PMC10157448_01
Right cervical pathological lymphadenopathy (a) Longitudinal and (b) transverse ultrasound images demonstrated loss of the fatty hila (solid white arrow), lobulated contours (solid white arrow heads) and increased short axis diameter of 1.69 cm.
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Right neck ultrasound revealed a cluster of large, lobulated, hypoechoic lymph nodes with loss of fatty hila (Figure 1a & b).
Fine needle aspiration biopsy of the cervical lymph node showed poorly cohesive malignant cells with a high nuclear-cytoplasmic ratio, scant cytoplasm, 'salt-and-pepper' chromatin and inconspicuous nucleoli similar to the cells seen in the urinary bladder. Papanicolaou stain, original magnification 400x (a) and Diff Quik stain, original magnification 400x (b).
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A lymph node fine needle aspiration biopsy proved metastatic carcinoma with morphological features suggestive of small-cell carcinoma (Figure 2a & b).
(a) PA CXR: Left hilar soft tissue mass with attenuation of the left main-stem bronchus and right tracheal shift (white arrow). Lateral CXR (b) shows hilar and mediastinal adenopathy (white arrow heads).
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A posteroanterior chest radiograph performed at presentation revealed a left hilar mass with attenuation of the left main-stem bronchus and accompanying contralateral mediastinal shift (Figure 3).
(a) CT chest axial: Confirms extensive hilar and mediastinal mass-nodal complex with necrosis (white arrow heads). The mass encases and narrows the left mainstem bronchus (solid white arrow), main pulmonary trunk (grey arrow), and (b) coronal reconstruction shows trans-spatial extent of the mass.
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Post-contrast staging chest CT (Figure 4) showed an infiltrative, central, trans-spatial mediastinal mass encasing the left main-stem bronchus, left and right main pulmonary arteries and descending aorta.
Abdomino-pelvic CT (a) multiple urinary bladder enhancing exophytic mural mass lesions (white arrows) (b) lesion (white arrow) located in the posterior bladder wall infiltrates the right vesico-ureteric junction (white arrow head), causing upstream obstructive uropathy (c) dilatation of the right renal pelvis (white arrow) secondary to tumour infiltrating the right vesico-ureteric junction.
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Abdomino-pelvic CT revealed multiple enhancing soft tissue mural lesions in the urinary bladder - consistent with metastases - the largest was located at the bladder base, with a similar lesion located anteriorly - in the space of Retzius - (Figure 5a), and complicated by right-sided hydro-uretero-nephrosis because of infiltration of the right vesico-ureteric junction (VUJ) by the largest deposit (Figure 5b & c).
Histological and immunohistochemical findings in the bladder biopsy. (a) Malignant cells are present in the lamina propria (left lower quadrant) with overlying normal urothelium and a lymphocytic aggregate to the right (haematoxylin and eosin, original magnification 200x). The tumour cells and urothelium express cytokeratins (MNF116) (b). Synaptophysin is expressed in the cytoplasm of the tumour cells (c) and thyroid transcription factor 1 is strongly expressed in the tumour cell nuclei (d).
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Immunohistochemical stains for broad-spectrum cytokeratin (MNF116), synaptophysin, chromogranin A and TTF-1 were all positive, confirming the diagnosis of metastatic small-cell neuroendocrine carcinoma (Figure 6a, b, c & d).