-a 23 year-old male
-symptoms: cough, hemoptoic expectoration and thoracic internal pain on the left side.
-the past 2-3 months the patient notes asthenia, fatigue, lack of appetite, weight loss (6-7kg/2 months) and night sweats.
-Two weeks ago, the patient began coughing and presented persistent mucous expectoration.
-The patient describes coughing tissular fragments on two different occasions.
Past medical history - none
ETOH – none
Smoking – none
-Physical examination: - indolent tumefaction of left testicle (approximately for 2 years)
Thoracic X-ray: left mediastino-pulmonary mass
RBC = 5.05/101*101/µL (NV=4,2-10/101*101/µL),
HGB = 12 g/dl (NV=14-18/g/dl),
HCT = 39% (NV=41-51%),
WBC = 14,9/*103/µL (NV=4,2-10/*103/µL),
Granulocytes = 82,6% (NV=30-75%),
Lymphocytes = 13,9% (NV=19-40%)
MID = 3,5% (NV=4-15%),
Sed rate (ESR) = 47 mm/1h and 110 mm/2h.
Biochemistry: ALAT, ASAT, blood sugar, total bilirubin, creatinine şi electrolytes, urine sample – all normal
Histopathological examination (of expectorated bronchial cast): necrotic tissue, fibrino-hematic deposits, thrombotic vascular structures, leukocytic elements and medium-sized tumour cells with high nuclear-cytoplasmic ratio, prominent nucleoli, amphiphilic to eosinophilic cytoplasm. Cells are isolated and in small groups.
The CD30 positive cells as well as the inflammatory cells plead for a Mixed Cellularity Hodgkin’s lymphoma. The only argument against this diagnostic is the positive panCK in 20% of the tumour cells.
- anti-LCA antibodies mark approximately 50% of the leucocytes in the cast
- anti-CD15 marks eosynophyles
- anti-CD68 marks 50% of the macrophages
- CD30 marks tumour cells
- panCK (present exclusively in epithelial cells) marks approximately 20% of the tumour cells
Thoracic CT: left adenopathic paramediastinal mass, Ø9.5 cm, in contact with large vessels and invading the left upper lobe of the lung. Similar right paramediastinal mass, Ø4.5 cm, in contact with the superior vena cava and invading the mediastinum. Right lower paratracheal adenopathy, Ø3 cm. Mass in right lower lobe, Ø3 cm. Adenopathic lomboaortic mass, approximately Ø6 cm.
Liver, spleen, kidneys, adrenal glands – normal structure and size.
Result CT: adenopathic mediastinal and lomboaortic masses (possible Hodgkin Syndrome); mass in right lower lobe.
Bronchoscopy: Exophytic lesion in left upper lobe bronchus. Biopsy reveals a proliferation of undifferentiated malignant tumour cells with large hyperchrome nuclei, prominent nucleoli, intracytoplasmic hyaline globules, with a solid, pseudoglandular, papillary and glomerulous-like architecture. Tumour cells are panCK positive and α-fetoprotein positive.
AFP = 1500 UI/ml (NV=0-2 UI/ml).
- differential diagnostics pros and cons for each
- investigation needed for diagnostic
- treatment if possible
- explain how you get the solution