Cytologically Yours: CoW: 20131209

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

• What are other immunohistochemical stains that would be applicable in this case?

• RCC
• CD10
• PAX2
• Kidney specific antigen

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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.