Contributed by Rashi Singhal, MD, MPH, and Anil Parwani, MD, PhD
The case is received in consultation. The patient is a 52-year-old female who presented to her primary care physician with presyncopal symptoms, nausea, and vomiting. A further history of right flank pain, intermittent hematuria, and weight loss of approximately 20 lb. over the past year was also elicited. Her past medical history includes alcoholic cirrhosis, diabetes mellitus type II, and thyroid surgery with thyroid hormone replacement therapy.
Laboratory studies show evidence of anemia of chronic disease, intact renal function, normal serum alpha fetoprotein, and hyperthyroid state:*
Hematologic studies: Hemoglobin 10.1 g/dL (12.3-15.5), hematocrit 30.5% (36-45), mean corpuscular volume 76.6% (80-100), ferritin 675 ng/mL (10-150), total iron-binding capacity 168 ug/mL (270-470), iron 15 ug/dL (30-150), fibrinogen 895 mg/dL (150-400), erythrocyte sedimentation rate >140 mm/hr (0-30).
Renal function studies: Blood urea nitrogen 3 mg/dL (6-24), creatinine 0.49 mg/dL (0.5-1.17).
Alpha fetoprotein: 2.9 ng/mL (0-8.1)
Endocrine studies: T4 1.5 ng/dL (0.8-1.4), thyroid-stimulating hormone 0.061 UIU/mL (0.3-4.0).
* Values in parentheses pertain to the laboratory's reference ranges.
Computed tomography of the abdomen and pelvis with contrast demonstrates a 6.0 cm, well-circumscribed mass within the upper pole of the right kidney with a necrotic center. The mass abuts the inferior margin of the liver and compresses the right renal vein which remains patent.
Computed tomography of the chest without contrast demonstrates multiple nodules in the posterior basal segment of the left lower lobe of the lung, ranging from 4 to 11 mm.
A right nephrectomy case was received in consultation (slides and accompanying tissue block). A 6.0 cm high-grade carcinoma occupies both the renal medulla and extends into the renal cortex (Image 1). The architectural growth pattern varies from large nests of back-to-back ducts (Image 2), papillary structures with fibrovascular cores (Images 3, 4), to tubulopapillary with areas of confluence of all three growth patterns. There is luminal and intercellular mucin which is focally more prominent (Images 5, 10), and luminal neutrophilic debris (Image 6). There is marked peritumoral desmoplasia and chronic inflammation (Image 7). A few ducts display hobnailing of the lining epithelial cells (Image 8). The cytomorphology of the malignant cells shows large cells with high nuclear:cytoplasmic ratios, irregular nuclear contours, vesicular chromatin with peripherally located nucleoli, and eosinophilic to vacuolated cytoplasm (Images 9, 10).
The carcinoma shows strong membranous and cytoplasmic staining for ulex europaeus-1, cytokeratin (CK) 7, and vimentin (Image 11). Racemase (P504s) shows weak non-specific staining (Image 12). CK20, high molecular weight cytokeratin 903, renal cell carcinoma antigen (RCC), CD10, CD117 (c-kit), and carbonic anhydrase-9 (CA-9) stains are negative (Image 13). Mucicarmine highlights focal duct lumen contents (image not currently available for review).