Changes

The patient is an 64 66 year old white male who presented with left sided back pain. Imaging showed a left perinephric retroperitoneal hematoma history of smoking, COPD, and a left renal lower pole cystic lesion diabetes. The patient presented with hemorrhage. Additional imaging showed numerous pulmonary lesions. A endobronchial ultrasound guided fine needle aspiration was scheduledincreased shortness of breath.

* Congestive heart failureDiabetes * Ventricular tachycardiaCOPD* Ischemic heart diseaseSquamous cell carcinoma of skin

* Coronary stent placementExcision of squamous cell carcinoma* Implant Removal of adenomatous polyp of AICDsigmoid colon

The concern is a primary renal malignancy with metastatic disease to lungsdifferential diagnosis includes worsening of COPD. An endobronchial ultrasound guided FNA CT imaging of chest is scheduled. An onsite rapid diagnosis by cytology was scheduledperformed.

* CT Abdomen Chest shows a large perinephric hematoma hilar lung mass and large low anterior structure in left lower pole suspicious for a hemorrhagic renal cell carcinomamultiple mediastinal lymph nodes showing increased uptake on PET scan.* CT Chest shows multiple small lung lesions measuring up to 13x12 mm in greatest dimension.

CytologicallyYoursCoW20131216Cytology6.jpg|PAX8 CD56 on 4R lymph node pleural fluid shows positive nuclear cytoplasmic staining.CytologicallyYoursCoW20131216Cytology7.jpg|PAX8 Synaptophysin on 4R lymph node pleural fluid shows positive nuclear cytoplasmic staining.