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+A 78-year-old previously healthy male heavy smoker presented at the Emergency Department with generalized jaundice (sclera and skin), ascites, and hepatic coma.
+The relatives declared that he was known to have a urinary bladder carcinoma that was diagnosed at a routine control performed 3 months before but no medical papers to prove this diagnosis were shown.
+They also mentioned a 2-month history of progressive jaundice, somnolence, and temporary loss of consciousness.
+No weight loss or other clinical signs were mentioned.
+No previously viral hepatitis or drug excess was reported.
+No family history of cancer was declared.
+At the present admission, the abdominal CT scan showed marked hepatomegaly with multiple small nodules (2–10 mm in diameter) that was supposed to be hepatic metastases from the bladder carcinoma.
+The thoracic x-ray showed a bilateral bronchopneumonia without abnormal opacities.
+The patient died with hepatic encephalopathy at 7 hours after admission.
+Prior to the autopsy, signed informed consent of the relatives was obtained for the case publication.
+Being about a case report, no Ethical Committee approval was necessary.
+At autopsy, the macroscopic examination showed a huge liver (6.5 kg) with widely distributed white nodules of varying sizes (Fig.1).
+The urinary bladder was not modified, but a 30 × 30 × 50 mm prostate nodule with infiltrative aspect was observed (Fig.2).
+The bilateral bronchopneumonia was confirmed, without any central tumor mass.
+A 10-mm white nodule was identified encasing a small bronchus from the middle lobe of the right lung, without peripheral nodules (Fig.3).
+Except for moderate edema, no other brain lesions were identified.
+The other organs did not show modifications.
+The tissues were fixed in 10% neutral formalin and embedded in paraffin together with iliac crest bone grafting.
+Microscopic examination of the prostate showed a 3+3 Gleason's grade 2 occult adenocarcinoma (Fig.2).
+Clusters and sheets of small round cells were seen in the liver parenchyma (Fig.1) and the lymph nodes from the hepatic hilum.
+Examination of the lung parenchyma showed a peribronchial SCLC with multiple tumor emboli in both veins and lymphatic vessels and multiple “coin-shaped” tumor nodules of 1 to 2 mm in diameter below the pleura (Fig.3).
+The small round tumor cells were also seen in bone marrow from the iliac crest bone (Fig.3).
+No brain metastases have been detected.
+Based on the macro- and microscopic features and clinical picture, the final diagnosis was “peribronchial and coin-like peripheral SCLC with massive angiolymphatic invasion and metastases in the lymph nodes, liver and bone, associated with encephalopathy and synchronous occult adenocarcinoma of the prostate.”