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Presented by Peter Illei, M.D. and prepared by Amy Duffield, M.D., Ph.D.
Case 1: Routine check up of this 67 y.o. female patient with hypertension detected elevated potassium levels.
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Question 1 of 1
1. Question
Week 313: Case 1
Routine check up of this 67 y.o. female patient with hypertension detected elevated potassium levels. Abdominal imaging studies revealed a 4.0 cm mass in the right kidney and a 7.5 cm mass in the left adrenal. A right radical nephrectomy and left total adrenelactomy was performed. Gross exam revealed a 4.0 cm extensively hemorrhagic tumor in the kidney that was confined to the kidney and shoed no evidence of vascular invasion. The adrenal weighed 295 grams and contained a 7.5 cm tumor that was also confined to the adrenal. No necrosis or hemorrhage was noted.images/kidney 6_11_07.jpg
images/kidney IHC 6_11_07.jpg
images/Adrenal 6_11_07.jpg
images/Adrenal IHC 6_11_07.jpgCorrect
Answer: Adrenal cortical carcinoma, and separate renal cell carcinoma
Histology: none provided
Discussion: Histologically, the tumors are similar with both exhibiting oncocytic features, both are confined to their respective organs, have a low proliferative index (<1% on immunostain for Ki67) and lack vascular invasion. Immunostains demonstrate that the cells of the renal tumor are strongly and diffusely cytokeratin (AE1/AE3) and EMA positive, but RCC, Melan-A and inhibin negative. Conversely, immunostains of the adrenal tumor demonstrate that the tumor cells are Melan-A positive, and cytokeratin (AE1/AE3), EMA, RCC and inhibin negative. Stains for PAX-2, CD10 and calretinin were performed but were non-contributory in both tumors. This staining pattern supports the diagnosis of a primary renal cortical and a primary adrenal cortical neoplasm.
The adrenal tumor cells are arranged in solid sheets and have predominantly pink granular cytoplasm and focally clear cytoplasm. The nuclei are pleomorphic and vary from round nuclei with clear chromatin with small nucleoli to enlarged and irregular hyperchromatic nuclei (consistent Fuhrman grade III/IV). The mitotic rate is low (<1 per 10 HPF). No venous invasion or necrosis are identified. Focal hemorrhage is present. The larger size of the tumor (7.5 cm, 295gr), the predominantly solid growth pattern, the minor (<25%) clear cell component, and the high nuclear grade suggests a malignant behaviour (based on the histopathologic criteria by Weiss) and warrant the diagnosis of adrenal cortical carcinoma.
The tumor in the kidney shows extensive hemorrhage, the cells are arranged in nests, and have pink granular cytoplasm with enlarged round nuclei and small nucleoli (Fuhrman grade II/IV). No central scar is noted. We feel that these features support the diagnosis of a renal cell carcinoma that is unclassifiable.
Reference(s):
- Weiss et al. AJSP 13:202-206, 1989.Incorrect
Answer: Adrenal cortical carcinoma, and separate renal cell carcinoma
Histology: none provided
Discussion: Histologically, the tumors are similar with both exhibiting oncocytic features, both are confined to their respective organs, have a low proliferative index (<1% on immunostain for Ki67) and lack vascular invasion. Immunostains demonstrate that the cells of the renal tumor are strongly and diffusely cytokeratin (AE1/AE3) and EMA positive, but RCC, Melan-A and inhibin negative. Conversely, immunostains of the adrenal tumor demonstrate that the tumor cells are Melan-A positive, and cytokeratin (AE1/AE3), EMA, RCC and inhibin negative. Stains for PAX-2, CD10 and calretinin were performed but were non-contributory in both tumors. This staining pattern supports the diagnosis of a primary renal cortical and a primary adrenal cortical neoplasm.
The adrenal tumor cells are arranged in solid sheets and have predominantly pink granular cytoplasm and focally clear cytoplasm. The nuclei are pleomorphic and vary from round nuclei with clear chromatin with small nucleoli to enlarged and irregular hyperchromatic nuclei (consistent Fuhrman grade III/IV). The mitotic rate is low (<1 per 10 HPF). No venous invasion or necrosis are identified. Focal hemorrhage is present. The larger size of the tumor (7.5 cm, 295gr), the predominantly solid growth pattern, the minor (<25%) clear cell component, and the high nuclear grade suggests a malignant behaviour (based on the histopathologic criteria by Weiss) and warrant the diagnosis of adrenal cortical carcinoma.
The tumor in the kidney shows extensive hemorrhage, the cells are arranged in nests, and have pink granular cytoplasm with enlarged round nuclei and small nucleoli (Fuhrman grade II/IV). No central scar is noted. We feel that these features support the diagnosis of a renal cell carcinoma that is unclassifiable.
Reference(s):
- Weiss et al. AJSP 13:202-206, 1989.
