PMC4437418_01
MRI T2 images showing thoracic and lumbar vertebral metastatic disease.
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This finding was highly suggestive of neoplastic metastases (Figure 1).
(a) Ct Brain 1.5 x 1.16 cm hemorrhagic right frontal lobe metastatic disease. (b, c) Postgadolinium MRI shows multiple ring enhancing metastatic lesions.
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Subsequent brain CT and MRI showed multiple edematous hyperdense lesions, also consistent with metastatic disease (Figures 2(a), 2(b), and 2(c)). 
(a) CT of chest with contrast in mediastinal view displaying 2 cm right suprahilar soft tissue mass. (b) CT of abdomen showing multiple hepatic metastatic foci.
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Upon closer examination, CT showed a 2 cm right suprahilar soft tissue mass suggestive of a central pulmonary neoplasm with surrounding atelectasis, marked mediastinal and right hilar lymphadenopathy, numerous low-density hepatic lesions suspicious of metastatic disease, abdominal lymphadenopathy, and a left adrenal nodule suggestive of metastatic disease (Figures 3(a) and 3(b)).
(a) Liver Biopsy:light microscopy at 200x magnification of metastatic lesion. (b) Liver Biopsy:light microscopy at 600x magnification of metastatic lesion. (c) Liver Biopsy:positive immunostaining with CD56. (d) Liver Biopsy:positive immunostaining with chromogranin.
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The cuboidal shaped cells also consistently demonstrated increased nuclear/cytoplasmic ratios with numerous prominent nucleoli (Figures 4(a) and 4(b)). Factor 1 (TTF-1) (Figures 4(c) and 4(d)). Final pathology report was consistent with high-grade large cell neuroendocrine carcinoma. 