Difference between revisions of "Cytologically Yours: CoW: 20131209"

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== Clinical Summary ==  
 
== Clinical Summary ==  
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The patient is an 64 year old white male who presented with left sided back pain. Imaging showed a left perinephric retroperitoneal hematoma and a left renal lower pole cystic lesion with hemorrhage. Additional imaging showed numerous pulmonary lesions. A endobronchial ultrasound guided fine needle aspiration was scheduled.  
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The patient is an 64 year old white male who presented with left sided back pain. Imaging showed a left perinephric retroperitoneal hematoma and a left renal lower pole cystic lesion with hemorrhage. Additional imaging showed numerous pulmonary lesions. An endobronchial ultrasound guided fine needle aspiration was scheduled.  
  
 
=== Past Medical History ===
 
=== Past Medical History ===
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===Clinical Plan===
 
===Clinical Plan===
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The concern is a primary renal malignancy with metastatic disease to lungs. An endobronchial ultrasound guided FNA is scheduled.
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The concern is a primary renal malignancy with metastatic disease to lungs. An endobronchial ultrasound guided FNA is scheduled. An onsite rapid diagnosis by cytology was scheduled.
  
 
==Radiology==
 
==Radiology==
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===Cytology===
 
===Cytology===
 
<gallery heights="250px" widths="250px">
 
<gallery heights="250px" widths="250px">
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CytologicallyYoursCoW20131209Cytology1.jpg|4x magnification of a 4R lymph node. There is a polymorphic lymphoid population with scattered large atypical cells.
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CytologicallyYoursCoW20131209Cytology1.jpg|4x magnification of a 4R lymph node. Groups of cohesive epithelial appearing cells can be seen on low power. Lymphoid tissue is not easily identified.
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CytologicallyYoursCoW20131209Cytology2.jpg|20x magnification of paracaval lymph node. There are small lymphocytes with background lymphoglandular bodies. Scattered eosinophils and large atypical cells with prominent nucleoli.
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CytologicallyYoursCoW20131209Cytology2.jpg|20x magnification of a 4R lymph node. This is a cellular specimen with groups of cells along what appear to be a papillary or papillary-like structure. Single cells are also dispersed in the background. The cells are haphazardly arranged.
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CytologicallyYoursCoW20131209Cytology3.jpg|40x magnification of paracaval lymph node. There are atypical binucleated cells among the large atypical cells.
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CytologicallyYoursCoW20131209Cytology3.jpg|40x magnification of a 4R lymph node. On higher power, the nuclei appear mildly atypical and the cytoplasm is delicate and finely vacuolated. The nuclear contours are somewhat irregular.
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CytologicallyYoursCoW20131209Cytology4.jpg|40x magnification of paracaval lymph node. There are atypical binucleated cells among the large atypical cells.
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CytologicallyYoursCoW20131209Cytology4.jpg|Cell block of 4R lymph node. The cytoplasm does not appear as vacuolated on alcohol fixed cell block material, but the nuclei are relatively uniform, but somewhat atypical.  
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CytologicallyYoursCoW20131209Cytology5.jpg|40x magnification of paracaval lymph node. There are atypical binucleated cells among the large atypical cells.
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</gallery>
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===Immunohistochemistry===
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<gallery heights="250px" widths="250px">
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CytologicallyYoursCoW20131209Cytology5.jpg|PAX8 on 4R lymph node shows positive nuclear staining.
  
 
</gallery>
 
</gallery>
  
 
====Resident Questions====
 
====Resident Questions====
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* <spoiler text="What is your differential diagnosis?">These groups of cells demonstrate malignant appearing cells in a background of an otherwise benign appearing lymphoid background. The atypical cells are scattered, with large nucleoli and several binucleate forms. In addition, there seem to be an increased number of eosinophils in the background. The differential diagnosis includes Hodgkin lymphoma; however, the possibility of the large atypical cells being melanoma cannot be ruled out.  </spoiler>
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* <spoiler text="What are other immunohistochemical stains that would be applicable in this case?">
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* <spoiler text="What ancillary tests would you recommend?">For this patient, we recommended that the radiologist perform a biopsy of the lesion so that it could be sent for immunohistochemical workup. Since the overall percentage of the atypical cells were low, we were worried that a cell block would not contain enough of the malignant cells for additional stains. We also sent the lymph node for flow since a hematologic malignancy was suspected; however, with Hodgkin lymphoma, we don't expect any diagnostic findings from flow cytometry.</spoiler>
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* RCC
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* <spoiler text="What immunohistochemical stains would you do?">CD15, CD30, and PAX5 would stain tumor cells in Hodkin lymphoma. Mart1, HMB45, and S100 could be used to rule out melanoma. Other additional stain in a lymphoma versus melanoma workup might include CD3, CD20, and keratin.</spoiler>
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*CD10
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*PAX2
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*Kidney specific antigen
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</spoiler>
  
  
  
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<div class="usermessage mw-customtoggle-diagnosis" style="cursor:pointer">Click here to toggle the diagnosis and case discussion.</div>
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<div class="usermessage mw-customtoggle-diagnosis" style="cursor:pointer">Click here to toggle the diagnosis.</div>
 
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==Final Diagnosis==
 
==Final Diagnosis==
 
===Cytology===
 
===Cytology===
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* '''Positive for malignancy, the differential diagnosis includes melanoma and Hodgkin lymphoma'''.
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* Rapid diagnosis: Non-small cell carcinoma.
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* Final diagnosis: Renal cell carcinoma.
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===Biopsy===
 
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* '''Classical Hodgkin lymphoma, favor mixed type'''.
 
  
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==Case Discussion==
 
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This is a classic case of metastatic renal cell carcinoma.
 
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</div></div>
 
  
 
{{Cytologically Yours}}
 
{{Cytologically Yours}}
  
 
[[Category:Case Reports]]
 
[[Category:Case Reports]]

Latest revision as of 22:01, 15 January 2014

Clinical Summary

The patient is an 64 year old white male who presented with left sided back pain. Imaging showed a left perinephric retroperitoneal hematoma and a left renal lower pole cystic lesion with hemorrhage. Additional imaging showed numerous pulmonary lesions. An endobronchial ultrasound guided fine needle aspiration was scheduled.

Past Medical History

  • Congestive heart failure
  • Ventricular tachycardia
  • Ischemic heart disease

Past Surgical History

  • Coronary stent placement
  • Implant of AICD


Clinical Plan

The concern is a primary renal malignancy with metastatic disease to lungs. An endobronchial ultrasound guided FNA is scheduled. An onsite rapid diagnosis by cytology was scheduled.

Radiology

  • CT Abdomen shows a large perinephric hematoma and large low anterior structure in left lower pole suspicious for a hemorrhagic renal cell carcinoma.
  • CT Chest shows multiple small lung lesions measuring up to 13x12 mm in greatest dimension.

Pathology

Cytology

  • 4x magnification of a 4R lymph node. Groups of cohesive epithelial appearing cells can be seen on low power. Lymphoid tissue is not easily identified.

  • 20x magnification of a 4R lymph node. This is a cellular specimen with groups of cells along what appear to be a papillary or papillary-like structure. Single cells are also dispersed in the background. The cells are haphazardly arranged.

  • 40x magnification of a 4R lymph node. On higher power, the nuclei appear mildly atypical and the cytoplasm is delicate and finely vacuolated. The nuclear contours are somewhat irregular.

  • Cell block of 4R lymph node. The cytoplasm does not appear as vacuolated on alcohol fixed cell block material, but the nuclei are relatively uniform, but somewhat atypical.

Immunohistochemistry

  • PAX8 on 4R lymph node shows positive nuclear staining.

Resident Questions



Click here to toggle the diagnosis.

Final Diagnosis

Cytology

  • Rapid diagnosis: Non-small cell carcinoma.
  • Final diagnosis: Renal cell carcinoma.



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