Presentation
Chest pain. Calf pain.
Patient Data
Single pulmonary nodule is seen in the medial left upper zone projecting over the left first rib end. Remainder of the lungs and pleural spaces are clear. Cardiomediastinal contour is normal. No destructive bone lesion identified.
There is a spiculated nodule at the left lung apex. Enlarged right and left lower paratracheal lymph nodes. No destructive bone lesion. Upper abdomen unremarkable.
Patient proceeded to endobronchial ultrasound guided lymph node biopsy.
Histopathology
MICROSCOPIC DESCRIPTION: The smears and cell block contain abundant malignant epithelial cells occurring singly and in occasional clusters, in a background of blood. The cells show a pleomorphic nuclei, hypochromatic chromatin, prominent nucleoli and foamy cytoplasm. Occasional cells are showing a single hard edge mucinous vacuole. The cell block contains approximately 80% tumor cells. By immunohistochemistry the tumor cells are positive for CK7 (diffuse), CK20 (focal), GATA3 (weak) and negative for CDX2, TTF1, NAPSIN-A, p40, PSA and PAX8.
DIAGNOSIS: TBNA 4L: Non-small cell carcinoma. Comment: The primary site is not clearly identified by immunohistochemistry. The more likely primary sites are urogenital tract, pancreaticobiliary tract, and upper gastrointestinal tract. A primary lung carcinoma is not excluded.
Case Discussion
The lung apices should be checked on every chest x-ray, regardless of whether in an exam or not. It is a common site of "hidden" pathology, and is a good place to search if an obvious abnormality is not seen on the initial search.
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