Cytodiagnosis of renal cell carcinoma – A case report

Cytodiagnosis of renal cell carcinoma ISSN: 2394-0026 (P)Case Report ISSN: 2394-0034 (O)Cytodiagnosis of renal cell carcinoma – A case report Disha Singla1, Gunvanti Rathod2* 1PG Student, 2Assistant ProfessorDepartment of Pathology, SBKS MI & RC, Sumandeep Vidyapeeth, Vadodara, Gujarat, India*Corresponding author email: [email protected] to cite this article: Disha Singla, Gunvanti Rathod. Cytodiagnosis of renal cell carcinoma – Acase report. IAIM, 2015; 2(2): 133-137.Available online at www.iaimjournal.comReceived on: 07-01-2015 Accepted on: 23-01-2015AbstractFine needle aspiration cytology (FNAC) under radiologic guidance for diagnosis of renal cellcarcinoma is well established and is increasingly utilized. Guided FNAC is very helpful for diagnosis,grading and determining operability of renal tumors in adults. Ultrasonography (USG) guidedpercutaneous fine needle aspiration cytology of renal masses was first reported by Kristensen, et al.The exact diagnosis is possible due to the characteristic cellular features of renal cell carcinoma(RCC). Here, we presented a case of 45 years old female patient, who had retroperitoneal massdiagnosed as renal cell carcinoma on USG guided percutaneous fine needle aspiration cytology.Key wordsUltrasonography, Fine needle aspiration cytology, Renal cell carcinoma.Introduction tumors. The diagnosis of renal cell carcinoma by fine needle aspiration cytology does not causeIn 1930, Martin and Colley, and a technical diagnostic difficulties whether the aspirates aredeveloper, Ellis, conducted aspirations from from the primary site or metastatic deposits [3].several organs and carried out cytological This is because renal cell carcinoma showsstudies on them [1]. Kristensen, et al. had first rather characteristic cellular features allowingreported ultrasonography (USG) guided their correct cytologic identification [3]. Also inpercutaneous fine needle aspiration cytology the present case, we had diagnosed the renal(FNAC) of renal masses [2]. FNAC under cell carcinoma from the cytology examination ofguidance is required for preoperative diagnosis the tumor cells. Here, we presented a case of 45if there is cystic change in solid renal masses or years old female patient, who hadif the masses are suspected to be malignant. In retroperitoneal mass diagnosed as renal celladults, guided FNAC is very helpful for diagnosis, carcinoma on FNAC.grading and determining operability of renalInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 133Copy right © 2015, IAIM, All Rights Reserved.

Cytodiagnosis of renal cell carcinoma ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Case report Photo – 1: Cellular smears with the tumor cells arranged in loose clusters and scattered singly asA 45 years old female patient from lower socio- well. (H & E, 4X)economic class presented with abdominal masssince 1 year in surgery outdoor patient Photo - 2: Cellular smears with cluster of thedepartment. On examination, patient had large tumor cells. (H & E, 10X)right sided abdominal mass with tenderness inright lumbar region. The clinician advised Photo – 3: Individual cells with distinct cellultrasonography (USG) which revealed mass in borders, eosinophilic granular cytoplasm andright side retroperitoneal region arise from the nuclear atypia. (H & E, 40X)lower pole of right kidney measuring 18 X 10 cm.Patient’s hematological and serologicalinvestigations were within normal limit. USGguided FNAC was advised and the mass to beaspirated was localised by USG. The site ofpuncture was marked on the skin and the areawas cleaned with an antiseptic solution [4, 5]. Alumbar puncture needle attached to a 10 mlsyringe was used for aspiration. The needle wasinserted under guidance into the lesion. When itwas clearly visualized within the mass, suctionwas applied and several passes were madewithin the lesion. The needle was withdrawnafter release of suction and the site of puncturewas sealed. The slides were grossly examined onthe spot. The slides were neither heavily bloodstained nor appeared to have scant material, sothat the aspirate was not repeated. The materialobtained was smeared on glass slides andimmediately fixed in 95% alcohol and submittedto the cytopathology laboratory for routineprocessing [6]. The smear thus obtained wasstained by hematoxylin and eosin (H and E) andPapanicolaou stains [7]. Diagnosis was made bymicroscopic examination of the stained slideswhich showed cellular smears with the cellsarranged in loose clusters and scattered singly aswell. The individual cells showed distinct cellborders and eosinophilic granular cytoplasmalong with nuclear atypia. There was dencelymphocytic infiltrate in the background ofhemorrhage. Overall features were that of renalcell carcinoma. (Photo - 1, Photo - 2, Photo – 3)International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 134Copy right © 2015, IAIM, All Rights Reserved.

Cytodiagnosis of renal cell carcinoma ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Discussion Its usual presentations are hematuria (59%), flank pain (41%) and abdominal mass (45%).The application of image guidance to aspiration However, the combination of these threecytology has brought about a revolution in the features, classically regarded as the diagnosticfield of cytopathological diagnosis. Where triad of renal cell carcinoma, occur in only nineinitially only superficial and easily palpable percent of the patients and are usually a latelesions could be subjected to aspiration, now, manifestation [15]. Almost 25% of renal celleven deep seated lesions can be visualized and carcinoma is asymptomatic in which discovery ofaspiration can be performed with a high degree the tumor is incidental to routine physicalof accuracy and minimum discomfort to the examination and radiological study [16].patient. The need for exploratory surgery and itsattendant morbidity is thus reduced Although renal cell carcinomas can be diagnosedsignificantly. Image guided fine needle fairly accurately on cytology, difficulties canaspiration (FNA) of retroperitoneal and pelvic arise in the presence of massive hemorrhage ormasses are now an increasingly common extensive necrosis [17]. This condition isdiagnostic procedure. particularly true for papillary variant of renal cell carcinoma because of the perculiar features ofAny structure visualized by dynamic this variant that show presence of cystic andultrasonography (USG) can be reached quickly extensive degenerative changes [11].and precisely by a fine needle in any desiredplane with constant visualization of needle tip Tumor cells may be single, or are arrangedduring insertion [8]. As compared to its more loosely in flat sheets, clusters, papillary fronds orillustrious counterpart, the computed an alveolar pattern. The smear pattern maytomography (CT) scan, USG has additional occasionally be mixed. Three distinct cell typesadvantages in that it is comparatively have been described on fine needle aspirationinexpensive, can be easily repeated, and avoids cytology [18], the clear cell, the granular cell andthe risk of radiation exposure [9]. the oncocytic cell types, occurring either exclusively or admixed together. The clear cellsSeveral studies had proven that fine needle of renal cell carcinoma have abundant, fragile,aspiration cytology of a renal mass is a useful finely vacuolated cytoplasm, best appreciateddiagnostic procedure. With reference to on the Diff-Quik stain. The cytoplasm is highlymalignancies, the usefulness of the method is characteristic [3]. In our case, the aspiratesrelated to its high sensitivity, 0.93, and high showed malignant cells with moderate amountdegree of typing accuracy [10, 11]. Reported of finely granular vacuolated cytoplasm andsuccess rates are 87-100% (mean of 93.5%) for macronucleoli suggestive of renal cellrenal tumors [10, 12]. carcinomas. These findings were corroborative with the findings from the study by Renshaw, etRenal cell carcinoma is a relatively rare tumor al. [19]. Granular cells have eosinophilic oraccounting for less than three percent of all cyanophilic cytoplasm, which is moderatelyadult cancers [13, 14]. It is generally a tumor of dense and granular. Oncocytic cells haveadults where the average age at diagnosis is extremely dense, eosinophilic, compactbetween 55-60 years [13, 14]. The clinical cytoplasm with well-defined cell borders. Rarely,diagnosis of renal cell carcinoma is difficult since renal cell carcinoma may show a diffuse spindledits clinical manifestations are quite variable. appearance.International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 135Copy right © 2015, IAIM, All Rights Reserved.

Cytodiagnosis of renal cell carcinoma ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)A nuclear grading system based on four nucleargrades defined in order of increasing nuclear Conclusionsize, irregularity and nucleolar prominence,proposed by Furhman, et al. [20] showed that With such applications, it is not unusual tonuclear grade was effective in predicting survival occasionally diagnose unexpected lesions inand development of metastasis after which the combined radiological and cytologicalnephrectomy [21]. This grading system has been assessments enable the clinician to pursue a linepopular in routine surgical material of renal cell of further investigation and make a correctcarcinoma and could readily be applied to fine management decision. Ultrasound guided fineneedle aspiration cytology material. Several needle aspiration is reliable, accurate, safe andstudies using Furhman’s nuclear grading system well tolerated and it should be considered theshowed high concordance between nuclear initial investigation for renal mass.grading in fine needle aspiration material andhistologic specimens (80-92%) [22]. ReferencesThe differential diagnosis includes primary 1. Gunvanti Rathod, Pragnesh Parmar. Fineadrenal cortical carcinoma which is very difficult needle aspiration cytology of swellingsto differentiate from renal cell carcinoma of head and neck region. Indian Journalinvading or metastasizing to the adrenal gland. of Medical Sciences, 2012; 66: 49-54.But the study by Bennington JL and Beckwiht JB1975, Weiss LM 1984 [13, 23] noted that adrenal 2. Kristensen JK, Bartels E, Jorgensen HE.cortical carcinoma tend to show more cellular Percutaneous renal biopsy under theanaplasia than do renal cell carcinomas. Electron guidance of ultrasound. Scand J Urolmicroscopic study of tumour tissue may be Nephrol, 1974; 8: 223-6.helpful in making a correct diagnosis. 3. Linsk JA, Franzen S. Aspiration cytologyFNA under image guidance should be considered of metastatic hypernephroma. Actaas first-line diagnostic approach for Cytol., 1984; 28(3): 250-260.retroperitoneal and other abdominal tumorsand lesions. However, a word of caution is 4. Rathod GB, Ghadiya V, Shinde P, Tandanessential. It is necessary to be selective in RK. Pleomorphic sarcoma in 60 years olddeciding which masses are to be aspirated. male – A case report. InternationalFurther, in some cases, cytology cannot be relied Journal of Current Microbiology andupon to exclude malignancy, as in the case of Applied Sciences, 2014; 3(8): 510-517.renal cysts [24] and cysts of large size.Histopathology remains the gold standard in 5. Gunvanti Rathod, Pragnesh Parmar,such cases. Therefore, the choice between pre- Sangita Rathod, Ashish Parikh.operative cytology and excisional biopsy lies Suprascapular malignant fibrouswith the surgeon. As in all cases, a thorough histiocytoma – A case report. Discovery,clinical workup is a pre-requisite and can help in 2014, 12(31): 50-53.reaching a good clinical decision. 6. Rathod GB, Goyal R, Bhimani RK, Goswami SS. Metaplastic carcinoma of breast in 65 years old female - A case report. Medical Science, 2014; 10(39): 77-81. 7. Gunvanti Rathod, Sangita Rathod, Pragnesh Parmar, Ashish Parikh. Diagnostic efficacy of fine needle aspiration cytology in cervical lymphadenopathy – A one year study. International Journal of Medical andInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 136Copy right © 2015, IAIM, All Rights Reserved.

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