Sabato 27 ottobre 2012 - Pacini Editore

COmuNiCaziONi ORali
To our knowledge, we report the first case of simultaneous occurrence
of squamous cell carcinoma of the lung and clear cell
renal cell carcinoma as a collision metastasis from both lesions in
a peribronchial lymph node.
Case presentation. The patient was a 74-year-old man, exsmoker,
with an history of squamous cell carcinoma of the upper
lobe of the right lung, for wich he underwent a lobectomy
in 1993.
In 2011, a chest Computed Tomography scan, revealed a mass in
the upper lobe of the left lung. A PET scan followed the CT in
order to identify metastases, with a negative result.
The transbronchial biopsy confirmed the diagnosis of squamous
cell carcinoma and a segmentary resection of the left lung was
subsequently performed.
rossly, the pulmonary parenchyma, showed a whitish and greyish
mass, centrally necrotic and with polycyclic edges. The main size
of the mass was 3 cm. The surrouding tissue presented stasis and
atelectasis. During the gross examination 9 peribronchial lymph
nodes were isolated.
Histologically, the mass was a squamous cell carcinoma, without
keratinization, moderately differentiated, with areas of comedonecrosis.
This features were similar to these of the former
tumor.
Surprisingly, concurrent metastasis from a clear cell neoplasia
were detected in six peribronchial lymph nodes, and one of this
revealed also one metastasis from the squamous cell carcinoma.
Himmunoistochemical studies were performed to characterize
the clear cell neoplasia, that revealed the following phenotype:
positivity for EMA, RCC, Vimentin; negativity for P63, CK7,
CD68, HMB-45, Melan A, High molecular weight keratin. The
squamous cell carcinoma was positive for p63, CK5/6; negative
for RCC and CK20.
The final diagnosis was the following: “Squamous cell carcinoma,
moderately differentiated, non-keratinizing. One lymph
node metastasis of squamous carcinoma and six of clear cell
neoplasia”.
A note suggested, into account of the different morphology and
immunoistochemistry, a diagnostic evalutation of the urogenital
system in order to exclude a clear cell renal cell carcinoma of
the kidney.
In this setting, an abdominal CT scan demonstrated a mass in the
left kidney, engaging the ipsilateral adrenal gland. The patient underwent
again to surgery. A radical nefrectomy with consensual
removal of the adrenal gland were performed.
Grossly, the lower pole of the kidney presented a variegated nodule,
greyish, brownish and withish. The main size was 4,5 cm.
The adrenal gland showed a multinodular aspect.
The pathologic diagnosis was that of clear cell renal cell carcino-
Fig. 4.
Fig. 5.
Fig. 6.
343
ma, G3-4 sec. Fuhrman, infiltrating the surrounding parenchyma
and, initially, the renal capsule and the renal vein.
The adrenal gland was uninfiltrated and showed cortical nodular
hyperplasia.
Discussion: Collision metastasis of lung and renal carcinoma is
rare. We suggested the total body examination before surgery.
In this case the patient made only a chest computed tomography
scan and a PET that was negative for secondarism. The clinical
hystory of patient suggested only a lung disease, and the nodule to
the lung another lung carcinoma. Clear cell renal carcinoma is often
negative to PET as in our case. The role of pathologist is been
very useful to indicate clinicians the possibility of a secondarism.
So the accurate sampling of lymph nodes revealed essential for
final diagnosis.
references
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