biopsy of the rib lesion, which was sent for histopathological examination and immunohistochemistry. Histopathological examination (HPE) of the biopsy revealed (figure 4) a malignant small round blue cell tumour composed of sheets of uniform round-to-oval cells with scant cytoplasm and round nuclei with fine chromatin and inconspicuous nucleoli, which showed positivity for vimentin, cluster of differentiation 99 (CD99), Friend Leukemia Integration 1 (FLI-1) and NK2 Homeobox 2 (NKX2-2) with a Ki-67 index of 40%–50% in most proliferative areas, suggestive of Ewing’s sarcoma.2 Patient received 16 cycles of chemotherapy, following which he showed a significant clinico-radiological improvement. Patient remains under the close follow-up of the medical oncology team and continues to show a favourable clinical response.",
  "authors": [
    {
      "affiliations": [
        "Respiratory Medicine, AFMC Campus, Pune, Maharashtra, India"
      ],
      "name": "Rahul Tyagi"
    },
    {
      "affiliations": [
        "Respiratory Medicine, AICTS, Pune, Maharashtra, India"
      ],
      "name": "Deepankar Khare"
    },
    {
      "affiliations": [
        "Department of Radiodiagnosis and Interventional Radiology, Armed Forces Medical College, Pune, Maharashtra, India"
      ],
      "name": "Bharat Hosur"
    },
    {
      "affiliations": [
        "Histopathology, AFMC Campus, Pune, Maharashtra, India",
        "Pathology, AFMC Campus, Pune, Maharashtra, India"
      ],
      "name": "Vikram Singh"
    }
  ],
  "title": "Ewing’s sarcoma of rib: sunburst appearance",
  "uid": "1f1c41dc-ded7-5dd4-837f-387a6e4108e5"
}