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Presented by Pedram Argani, M.D. and prepared by ChanJuan Shi, M.D., PhD.
Case 6: (none provided)
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1. Question
Week 382: Case 6
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images/argani-020909-6c.jpgCorrect
Answer: Metastatic renal cell carcinoma
Histology: This is a mushroom-shaped ulcerated lesion involving the small bowel. The overlying surface has the appearance of ulcerated granulation tissue. However, within the deeper portions of this polyp are nests of clear cells. The tumor cells are immunoreactive for EMA and cytokeratin, and not for CD117. This patient had a history of renal cell carcinoma resected a few years previously at our institution.
Discussion: Gastrointestinal stromal tumor is a major consideration for any epithelioid lesion involving the gastrointestinal tract. However, the absence of immunoreactivity for CD117 as well as the immunoreactivity for cytokeratins and EMA argues against this possibility. Clear cell sarcoma should label for S100 protein, but not for epithelial markers. Granulation tissue would lack the nests of clear cells within the current lesion.
As the current case demonstrates, renal cell carcinoma frequently metastasizes to unusual sites, such as the small bowel and the skin of the scalp. A new clear cell lesion in a patient with a history of renal cell carcinoma should be considered a metastasis until proven otherwise.
Incorrect
Answer: Metastatic renal cell carcinoma
Histology: This is a mushroom-shaped ulcerated lesion involving the small bowel. The overlying surface has the appearance of ulcerated granulation tissue. However, within the deeper portions of this polyp are nests of clear cells. The tumor cells are immunoreactive for EMA and cytokeratin, and not for CD117. This patient had a history of renal cell carcinoma resected a few years previously at our institution.
Discussion: Gastrointestinal stromal tumor is a major consideration for any epithelioid lesion involving the gastrointestinal tract. However, the absence of immunoreactivity for CD117 as well as the immunoreactivity for cytokeratins and EMA argues against this possibility. Clear cell sarcoma should label for S100 protein, but not for epithelial markers. Granulation tissue would lack the nests of clear cells within the current lesion.
As the current case demonstrates, renal cell carcinoma frequently metastasizes to unusual sites, such as the small bowel and the skin of the scalp. A new clear cell lesion in a patient with a history of renal cell carcinoma should be considered a metastasis until proven otherwise.
