CASE N°21 – Lymph node metastases: there’s no two without three

Clinical History:

Age: 38

Sex: Male

– January 2003:  pain in right lumbar region and the ipsilateral testis.
Ultrasonography: right testicular lesion about 3cm in diameter and 4 cm pelvic adenopathy.
Biochemistry: betaHCG 12 UI/l, alfafetoproteina 196 UI/ml
The patient underwent left orchifunicolectomy. Histology: mature type teratoma associated with immature areas.
From April to late june 2003, four cycles of chemotherapy (maximum dose of bleomycin administered 190 mg) with a partial radiological response. Subsequent tests negative for recurrent disease (last checked july 2009).
-September 2009  abdominal pain.
TAC-SCAN abdomen: in the upper pole of left kidney solid, well-defined nodule (about 2 cm in diameter), suspicious for neoplasia, currently well capsulated
Histology: Renal cell carcinoma, “clear cell” variety, grade I Fuhrmann, Stage PT1a, N0, M0.
Subsequent tests negative for disease recurrence (last checked December 2011).
– February 2012: tingling in the right preauricular; neck ultrasonography: presence of 9 mm nodular lesion in the left lobe of thyroid, with peripheral hypoechoic halo, with signs of intrinsic vascularity, also hypoechoic laterocervical adenopathy of 33×14 mm.

Cytological Images:

Cytological material: Laterocervical Lymphadenopahty, FNAC

Papanicolaou 400x

Papanicolaou 400x

Papanicolaou 600x

Papanicolaou 600x

Giemsa stain 200x

Giemsa stain 100x

Giemsa stain 100x

Giemsa stain  400x

Cytoblock

Cytoblock

Cytoblock

 Cytoblock; vimentin

Cytoblock; cd10

Cytoblock; EMA

Cytoblock; TTF1

Cytoblock; Tireoglobulin

Cytological Report:

Absence of lymph node cellularity. Abundant bloody material in wich have been found rare aggregates of malignant cells arranged in papillae and to circumscribe psammoma bodies, characterized by the following immunohistochemical profile: TTF1 +, + thyroglobulin. Overall, this findings appears compatible with lymph node metastasis of thyroid origin (probably papillary Thyroid carcinoma).

Histological Images:

Histological material: Laterocervical Lymphnode, biopsy

H/E

H/E

Histological Report:

A small piece of lymph node tissue which have been found in two microaggregates of epithelial cells no further typable using immunohistochemical investigations, for exhaustion of the material in sections arranged for this purpose.immunohistochemistry CKpool+

Discussion:

The histological and cytological specimen came together in pathology department.
The cytologists have thought that it was metastasis of epithelial carcinoma but they would not believe the presence of a third tumor. The first hypothesis was that of a recurrence of renal cell carcinoma due to some large cells with clear cytoplasm and nucleolus, mainly found in the material included paraffin. The second hypothesis was that of a metastasis from papillary thyroid carcinoma due to papillary arrangement of the cellular aggregates , presence of some cells arranged around psammoma bodies, sex, age and physical examination of the patient. This second hypothesis was also supported by the occasional presence of nuclear pseudoinclusions that were found in a few cells in the histological specimen. Immunohistochemistry performed on paraffin-embedded cytological material confirmed the second hypotesis: metastases from thyroid carcinoma.

As you can see, the panel also included immunohistochemical staining markers of renal cell carcinoma, it is curious that if  it was not thought to the possibility of a thyroid origin, the positivity to CD10, Vimentin and EMA might have run into a gross misdiagnosis.

This case has taught us that we must never take anything for granted, then the hypothesis of a third, fourth tumor must always be suspected in presence of certain morphological features of cells. Immunohistochemistry is just to confirm, not to make a diagnosis.

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