A 23-year-old male presented with cough, hemoptysis, and left-sided chest pain for 2-3 months. Imaging showed left mediastinal and lung masses. Biopsy of an expectorated cast revealed malignant cells consistent with mixed cellularity Hodgkin's lymphoma. Further workup found widespread lymphadenopathy and additional lung and liver lesions. Biopsy of a lung lesion found alpha-fetoprotein positive cells. Differential diagnoses include mixed cellularity Hodgkin's lymphoma and hepatocellular carcinoma. Further testing is needed to determine the final diagnosis and guide treatment.

1. -a 23 year-old male
-symptoms: cough, hemoptoic expectoration and thoracic internal pain on the left side.
-the past 2 -3 months the patient notes asthenia, fatigue, lack of appetite, weight loss (6 -7kg/2
months) and night sweats.
-T wo weeks ago, the patient began coughing and presented persistent mucous expectoration.
-T he patient describes coughing tissular fragments on two different occasions.
P ast medical history - none
ET OH – none
Smoking – none
NKDA
-P hysical examination: - indolent tumefaction of left testicle (approximately for 2 years)
T horacic X-ray: left mediastino-pulmonary mass
Laboratory tests:
RBC = 5.05/101*101/µL (NV=4,2-10/101*101/µL),
HGB = 12 g/dl (NV =14-18/g/dl),
HC T = 39% (NV=41-51%),
WBC = 14,9/*103/µL (NV=4,2 -10/*103/µL),
Granulocytes = 82,6% (NV=30-75%),
Lymphocytes = 13,9% (NV=19-40%)
M ID = 3,5% (NV=4 -15%),
Sed rate (ESR) = 47 mm/1h and 110 mm/2h.
Biochemistry: A LAT, A SAT, blood sugar, total bilirubin, creatinine şi electrolytes, urine sample – all
normal
Histopathological examination (of expectorated bronchial cast): necrotic tissue, fibrino-hematic
deposits, thrombotic vascular structures, leukocytic elements and medium-sized tumour cells with
high nuclear-cytoplasmic ratio, prominent nucleoli, amphiphilic to eos inophilic cytoplasm. C ells are
isolated and in small groups.
Immunehistochemistry:
 anti-LCA antibodies mark approximately 50% of the leucocytes in the cast
 anti-C D15 marks eosynophyles
 anti-C D68 marks 50% of the macrophages
 C D30 marks tumour cells
 panC K (present exclusively in epithelial cells) marks approximately 20% of the tumour
cells
T he C D30 positive cells as well as the inflammatory cells plead for a M ixed C ellularity Hodgkin’s
lymphoma. T he only argument against this diagnostic is the positive panCK in 20% of the tumour
cells.
T horacic C T: left adenopathic paramediastinal mass, Ø9.5 cm, in contact with large vessels and
invading the left upper lobe of the lung. Similar right paramediastinal mass, Ø 4.5 cm, in contact
with the superior vena cava and invading the mediastinum. Right lower paratracheal adenopathy,
Ø 3 cm. M ass in right lower lobe, Ø 3 cm. A denopathic lomboaortic mass, approximately Ø6 cm.
Liver, spleen, kidneys, adrenal glands – normal structure and size.
Result C T: adenopathic mediastinal and lomboaortic masses (possible Hodgkin Syndrome); mass in
right lower lobe.
Bronchoscopy: Exophytic lesion in left upper lobe bronchus. Biopsy reveals a proliferation of
undifferentiated malignant tumour cells with large hyperchrome nuclei, promine nt nucleoli,
intracytoplasmic hyaline globules, with a solid, pseudoglandular, papillary and glomerulous-like
architecture. T umour cells are panCK positive and α-fetoprotein positive.
A FP = 1500 UI/ml (NV=0 -2 U I/ml).
We require:
- differential diagnostics pros and cons for each
- investigation needed for diagnostic
- treatment if possible
- explain how you get the solution
- 23 a�os de edad, hombres
-S�ntomas: tos, expectoracion hemoptoica y dolor toracico interna en el lado izquierdo.
-Los ultimos 2 -3 meses astenia, fatiga, falta de apetito, perdida de peso (6 -7kg / 2 meses) y los
sudores nocturnos.
-Hace dos semanas, el paciente empezo a toser y presento expectoracion mucosa persistente.
-El paciente describe en la tos fragmentos tisular en dos ocasiones diferentes.
A ntecedentes medicos: ninguno
ET OH (ethanol- Alcohol): no
fumador: no
NKDA (no known drug allergies) alergias medicamentosas conocidas:
Examen fisico: - tumefaccion indolente de testiculo izquierdo (aproximadamente de 2 a�os)
Radiografia de torax: masa izquierda mediastino-pulmonar
P ruebas de laboratorio:
Globulos rojos = 5.05/101 * 101/microL (NV = 4,2 -10 / 101 * 101/microL),
HGB = 12 g / dl (V N = 14 -18/g/dl),
Hto = 39% (VN = 41 -51%),
Globulos blancos = 14,9 / * 103/microL (NV = 4,2 -10 / * 103/microL),
granulocitos = 82,6% (VN = 30 -75%),
Linfocitos = 13,9% (V N = 19 -40%)
M ID = 3,5% (V N = 4 -15%),
Eritrosedimentacion = 47 y mm/1h mm/2h 110.
Bioquimica: A LAT, A SAT, azucar en la s angre, la bilirrubina total, creatinina electrolitosi, muestra de
orina - todos normales
Examen histopatologico normal (del molde bronquial expectorado): tejido necrotico, depositos
fibrino-hematica, estructuras vasculares tromboticos, elementos de leucocitos y celulas tumorales
de tama�o mediano con elevada relacion nucleo-citoplasma , nucleolos prominentes, anfifilicas al
citoplasma eosinofilo. Las celulas son aisladas y en grupos peque�os.
Inmunohistoquimica:
- anticuerpos A nti LCA de aproximadamente 50% de los leucocitos en el elenco
-C D15 marca eosinofilos
-C D68 marca 50% de los macrofagos
-C D30 marca tumor panCK(?) celulas (presente exclusivamente en las celulas epiteliales) marca
aproximadamente el 20% de las celulas tumorales
El C D30 celulas positivas, asi como las celulas inflamatorias, abogan por un linfoma de Hodgkin de
celularidad mixta. El unico argumento en contra de este diagnostico es el panCK positivo en el 20%
de las celulas tumorales.
T C toracica: masa adenopatica izquierda paramediastinica, �9.5 cm, en contacto con los grandes
vasos e invadiendo la parte superior del lobulo izquierdo del pulmon.
M asa similar en el paramediastino derecho, 4.5 cm, en contacto con la vena cava superior e
invadiendo el mediastino.
A denopatica paratraqueal derecha baja, 3 cm. M asa en el lobulo inferior derecho, 3 cm.
M asa A denopatica lumboaortica, aproximadamente 6 cm.
Higado, bazo, ri�ones, glandulas suprarrenales - estructura y tama�o normales.
C T Resultado: masas adenopaticas y lumboaorticas mediastinicas (posible sindrome de Hodgkin);
masa en lobulo inferior derecho.
Broncoscopia: lesi�n exofitica en el bronquio del lobulo superior izquierdo. La biopsia revela una
proliferacion de celulas indiferenciadas con nucleos tumor maligno hipercromaticos grandes,
nucleolos prominentes, globulos hialinos intracitoplasmaticos,la arquitectura es pseudoglandular,
papilar y glomerular. Las celulas tumorales son positivas panCK positiva y alfa -fetoproteina.
A FP = 1500 UI / ml (V N = 0 -2 U I / ml).
Se requiere:
- Diagnostico diferencial, los pro y los contras de cada uno
- Investigaciones necesarias para el diagnostico
- T ratamiento, si es posible
- explica como obtuvo la solucion