PMC6699001_01
Computed tomography chest angiography to rule out pulmonary embolism instead
found carinal, hilar (left), and paratracheal lymphadenopathy (right).
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The patient underwent a computed tomography (CT) angiography to rule out pulmonary embolism, but the imaging found instead moderately prominent intrathoracic lymphadenopathy of uncertain etiology (Figure 1).
Computed tomography scan of abdomen and pelvis revealed a cystic structure in
the right adnexa.
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CT scan of the abdomen and pelvis demonstrated prominent lymph nodes in the upper retroperitoneal region including a 3.3-cm ovarian cystic structure (Figure 2).
Ultrasound of pelvis did not show any obvious lesions or cystic
structures.
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However, no discrete lesion or adnexal masses was identified on ultrasound of pelvis (Figure 3).
Computed tomography scan of the neck with intravenous contrast revealed
thrombus in the right internal jugular vein extending from the
mediastinum.
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Imaging found a thrombus extending from the midportion of the right internal jugular vein down to the superior mediastinum (Figure 4).
Magnetic resonance imaging of brain T1 axial showed no hydrocephalus (A),
leptomeningeal enhancement most prominent in the falx cerebri (seen in axial
[B], coronal [C], and sagittal [D] T1 images with gadolinium). Magnetic
resonance venography showed a narrowing of the distal cerebral venous sinus
(E).
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Magnetic resonance venography/magnetic resonance imaging (MRI) were remarkable for slight narrowing of the distal portion of the straight sinus and leptomeningeal enhancement but negative for hydrocephalus (Figure 5).
(A) Computed tomography scan of neck found several new lymphadenopathies of
increasing sizes. Cerebrospinal fluid (CSF) malignant cells are seen on CSF
gram stain (B) and wet mount (C). Placental alkaline phosphatase staining
not shown.
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CT scan of chest and neck showed new findings of cervical lymphadenopathy that was not present on previous CT 6 weeks prior (Figure 6). Additionally, evidence of PLAP was identified persistently on cerebrospinal fluid (CSF) cytology, which confirms leptomeningeal carcinomatosis (Figure 6).
Immunohistochemistry stains of cervical lymph node biopsy. (A) Hematoxylin
and eosin, 4x: Showing malignant cells infiltrating subcapsular sinus and
spread throughout the sinusoids. (B) CK 7 positive, 10x: seen in lung,
breast, and upper gastrointestinal adenocarcinoma type malignancies. (C)
CDX2 positive, 10x: Seen in gastrointestinal primary malignancies and
ovarian mucinous carcinoma. (D) Placental alkaline phosphatase positive,
10x: Nonspecific, typically associated with germ cell tumor. (E) TTF-1
negative, 10x: Seen in thyroid and lung malignancies.
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Immunohistochemical staining and cytopathology focusing on search for occult primary were positive for cytokeratin 7 and 20, PLAP, and CDX2 (Figure 7).