Cytologically Yours: CoW: 20131216: Difference between revisions

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== Clinical Summary ==  
== 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. A endobronchial ultrasound guided fine needle aspiration was scheduled.  
The patient is an 66 year old white male with a history of smoking, COPD, and diabetes. The patient presented with increased shortness of breath.  


=== Past Medical History ===
=== Past Medical History ===
* Congestive heart failure
* Diabetes
* Ventricular tachycardia
* COPD
* Ischemic heart disease
* Squamous cell carcinoma of skin


=== Past Surgical History ===
=== Past Surgical History ===
* Coronary stent placement
* Excision of squamous cell carcinoma
* Implant of AICD
* Removal of adenomatous polyp of sigmoid colon




===Clinical Plan===
===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.
The differential diagnosis includes worsening of COPD. CT imaging of chest is performed.


==Radiology==
==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 hilar lung mass and multiple mediastinal lymph nodes showing increased uptake on PET scan.
* CT Chest shows multiple small lung lesions measuring up to 13x12 mm in greatest dimension.
 
==Pathology==
==Pathology==


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===Immunohistochemistry===
===Immunohistochemistry===
<gallery heights="250px" widths="250px">
<gallery heights="250px" widths="250px">
CytologicallyYoursCoW20131216Cytology6.jpg|PAX8 on 4R lymph node shows positive nuclear staining.
CytologicallyYoursCoW20131216Cytology6.jpg|CD56 on pleural fluid shows positive cytoplasmic staining.
CytologicallyYoursCoW20131216Cytology7.jpg|PAX8 on 4R lymph node shows positive nuclear staining.
CytologicallyYoursCoW20131216Cytology7.jpg|Synaptophysin on pleural fluid shows positive cytoplasmic staining.


</gallery>
</gallery>

Revision as of 16:51, 14 January 2014

Clinical Summary

The patient is an 66 year old white male with a history of smoking, COPD, and diabetes. The patient presented with increased shortness of breath.

Past Medical History

  • Diabetes
  • COPD
  • Squamous cell carcinoma of skin

Past Surgical History

  • Excision of squamous cell carcinoma
  • Removal of adenomatous polyp of sigmoid colon


Clinical Plan

The differential diagnosis includes worsening of COPD. CT imaging of chest is performed.

Radiology

  • CT Chest shows hilar lung mass and multiple mediastinal lymph nodes showing increased uptake on PET scan.

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.
    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.
    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.
    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.
    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.
  • 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.
    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

  • CD56 on pleural fluid shows positive cytoplasmic staining.
    CD56 on pleural fluid shows positive cytoplasmic staining.
  • Synaptophysin on pleural fluid shows positive cytoplasmic staining.
    Synaptophysin on pleural fluid shows positive cytoplasmic staining.

Resident Questions



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Final Diagnosis

Cytology

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


Case Discussion

This is a classic case of metastatic renal cell carcinoma.

Cases of the Week
Unknowns
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