Sarcoidosis and Renal Cell Carcinoma
Sarcoidosis and Renal Cell Carcinoma
A 53-year-old white woman, a nurse practitioner, self-referred to the urology service because of asymptomatic gross hematuria. In 1972, based on mediastinoscopy and lymph node biopsy, she received a diagnosis of sarcoidosis; however, she never required treatment. She also had a history of Raynaud phenomenon, stable vitiligo, migraines, and hypercholesterolemia. She did not smoke or take medications.
Her surgical history included a total vaginal hysterectomy for benign hypermenorrhea in 1971; right subcutaneous mastectomy (without lymphadenectomy) for carcinoma in situ, contralateral prophylactic subcutaneous mastectomy because of a strong family history of breast cancer, and placement of silicone breast implants in 1985; bilateral coronal brow lifts for ptosis and cosmetic placement of dermal fat grafts to her lips in 1993; exchange of both breast implants for larger saline-filled implants in 1996; and bilateral lower extremity varicose vein stripping in 1996.
The patient's physical examination was unremarkable. Her complete blood cell (CBC) count; erythrocyte sedimentation rate (ESR); serum electrolyte, calcium, and alkaline phosphatase levels; and liver function were normal. The serum creatinine level was 0.8 mg/dL (normal, 0.6 to 1.1 mg/dL). Urinalysis demonstrated large amounts of blood on dipstick testing and 150 to 200 red blood cells and 3 to 5 white blood cells per high-power field. The urine culture showed no growth.
Excretory urography revealed a mass arising from the upper pole of the left kidney. A CT scan showed a 7-cm left renal necrotic soft tissue mass without lymphadenopathy and an asymptomatic gallstone. Tumor thrombus into the renal vein and/or inferior vena cava could not be excluded. MRI did not demonstrate involvement of the renal vein or inferior vena cava (Figure 1). Findings on a chest radiograph and bone scan were normal.
(Enlarge Image)
An MRI of the abdomen demonstrates a solid mass arising from the upper pole of the left kidney (arrow).
A left radical nephrectomy was performed by means of an extrapleural extraperitoneal incision through the bed of the resected 11th rib. Pathologic evaluation revealed clear cell adenocarcinoma involving the proximal portion of the renal vein deep inside the renal hilum (not appreciated on preoperative MRI), with extension through the capsule into the perinephric fat (stage T3b N0 M0). The adrenal gland, local lymph nodes, and surgical margins were free of tumor.
Two months later, the patient complained of persistent fatigue. The repeated CBC count and measurements of ESR, serum electrolytes, calcium, alkaline phosphatase, and liver function were normal. The serum creatinine level was 1.1 mg/dL. The postoperative chest radiograph, however, showed hilar adenopathy not seen previously. A CT scan of the chest, abdomen, and pelvis revealed extensive mediastinal adenopathy, bilateral breast implants, an unchanged gallstone, and a surgically absent left kidney. There were no soft tissue masses in the parenchyma of the lungs. Diagnostic mediastinoscopy and lymph node biopsy were performed (Figure 2).
(Enlarge Image)
Pathologic evaluation of the resected mediastinal lymph node shows several discrete noncaseating granulomas composed of pale-staining epithelioid histiocytes at the periphery and multinucleated giant cells in the center (arrow). Smaller darkly stained lymphocytes surround the prominent granulomas. Schaumann and asteroid bodies are not demonstrated in this histologic section.
Which of the following statements is correct?
A 53-year-old white woman, a nurse practitioner, self-referred to the urology service because of asymptomatic gross hematuria. In 1972, based on mediastinoscopy and lymph node biopsy, she received a diagnosis of sarcoidosis; however, she never required treatment. She also had a history of Raynaud phenomenon, stable vitiligo, migraines, and hypercholesterolemia. She did not smoke or take medications.
Her surgical history included a total vaginal hysterectomy for benign hypermenorrhea in 1971; right subcutaneous mastectomy (without lymphadenectomy) for carcinoma in situ, contralateral prophylactic subcutaneous mastectomy because of a strong family history of breast cancer, and placement of silicone breast implants in 1985; bilateral coronal brow lifts for ptosis and cosmetic placement of dermal fat grafts to her lips in 1993; exchange of both breast implants for larger saline-filled implants in 1996; and bilateral lower extremity varicose vein stripping in 1996.
The patient's physical examination was unremarkable. Her complete blood cell (CBC) count; erythrocyte sedimentation rate (ESR); serum electrolyte, calcium, and alkaline phosphatase levels; and liver function were normal. The serum creatinine level was 0.8 mg/dL (normal, 0.6 to 1.1 mg/dL). Urinalysis demonstrated large amounts of blood on dipstick testing and 150 to 200 red blood cells and 3 to 5 white blood cells per high-power field. The urine culture showed no growth.
Excretory urography revealed a mass arising from the upper pole of the left kidney. A CT scan showed a 7-cm left renal necrotic soft tissue mass without lymphadenopathy and an asymptomatic gallstone. Tumor thrombus into the renal vein and/or inferior vena cava could not be excluded. MRI did not demonstrate involvement of the renal vein or inferior vena cava (Figure 1). Findings on a chest radiograph and bone scan were normal.
(Enlarge Image)
An MRI of the abdomen demonstrates a solid mass arising from the upper pole of the left kidney (arrow).
A left radical nephrectomy was performed by means of an extrapleural extraperitoneal incision through the bed of the resected 11th rib. Pathologic evaluation revealed clear cell adenocarcinoma involving the proximal portion of the renal vein deep inside the renal hilum (not appreciated on preoperative MRI), with extension through the capsule into the perinephric fat (stage T3b N0 M0). The adrenal gland, local lymph nodes, and surgical margins were free of tumor.
Two months later, the patient complained of persistent fatigue. The repeated CBC count and measurements of ESR, serum electrolytes, calcium, alkaline phosphatase, and liver function were normal. The serum creatinine level was 1.1 mg/dL. The postoperative chest radiograph, however, showed hilar adenopathy not seen previously. A CT scan of the chest, abdomen, and pelvis revealed extensive mediastinal adenopathy, bilateral breast implants, an unchanged gallstone, and a surgically absent left kidney. There were no soft tissue masses in the parenchyma of the lungs. Diagnostic mediastinoscopy and lymph node biopsy were performed (Figure 2).
(Enlarge Image)
Pathologic evaluation of the resected mediastinal lymph node shows several discrete noncaseating granulomas composed of pale-staining epithelioid histiocytes at the periphery and multinucleated giant cells in the center (arrow). Smaller darkly stained lymphocytes surround the prominent granulomas. Schaumann and asteroid bodies are not demonstrated in this histologic section.
Which of the following statements is correct?
The lymph node biopsy reveals metastatic renal cell carcinoma (RCC).
The lymph node biopsy result is consistent with sarcoidosis.
The patient should be evaluated for a primary malignancy of the GI tract.
Appropriate cultures should be obtained and antibiotic therapy instituted.