Difference between revisions of "Cytologically Yours: CoW: 20131216"

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(Created page with "== 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...")
 
 
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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 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 ===
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* Congestive heart failure
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* Diabetes
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* Ventricular tachycardia
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* COPD
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* Ischemic heart disease
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* Squamous cell carcinoma of skin
  
 
=== Past Surgical History ===
 
=== Past Surgical History ===
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* Coronary stent placement
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* Excision of squamous cell carcinoma
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* Implant of AICD
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* Removal of adenomatous polyp of sigmoid colon
  
  
 
===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. An onsite rapid diagnosis by cytology was scheduled.
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The differential diagnosis includes worsening of COPD. CT imaging of chest is performed.
  
 
==Radiology==
 
==Radiology==
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* CT Abdomen shows a large perinephric hematoma and large low anterior structure in left lower pole suspicious for a hemorrhagic renal cell carcinoma.
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* CT Chest shows hilar lung mass and multiple mediastinal lymph nodes showing increased uptake on PET scan.
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* CT Chest shows multiple small lung lesions measuring up to 13x12 mm in greatest dimension.
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==Pathology==
 
==Pathology==
  
 
===Cytology===
 
===Cytology===
 
<gallery heights="250px" widths="250px">
 
<gallery heights="250px" widths="250px">
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CytologicallyYoursCoW20131216Cytology1.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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CytologicallyYoursCoW20131216Cytology1.jpg|10x magnification of pleural fluid(ThinPrep). Groups of cohesive epithelial appearing cells are seen on low power.
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CytologicallyYoursCoW20131216Cytology2.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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CytologicallyYoursCoW20131216Cytology2.jpg|40x magnification of pleural fluid (ThinPrep). Cluster of atypical cells showing nuclear pleomorphism and scant cytoplasm.
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CytologicallyYoursCoW20131216Cytology3.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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CytologicallyYoursCoW20131216Cytology3.jpg|40x magnification of pleural fluid (ThinPrep). Chromatin is irregular and clumped with salt and pepper appearance; although, occasional nucleoli are also seen.
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CytologicallyYoursCoW20131216Cytology4.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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CytologicallyYoursCoW20131216Cytology4.jpg|40x magnification of pleural fluid (ThinPrep). Some nuclear molding can be appreciated and a mitotic figure is present.
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CytologicallyYoursCoW20131216Cytology5.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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CytologicallyYoursCoW20131216Cytology5.jpg|Cell block of pleural fluid. Group of malignant cells showing nuclear molding, scant cytoplasm, and salt and pepper chromatin. Nucleoli are also seen.  
  
  
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===Immunohistochemistry===
 
===Immunohistochemistry===
 
<gallery heights="250px" widths="250px">
 
<gallery heights="250px" widths="250px">
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CytologicallyYoursCoW20131216Cytology6.jpg|PAX8 on 4R lymph node shows positive nuclear staining.
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CytologicallyYoursCoW20131216Cytology6.jpg|CD56 on pleural fluid shows positive cytoplasmic staining.
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CytologicallyYoursCoW20131216Cytology7.jpg|PAX8 on 4R lymph node shows positive nuclear staining.
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CytologicallyYoursCoW20131216Cytology7.jpg|Synaptophysin on pleural fluid shows positive cytoplasmic staining.
  
 
</gallery>
 
</gallery>
  
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====Resident Questions====
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====Other immunostains performed====
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* <spoiler text="What are other immunohistochemical stains that would be applicable in this case?">
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* BerEp4 Positive
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* RCC
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* Moc31 Faintly positive
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*CD10
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* Calretinin Negative
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*PAX2
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* TTF1 Negative
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*Kidney specific antigen
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* Chromogranin Positive
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</spoiler>
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* Synaptophysin Positive
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* CD56  Positive
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* Napsin A  Negative
  
  
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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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* Rapid diagnosis: Non-small cell carcinoma.
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* Small cell carcinoma
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* Final diagnosis: Renal cell carcinoma.
 
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===Discussion===
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The differential diagnosis includes large cell neuroendocrine carcinoma, and possibly nonkeratinizing squamous cell carcinoma and adenocarcinoma. In this case, we know that we are dealing with a poorly differentiated neuroendocrine carcinoma based on immunohistochemistry. In addition, except for the occasional nucleoli, this lesion has all of the features of a small cell carcinoma (scant cytoplasm, nuclear molding). In this case, the possibility of a poorly differentiated carcinoma with mixed large cell and small cell features may not be able to be completely ruled out on cytology of the pleural fluid. It has been determined that prominent nucleoli may be seen in small cell carcinomas up to 24% of the time (Khalbuss WE The cytomorphologic spectrum of small-cell carcinoma and large-cell neuroendocrine carcinoma in body cavity effusions: A study of 68 cases. CytoJournal 2011,  8:18. [[http://www.cytojournal.com/article.asp?issn=1742-6413;year=2011;volume=8;issue=1;spage=18;epage=18;aulast=Khalbuss]]
  
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==Case Discussion==
 
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This is a classic case of metastatic renal cell carcinoma.
 
 
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Latest revision as of 22:03, 15 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

  • 10x magnification of pleural fluid(ThinPrep). Groups of cohesive epithelial appearing cells are seen on low power.

  • 40x magnification of pleural fluid (ThinPrep). Cluster of atypical cells showing nuclear pleomorphism and scant cytoplasm.

  • 40x magnification of pleural fluid (ThinPrep). Chromatin is irregular and clumped with salt and pepper appearance; although, occasional nucleoli are also seen.

  • 40x magnification of pleural fluid (ThinPrep). Some nuclear molding can be appreciated and a mitotic figure is present.

  • Cell block of pleural fluid. Group of malignant cells showing nuclear molding, scant cytoplasm, and salt and pepper chromatin. Nucleoli are also seen.

Immunohistochemistry

  • CD56 on pleural fluid shows positive cytoplasmic staining.

  • Synaptophysin on pleural fluid shows positive cytoplasmic staining.

Other immunostains performed

  • BerEp4 Positive
  • Moc31 Faintly positive
  • Calretinin Negative
  • TTF1 Negative
  • Chromogranin Positive
  • Synaptophysin Positive
  • CD56 Positive
  • Napsin A Negative


Click here to toggle the diagnosis.

Final Diagnosis

Cytology

  • Small cell carcinoma

Discussion

The differential diagnosis includes large cell neuroendocrine carcinoma, and possibly nonkeratinizing squamous cell carcinoma and adenocarcinoma. In this case, we know that we are dealing with a poorly differentiated neuroendocrine carcinoma based on immunohistochemistry. In addition, except for the occasional nucleoli, this lesion has all of the features of a small cell carcinoma (scant cytoplasm, nuclear molding). In this case, the possibility of a poorly differentiated carcinoma with mixed large cell and small cell features may not be able to be completely ruled out on cytology of the pleural fluid. It has been determined that prominent nucleoli may be seen in small cell carcinomas up to 24% of the time (Khalbuss WE The cytomorphologic spectrum of small-cell carcinoma and large-cell neuroendocrine carcinoma in body cavity effusions: A study of 68 cases. CytoJournal 2011, 8:18. [[1]]

Cases of the Week
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