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.