CBC showed WBC of 6.45 × 109
/L, RBC 4.59 × 1012
/L, hemoglobin of 11.9
g/dL, hematocrit 37.5%, MCV of 81.8 fL, MCH of 26
pcg, MCHC 31.8
g/dL, RDW 12.5%, platelet count of 453 × 109
/L, mean platelet volume of 8.4
fL, neutrophils of 60.8%, lymphocytes 18.7%, monocytes 10.4%, eosinophils 7.1%, basophils 1.7%, lymphocyte count absolute 1.21, monocytes 0.67, that is 670, eosinophils 0.46, basophils 0.11, atypical cells 1.2% and nucleated RBCs per high power field.
bilirubin of 6.3
mcmol/L, alkaline phosphatase 99
U/L, ALT of 24
U/L, AST of 12
U/L, GGT of 29
U/L, total protein of 79
g/L, albumin of 29
g/L, and albumin/globulin ratio was 0.6.
Coagulation profile: PT of 13.45
sec, INR of 1.07
sec, and PTT of 36.41
Renal panel: sodium of 137
mmol/L, potassium of 4.6
mmol/L, chloride of 102.1
mmol/L, bicarbonate of 27
mmol/L, BUN of 3.3
mmol/L, and creatinine of 86
mcmol/L. MDRD calculated was more than 60
Bone panel: Phosphorus of 1.24
mmol/L, ALP of 101
U/L, total protein of 70
g/L, albumin of 31
g/L, calcium of 2.04
mmol/L and corrected calcium of 2.25. Magnesium of 0.95
C-reactive protein = 80.9
mg/L. CMV IgG was reactive, CMV IgM non reactive. ESR of 16
The chest X-ray revealed ill-defined area of consolidation seen at the left hilar region, no evidence of rib destruction, no pleural effusion in comparison to previous radiographs as per the radiologist. Abdominal ultrasound was done and did not show any abnormalities.
The patient underwent CT chest, abdomen, and pelvis. It showed left upper lung lobe mass, there was a nodular peribronchovascular infiltration involving the left lingular segment suggestive of lymphomatous infiltration, multiple enlarged mediastinal lymph nodes located at anterior mediastinal, paratracheal, peribronchial, subcarinal, and bilateral hilar groups, with the largest was at the paratracheal group measured 2.65 × 1.6
cm, still the thrombus in the right brachiocephalic vein and superior vena cava extended to the right atrium and the right subclavian vein with calcification of right axillary vein suggestive of chronic thrombosis with recanalization of the right subclavian vein. Minimal pericardial effusion was noted. No pleural effusion. The size and configuration of cardiac and mediastinal silhouette structures were maintained. The liver was normal in size in form of attenuation, no focal lesion, and no biliary dilatation. Inferior vena cava, hepatic, and portal vein were patent. Spleen, pancreas, both adrenals, and both kidneys were normal. No ascites was noted. The visualized thoracic bony cage, spine, and pelvis showed no focal bony lesions.
The patient underwent bronchoscopy with transbronchial biopsy. The bronchoscopy showed the vocal cords were normal, trachea normal, carina shape normal, and in right and left lungs, no bronchial lesion was seen. Transbronchial biopsy was taken from the left upper lobe. The report of the bronchoalveolar lavage fluid showed excessive blood few scattered benign bronchial cells otherwise normal study. Microscopic description showed lung tissue with rhabdoid appearance, which was strongly positive for pan CK, vimentin, but negative for actin, myogenin, desmin, and myoglobin. Finally, the immunohistochemistry demonstrated lack of nuclear INI1 protein expression ().
(a) Tumor cells with a cytoplasmic pink ball pushing the nucleus, (b) Pan Cytokeratin positivity, (c) Vimentin positivity, (d) Pan Cytokeratin high-power view.
The patient underwent mediastinoscopy and the pathological report of the biopsy of the mediastinal lymph node that was taken on the mediastinoscopy. The biopsy specimen was reviewed, gross specimens consisted of mediastinal lymph nodes; measuring in aggregate 1.5 × 0.5
cm, frozen section diagnosis was metastatic tumor, whereas the specimen received in formalin consisted a piece of brownish tissue measuring 0.7 × 0.4 × 0.3
cm, grayish brown tissue measuring 0.9 × 0.8 × 0.3
cm. Microscopic description showed lymph nodes in all the above with metastasis with rhabdoid appearance, which was also strongly positive for pan CK, vimentin, but negative for actin, myogenin, desmin, and myoglobin. Finally, the immunohistochemistry demonstrated lack of nuclear INI1 protein expression.
Pathological diagnosis: Left lung upper lobe rhabdoid tumor with mediastinal lymph nodes nodal metastasis.
Diagnosis: left lung upper lobe rhabdoid tumor with multiple mediastinal lymphadenopathies with superior vena cava thrombosis.