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.”