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== Clinical Summary ==  
== Clinical Summary ==  
The patient is an 60 year old male with a remote history of an abdominal melanoma that was excised with negative margins. The patient has been experiencing lower back pain for the past several months and has received epidural injections. As a part of the workup, the patient had a CT which revealed retroperitoneal lymphadenopathy. A CT guided fine needle aspiration and biopsy of a paracaval lymph node was performed.
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 ===
* 2003 Melanoma
* Congestive heart failure
* Diabetes
* Ventricular tachycardia
* Hypertension
* Ischemic heart disease


=== Past Surgical History ===
=== Past Surgical History ===
* 2013 Arthroscopic knee surgery
* Coronary stent placement
* 2003 Excision of melanoma
* Implant of AICD
* 2002 Discectomy




===Clinical Plan===
===Clinical Plan===
The differential diagnosis for otherwise asymptomatic lymphadenopathy in this patient is melanoma, lymphoma, or occult malignancy.
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==
* PET CT showed hypermetabolic activity with an SUV of 12.7.  
* CT Abdomen shows a large perinephric hematoma and large low anterior structure in left lower pole suspicious for a hemorrhagic renal cell carcinoma.
* CT of abdomen and pelvis showed adenopathy adjacent to the aorta and inferior to the vena cava at the level of the right kidney. The largest node measured 4 cm in greatest dimension.
* CT Chest shows multiple small lung lesions measuring up to 13x12 mm in greatest dimension.
==Pathology==


===Cytology===
<gallery heights="250px" widths="250px">
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.
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.
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.
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.


==Pathology==
</gallery>


===Cytology===
===Immunohistochemistry===
<gallery heights="250px" widths="250px">
<gallery heights="250px" widths="250px">
CytologicallyYoursCoW20131209Cytology1.jpg|4x magnification of a 4R lymph node. There is a polymorphic lymphoid population with scattered large atypical cells.
CytologicallyYoursCoW20131209Cytology5.jpg|PAX8 on 4R lymph node shows positive nuclear staining.
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.
CytologicallyYoursCoW20131209Cytology3.jpg|40x magnification of paracaval lymph node. There are atypical binucleated cells among the large atypical cells.
CytologicallyYoursCoW20131209Cytology4.jpg|40x magnification of paracaval lymph node. There are atypical binucleated cells among the large atypical cells.
CytologicallyYoursCoW20131209Cytology5.jpg|40x magnification of paracaval lymph node. There are atypical binucleated cells among the large atypical cells.


</gallery>
</gallery>


====Resident Questions====
====Resident Questions====
* <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>
* <spoiler text="What are other immunohistochemical stains that would be applicable in this case?">
* <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>
* RCC
* <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>
*CD10
*PAX2
*Kidney specific antigen
</spoiler>
 






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==Final Diagnosis==
==Final Diagnosis==
===Cytology===
===Cytology===
* '''Positive for malignancy, the differential diagnosis includes melanoma and Hodgkin lymphoma'''.
* Rapid diagnosis: Non-small cell carcinoma.
* Final diagnosis: Renal cell carcinoma.
 
 


===Biopsy===
* '''Classical Hodgkin lymphoma, favor mixed type'''.


==Case Discussion==
This is a classic case of Hodgkin lymphoma.
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{{Cytologically Yours}}
{{Cytologically Yours}}


[[Category:Case Reports]]
[[Category:Case Reports]]
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