A 49-year-old male was presented at our department with lower back pain and walking instability for the last few days. The patient suffered from end-stage renal disease on dialysis for the last 15 years and had a history of successful renal transplantation about 25 years ago. The initial renal insufficiency resulted from a chronic glomerulonephritis and the allograft was rejected 9 years after transplantation due to the same underlying condition. Furthermore, about 2 years ago, he underwent bilateral nephrectomy for solid tumorous masses in both nonfunctioning kidneys. The histologic examination revealed, bilaterally at that time, type 1 papillary renal cell carcinoma (pT1aN0M0, Fuhrman grade II, in sano resection). Additionally, the nonfunctioning transplant kidney was removed about 6 months ago due to recurrent episodes of macrohaematuria, without evidence for a malign tumour. At that time, there were no signs for a metastatic disease.\nAt current presentation, the performed magnetic resonance imaging (MRI) of the spine showed a pathologic facture at the right side of the first and second lumbar vertebral body () from a metastatic solid mass, as well as multiple osteolytic metastases from 7th cervical to 2nd lumbar vertebra. A staging computed tomography (CT) of the thorax and abdomen showed further osseous osteolytic metastatic lesions at the sternum, both scapulae, the bone pelvis, and the left proximal femoral bone. The performed biopsy of the osteolytic metastatic lesion at the second lumbar vertebra revealed a metastatic, mucin-poor variant, of a mucinous tubular and spindle cell carcinoma of the kidney (). A thorough reexamination of the old nephrectomy specimens showed that the tumour of the right kidney was also a mucin-poor variant of a MTSCC of the kidney, while the tumour of the left kidney was confirmed as a papillary RCC.\nHistologically, both the biopsy sample and the nephrectomy-specimen of the right kidney showed a renal cell tumour with a spindle cell component, as well as tubular and papillary parts without any clear cells. Both spindle and tubular-papillary parts were delimited by a basal membrane, forming a ball-shaped, epithelial tumour-growth pattern with spindled nuclear morphology, which did not match a sarcomatoid differentiation. Immunohistochemically, the tumour was negative for desmin and actin and S100 protein, as well as for HMB45, MITF1, MART1, and SOX-10. A positive reaction to Racemase (AMARC), PAX-8, and RCC was found, with focal positivity for CD10. Pan-Cytokeratin (AE1/AE3) and CK7 were negative except from the papillary parts. The Ki67 stain showed focal proliferation rates up to 30%. Furthermore, no mucoid interstitial matrix was found with H&E stain. Only with Alcian blue staining, <1% mucin in cellular areas was observed.\nAccording to our interdisciplinary tumour conference board's recommendation, the patient followed a systemic treatment with pazopanib and focal radiotherapy to lumbar and cervical vertebrae metastases. In further follow-up, irrespective of the started treatment, the tumour spread rapidly and after three months the patient presented with additional hepatic and pulmonary metastases. The patient finally succumbed to the disease a few months later.
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.