Case Report
Metastatic
renal cell carcinoma from a native kidney of a renal transplant patient
diagnosed by endoscopic ultrasound-guided fine needle aspiration
(EUS-FNA) biopsy
Yaseen Alastal1*, Tariq A Hammad1*, Ehsan Rafiq2, Mohamad Nawras1, Osama Alaradi2, Ali Nawras2
1Department of Internal Medicine, University of Toledo Medical Center; 2Department
of Gastroenterology and Hepatology, University of Toledo Medical
Center, 3000 Arlington Avenue, MS 1150, Toledo, OH 43614,
USA.
Abstract
Endoscopic
ultrasound-guided fine needle aspiration (EUS-FNA) biopsy sampling of enlarged
lymph nodes is increasingly used to diagnose metastatic tumors, especially of
the gastrointestinal tract and the lungs. Herein, we describe the diagnosis of
metastatic renal cell carcinoma from a native kidney of a 54 year-old male patient,
who had a 5-years history of renal transplant, by EUS-FNA of mediastinal and
celiac lymph nodes. Histological and immunohistochemical findings confirmed the
origin of metastatic tumor. EUS-FNA with proper cytological evaluation can be
useful in the diagnosis of metastatic renal cell carcinoma in renal transplant
patients. Copyright: The Authors.
Received: 25 March 2015; Accepted after revision: 19 April 2015; Published: 20 April 2015.
Author
for correspondence: Ali
Nawras MD, FACP, FACG, FASGE, Department of Gastroenterology and Hepatology,
University of Toledo Medical Center, 3000 Arlington Avenue, MS 1150, Toledo, OH
43614, USA. Email:[email protected]. * Contributed equally.
How
to cite: Alastal
Y, Hammad TA, Rafiq E, Nawras M, Alaradi O, Nawras A. Metastatic renal cell
carcinoma from a native kidney of a renal transplant patient diagnosed by
endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy. Journal
of Kidney Cancer and VHL 2015;2(2):70-74. Doi: http://dx.doi.org/10.15586/jkcvhl.2015.25.
Endoscopic ultrasound-guided fine
needle aspiration (EUS-FNA) biopsy is increasingly used to diagnose metastatic
tumors. Lymph node sampling by fine needle aspiration (FNA) offers a chance to
evaluate the origin of tumor cells, and subsequently aid the management of such
tumors. Herein, we present a case of metastatic renal cell carcinoma (RCC) of
the native kidney, in a renal transplant patient, diagnosed by EUS-FNA biopsy
of the mediastinal and celiac lymph nodes.
Case report
Informed Consent was obtained from the patient as
per the policy of our institution. A 54 year old male patient with a 5-year
history of living-related donor renal transplant, secondary to Goodpasture
syndrome, presented with nausea, vomiting and moderate lower abdominal pain for
3 weeks. The patient also reported a 10 lb weight loss in 2 months. He had a
history of smoking, 25 packs of cigarettes per year, but quit about 6 years
earlier. His father died of renal cancer at the age of 60. At presentation, he
was afebrile and normotensive. Abdominal examination revealed a soft non-tender
abdomen, with no graft tenderness. Laboratory work-up showed white blood cell
counts of 7.4 x109/L, hemoglobin of 9.5 g/dL, and platelets of 311 x109/L. His serum creatinine was 3.27 mg/dL (his baseline creatinine
was 2 mg/dL) while electrolytes were within normal limits. Liver function test,
amylase and lipase were all within normal limits. Renal ultrasound revealed
multiple hypoechoic lesions in the right native kidney, which were possibly
solid in nature (Figure 1A). The
patient underwent abdominal magnetic resonance imaging (MRI) for further
evaluation of these lesions. MRI revealed an enlarged right native kidney with
irregular margins. Additionally, retroperitoneal adenopathy was observed
below the level
of the left
renal vein, with largest lymph
node measures of approximately 4.7
x 3.8 cm in cross-section below the
left kidney (Figure 1 B, C).
Figure 1. A, Renal ultrasound revealed multiple hypoechoic
lesions in the right native kidney. Abdominal MRI showed an enlarged right native kidney with irregular
margins (B). Additionally,
retroperitoneal adenopathy was observed (C).
Positron emission tomography (PET) scan revealed
significant supraclavicular, mediastinal and retrocrural adenopathy in addition
to the extensive retroperitoneal adenopathy. The right native kidney showed
abnormal enlargement and increased radiopharmaceutical accumulation which is
abnormal in the setting of renal transplant history with atrophic native
kidneys. Abnormal uptake was also identified in the T11
vertebral body, L3
vertebral body and
in the posterior
column of the
right acetabulum which
could represent bone
metastases (Figure 2).
Figure 2. PET scan:
Abnormal uptake in T11, L3 and the right acetabulum; significant
supraclavicular, mediastinal and retrocrural adenopathy in addition to the
extensive retroperitoneal adenopathy; abnormal enlargement of right kidney.
The
patient was scheduled for EUS to evaluate the perigastric/peripancreatic area
for possible FNA of lymph nodes. EUS revealed multiple large round and
hypoechoic mediastinal lymphadenopathy distributed between the subcarinal and
the paraesophageal areas, and at the peripancreatic/periduodenal areas, the
largest measured 33.7 mm x 21.2 mm in size (Figure 3 A). Additionally multiple celiac lymph nodes were
identified, the largest measured 20.9 mm x 14.5 mm. EUS-FNA of enlarged celiac
lymph node was performed (Figure 3 B).
The histologic features showed enlarged and hyperchromatic tumor cells without
polarity (Figures 3, C, D).
Histochemical findings were consistent with metastatic adenocarcinoma of kidney
origin (Positive = PAX8 and vimentin; Negative = CK7, CK20, CDX-2, S100, TTF-1,
Pan CK, data not shown). The patient was started on chemotherapy and referred
for palliative radiotherapy but he decided to discontinue treatment and
proceeded with Hospice Care.
Figure 3. A, EUS showed an enlarged
peripancreatic/periduodenal lymph node; B, EUS-FNA
of enlarged celiac lymph node; Enlarged and hyperchromatic tumor
cells (Diff Quickistain) displaying lack of polarity in low power (C), and high
power (D).
Discussion
RCC is an increasingly incident malignant tumor
that accounts for 2–3% of all adult malignancies (1; 2). Smoking is one of the
most recognized risk factors for RCC (3). Once patients developed metastatic
disease, their prognosis is poor with a median survival of about 13 months (4).
About 30% of patients with RCC have metastatic disease at the time of
presentation with lungs, lymph nodes, liver, and bone being the common sites
(2). Similar to other malignancies, diagnosis mainly relies on tissue sampling
of the primary tumor or secondary metastasis. Sometimes, metastatic lesions
could be the first presentation of the tumor, and sampling of these secondary
lesions could point to the primary origin. With the increasing use of EUS in
evaluation and sampling of lymph nodes and gastrointestinal masses, it could
also assist in the diagnosis of metastatic RCC. The role of EUS in the
diagnosis of metastatic RCC has been discussed in the literature. In most
cases, EUS was used to evaluate pancreatic masses, which then were diagnosed as
secondary metastasis from RCC. Bechade et al. used EUS-FNA in 11 patients, who
had a history of RCC and a solid mass within the pancreas, and identified 9 of
them having pancreatic metastases of RCC (5). Additionally, Waters et al. did a
retrospective review of 66 patients who underwent EUS-FNA for tumors that have
metastasized to the pancreas and found that the most common site of origin for
these metastases was kidney (27 [41%] cases) (6).
Another possible role of EUS in diagnosis of
metastatic RCC is sampling of the metastatic lymph nodes. The mediastinum is
one of the common sites of metastases from RCC. This makes EUS a proper
diagnostic modality in this setting. Fritscher-Ravens et al. used EUS-FNA in
111 patients for evaluation of mediastinal lymph nodes. Seven patients were
diagnosed by cytology to have metastatic RCC, and four of them were first
diagnosed based on this study (7). This makes EUS-FNA a less invasive technique
for evaluation of mediastinal lymph nodes, which then can lead to the diagnosis
of metastatic RCC. Additionally, endobronchial ultrasound has been used
similarly to diagnose metastatic RCC to the mediastinum (8; 9).
In our case, we used EUS-FNA biopsy to diagnose
metastatic RCC. Our patient had radiological finding of multiple enlarged lymph
nodes in the mediastinum and abdomen. By using EUS, we were able to access both
the mediastinal and celiac lymph nodes and obtain multiple FNAs from both lymph
nodes, and we were able to accurately diagnose the site of origin of the
metastases. Our case is unique in multiple aspects. First, our patient had a
history of renal transplantation, and he developed metastatic RCC of the native
kidney. To the best of our knowledge, there are no similar case reports of
EUS-FNA of lymph nodes used in the diagnosis of metastatic RCC in renal
transplant patients. Studies suggest that kidney cancer is approximately
15-fold more common in renal transplant patients compared to general
population, in addition to the increased risk of other malignancies, which
could be related to immunosuppressive medications or viral infections (10).
This risk, in addition to smoking and family history, may have contributed to
the development of RCC in our patient. Second, the extensive lymph node
involvement in our patient was more suggestive of lymphoma rather than RCC.
EUS-FNA helped in confirming the diagnosis as metastatic adenocarcinoma of
kidney origin.
Conclusion
EUS-FNA can be useful in the diagnosis of
metastatic RCC in renal transplant patients. It can contribute to diagnosis by
sampling mediastinal lymph nodes or pancreatic masses. Proper cytological
evaluation can identify the primary source and guide therapy.
Conflict of interest
The authors declare that they have no
competing interests.
References
1. Rini BI, Campbell SC, Escudier B. Renal cell
carcinoma. Lancet. 2009;373(9669):1119-32. Doi: http://dx.doi.org/10.1016/S0140-6736(09)60229-4
2. Abe H, Kamai T. Recent advances in the treatment
of metastatic renal cell carcinoma. Int J Urol. 2013;20(10):944-55. Doi: http://dx.doi.org/10.1111/iju.1218
3. Theis RP, Dolwick Grieb SM, Burr D, Siddiqui T,
Asal NR. Smoking, environmental tobacco smoke, and risk of renal cell cancer: a
population-based case-control study. BMC Cancer. 2008;8:387. Doi: http://dx.doi.org/10.1186/1471-2407-8-387
4. Cohen HT, McGovern FJ. Renal-cell carcinoma. N
Engl J Med. 2005;353(23):2477-90. Doi: http://dx.doi.org/10.1056/NEJMra043172
5. Bechade D, Palazzo L, Fabre M, Algayres JP.
EUS-guided FNA of pancreatic metastasis from renal cell carcinoma. Gastrointest
Endosc. 2003;58(5):784-8.
Doi: http://dx.doi.org/10.1016/S0016-5107(03)02034-0
6. Waters L, Si Q, Caraway N, Mody D, Staerkel G,
Sneige N. Secondary tumors of the pancreas diagnosed by endoscopic
ultrasound-guided fine-needle aspiration: a 10-year experience. Diagn
Cytopathol. 2014;42(9):738-43. Doi: http://dx.doi.org/10.1002/dc.23114
7. Fritscher-Ravens A, Sriram PV, Topalidis T,
Jaeckle S, Thonke F, Soehendra N. Endoscopic ultrasonography-guided fine-needle
cytodiagnosis of mediastinal metastases from renal cell cancer. Endoscopy.
2000;32(7):531-5. Doi: http://dx.doi.org/10.1055/s-2000-3815
8. Nakajima T, Yasufuku K, Wong M, Iyoda A, Suzuki
M, Sekine Y, Shibuya K, Hiroshima K, Iizasa T, Fujisawa T. Histological
diagnosis of mediastinal lymph node metastases from renal cell carcinoma by
endobronchial ultrasound-guided transbronchial needle aspiration. Respirology.
2007;12(2):302-3. Doi: http://dx.doi.org/10.1111/j.1440-1843.2006.01023
9. Lew M, Foo WC, Roh MH. Diagnosis of metastatic
renal cell carcinoma on fine-needle aspiration cytology. Arch Pathol Lab Med.
2014;138(10):1278-85.
Doi: http://dx.doi.org/10.5858/arpa.2014-0283-CC
10. Kasiske BL, Snyder JJ, Gilbertson DT, Wang C.
Cancer after kidney transplantation in the United States. Am J Transplant.
2004;4(6):905-13.
Doi: http://dx.doi.org/10.1111/j.1600-6143.2004.00450.x