case_images: PMC9938771_01
case_images: Screening chest computed tomography (CT) scan revealed multiple bilateral pulmonary nodules, measuring up to 7.8 mm.
case_images: CRIPA2023-8323821.001.jpg
case_images: PMC9938771_01_CRIPA2023-8323821.001.jpg
case_images: fig1
case_images: (a) Histologic sections of the needle core biopsy of a right lower lobe nodule demonstrated a proliferation of neoplastic glands with pseudostratified columnar epithelium and intraluminal mucin secretions, consistent with moderately differentiated adenocarcinoma. Immunohistochemistry revealed positivity for cytokeratin 7 (CK7) (b), cytokeratin 20 (CK20) (c), and PAX-8 (d). Transcription termination factor-1 (TTF-1) (e) and estrogen receptor (ER) (f) were negative. Magnifications in (a)-(c) and (f) is 10x and in (d) and (e) is 20x.
case_images: CRIPA2023-8323821.002.jpg
case_images: PMC9938771_01_CRIPA2023-8323821.002.jpg
case_images: fig2
case_images: Systems, Oro Valley, AZ, USA) (Figures 2(e) and 2(f), respectively); GATA binding protein 3 (GATA3) (Ventana Medical Systems, Oro Valley, AZ, USA) staining appeared cytoplasmic. Because of the immunophenotype, the differential diagnosis included a colorectal primary, and PAX-8 immunoexpression raised the possibility of a gynecologic/Mullerian primary. She had markedly elevated carcinoembryonic antigen (CEA) and cancer antigen 19-9 (CA 19-9) levels.
case_images: (a) A follow-up CT of the abdomen/pelvis revealed multiple new and enlarging pulmonary nodules in bilateral lungs, and a new sclerotic lesion in the right ilium (b).
case_images: CRIPA2023-8323821.003.jpg
case_images: PMC9938771_01_CRIPA2023-8323821.003.jpg
case_images: fig3
case_images: A follow-up CT of the abdomen/pelvis revealed multiple new and enlarging solid bilateral pulmonary nodules accompanied by scattered ground glass opacities (Figure 3(a)) and new sclerotic lesions in the right ilium (Figure 3(b)) and vertebral body, concerning for osseous metastasis.
case_images: (a) Histologic sections of the urethral biopsy showed intestinal metaplasia of squamous mucosa with transition from a mature to dysplastic phenotype with the adenocarcinoma appearing to originate from the dysplastic intestinal metaplasia. Immunohistochemistry showed positivity for CK20 (b), caudal-type homeobox 2 (CDX2) (c), patchy expression of SAT-B2 (d) and PAX-8 (e), and negative for p16 (f). Magnification in (a), (b), and (f) is 10x and in (c)-(e) is 20x.
case_images: CRIPA2023-8323821.004.jpg
case_images: PMC9938771_01_CRIPA2023-8323821.004.jpg
case_images: fig4
case_images: Morphologic examination of the urethral biopsy demonstrated intestinal metaplasia of squamous mucosa with transition from a mature to dysplastic phenotype where the adenocarcinoma originated from (Figure 4(a)). The urethral and vaginal wall biopsies showed a similar immunophenotype as the pulmonary nodule biopsy: positive for CK7, CK20 (Figure 4(b)), CDX2 (Ventana Medical Systems, Oro Valley, AZ, USA) (Figure 4(c)), beta-catenin (BD Sciences, San Jose, CA, USA) (membrane stain), CEA (Biocare Medical, Pacheco, CA, USA), patchy expression of SAT-B2 (Figure 4(d)) and PAX-8 (Figure 4(e)), and negative for TTF-1, p16 (Ventana Medical Systems, Oro Valley, AZ, USA) (Figure 4(f)), ER, vimentin (Dako/Agilent, Santa Clara, CA, USA), and GATA3.