PMC9177346_01
Thoracic CT at the initial diagnosis, without intravenous administration of contract material (increased creatinine levels): (a) dense mediastinal pulmonary mass localized in the medium lobe of the right lung, which meets the pulmonary hilum, and cannot be separated from the mediastinal structures, mediastinal, and retrocrural lymphadenopathies; (b) adrenal glands with diffuse increased sizes and spontaneous tissue density.
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The computed tomography (CT) scan of the chest showed minimal right pleural effusion with an ipsilateral pulmonary mass, lymphadenopathy of the mediastinal and retrocrural spaces, and bilateral adrenal masses (Figures 1(a) and 1(b)).
Gross findings of the autopsy specimens: (a) 4 x 3 cm poorly defined lesion in contact with the pulmonary hilum, and multiple foci of necrotic nodules, localized in the right lung. (b) Gross view of the gastric mucosa with one ulcerative, infiltrative lesion. (c) Whitish-yellow, poorly defined lesion in the right adrenal gland. (d) Left kidney showing a surface of cut section with multiple poorly defined lesions with diffuse disposition.
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Macroscopically, a 4 x 3 cm poorly defined lesion was found in the middle lobe of the right lung, with multiple bilateral necrotic nodules, varying in size from 0.5 cm to 1.5 cm in diameter (Figure 2(a)). The gastric examination diagnosed an ulcerative and infiltrative lesion, measuring 1 cm in the greatest dimension (Figure 2(c)). Moreover, multiple poorly defined lesions were found in both kidneys and the adrenal glands (Figures 2(b) and 2(d)).
Microscopical features of (a) lung tumor composed of malignant cells, predominantly arranged in an alveolar growth pattern, defined by solid sheets and tumor nests (H&E, 40X); (c) gastric mucosal lesion-malignant epithelial proliferation with adenocarcinoma morphology (H&E, 100X); (b) renal lesion; and (d) adrenal lesion-malignant epithelial proliferation with cytological and architectural modifications like that found in the lungs, presenting with massive alveolar growth pattern and extensive foci of necrosis (H&E, 40X).
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Malignant cells were predominantly arranged in a solid growth pattern, focally presenting papillary features (Figure 3(a)). Morphological evaluation of the lesion found in the stomach also revealed a malignant epithelial proliferation of the gastric mucosa with glandular differentiation, which extended to the muscular layer, accompanied by lymphovascular invasion (Figure 3(b)).
Immunohistochemistry evaluation of the lung surgical specimen. (a) 90% positive nuclear immunostaining for TTF-1 biomarker (IHC; 40X). (b) 85% positive cytoplasmic immunostaining for Napsin A biomarker (IHC; 40X). (c) Diffuse and intense membranous staining reaction for CK7 biomarker (IHC; 40X). (d) Negative immunostaining for CK20 biomarker (IHC; 40X).
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Napsin A (Figure 4(b)) and a diffuse and intense membranous staining reaction for the cytokeratin 7 (CK7) biomarker (Figure 4(c)) were remarked. Negative results were noticed for cytokeratin 20 (CK20), p40, synaptophysin, and chromogranin A biomarkers (Figure 4(d)).