PMC6671883_01
- Complete opacification of the right hemithorax. Note obliteration of ipsilateral main bronchus and foci of perihilar alveolar opacity on the left lung.
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A perihilar alveolar opacification was seen on the left lung (Figure 1).
- Axial computed tomography (CT) of the chest - mediastinal window - showing voluminous hypodense collection with discrete pleural thickening and enhancement associated with retraction of the apex of the right hemithorax.
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The chest computed tomography showed volumetric reduction of the right lung parenchyma, which had totally collapsed, with bronchial and alveolar areas filled in by fluid content (Figure 2).
- Axial CT of the chest - mediastinal window. A - Hypodense liquid content in the right main bronchus (arrow) and heterogeneous enhancement of the lung parenchyma; B - Hypodense liquid content within the interlobar bronchus (arrow); C - Irregularity and thinning of the pulmonary veins close to the left atrium. Note pleural and pericardial effusion as well as bilateral gynecomastia.
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The basal segments had heterogeneous attenuation with some parenchymal calcifications, which suggested the presence of a poorly delimited expanding mass (Figure 3).
- Axial CT of the chest - pulmonary window. A and B - Fissure thickening with micronodules. Septal thickening and ground glass opacities associated with septal thickening ("crazy paving") in the left upper lobe.
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Ground-glass opacity areas associated with diffuse interstitial thickening displaying a mosaic pattern was present in the left lung (Figure 4).
- A - Gross examination of right lung showing pleural thickening, adherence to diaphragm, and pneumonia-like pattern; B - Photomicrography of tumor cells filling alveolar spaces (air dissemination) (H&E 200x); C - Photomicrography of tumor lymphatic dissemination; note fluid edema in bronchiolar lumen (right bottom) (H&E 200x); D - Photomicrography of segmental bronchus invaded and obliterated by tumor (H&E original magnification 12.5x).
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Microscopic dissemination through lymphatics, pleura, and airways was detected (Figure 5). Histological examination revealed mucin-producing neoplastic cells arranged in solid sheets or dyscohesive clusters, which filled the alveolar spaces (Figure 5).
- Photomicrographs. A - Acinar pattern with columnar cells (H&E 400x); B - Solid pattern with mucin vacuoles (H&E 400x); C - Signet-ring cells (H&E 400x); D - Sheet-like pattern of poorly cohesive cells with eosinophilic cytoplasm (H&E 400x).
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Moderately differentiated areas with columnar cells and acini as well as foci of keratinization and necrosis were seen scattered through the tumor (Figure 6).
- Photomicrographs. A - Large eosinophilic cells in focal trabecular pattern (H&E 400x); B - Clear cells (H&E 400x); C - Eosinophilic globules (H&E 400x); D - Large nuclear pseudoinclusion (arrow) (H&E 400x).
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Nuclear pseudoinclusions were occasionally seen (Figure 7).
- Photomicrographs. A - Immunohistochemistry for keratin 7 (H&E 400x); B - Focal nuclear TTF-1 immunostaining (H&E 400x); C - Focal keratinization (H&E 400x); D - Focal immunostaining for keratin 5/6 (H&E 400x).
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Staining for keratins 5/6 was focally positive, especially in the foci of keratinization (Figures 8 and 9).
- Photomicrographs. A - Immunohistochemistry for CEA with diffuse staining (H&E 100x); B - Multifocal immunostaining for AFP (H&E 400x); C - Diffuse Hep-par (H&E 400x); D - Cytoplasmatic granular TTF-1 staining (H&E 400x).
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Staining for keratins 5/6 was focally positive, especially in the foci of keratinization (Figures 8 and 9).