The role of fine-needle aspiration cytology in the evaluation of metastatic clear cell tumors

Emergent Management of Growing Teratoma Syndrome: A Case Presentation

Growing teratoma syndrome (GTS) represents a rare yet significant complication following treatment for non-seminomatous germ cell tumors (NSGCT), characterized by the growth of mature teratoma elements despite prior chemotherapy. We present the case of a 30-year-old male who, following orchidectomy for NSGCT and subsequent chemotherapy, developed acute abdominal pain and pulmonary metastasis. Despite normal serum tumor markers, imaging revealed a large retroperitoneal mass encasing significant vessels. Surgical excision led to symptom resolution. This case underscores the diagnostic challenges GTS poses, the importance of imaging in diagnosis, and the efficacy of prompt surgical intervention in achieving favorable outcomes.

Metastatic clear cell renal carcinoma to the auricular region disguised as a vascular thrombus: Case report

In about 25-30% of patients with primary renal cell carcinoma, metastasis is not uncommon and usually does not give rise to difficulties in diagnosis. However, its presentation as a subcutaneous mass following an elapse of several years after the initial diagnosis is not only uncommon but may be also mistaken for a thrombus in imaging studies due to its common high vascularization. We present here a case of a 70-year-old woman with an oncologic history of renal cell carcinoma who noticed after five years a mass in the auricular region radiologically suggestive of a vascular thrombus. Fine-needle aspiration cytology showed malignant epithelial cells compatible with metastasis of renal clear cell carcinoma, supported by immunohistochemistry performed on the cell block. This rather uncommon presentation and precise diagnosis by fine-needle aspiration prompted us to report the case, emphasizing the role of cytopathology as a useful, fast and minimally invasive method for clarifying the neoplastic nature of highly vascularized lesions.

Metastases to the thyroid gland from renal cancer

Aims and background

Metastases to the thyroid gland from renal cancer pose a challenge to physicians, due in part to the rarity of the phenomenon, the prolonged time interval between removal of the primary renal cancer and the appearance of metastases, the difficulty in diagnosis, and the uncertainty regarding long-term prognosis. We report our experience with diagnosis and management of patients affected by thyroid metastases from renal clear cell carcinoma.

Study design

We report herein three clinical cases of thyroid metastases from renal clear cell carcinoma. We also present a review of the literature and examine common features of clinical presentation and management recommendations.

Results

Over the past 17 years, 918 patients underewent surgery for thyroid cancer in our institution. Histological examination demonstrated a thyroid secondary malignancy from kidney cancer in 3 cases. Two patients underwent total thyroidectomy, whereas in the third patient a palliative right lobectomy with homolateral latero-cervical lymphoadenectomy was performed. At a 5-year follow-up, only one patient survived and was disease-free.

Conclusions

Thyroid metastases from renal clear cell carcinoma are a rare occurrence but should be taken into consideration in the differential diagnosis of a thyroid nodule. Preoperative diagnosis is often difficult. Nevertheless, an extensive diagnostic workup is recommended because the subsequent therapy must be tailored on the basis of the local extension of metastases. Surgical treatment of solitary thyroid metastases is recommended. However, patients with disseminated disease have a poor prognosis, and palliative care is the indicated recommendation. In these patients and in surgically untreatable patients, prolonged survival may be achieved by adjuvant medical therapy.

Endoscopic ultrasound-guided fine-needle aspiration diagnosis of secondary tumors involving the pancreas: An institution's experience

BACKGROUND

Pancreatic masses may seldom represent a metastasis or secondary involvement by lymphoproliferative disorders. Recognition of this uncommon occurrence may help render an accurate diagnosis and avoid diagnostic pitfalls during endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). In this study, we review our experience in diagnosing secondary tumors involving the pancreas.

MATERIALS AND METHODS

The electronic database of cytopathology archives was searched for cases of secondary tumors involving the pancreas at our institution and a total of 31 cases were identified. The corresponding clinical presentations, imaging study findings, cytological diagnoses, the results of ancillary studies, and surgical follow-up, if available, were reviewed.

RESULTS

Nineteen of the patients were male and 12 female, with a mean age of 66 years. Twenty-three patients (74%) had a prior history of malignancy, with the latency ranging from 6 months to 19 years. The secondary tumors involving the pancreas included metastatic carcinoma (24 cases), metastatic sarcoma (3 cases), diffuse large B-cell lymphoma (2 cases), and plasma cell neoplasm (2 cases). The most common metastatic tumors were renal cell carcinoma (8 cases) and lung carcinoma (7 cases). Correct diagnoses were rendered in 29 cases (94%). The remaining two cases were misclassified as primary pancreatic carcinoma. In both cases, the patients had no known history of malignancy, and no ancillary studies were performed.

CONCLUSIONS

Secondary tumors involving the pancreas can be accurately diagnosed by EUS-FNA. Recognizing uncommon cytomorphologic features, knowing prior history of malignancy, and performing ancillary studies are the keys to improve diagnostic performance and avoid diagnostic pitfalls.

Secondary tumors of the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration: a 10-year experience

Determining whether a pancreatic mass is a primary or secondary neoplasm is necessary for appropriate treatment. We reviewed our experience using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for diagnosis of pancreatic tumors to identify clinical and cytopathologic characteristics of metastatic disease. We reviewed all cases of tumors metastatic to the pancreas evaluated at The University of Texas MD Anderson Cancer Center and The Methodist Hospital in Houston, Texas during the period from 2002 to 2012. The review included cytologic specimens, clinical history, radiologic findings, primary tumor type, and clinical follow-up. We identified 66 patients with disease metastatic to the pancreas for which cytologic material was available: 38 (58%) men and 28 (42%) women, with an average age of 63 years (range, 40-89 years). Most metastases (98%) were single lesions, and nearly half were located in the head of the pancreas (30/66). The most common site of origin for these metastases was kidney (27 [41%] cases). Follow-up information was available for 65 (98%) patients, and duration of follow-up ranged from <1 to 10 years (mean, 2.3 years). Thirty-three patients (50%) were alive at the time of the most recent follow-up contact. Of the 25 patients with metastatic renal cell carcinoma, clear cell type, 19 (76%) were alive at the time of the most recent follow-up. It was concluded that metastases may mimic primary pancreatic carcinomas both clinically and cytologically. Ancillary studies in conjunction with clinical history are necessary for the accurate diagnosis of FNAs of secondary pancreatic tumors.

Immunohistochemical distinction of primary adrenal cortical lesions from metastatic clear cell renal cell carcinoma: a study of 248 cases

The diagnosis of metastatic clear cell renal cell carcinoma (CC-RCC) can be difficult because of its morphologic heterogeneity and the increasing use of small image-guided biopsies that yield scant diagnostic material. This is further complicated by the degree of morphologic and immunophenotypic overlap with nonrenal neoplasms and tissues, such as adrenal cortex. In this study, a detailed immunoprofile of 63 adrenal cortical lesions, which included 54 cortical neoplasms, was compared with 185 metastatic CC-RCCs using traditional [anticalretinin, CD10, antichromogranin, antiepithelial membrane antigen, anti-inhibin, antimelanA, anticytokeratins (AE1/AE3 and AE1/CAM5.2), antirenal cell carcinoma marker, and antisynaptophysin)] and novel [anticarbonic anhydrase-IX, antihepatocyte nuclear factor-1b, antihuman kidney injury molecule-1 (hKIM-1), anti-PAX-2, anti-PAX-8, antisteroidogenic factor-1 (SF-1), and anti-T-cell immunoglobulin mucin-1] antibodies. Tissue microarray methodology was used to simulate small image-guided biopsies. Staining extent and intensity were scored semiquantitatively for each antibody. In comparing different intensity thresholds required for a "positive" result, a value of ≥2+ was identified as optimal for diagnostic sensitivity/specificity. For the distinction of adrenal cortical lesions from metastatic CC-RCCs, immunoreactivity for the adrenal cortical antigens SF-1 (86% adrenal; 0% CC-RCC), calretinin (89% adrenal; 10% CC-RCC), inhibin (86% adrenal; 9% CC-RCC), and melanA (86% adrenal; 10% CC-RCC) and for the renal epithelial antigens hKIM-1 (0% adrenal; 83% CC-RCC), PAX-8 (0% adrenal; 83% CC-RCC), hepatocyte nuclear factor-1b (0% adrenal; 76% CC-RCC), epithelial membrane antigen (0% adrenal; 78% CC-RCC), and carbonic anhydrase-IX (3% adrenal; 87% CC-RCC) had the most potential use. Use of novel renal epithelial markers hKIM-1 (clone AKG7) and/or PAX-8 and the adrenocortical marker SF-1 in an immunohistochemical panel for distinguishing adrenal cortical lesions from metastatic CC-RCC offers improved diagnostic sensitivity and specificity.

The use of immunohistochemistry in the diagnosis of metastatic clear cell renal cell carcinoma: a review of PAX-8, PAX-2, hKIM-1, RCCma, and CD10

The diagnosis of metastatic clear cell renal cell carcinoma may be difficult in some cases, particularly in the small image-guided biopsies that are becoming more common. As targeted therapies for renal cell carcinoma are now standard treatment, the recognition and diagnosis of renal cell carcinoma has become even more critical. Many adjunctive immunohistochemical markers of renal epithelial lineage such as CD10 and RCCma have been proposed as aids in the diagnosis of metastatic renal cell carcinoma, but low specificities often limit their utility. More recently described markers (PAX-2, PAX-8, human kidney injury molecule-1, hepatocyte nuclear factor-1-β, and carbonic anhydrase-IX) offer the potential for greater sensitivity and specificity in this diagnostic setting; however, knowledge of their expected staining in other neoplasms and tissues is critical for appropriate use. In this review, we discuss the most widely used immunohistochemical markers of renal lineage with an emphasis on their sensitivity and specificity for metastatic clear cell renal cell carcinoma. Subsequently, we present a variety of organ-specific differential diagnostic scenarios in which metastatic clear cell renal cell carcinoma might be considered and we propose immunopanels for use in each situation.

Thyroid metastasis of clear cell renal carcinoma: Report of a case

Renal cell carcinoma can recur many years after diagnosis and nephrectomy metastasizing even in uncommon sites, including thyroid gland. Thyroid metastases are extremely rare, the most frequent site of origin are renal tumors. Metastases in thyroid gland appear as painless nodules or masses, "cold" at scintiscan. We report the case of a 67-year-old male patient affected by clear cell renal carcinoma, diagnosed by fine-needle aspiration cytology procedures, and treated with anticancer medical therapy, who noticed after some months a mass in the neck-thyroid region requiring deeper medical investigations. By this way, thyroid fine-needle aspiration cytology reported a lesion made of malignant epithelial cells compatible with metastases of renal carcinoma (clear cell). Clinical and pathological data, together with immunostaining, supported the diagnosis of metastatic clear cell renal carcinoma. The diagnosis of metastatic disease, although difficult clinically and pathologically, should be suspected in patients with a clinical history of cancer, particularly in case of renal cell carcinoma, but fine-needle aspiration cytology can provide the clue for diagnosis.

Surgical resection of a solitary pancreatic metastasis from colorectal cancer: a new step to a cure?

Isolated metastases to the pancreas from colorectal cancer (CRC) are very rare. We report a case of a 37-year-old man with a hereditary nonpolyposis CRC with a solitary metastasis to the pancreas who was treated with right hemicolectomy, neoadjuvant chemotherapy, complete surgical resection of the pancreatic metastasis, and adjuvant chemotherapy. After 12 months of follow-up, the patient remains free of disease. Differential diagnosis of isolated metastasis to the pancreas should be performed with pancreatic primary adenocarcinomas and neuroendocrine tumors. Symptoms and signs might be similar in these diseases: pain, weight loss, obstructive jaundice, and duodenal obstruction. Nevertheless, both primary and secondary tumors might be totally asymptomatic. Imaging techniques such as computed tomography, ultrasonography, magnetic resonance imaging, positron emission tomography, or endoscopic retrograde colangiopancreatography can provide relevant information about pancreatic lesions. However, it remains difficult to distinguish primary from metastatic pancreatic tumors. Although there is currently very limited experience with the surgical resection of isolated pancreatic metastases from CRC, it should be considered in selected patients with low surgical risk in order to prolong progression-free survival and overall survival. Additional chemotherapy is recommended.

Granular cell tumor of the neurohypophysis: report of a case with intraoperative cytologic diagnosis

Cytological techniques including touch and smear preparations are very useful diagnostic modality in the evaluation of central nervous system (CNS) lesions and, in many instances, may be effectively used as the sole modality of tissue preparation for intraoperative consultation. Cytologic preparations offer many advantages over frozen sections for CNS specimens. These include selective examination of multiple areas from small biopsy specimens, superior preservation and details of cellular morphology, fewer artifacts, faster results, and improved cost-effectiveness. We describe the cytologic diagnosis of a granular cell tumor (GCT) of the neurohypophysis in a 33-year-old male who presented with headache and blurred vision. CT scan revealed an enlarged sella with a 2.15 x 2.0 cm pituitary lesion. Transsphenoidal resection of the mass was performed and submitted for intraoperative consultation. Smears and touch preparations were made on a portion of the mass that showed uniform polygonal cells with round to ovoid nuclei and abundant eosinophilic granular cytoplasm. An intraoperative cytological diagnosis of "favor GCT" was rendered. The histologic sections of the remaining material confirmed the diagnosis. Although GCT of the neurohypophysis is very rare, a specific intraoperative cytological diagnosis is possible. We report the clinical, cytological, and pathological findings of a GCT affecting the neurohypophysis.

Aportación de la ecoendoscopia al diagnóstico de las metástasis pancreáticas del carcinoma renal: a propósito de dos casos

Pancreatic metastases represent 2% of pancreatic tumors. The neoplasms most frequently metastasizing to the pancreas are breast, lung, melanoma and kidney tumors. We present the cases of two patients with pancreatic metastases from renal carcinoma diagnosed 4 and 8 years after the diagnosis and surgical treatment of the primary renal tumor. In both patients, endoscopic ultrasound was useful in the detection and characterization of these pancreatic lesions and allowed fine-needle aspiration for cytological study to be performed.

Intraoperative cytology of clear cell carcinoma of the ovary

OBJECTIVE

To describe the cytomorphology of clear cell carcinoma (CCC) of the ovary in intraoperative samples of peritoneal fluid, imprint and scraping samples of the tumour tissue.

STUDY DESIGN

Fourteen histologically confirmed cases, stained by standard cytological procedures, were analysed by light microscopy.

RESULTS

In 33.3% of peritoneal fluid samples and 92.9% of imprint and scraping cytological samples, besides variable clear cell cellular morphology, one or both distinct cytological characteristics were observed: eosinophilic, hyaline, extracellular, globular substance with or without formation of a 'raspberry' body and an eosinophilic, intracytoplasmic inclusions. These structures were clearly seen only in samples stained by May-Grünwald-Giemsa.

CONCLUSION

Using cytological analysis of imprint and scraping samples of ovarian tumours it is possible to make a precise intraoperative cytological diagnosis in most cases of CCC of the ovary.

Surgical treatment of metastatic tumors to the pancreas: a single center experience and review of the literature

BACKGROUND

Unlike primary pancreatic carcinoma, metastases to the pancreas are rare, and their resection may be performed as palliative treatment. The aim of this study was to review our experience with the operative management of pancreatic metastases.

MATERIALS AND METHODS

Between January 1994 and December 2004 13 patients (nine women and four men; median age: 59 years; range: 36-79 years) were admitted to our institution with metastatic lesion to the pancreas. The clinical features of the treatment and results were examined.

RESULTS

Primary tumors were renal cell carcinoma (n=5), lobular carcinoma of the breast (n=3), endometrioid carcinoma of the ovary (n=1), colonic adenocarcinoma (n=1), jejunal leiomyosarcoma (n=1), melanoma (n=1), and non-small-cell lung cancer (n=1). The median interval between primary tumor and pancreatic metastases was 36 months (range: 5-192 months). Six patients (46%) were asymptomatic, while the other seven patients presented with jaundice, pain, and duodenal obstruction. Two patients with extrapancreatic disease underwent palliative surgery, and the remaining 11 patients underwent operative procedures that included seven pancreaticoduodenectomy and four distal pancreatectomies with splenectomy. Postoperative mortality was nil, and the morbidity rate was 30%. The two patients who underwent palliative surgery died after 7 and 9 months, respectively. The median survival of the resected patients was 26 months (range: 13-95 months). Five patients died of disease, eight are alive at the time of this report.

CONCLUSION

A trend towards improved survival, even if not statistically significant, was observed in the renal carcinoma patients reported here. Surgical resection can be performed safely in selected patients with isolated metastases to the pancreas, achieving long-term survival as well as good palliation.

A multinodular goiter as the initial presentation of a renal cell carcinoma harbouring a novel VHL mutation

BACKGROUND

Secondary involvement of the thyroid gland is rare. Often the origin of the tumor is difficult to identify from the material obtained by fine-needle aspiration cytology. Renal cell carcinoma of the clear-cell type is one of the more common carcinomas to metastasize to the thyroid gland. Somatic mutations of the von Hippel-Lindau tumor suppressor gene are associated with the sporadic form of this tumor. We aimed to illustrate the potential utility of DNA based technologies to search for specific molecular markers in order to establish the anatomic site of origin.

CASE PRESENTATION

A 54-yr-old Caucasian male complaining of a rapidly increasing neck tumor was diagnosed as having a clear-cell tumor by fine-needle aspiration cytology. A positive staining for cytokeratin as well as for vimentin and CD10 in the absence of staining for thyroglobulin, calcitonin and TTF1 suggested a renal origin confirmed by computed tomography. Using frozen RNA, obtained from cells left inside the needle used for fine needle aspiration cytology, it was possible to identify a somatic mutation (680 delA) in the VHL gene.

CONCLUSION

In the presence of a clear-cell tumor of the thyroid gland, screening for somatic mutations in the VHL gene in material derived from thyroid aspirates might provide additional information to immunocytochemical studies and therefore plays a contributory role to establish the final diagnosis. Moreover, in a near future, this piece of information might be useful to define a targeted therapy.

Fine-needle aspiration biopsy of hepatic lesions: computerized tomographic-guided versus endoscopic ultrasound-guided FNA

BACKGROUND

Computerized tomographic (CT)-guided fine-needle aspiration (FNA) cytology is a well-established tool in the diagnosis of hepatic lesions. Endoscopic ultrasound-guided FNA (EUS-FNA), developed recently and used predominantly in evaluating mediastinal and pancreatic lesions, provides access to a significant portion of the liver and to perihepatic structures not readily accessible by a percutaneous approach.

METHODS

A recent experience (1997-2002) with CT-guided FNA of liver lesions at the University of Alabama Birmingham (UAB) was compared with the first 2.5 years of EUS-FNA experience (2000-2002). Cases were identified using a SNOMED search and all reports and cytologic slides were retrieved for review.

RESULTS

In 6 years, 34 percutaneous CT-FNA liver biopsies were performed at UAB; in approximately 2.5 years, 16 EUS-FNA liver biopsies were done. In both groups the primary clinical indication was suspected metastatic carcinoma (CT, 41% of cases vs. EUS, 56%). The 2 techniques yielded a similar range of benign, atypical, and malignant diagnoses (CT: 26%, 18%, and 56% vs. EUS: 19%, 25%, and 56%). Because of the clinical setting in which EUS-FNA is usually performed, a much narrower range of neoplasms was sampled by EUS-FNA. Benign gastrointestinal epithelial cells were identified in 60% of the EUS-FNA specimens.

CONCLUSIONS

Early experience suggests EUS-FNA is comparable to CT-FNA in terms of diagnostic utility for hepatic lesions. Anatomy limits EUS-FNA to only a fraction of the hepatic parenchyma, but that fraction includes the hilum and left lobe of the liver and the proximal biliary tract. The gallbladder, extrahepatic biliary system, and perihilar lymph nodes are readily accessible. Proximate high-resolution ultrasound imaging and cytopathologist involvement in the EUS-FNA process are further advantages. Awareness of artifacts inherent in EUS-FNA sampling (i.e., gut epithelial cells) can minimize a potential diagnostic pitfall.

Cholangiocarcinoma at the cystic duct discovered by lymph node metastases with clear cell transformation

We encountered a case with cholangiocarcinoma of the cystic duct, which was first manifested by multiple lymph node metastases with clear cell changes resembling clear cell adenocarcinoma (CCC). Because the clear cell changes were not prominent at the primary site, clear cell transformation might have occurred preferentially at the metastatic lesion in this case. Alternatively, tumor cells with clear cell transformation, found at the primary site, might have high metastatic potential. The patient showed thromboembolism and hypercalcemia as paraneoplastic syndromes at the terminal stage as reported in patients with CCC of the ovary. Those complications might be common biological features of CCC.

Fine needle aspiration biopsy of the liver: Algorithmic approach and current issues in the diagnosis of hepatocellular carcinoma

The role of fine needle aspiration biopsy (FNAB) in the evaluation of focal liver lesions has evolved. Guided FNAB is still useful to procure a tissue diagnosis if clinical, biochemical and radiologic findings are inconclusive. Major diagnostic issues include: (i) Distinction of benign hepatocellular nodular lesions from reactive hepatocytes, (ii) Distinction of well-differentiated hepatocellular carcinoma (WD-HCC) from benign hepatocellular nodular lesions, (iii) Distinction of poorly differentiated HCC from cholangiocarcinoma and metastatic carcinomas, (iv) Determination of histogenesis of malignant tumor, and (v) Determination of primary site of origin of malignant tumor. This review gives a general overview of hepatic FNAB; outlines an algorithmic approach to cytodiagnosis with emphasis on HCC, its variants and their mimics; and addresses current diagnostic issues. Close radiologic surveillance of high-risk cirrhotic patients has resulted in the increasing detection of smaller lesions with many subjected to biopsy for tissue characterization. The need for tissue confirmation in clinically obvious HCC is questioned due to risk of malignant seeding. When a biopsy is indicated, core needle biopsy is favored over FNAB. The inherent difficulty of distinguishing small/early HCC from benign hepatocellular nodular lesions has resulted in indeterminate reports. Changing concepts in the understanding of the biological behavior and morphologic evolution of HCC and its precursors; and the current lack of agreement on the morphologic criteria for distinguishing high-grade dysplastic lesions (with small cell change) from WD-HCC, have profound impact on nomenclature, cytohistologic interpretation and management. Optimization of hepatic FNAB to enhance the yield and accuracy of diagnoses requires close clinicopathologic correlation; combined cytohistologic approach; judicious use of ancillary tests; and skilled healthcare teams.

Metastases in the pancreas from nonhematologic neoplasms: report of 20 cases evaluated by fine-needle aspiration

We reviewed fine-needle aspiration (FNA) samples of metastatic tumor in the pancreas from nonhematologic neoplasms over a 5-year period. In 1,050 total procedures, 20 metastases were diagnosed: 9 renal-cell carcinomas (RCCs), 3 melanomas, 2 pulmonary small-cell carcinomas, 2 breast carcinomas, 1 prostate carcinoma, 1 colon adenocarcinoma, 1 pulmonary squamous-cell carcinoma, and 1 gastrointestinal stromal tumor. A wide range of latency from primary diagnosis was noted; the longest was RCC at 12.6 years (range, 5-28). Sites of involvement were: 13 heads, 4 bodies, and 3 tails. Eighteen cases presented as a solitary mass. The average size was 4.7 cm (range, 1.5-9.8), and a case of RCC (9.8 cm) was the largest. In seven cases, the clinical and radiographic impression was of a pancreatic primary. We conclude that metastases to the pancreas are rarely diagnosed by FNA and may clinically mimic a pancreatic primary.

Clear-cell adenocarcinoma of the female genital tract: Presence of Hyaline stroma and tigroid background in various types of cytologic specimens

Hyaline basement membrane-like stromal material and tigroid background are distinctive cytologic features observed in Diff-Quik (DQ)- or Giemsa-stained smears of clear-cell adenocarcinoma (CCA) of the female genital tract. However, it is uncertain how often these features are present in different types of cytologic specimens, and which type of preparation is optimal for this diagnosis. We therefore reviewed the cytologic features of CCA in three types of specimens, including 15 scrape cytology specimens, 7 fine-needle aspiration (FNA) specimens, and 15 peritoneal cytology specimens, with emphasis on the features observed in DQ-stained smears. The cell morphology in scrape cytology specimens and FNA specimens was comparable, whereas in peritoneal cytology specimens, the cytoplasm was better preserved. Most tumor cells had fragile cytoplasm containing variable amounts of fine vacuoles, and round nuclei with distinct or prominent nucleoli. Hyaline stroma was present in 93% of scrape cytology specimens, 71% of FNA specimens, and 80% of peritoneal cytology specimens. Tigroid background was observed in 47% of scrape cytology specimens, 43% of FNA specimens, but in none of the peritoneal cytology specimens. Formation of a tigroid background may be prevented by the abundant fluid content in peritoneal cytology specimens. Hyaline stroma and tigroid background were uncommonly seen in scrape smears from other types of primary ovarian tumors, mainly juvenile granulosa cell tumor and yolk sac tumor. However, the additional presence of papillary structures allows CCA to be readily distinguished from these other tumors. We propose that scrape cytology offers the best approach for the intraoperative cytologic diagnosis of CCA.

Utility of CD10 and RCCma in the diagnosis of metastatic conventional renal-cell adenocarcinoma by fine-needle aspiration biopsy

The cytologic diagnosis of primary conventional renal-cell adenocarcinoma (cRCC) is usually straightforward; however, metastatic cRCC must be distinguished from a variety of neoplasms with clear-cell features. CD10, a cell membrane-associated neutral endopeptidase, and renal-cell carcinoma marker (RCCma), an antibody against human proximal tubular brush border antigen, have recently been shown to be useful in the diagnosis of cRCC. We compared CD10 and RCCma in cell block material from fine-needle aspiration biopsies (FNABs) to assess their utility in the diagnosis of metastatic cRCC, in cytologic specimens. Seven primary and sixteen metastatic cRCCs were immunostained with CD10 and RCCma. The immunoreactivity results were compared with those of a variety of neoplasms originating from other sites such as the liver, lungs, breast, and the gastrointestinal tract. The sensitivity and specificity of CD10 for cRCC were 100% and 59%, respectively. The sensitivity and specificity of RCCma for cRCC were 35% and 100%, respectively. We conclude that CD10 has limited value in confirming the diagnosis of cRCC because of its low specificity. RCCma, when positive, is highly specific for cRCC, but its low sensitivity hinders its diagnostic usefulness.

Metastatic renal clear cell carcinoma mimicking stage IV lung cancer

We present a 63-year-old man who was investigated for a lesion in the apex of the left lung and a coexisting osteolytic lesion in the right major trochanter. FNA of the thoracic mass was suggestive for malignancy yet not diagnostic regarding the tumor type and the site of the primary tumor. A diagnosis of a stage IV lung cancer was favored and he underwent a left exploratory thoracotomy in view to resect the primary tumor. An extrapulmonary mass localized to the pleura not involving the ipsilateral lung was disclosed. Multiple biopsies revealed metastatic clear cell RCC. A 5 x 7 cm left renal tumor was revealed in a postoperative abdominal CT scan. He was treated with combination of interferon A and vinblastin followed by radical nephrectomy. Twenty-four months after the diagnosis he is alive without evidence of local or distant recurrence. Pleural metastases from RCC are mainly presented as malignant pleural effusions. Thoracic metastatic lesions localized to the pleura, forming solitary or multiple mass(es) have been rarely reported. We review the literature regarding this rare clinical manifestation of the disease and we discuss diagnostic and therapeutic options.

Pancreatic Resection for Metastatic Renal Cell Carcinoma: Presentation, Treatment, and Outcome

BACKGROUND

The diverse natural history of renal cell carcinoma (RCC) includes metastases to the pancreas, a very unusual site for distant spread of other cancers. Considering the relatively indolent behavior of some cases of metastatic RCC, pancreatic resection is offered to select patients.

METHODS

We reviewed the records of patients at three affiliated university hospital centers who had prior nephrectomy for RCC and subsequent pancreatic resection of metastases.

RESULTS

Fourteen patients--9 women and 5 men with a median age of 63.8 years--underwent a total of 15 pancreatic resections for metastatic RCC. Nine (64%) had solitary metastases. The median interval from nephrectomy to diagnosis of pancreatic metastases was 83 months. The median size of metastases was 4.6 cm. There was one perioperative death. Pancreatic recurrence occurred in five patients (36%), and one patient underwent repeat resection. At a median follow-up of 32 months, seven patients (50%) are alive without evidence of disease, and four patients (28%) are alive with recurrent disease.

CONCLUSIONS

Resection of pancreatic metastases from RCC is associated with long-term survival and should be considered for patients in whom complete resection is possible.

Diagnostic utility of renal cell carcinoma marker in cytopathology

Renal cell carcinoma (RCC) not uncommonly presents with metastases and causes diagnostic difficulty to the cytopathologist who is involved in the initial diagnostic workup of tumors with an unknown primary site. RCC marker (RCC Ma) recognizes a human proximal tubule antigen and was shown to have high specificity and relatively low sensitivity in preliminary studies on routinely processed tissue sections. We investigated the diagnostic usefulness of RCC Ma immunohistochemically in fine-needle aspiration (FNA) samples. A total of 34 FNA samples obtained from the following carcinomas were used: 7 RCCs, 5 metastatic RCCs, 4 hepatocellular carcinomas, 2 non-small cell carcinomas of the lung, 3 metastatic non-small cell carcinomas of the lung, 4 invasive ductal carcinomas of the breast, 2 pancreatic ductal adenocarcinomas, 4 metastatic transitional cell carcinomas of the urinary bladder, and 3 metastatic colon carcinomas. Routinely processed cell block sections of FNA specimens were stained with RCC Ma by using routine immunohistochemistry. Presence and distribution of staining were evaluated. Two of 7 (29%) primary and 2 of 5 (40%) metastatic RCCs showed immunoreactivity in less than 50% of carcinoma cells. Staining was focal, cytoplasmic, and granular. Scattered positive cells were present in two of the four hepatocellular carcinomas. All breast, lung, pancreas, colon, and transitional cell carcinomas were negative. RCC antibody has a low sensitivity (33%), most likely because of its focal staining pattern, and a high specificity (91%) in FNA specimens. Immunoreactivity in metastatic carcinoma of an unknown primary site, especially as part of a panel of antibodies, is useful in diagnostic cytopathology. RCC antibody has not been studied in hepatocellular carcinoma, and the significance of positivity observed in some of our cases is unclear.

Distribution of subtypes of metastatic renal-cell carcinoma: correlating findings of fine-needle aspiration biopsy and surgical pathology

Clear-cell (CRCC), papillary (PRCC), and chromophobe (CHRCC) renal-cell carcinoma (RCC) are the three most frequent subtypes of RCC. The rate and distribution of their metastatic lesions have not been well studied in cytopathological materials. Sixty-two fine-needle aspiration biopsy cases of metastatic RCC were studied and correlated with surgical pathology of RCCs with and without metastasis. Special stains for glycogen and immunostaining for cytokeratins, vimentin epithelial membrane antigen (EMA), and carcinoembryonic antigens, and electron microscopic studies were performed. Fifty-nine cases of CRCC and three of PRCC subtypes were retrieved from the cytopathology files at the Ottawa Hospital in a period of 10 years. Of these cases, 10 metastatic CRCC and one metastatic PRCC were diagnosed prior to the diagnosis of the primary tumor. CHRCC and sarcomatoid RCC were not represented in cytopathological specimens. CRCC displayed characteristic filmy cytoplasm and nuclei with prominent nucleoli. PRCC was characterized by dense cytoplasm, large nuclei with prominent nucleoli, and papillary architectures. In addition, all RCCs were characterized by the presence of glycogen and the absence of mucin by using histochemical techniques and electron microscopic studies and positive reactivity for cytokeratins (CK) and vimentin (VIM). In the same period, there were a total of 380 patients with RCC divided into 310 CRCCs, 55 PRCCs, and 15 CHRCCs associated with metastases in 142, 9, and 1 case, respectively. CRCC is by far the most common subtype found in metastases sampled in cytopathology. PRCC, CHRCC, and sarcomatoid RCC were underrepresented. Awareness of this propensity of RCC and the characteristic cytopathological, histochemical, immunohistochemical, and ultrastructural features are helpful in the diagnosis of metastatic RCC.

CD10 facilitates the diagnosis of metastatic renal cell carcinoma from primary adrenal cortical neoplasm in adrenal fine-needle aspiration

Renal cell carcinoma (RCC) frequently metastasizes or invades the adrenal gland. Metastatic RCC is often difficult to differentiate from primary adrenal cortical neoplasm (ACN) in an adrenal fine-needle aspiration (FNA). Recently, CD10 immunoreactivity was observed in more than 90% of RCC, but none in primary ACN. To facilitate the accurate diagnosis of metastatic RCC in adrenal FNA, we retrospectively studied the cytomorphology and CD10 immunohistochemistry in 20 cases of FNA specimens, including 10 cases of adrenal FNA (six cases of metastatic RCC and four cases of primary ACN) and 10 cases of primary RCC. Cytomorphologically, several overlapping features were observed between primary ACN and metastatic RCC, including: abundant clear cytoplasm, often with microvesicles, large nuclei with prominent nucleoli, bare nuclei, and prominent vascularity. Immunostaining for CD10 was positive in 9/10 cases of primary RCC, 5/6 cases of metastatic RCC in the adrenal gland, and 0/4 cases of primary ACN. Our study indicates that: 1) an accurate diagnosis of ACN in FNA specimens can often be difficult due to overlapping cytomorphologic features with RCC, and 2) CD10 immunostaining is helpful in separating metastatic RCC from a primary ACN and can reliably be performed on a cytologic sample.

Metastatic hepatocellular carcinoma to the heart

Right ventricular heart involvement of an otherwise unknown hepatocellular carcinoma is presented and the cytologic differential diagnosis is discussed. This tumor displays classic cytologic features of hepatocellular carcinoma, including trabecular arrangements with prominent endothelial cells and numerous intracytoplasmic hyaline bodies. The background contains many "naked nuclei" and extracellular hyaline bodies. The patient is alive with residual disease 4 months after surgical extirpation of the cardiac mass.