A Young Woman With Multiple Kidney Lesions

SECOND OPINION
Multidisciplinary Consultations on Challenging Cases

The University of Colorado Denver School of Medicine faculty holds weekly second opinion conferences focusing on cancer cases that represent most major cancer sites. Patients seen for second opinions are evaluated by an oncologic specialist. Their history, pathology, and radiographs are reviewed during the multidisciplinary conference, and then specific recommendations are made. These cases are usually challenging, and these conferences provide an outstanding educational opportunity for staff, fellows, and residents in training.

The second opinion conferences include actual cases from genitourinary, lung, melanoma, breast, neurosurgery, gastrointestinal, and medical oncology.

E. David Crawford, MD
Thomas W. Flaig, MD
Guest Editors

University of Colorado Denver School of Medicine
and University of Colorado Cancer Center
Aurora, Colorado

The patient is a 26-year-old woman with a complex oncologic history. At 1 year of age, she was diagnosed with a stage III abdominal neuroblastoma, which was treated with surgery and combination chemotherapy (vincristine, cyclophosphamide, and dacarbazine [DTIC]). A right adrenalectomy was performed subsequent to this initial surgery for a suspicious lesion, although no malignancy was identified in the sample. At age 9, she had a recurrence of neuroblastoma in the left axilla. After surgical resection, she received postoperative radiation therapy and an extended course of combination chemotherapy (cyclophosphamide, vincristine, doxorubicin, and dacarbazine). She was in her usual state of good health until 18 months ago, when she presented with hematuria and was found to have a right-sided kidney mass. A radical nephrectomy was performed via a laparoscopy.

Currently, she is being followed closely both clinically and radiographically. She continues to remain asymptomatic. Imaging has demonstrated several areas of note including multiple lesions in her remaining kidney and small, nonspecific lung nodules. Her past medical history is otherwise unremarkable. In her family history, there are no first degree relatives with a diagnosis of cancer. She has never used tobacco.

Current Status

Physical Findings

Dr. Thomas W. Flaig: Her temperature was 99.5°F, pulse was 90 beats per minute, respiratory rate was 16 per minute, and blood pressure was 140/88 mm Hg. She is in no acute distress. Her lungs are clear to auscultation bilaterally. She has a regular heart rate without murmur. Her abdomen is soft, not tender and without mass or organomegaly. Her Zubrod performance status was 0 (without limitations).

Laboratory Results

Creatinine was 0.97 mg/dL; sodium, 138 mmol/L; calcium, 9.4 mg/ dL; total bilirubin, 0.7 mg/dL; alanine aminotransferase, 29 U/L; albumin, 3.8 g/dL; white blood cell count, 5.7 × 10⁹; hemoglobin, 14.9 g/ dL; and platelets, 242 × 10⁹.

Pathology

Dr. Flaig: Dr. La Rosa, will you review the patient’s pathology?

FIGURE 1

Renal Cell Carcinoma-

High-grade renal cell carcinoma seen on

(A)

H&E staining, 40× objective;

(B)

Immunostaining for RCC antigen, 40× objective. H&E = hematoxylin and eosin.

Dr. Francisco G. La Rosa: We received from an outside hospital, for our review and second opinion diagnosis, 19 glass slides accompanied by their corresponding pathology report. The patient’s specimen corresponds to a right radical nephrectomy performed 18 months ago. The slides show a high-grade renal cell carcinoma, clear cell type, bifocal (8–9 × 1.1 cm by outside report), with a Fuhrman nuclear grade 4 of 4. We found no definitive evidence of extension into the renal capsule or perinephric fat and no evidence of involvement of the renal vein or lymphovascular invasion. However, according to the outside pathology report, the tumors were very friable during the gross examination; thus, the histologic preparations show renal parenchyma and perirenal adipose tissue with extensive contamination artifact by tumor cells, making it difficult to determine whether malignant infiltration of perinephric tissue and/or lymphovascular invasion are present.

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