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-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. -Two weeks ago, the patient began coughing and presented persistent mucous expectoration. -The patient describes coughing tissular fragments on two different occasions. Past medical history - none ETOH – none Smoking – none NKDA -Physical examination: - indolent tumefaction of left testicle (approximately for 2 years) Thoracic 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), HCT = 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%) MID = 3,5% (NV=4-15%), Sed rate (ESR) = 47 mm/1h and 110 mm/2h. Biochemistry: ALAT, ASAT, 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 eosinophilic cytoplasm. Cells are isolated and in small groups. Immunehistochemistry: anti-LCA antibodies mark approximately 50% of the leucocytes in the cast anti-CD15 marks eosynophyles anti-CD68 marks 50% of the macrophages CD30 marks tumour cells panCK (present exclusively in epithelial cells) marks approximately 20% of the tumour cells The CD30 positive cells as well as the inflammatory cells plead for a Mixed Cellularity Hodgkin’s lymphoma. The only argument against this diagnostic is the positive panCK in 20% of the tumour cells. Thoracic CT: 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, Ø4.5 cm, in contact with the superior vena cava and invading the mediastinum. Right lower paratracheal adenopathy, Ø3 cm. Mass in right lower lobe, Ø3 cm. Adenopathic lomboaortic mass, approximately Ø6 cm. Liver, spleen, kidneys, adrenal glands – normal structure and size. Result CT: 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, prominent nucleoli, intracytoplasmic hyaline globules, with a solid, pseudoglandular, papillary and glomerulous-like architecture. Tumour cells are panCK positive and α -fetoprotein positive. AFP = 1500 UI/ml (NV=0-2 UI/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. Antecedentes medicos: ninguno ETOH (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 Pruebas de laboratorio: Globulos rojos = 5.05/101 * 101/microL (NV = 4,2-10 / 101 * 101/microL), HGB = 12 g / dl (VN = 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% (VN = 19-40%) MID = 3,5% (VN = 4-15%), Eritrosedimentacion = 47 y mm/1h mm/2h 110. Bioquimica: ALAT, ASAT, azucar en la sangre, 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 Anti LCA de aproximadamente 50% de los leucocitos en el elenco -CD15 marca eosinofilos -CD68 marca 50% de los macrofagos -CD30 marca tumor panCK(?) celulas (presente exclusivamente en las celulas epiteliales) marca aproximadamente el 20% de las celulas tumorales El CD30 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.

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-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. -Two weeks ago, the patient began coughing and presented persistent mucous expectoration. -The patient describes coughing tissular fragments on two different occasions. 

Past medical history - noneETOH – noneSmoking – noneNKDA

-Physical examination: - indolent tumefaction of left testicle (approximately for 2 years) 

Thoracic 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), HCT = 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%) MID = 3,5% (NV=4-15%), Sed rate (ESR) = 47 mm/1h and 110 mm/2h. Biochemistry: ALAT, ASAT, blood sugar, total bilirubin, creatinine şi electrolytes, urine sample – all normalHistopathological 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 eosinophilic cytoplasm. Cells are isolated and in small groups.Immunehistochemistry: 

anti-LCA antibodies mark approximately 50% of the leucocytes in the cast anti-CD15 marks eosynophyles anti-CD68 marks 50% of the macrophages CD30 marks tumour cells panCK (present exclusively in epithelial cells) marks approximately 20% of the tumour

cellsThe CD30 positive cells as well as the inflammatory cells plead for a Mixed Cellularity Hodgkin’s lymphoma. The only argument against this diagnostic is the positive panCK in 20% of the tumour cells. 

Thoracic CT: 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, Ø4.5 cm, in contact with the superior vena cava and invading the mediastinum. Right lower paratracheal adenopathy, Ø3 cm. Mass in right lower lobe, Ø3 cm. Adenopathic lomboaortic mass, approximately Ø6 cm.Liver, spleen, kidneys, adrenal glands – normal structure and size.Result CT: 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, prominent nucleoli, intracytoplasmic hyaline globules, with a solid, pseudoglandular, papillary and glomerulous-like architecture. Tumour cells are panCK positive and α-fetoprotein positive. AFP = 1500 UI/ml (NV=0-2 UI/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. Antecedentes medicos: ninguno ETOH (ethanol- Alcohol): nofumador: 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 

Pruebas de laboratorio: Globulos rojos = 5.05/101 * 101/microL (NV = 4,2-10 / 101 * 101/microL), HGB = 12 g / dl (VN = 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% (VN = 19-40%) MID = 3,5% (VN = 4-15%), Eritrosedimentacion = 47 y mm/1h mm/2h 110. Bioquimica: ALAT, ASAT, azucar en la sangre, 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 Anti LCA de aproximadamente 50% de los leucocitos en el elenco-CD15 marca eosinofilos-CD68 marca 50% de los macrofagos -CD30 marca tumor panCK(?) celulas (presente exclusivamente en las celulas epiteliales) marca aproximadamente el 20% de las celulas tumorales El CD30 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. 

TC toracica: masa adenopatica izquierda paramediastinica, �9.5 cm, en contacto con los grandes vasos e invadiendo la parte superior del lobulo izquierdo del pulmon. Masa similar en el paramediastino derecho, 4.5 cm, en contacto con la vena cava superior e invadiendo el mediastino. Adenopatica paratraqueal derecha baja, 3 cm. Masa en el lobulo inferior derecho, 3 cm. Masa Adenopatica lumboaortica, aproximadamente 6 cm. 

Higado, bazo, ri�ones, glandulas suprarrenales - estructura y tama�o normales. CT 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. 

AFP = 1500 UI / ml (VN = 0-2 UI / ml). Se requiere: - Diagnostico diferencial, los pro y los contras de cada uno- Investigaciones necesarias para el diagnostico- Tratamiento, si es posible- explica como obtuvo la solucion