Journal of Pathology and Translational Medicine

Case Studies

Cytologic Characteristics of Thymic Adenocarcinoma with Enteric Differentiation: A Study of Four Fine-Needle Aspiration Specimens: Ah-Young Kwon, Joungho Han, Hae-yon Cho, Seokhwi Kim, Heejin Bang, Jiyeon Hyeon; J Pathol Transl Med. 2017;51(5):509-512. Published online August 4, 2017; DOI: https://doi.org/10.4132/jptm.2017.03.22

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Thymic adenocarcinoma is extremely rare. Although its histologic features have been occasionally reported, a lack of description of the cytologic features has hampered the prompt and accurate diagnosis of this condition. Herein, we describe the cytologic findings and histology of four aspiration cytology specimens of thymic adenocarcinoma. The specimens were obtained from primary tumors, metastatic lymph nodes, and pericardial effusions. All four specimens showed three-dimensional glandular clusters with a loss of polarity and nuclear overlapping. One specimen had extensive extracellular mucinous material. Three specimens contained tumor cells with intracytoplasmic vacuoles. While the specimen with extracellular mucin showed relatively mild cytologic atypia, other specimens exhibited more atypical cytologic changes: irregular nuclear membranes, a coarse chromatin pattern, and prominent nucleoli. The cytologic features were correlated with the histologic features in each case of enteric type thymic adenocarcinoma. The differential diagnosis included other thymic carcinomas, yolk sac tumors, and metastatic adenocarcinoma from the lung or colorectum.

Citations

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Case report: Primary adenocarcinoma NOS of the thymus and cytological features
Jonathan Willner, Osvaldo Hernandez, Lea Azour, Andre L. Moreira
Diagnostic Cytopathology.2023;[Epub] CrossRef
Systemic chemotherapy for unresectable or recurrent primary thymic adenocarcinoma of enteric type
Xiaofang Gao
International Cancer Conference Journal.2022; 12(1): 46. CrossRef
Thymic adenocarcinoma accompanied by type A thymoma and pulmonary minimally invasive adenocarcinoma and harboring distinct gene alterations
Yi-Wen Zheng, Lin-Lin Bai, Gui-Yang Jiang, Xu-Yong Lin, Yang Liu, Hong-Tao Xu
Medicine.2021; 100(15): e25254. CrossRef
A case report: primary thymic adenocarcinoma with enteric differentiation
Yuuki Kou, Hirokazu Tanaka, Nobuhisa Yamazaki, Hiroyoshi Watanabe, Makoto Sonobe
The Journal of the Japanese Association for Chest Surgery.2020; 34(2): 107. CrossRef
Primary thymic adenocarcinoma with an aggressive clinical course: An autopsy case showing signet ring cell‐like features
Ayako Shiono, Takashi Fujino, Kyoichi Kaira, Tomomi Kato, Masanori Yasuda, Kunihiko Kobayashi, Hiroshi Kagamu
Thoracic Cancer.2020; 11(12): 3609. CrossRef
Primary Thymic Signet Ring Cell Adenocarcinoma: A Currently Unrecognized Variant
Richard Benedict Supan Roxas, Marie Christine Fajatin Bernardo, Araceli Pacis Jacoba, Janet Lim-Dy, Anarose Cariaga Alvarado, Jasna Metovic, Laura Annaratone, Mauro Papotti
International Journal of Surgical Pathology.2019; 27(3): 315. CrossRef
Disseminated and massive tumor burden in a case of primary thymic mucinous adenocarcinoma
Hui-Wen Liu, Chih-Yi Liu, Yi-Chen Yeh
Journal of Cancer Research and Practice.2019; 6(3): 151. CrossRef

Thymoma and Synchronous Primary Mediastinal Seminomas with Florid Follicular Lymphoid Hyperplasia in the Anterior Mediastinum: A Case Report and Review of the Literature: Hyang-im Lee, In-seok Jang, Kyung Nyeo Jeon, Gyung Hyuck Ko, Jong Sil Lee, Dong Chul Kim, Dae Hyun Song, Jeong-Hee Lee; J Pathol Transl Med. 2017;51(2):165-170. Published online February 2, 2017; DOI: https://doi.org/10.4132/jptm.2016.08.24

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Abstract PDF

Thymoma is the most common neoplasm of the anterior mediastinum and has malignant potential. Germ cell tumors (GCTs) found in the anterior mediastinum are usually benign, and malignant GCTs, such as seminomas, are rare. Histologically, mediastinal seminoma is indistinguishable from testicular seminoma except for site-associated morphological features such as lymphoid follicular hyperplasia. Therefore, excluding metastasis is very important. Recently, we treated a young adult patient with multiple thymic masses that occurred simultaneously. The patient underwent a thymectomy for the removal of the mediastinal masses, one of which was diagnosed as type B2 invasive thymoma, and two of which were diagnosed as primary mediastinal seminomas with massive follicular hyperplasia. The patient received adjuvant chemotherapy after surgical resection. To our knowledge, this is the first description of a thymoma and a mediastinal seminoma occurring simultaneously in the thymus. We present this case along with a literature review.

Citations

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Primary germ cell tumours of the mediastinum: A review with emphasis on diagnostic challenges
Alexander Fichtner, Alexander Marx, Philipp Ströbel, Felix Bremmer
Histopathology.2024; 84(1): 216. CrossRef
Combined type A thymoma and yolk sac tumour of the mediastinum
Dong Sheng, Yu-Chen Han
Pathology.2024; 56(6): 927. CrossRef
Combined Thymic Epithelial Neoplasms – a Review
Annikka Weissferdt
International Journal of Surgical Pathology.2023; 31(6): 917. CrossRef
Primary mediastinal seminoma presenting with paraneoplastic anti-Hu encephalitis: a case report and literature review
Chelsey M. Williams, Derek B. Allison, Adam B. Coleman, Roshmita Bardhan, Jordan D. Miller, Zin W. Myint
Frontiers in Oncology.2023;[Epub] CrossRef
Primary mediastinal seminoma with florid follicular lymphoid hyperplasia: a case report and review of the literature
Charlotte Holmes, Peh Sun Loo, Sion Barnard
Diagnostic Pathology.2021;[Epub] CrossRef

Mediastinal Glomus Tumor: A Case Report and Literature Review: Si-Hyong Jang, Hyun Deuk Cho, Ji-Hye Lee, Hyun Ju Lee, Hae Yoen Jung, Kyung-Ju Kim, Sung Sik Cho, Mee-Hye Oh; J Pathol Transl Med. 2015;49(6):520-524. Published online August 4, 2015; DOI: https://doi.org/10.4132/jptm.2015.07.02

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Abstract PDF

A glomus tumor in the mediastinum is very uncommon, and only five cases have been reported in the English literature. We recently encountered a 21-year-old woman with an asymptomatic mediastinal mass that measured 5.3 × 4.0 cm. Surgical excision was performed, and the tumor was finally diagnosed as mediastinal glomus tumor with an uncertain malignant potential. After reviewing this case and previous reports, we analyzed the clinicopathologic features associated with progression of such a tumor.

Citations

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Primary glomus tumor of the thymus in a 66-year-old patient
Yibing Zang, Ruixing Zhao, Chengquan Ma, Dejun Gao
Journal of Cardiothoracic Surgery.2024;[Epub] CrossRef
A case of mediastinal mesenchymal tumor with pericytic neoplasm feature that responded to radiation therapy
Miho Muramoto, Shintaro Kanda, Takashi Kobayashi, Hisashi Tamada, Ayumu Fukazawa, Keiichirou Koiwai, Tomonobu Koizumi
Thoracic Cancer.2023; 14(13): 1204. CrossRef
Report of a vagal paraganglioma at the cervicothoracic junction
Jun Yun, Danielle Kapustin, Aisosa Omorogbe, Samuel J. Rubin, Daniel G. Nicastri, Reade A. De Leacy, Azita Khorsandi, Mark L. Urken
Head & Neck.2023;[Epub] CrossRef
Total-Body Irradiation Is Associated With Increased Incidence of Mesenchymal Neoplasia in a Radiation Late Effects Cohort of Rhesus Macaques (Macaca mulatta)
W. Shane Sills, Janet A. Tooze, John D. Olson, David L. Caudell, Greg O. Dugan, Brendan J. Johnson, Nancy D. Kock, Rachel N. Andrews, George W. Schaaf, Richard A. Lang, J. Mark Cline
International Journal of Radiation Oncology*Biology*Physics.2022; 113(3): 661. CrossRef
Mesenchymal Tumors of the Mediastinum: An Update on Diagnostic Approach
Joon Hyuk Choi, Jae Y. Ro
Advances in Anatomic Pathology.2021; 28(5): 351. CrossRef
La glomangiomatose médiastinale postérieure : localisation exceptionnelle d’une tumeur rare. À propos d’un cas
A. Machboua, S. Hamraoui, S. Zarouki, I. Kamaoui, I. Alloubi
Revue des Maladies Respiratoires.2021; 38(8): 848. CrossRef
An unusual case of chest wall glomus tumor presenting with axillary pain: a case report and literature review
Leila Oryadi Zanjani, Bahman Shafiee Nia, Farzad Vosoughi, Elham Mirzaian, Leila Aghaghazvini, Aidin Arabzadeh
European Journal of Medical Research.2021;[Epub] CrossRef
Clinical Implications of 18F-FDG PET/CT in Malignant Glomus Tumors of the Esophagus
Romain-David Seban, Laurence Bozec, Laurence Champion
Clinical Nuclear Medicine.2020; 45(6): e301. CrossRef
Symplastic glomus tumor of the urinary bladder treated by robot-assisted partial cystectomy: a case report and literature review
Franco Palmisano, Franco Gadda, Matteo G. Spinelli, Marco Maggioni, Bernardo Rocco, Emanuele Montanari
Urologia Journal.2018; 85(3): 130. CrossRef
Thoracoscopic Surgery for Glomus Tumor: An Uncommon Mediastinal Neoplasm and Iatrogenic Tracheal Rupture
Zhongjie Fang, Dehua Ma, Baofu Chen, Huarong Luo
Case Reports in Surgery.2017; 2017: 1. CrossRef
Asymptomatic Glomus Tumor of the Mediastinum
Meletios Kanakis, Nikoletta Rapti, Maria Chorti, Achilleas Lioulias
Case Reports in Surgery.2015; 2015: 1. CrossRef

Nodular Fasciitis of the Parotid Gland, Masquerading as Pleomorphic Adenoma: Chung Su Hwang, Chang Hun Lee, Ahrong Kim, Nari Shin, Won Young Park, Min Gyoung Park, Do Youn Park; Korean J Pathol. 2014;48(5):366-370. Published online October 27, 2014; DOI: https://doi.org/10.4132/KoreanJPathol.2014.48.5.366

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Abstract PDF

It is difficult to distinguish nodular fasciitis (NF) from other neoplasm of the parotid gland, especially pleomorphic adenoma (PA) by fine needle aspiration cytology. A 39-year-old female noticed a mass in the parotid region. The aspirate material showed cohesive parts composed of the cells that had oval or spindle-shaped nuclei and relatively abundant cytoplasm and some cells with plasmacytoid features. The background substance was fibromyxoid. PA was diagnosed based on the cytologic findings. Subsequently, parotidectomy was performed and NF was diagnosed based on histologic and immunohistochemical findings. NF in the parotid region is rare and may be misdiagnosed as other benign or malignant tumors of the parotid gland. The clinical history of rapid growth and the presence of mitoses and inflammatory cells help to distinguish NF from PA. In addition, immunohistochemical stains for smooth muscle actin and CD68 are useful to confirm the diagnosis of NF.

Citations

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A case report of nodular fasciitis of the parotid gland: An entity of concern
Andrea Varazzani, Laura Tognin, Silvia Eleonora Gazzani, Luigi Corcione, Tito Poli
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology.2024; 36(3): 422. CrossRef
Cytologic findings of nodular fasciitis in the parotid region
Yoshihiro KATO, Keiko TSUCHIDO, Makoto YAMADA, Yasuhiro AKAZAWA, Shogo MIZUNO, Yoshiro OTSUKI, Shin-ichi SHIMIZU, Hiroshi KOBAYASHI
The Journal of the Japanese Society of Clinical Cytology.2024; 63(3): 129. CrossRef
A Rare Case of Parotid Nodular Fasciitis in a Six-Month-Old Female
Mazin Merdad, Linah Qasim, Mohammed Nujoom, Hani Z Marzouki, Abdulaziz Neazy
Cureus.2023;[Epub] CrossRef
A rare case of nodular fasciitis presenting as a parotid tumor: Clues to cytodiagnosis
Seetu Palo, Chitrawati Bal Gargade
Journal of Laboratory Physicians.2023; 16: 124. CrossRef
Condylar Reshape in Orthognathic Surgery: Morphovolumetric and Densitometric Analysis Based on 3D Imaging and Digital Workflow
Vincenzo Abbate, Giovanni Audino, Giovanni Dell’Aversana Orabona, Marco Friscia, Paola Bonavolontà, Carmelo Lo Faro, Umberto Committeri, Carlos Navarro Cuéllar, Giorgio Iaconetta, Luigi Califano
Journal of Maxillofacial and Oral Surgery.2022; 21(2): 501. CrossRef
Nodular fasciitis of the submandibular gland
Ting Suen Wong, Richard Wei Chern Gan, Laszlo Karsai, Bun Yin Winson Wong
BMJ Case Reports.2022; 15(4): e245584. CrossRef
Nodular fasciitis in cervicofacial region: a rare case description and literature review
Vincenzo Abbate, Giovanni Dell’Aversana Orabona, Giovanni Audino, Antonio Romano, Paola Bonavolontà, Daniela Russo, Silvia Varricchio, Roberto Ferrigno, Giorgio Iaconetta, Luigi Califano
Oral Surgery.2022; 15(4): 550. CrossRef
Nodular fasciitis of the parotid gland engulfing the facial nerve: a conservative approach
Stephen Bennett, Kristian Hutson, Olakunle Ajayi, Andreas Hilger
BMJ Case Reports.2019; 12(10): e231203. CrossRef

Original Article

Fine Needle Aspiration Cytology of the Mediastinal Lesions.: In Ae Park, Eui Keun Ham; Korean J Cytopathol. 1990;1(1):43-50.

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Abstract PDF: The authors report 16 cases of mediastinal fine-needle aspiration cytology from Jan. 1985 to Mar. 1988 at the Seoul National University Hospital. Among them, diagnostic materal were obtained in fifteen cases, establishing the diagnosis of 7 thymomas, 2 germinomas, 2 neurogenic tumosr, 1 lymphoma, and 3 meastatic carcinomas. The 9 cytologic diagnoses could be confirmed by histologic examination in 8 patients and by another cytologic method in one patient, allowing concordance rate of 77%.

Case Reports

Localized Primary Thymic Amyloidosis Presenting as a Mediastinal Mass: A Case Report.: Sang Yun Ha, Jae Jun Lee, Heejung Park, Joungho Han, Hong Kwan Kim, Kyung Soo Lee; Korean J Pathol. 2011;45:S41-S44.; DOI: https://doi.org/10.4132/KoreanJPathol.2011.45.S1.S41

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Abstract PDF

We herein describe a case of a 55-year-old healthy woman with localized primary thymic amyloidosis presented as a mediastinal mass, found incidentally by chest radiography. Computed tomography revealed a 4.1 cm soft tissue lesion with nodular calcification in the left anterior mediastinum. The resected specimen was a well-defined lobulating mass with calcification. Microscopically, the mass was consisted of amorphous eosinophilc hyalinized substances involving the thymus and intrathymic lymph nodes. These eosinophilic substances showed apple-green bi-refringence under polarized light after staining with Congo red. In immunohistochemical study, they were positive for kappa and lambda light chains and negative for amyloid A. There was no evidence of systemic amyloidosis in clinical investigations. A final diagnosis of localized primary thymic amyloidosis was made.

Citations

Citations to this article as recorded by

EBUS-TBNA diagnosis of localised amyloidosis presenting as mediastinal lymphadenopathy
Avnee Kumar, Barathi Sivasailam, Ellen Marciniak, Janaki Deepak
BMJ Case Reports.2018; 11(1): e226619. CrossRef
Ocular Myasthenia Gravis Associated With Thymic Amyloidosis
Kristin O. Chapman, Debra M. Beneck, Marc J. Dinkin
Journal of Neuro-Ophthalmology.2016; 36(1): 50. CrossRef
Localized Thymic Amyloidosis Presenting with Myasthenia Gravis: Case Report
Seung-Myoung Son, Yong-Moon Lee, Si Wook Kim, Ok-Jun Lee
Journal of Korean Medical Science.2014; 29(1): 145. CrossRef

Inflammatory Myofibroblastic Tumor in Posterior Mediastinum.: Seung Sam Paik, Seok Hoon Jeon, Se Jin Jang, Moon Hyang Park, Jung Dal Lee; Korean J Pathol. 1997;31(1):63-67.

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Abstract PDF: Inflammatory myofibroblastic tumor(IMT) or inflammatory pseudotumor is a rare, solid tumor that most often affects children. This tumor is characterized by a spindle cell proliferation admixed with a variety of inflammatory cells. Although it has disputed nosology, a distinctive fibroinflammatory and even pseudosarcomatous appearance have been well appreciated. Herein, we report a case of IMT in the posterior mediastinum in a 19-year-old girl with clinical findings. The immunohistochemical and ultrastructural studies on the tumor cells are reported, and their distinctive characteristics are discussed in details.

Malignant Solitary Fibrous Tumor of the Pleura in Mediastinum.: Yun Kyung Kang, Hyun Joo Yoo, Ho Kee Yum, Hong Sup Lee; Korean J Pathol. 1997;31(4):351-356.

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Abstract PDF: Solitary fibrous tumors (SFTs) most often involve the pleura and also may encompass the peritoneum and nonserosal sites. They occur as solitary encapsulated tumors and pursue a relatively benign clinical course. The usual criteria for malignancy are high cellularity, mitotic activity (more than 4 per 10 high-power fields), cellular pleomorphism, hemorrhage and necrosis as well as infiltrative growth. We report a case of malignant SFT of pleura who presented with an anterior mediastinal mass. Grossly, it was a 10x8x6.5 cm sized, encapsulated and well-demarcated, solid neoplasm with areas of extensive necrosis. Microscopically, parallel or haphazard arrangement of spindle cells with variable degrees of collagenous background were noted. Storiform fascicle formation, hemangiopericytoma-like pattern, and epithelioid cell clusters were often intermingled. Nodular areas with high cellularity and mitotic activity (> or =10/10 HPFs) were scattered throughout the neoplasm, however no definite cellular pleomorphism was encountered. Tumor cells were immunoreactive for vimentin and CD-34, which distinguished them from the mesothelial cells. Electron microscopically, they revealed fibroblastic and myofibroblastic differentiation.

Mediastinal Hemangioma: Report of a case.: Jong Ok Kim, Bum Kyeong Kim, Kyoung Hee Kim, Dae Young Kang, Kwang Sun Suh; Korean J Pathol. 1997;31(9):891-894.

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Abstract PDF: Benign hemangioma of the mediastinum is rare. This slowly growing tumor is described as well circumscribed, cystic, hemorrhagic tumor. Histologically it can be differentiated into capillary or cavernous form. We present a case of mediastinal hemangioma. A 20-year-old-man was presented with a slowly growing posterior mediastinal mass of 6 years duration, 8x6 cm in size. The mass was relatively well defined but focally invasive. Microscopically, it was differentiated into vessels of capillary, cavernous, and venous patterns. A solid cellular proliferation with inconspicuous capillary lumens was focally seen. The stroma between variable-sized vessels showed marked myxoid change associated with some smooth muscle bundles and adipose tissue. Ultrastructurally, areas of solid cellular proliferation showed formation of lumens. These lumens were lined by active endothelial cells showing plasmalemmal vesicles and Weibel-Palade bodies on the abluminal surface.

A Pancreatic Cyst of the Anterior Mediastinum.: Kye Weon Kwon, Kyung Young Jung, Woo Ick Yang; Korean J Pathol. 1998;32(11):1025-1027.

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Abstract: Although heterotopia of pancreatic tissue is a developmental anomaly found in approximately 2% of all autopsies, pancreatic tissue within the thorax and mediastinum is uncommon. In most of these instances, the pancreatic tissue is a component of gastroenteric duplication cysts, intralobar pulmonary sequestrations or teratomas. We describe an anterior mediastinal cyst consisting entirely of pancreatic tissue. A previously healthy 27-year-old woman was admitted due to chest pain during deep inspiration. The computed tomographic scan of the thorax showed a large cyst occupying the right anterior mediastinum. The excised multilocular cystic lesion measured 12 cm in maximum diameter and contained a brown, turbid fluid. The wall was fibrotic and showed a haphazard mixture of ducts and exocrine acini without islets. The histogenesis of this lesion is unclear.

Pigmented Mediastinal Paraganglioma: A case report.: Seong Ho Kim, Yoon Hee Jin, Eun Kyung Hong, Moon Hyang Park; Korean J Pathol. 2000;34(8):597-600.

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Abstract PDF: Pigmented extraadrenal paraganglioma is an unusual neoplasm that has rarely been reported in the literature. Based on histochemical staining or electron microscopy, pigment has been classified as lipofuscin, neuromelanin or true melanin. We report a case of pigmented extraadrenal paraganglioma in the posterior mediastinum of a 70-year-old woman. Histologically, the tumor had a characteristic organoid architecture of "zellballen" pattern with rich delicate microvasculature. Tumor cells contained numerous coarse brown-black pigment granules. Ultrastructurally, the tumor showed abundant large electron-dense pigment granules that vary in size and shape and smaller membrane-bound neurosecretory granules. The larger granules were consistent with neuromelanin or lipofuscin. Histochemically, the pigment is most likely neuromelanin, which is a waste product of catecholamine metabolism.

Neuroblastoma of Mediastinum Diagnosed by Fine Needle Aspiration: A Cese Report.: Eun Joo Seo, An Hee Lee; Korean J Cytopathol. 1995;6(2):183-186.

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Abstract PDF: Fine needle aspiration has been effectively being applided to pediatric tumors since it renders a rapid diagnosis with minimal intervention. This measure is especially required for the large pediatric mass, which needs preoperative chemotherapy or radiotherapy to shrink the tumor to an operable size. A case of neuroblastoma of mediastinum, stage IV diagnosed by CT-guided FNA is described.

Fine Needle Aspiration Cytology of Ganglioneuroma: A Case Report.: Hee Kyung Kim, Dong Wha Lee, So Young Jin; Korean J Cytopathol. 2003;14(1):12-16.

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Abstract PDF: Ganglioneuroma is a well-differentiated, benign tumor of the sympathetic nervous system. These tumors belong to a family of neoplasm that exhibit a wide range of differentiation, with neuroblastoma at one end and ganglioneuroma at the other. Because it share morphologic features with other both benign and malignant neural tumors, accurate preoperative diagnosis is often difficult. Nonetheless, it is critical for proper management. Fine needle aspiration cytology(FNAC) in the diagnosis of the ganglioneuroma has been a little documented. We describe a case of mediastinal ganglioneuroma in a 33-month-old girl. The diagnosis was suggested on FNAC and was confirmed by histopathologic examination later.

Extraskeletal Osteosarcoma of the Posterior Mediastinum: A Case Report.: Weon Cheol Han, Hyang Jung Cho, Jai Kyoo Lee, Hyung Bae Moon, Jae Y Ro; Korean J Pathol. 2004;38(5):350-352.

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Abstract PDF: Extraskeletal osteosarcoma is a rare malignant tumor of soft tissue. In addition, there are only several cases of osteosarcoma of the mediastinum as a primary site in the world. We report a case of extraskeletal osteosarcoma arising in the posterior mediastinum. A 54-year-old man visited our hospital because of chest pain. Chest CT showed a 12 cm sized huge mediastinal mass. The mass revealed solid and ivory-colored cut surface with multifocally ovoid cystic spaces and hemorrhage. Microscopically, the tumor consisted of polygonal stromal cells, giant cells and varying amounts of neoplastic new bone, and mitotic figures were frequently observed. There were no distant metastasis and regional lymph node involvement.

Mesothelial Cell Inclusions Mimicking Metastatic Carcinoma in Mediastinal Lymph Node: A Case Report.: Young Min Kim, Kyu Rae Kim, Jae Y Ro; Korean J Pathol. 2004;38(1):46-49.

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Abstract PDF: The presence of benign mesothelial cell inclusions in the mediastinal lymph node is extremely rare and thus difficult for the pathologist distinguishing from sinus histiocytosis, metastatic carcinoma, or metastatic mesothelioma. We recently had a case of benign mesothelial cell inclusions in the mediastinal lymph node, which is initially misinterpreted as metastatic carcinoma of unknown origin. However, further clinical studies failed to identify the primary site. Subsequent immunostaining with calretinin demonstrated the strong nuclear and cytoplasmic immunore-activity, suggesting that these cells are mesothelial cells. It is important that when the nodal changes resemble metastatic carcinoma morphologically in the mediastinal lymph nodes, but the primary site can not be identified clinically, the possibility of mesothelial cell inclusions should be raised and the proper use of immunohistochemistry in conjunction with a clinical finding is recommended.

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