Papillary renal cell carcinoma with “hyaline globules” simulating adenoid cystic carcinoma

Abstract

A 59-year-old man with a history of papillary renal cell carcinoma (status-post nephrectomy), HIV infection, and Hepatitis C presented with a right humerus fracture. On physical exam, he was found to have a ''ping-pong ball'' sized swelling in the left supraclavicular region with massive, bilateral cervical and axillary lymphadenopathy. CT scan confirmed significant chest and abdominal adenopathy, compression of major neurovascular bundles and airway by cervical adenopathy, and bilateral lung lesions. There were no lesions in the area of his right radical nephrectomy performed 1 year ago for papillary renal cell carcinoma (PRCC). Pathology of the resected lesion at that time revealed a 4 cm, Fuhrman grade III carcinoma extending into the renal pelvis. Margins were uninvolved and there was no evidence of metastatic disease.Fine needle aspiration (FNA), of one of the enlarged lymph nodes in the left neck was performed using a 25-gauge needle. Smears were either air-dried or alcoholfixed and stained with Diff-Quik and Papanicolaou stains, respectively. Cytomorphology was characterized by hypercellular smears composed of highly unusual, eyecatching, well-defined globoid structures surrounded by a uniform population of malignant cells (Fig. C-1). These globoid structures had a bright magenta or metachromatic appearance on Diff-Quik stain and were highly reminiscent of adenoid cystic carcinoma, especially when surrounded by epithelial cells with a vague basaloid appearance ( Fig. C-2). However, the presence of fine cytoplasmic vacuoles provided evidence that these cells were in fact not basaloid in origin. The hyaline globules appeared pale green and translucent on Papanicolaou stain surrounded by hyperchromatic and crowded malignant cells (Fig. C-3). The hyaline globular material was exclusively extracellular and none of the malignant cells showed intracytoplasmic inclusions. Location of this lesion in the neck did raise the possibility of a salivary gland adenoid cystic carcinoma; however, some of the other smears had true papillary fragments with finely vacuolated neoplastic epithelial cells, abundant macrophages, and other features consistent with metastasis from patient's known PRCC.Papillary renal cell carcinoma (PRCC) comprises from 7 to 15% of all renal cell carcinomas and more commonly presents in women. It has a distinct clinical and pathologic presentation that can separate it from low-grade transitional cell carcinoma, metastatic adenocarcinoma, and Wilms' tumor.1 PRCC can present with a variety of cytological features such as the presence of psammoma bodies, cytoplasmic vacuoles, hyperchromasia, and nuclear grooves.2 However, smooth bordered papillary fragments with fibrovascular cores, lipid-laden foamy macrophages, and intracytoplasmic hemosiderin have been found to be most sensitive for the diagnosis of PRCC.3 Along with cytology, immunoreactivity to CK7 4 and a characteristic cystic, necrotic radiographic finding are useful diagnostic tools.

Hyaline globules and papillary fragments in cytologic smears from two intra‐abdominal tumors (ovarian and hepatic) in female patients: A diagnostic pitfall with histologic correlation

“…A lymphoid background is common in seminoma, while a mucoid/myxoid background associated with vacuolated cells, hyaline globules and intercellular basement membrane deposits suggest a diagnosis of YST . Ovarian epithelial tumors (papillary serous carcinoma and CCC), ovarian metastatic adenocarcinoma or metastatic papillary or clear cell variant of renal cell carcinoma (RCC) should also be included in the differential diagnosis of YST in certain clinical contexts . The distinction between YST and ovarian CCC is even more complex since hyaline globules, clear and/or vacuolated cytoplasm, papillary or pseudopapillary structures can be observed in the cytologic and/or histological section of both neoplasms .…”

“…In addition, liver metastasis from RCC, papillary thyroid carcinoma and hepatocellular carcinoma (HCC) containing hyaline globules should also be included in the differential diagnosis of SPNP …”

“…[3][4][5][6][7][8] Ovarian epithelial tumors (papillary serous carcinoma and CCC), ovarian metastatic adenocarcinoma or metastatic papillary or clear cell variant of renal cell carcinoma (RCC) should also be included in the differential diagnosis of YST in certain clinical contexts. 1,[3][4][5][6][7][8]27 The distinction between YST and ovarian CCC is even more complex since hyaline globules, clear and/or vacuolated cytoplasm, papillary or pseudopapillary structures can be observed in the cytologic and/or histological section of both neoplasms. [1][2][3][4][5][6][7][8] In this setting, IHC is undoubtedly a very useful tool to support the diagnosis of YST, and exclude other tumors with similar morphology, essentially in cases with unusual histological patterns or uncommon clinical-radiological presentation.…”

“…In addition, liver metastasis from RCC, papillary thyroid carcinoma and hepatocellular carcinoma (HCC) containing hyaline globules should also be included in the differential diagnosis of SPNP. [27][28][29] Hyaline globules have been observed in many of the histologic subtypes of RCC without correlation between quantity of hyaline globules and the nuclear grade. 27 In one reported study, the smears from RCC contained clear or granular cells with or without papillary branches, in addition the neoplasms had cells with small intracytoplasmic vacuoles, eccentrically located nuclei and large central nucleoli depending of the histological grade.…”

“Raspberry bodies,” extracellular hyaline globules and branching hyaline stromal fragments in a fine‐needle aspirate of metastatic clear cell carcinoma of the ovary

“…However, the cytomorphology of the surrounding cells and the clinical context are crucial in the correct interpretation of their significance because very similar appearing extracellular material structures can occur in different tumor types, and different types of extracellular material can have a similar appearance in cytologic specimens. Globular hyaline extracellular material formed of collagen may be seen surrounded by cells or lying freely in the smear background in benign and malignant mesothelial proliferations (“collagen balls”), adenoid cystic carcinomas and other proliferations with a myoepithelial participation, solid pseudopapillary tumors of the pancreas (SPPT), papillary renal cell carcinoma, and basaloid squamous cell carcinomas . Structures similar to the “raspberry bodies” may also be rarely encountered in papillary thyroid carcinoma, and may give the aspirate an adenoid‐cystic like appearance .…”