A 52-year-old man was referred to our hospital because of a growing left renal tumor. A contrast-enhanced CT scan revealed the presence of a 93-mm tumor in the upper pole of the left kidney (Fig. a,b) with tumor thrombus observed in the left renal vein (Fig. c). The tumor was gradually enhanced from the corticomedullary phase to the excretory phase. Enlarged lymph nodes were present at the left external iliac lesion; they were extra-regional lymph nodes and no other distant metastasis was observed (Fig. d). We diagnosed him as having left RCC classified as cT3aN0M1.\nOpen radical nephrectomy and dissection of left-sided pelvic lymph nodes were performed. The tumor and lymph nodes were examined macroscopically and microscopically. Macroscopically, a 80 × 80-mm, gray–whitish and solid tumor with necrotic tissue was located in the upper pole of the resected left kidney. Microscopically, the tumor consisted of a tubular and partly papillary structure (Fig. a). The neoplastic cells were cuboidal with eosinophilic cytoplasm. The Fuhrman nuclear grading system is used to describe the RMTSCC., This case was classified as Fuhrman nuclear grade 3 (Fig. b). The tumor was invaded into left renal vein, and metastatic lymph nodes were found at the left external iliac area (Fig. c). Fascicular growth with spindle cells and mucin stained by Alcian blue stain were found (Fig. a). Immunohistochemical findings showed the neoplastic cells to be diffusely positive for AMACR (Fig. b) and CK 7 (Fig. c). CD 10 was negative in the neoplastic cells (Fig. d). Although Ki-67 and p53 were negative in the neoplastic cells with low nuclear grade, they were positive in the neoplastic cells with high nuclear grade (Fig. e,f). We subsequently diagnosed him as having left RMTSCC classified as pT3aN0M1.\nThree months after nephrectomy, a PET-CT scan showed metastasis at the second lumbar vertebra with a maximum standard uptake value of 5.7 (data not shown). Six months after nephrectomy, vertebrectomy was performed for metastasis at the second lumbar vertebra. The pathological findings showed metastasis of the RMTSCC to the second lumbar vertebra. Nine months after nephrectomy, another PET-CT scan showed two 10-mm lymph nodes at the left internal iliac lesion with a maximum standard uptake value of 5.1 (data not shown). These were not regional lymph nodes of RCC, but he was not suffering from other causative diseases such as prostate or rectal cancer. Therefore, we diagnosed these lymph nodes as metastasis of RMTSCC. We are planning on administration of tyrosine kinase inhibitor.
A 56-year-old female was admitted to our clinic with a complaint of multiple masses in her left neck region. The past medical history of the patient included a left nephrectomy for renal cell carcinoma (the pathological analysis revealed clear cell + chromophob cell carcinoma) in 2000, otherwise normal. A physical examination of the patient revealed multiple painless cervical masses at different lymphatic levels in the left cervical region [].\nLaboratory findings were as follows, hemoglobin:14 gr/dl, hematocrit: 41,1%, erythrocyte count: 5.180.000/ mm3, leucocyte count: 6.390 / mm3 (66.4% neutrophils, 23.9% lymphocytes, and 7.2% monocytes), and erythrocyte sedimentation rate 31 mm / 1 hour. Urine analysis was normal. The Brucella agglutination test, and the MONO, VDRL, ANA, ANTİ-DNA, ASMA, AMA, ASO, and CRP tests were normal. The thyroid function tests were normal. The scintigraphic bone scan imaging was negative for metastatic lesions. Thyroid ultrasonographic examination and high resolution Pulmonary imaging were also found to be negative for metastasis. An abdominal ultrasonograpic examination showed a nephrectomy scar on the left side, but was otherwise normal. Ultrasonographic examination of the neck detected five lymphadenopathies of different sizes with the greatest dimension of 3 × 3 cm. The magnetic resonance imaging (MRI) scan also confirmed the ultrasonographic findings, and post contrast scanning showed heterogen and noduler contrast. Pathological examination of the fine needle aspiration biopsy (FNAB) of the lymphadenopathy that was greatest in dimension showed renal cell carcinoma (RCC), clear cell type.\nIn December 2006, left functional neck dissection was performed. Totally 23 lymphadenopathies were counted in the surgical specimen. The greatest lymph-node metastasis appeared as a thick, irregularly walled cystic mass, with a minimally enhancing or dense surrounding reaction that effaced the adjacent tissue planes []. In the pathological examination of the dissected lymphadenopathies, it was found that a third of them in the jugulodigastric region were metastatic renal cell carcinoma []. Postoperative radiotherapy to the neck region was performed. In the second and fourth months after the second operation, she has no evidence of recurrence in the neck region.