Practice questions renal neoplasms
Practice questions II
Renal neoplasms
© Jun Wang, MD, PhD
1. Use this case for next three questions.
A 45-year-old man presents with left flank discomfort for 4 months. He has a
history of seizure and arrhythmia since age of 8. He denies history of other
health problems. He does not smoke nor drink alcohol. His father has a history
of arrhythmia. His mother has type II diabetes and diabetic nephropathy. He has
an irregularly irregular pulse rate at approximately 68 per minute. His vitals
signs are otherwise unremarkable. No other abnormalities are noted through
physical examination, except a few brown skin fibrous plaque on his face. Radiologic
examinations reveal a 5.5 cm solid mass at his left kidney. His right kidney is
unremarkable. Cardiac sonographic examination reveal multiple
well-circumscribed myocardial mass in the left ventricle. Biopsy of the renal
mass reveal distorted vessles with thick walls, scattered adipose tissue and
bundles of spindle cells. There is no evidence of cytological atypia or
necrosis. Immunohistochemistry studies reveal the spindle cells are positive
for vimentin and desmin. What is most likely the diagnosis?
A. Angiomyolipoma
B. Collecting duct
carcinoma
C. Papillary adenoma
D. Rhabdomyoma
E. Well
differentiated liposarcoma
2. A 45-year-old man
presents with left flank discomfort for 4 months. He has a history of seizure
and arrhythmia since age of 8. He denies history of other health problems. He
does not smoke nor drink alcohol. His father has a history of arrhythmia. His
mother has type II diabetes and diabetic nephropathy. He has an irregularly
irregular pulse rate at approximately 68 per minute. His vitals signs are
otherwise unremarkable. No other abnormalities are noted through physical examination,
except a few brown skin fibrous plaque on his face. Radiologic examinations
reveal a 5.5 cm solid mass at his left kidney. His right kidney is
unremarkable. Cardiac sonographic examination reveal multiple
well-circumscribed myocardial mass in the left ventricle. Biopsy of the renal
mass reveal distorted vessles with thick walls, scattered adipose tissue and
bundles of spindle cells. There is no evidence of cytological atypia or
necrosis. Immunohistochemistry studies reveal the spindle cells are positive
for vimentin and desmin. What additional markers likely to be expressed by the
kidney lesion?
A. CK7
B. HMB45
C. p63
D. TFE-3
E. WT-1
3. A 45-year-old man
presents with left flank discomfort for 4 months. He has a history of seizure
and arrhythmia since age of 8. He denies history of other health problems. He
does not smoke nor drink alcohol. His father has a history of arrhythmia. His
mother has type II diabetes and diabetic nephropathy. He has an irregularly
irregular pulse rate at approximately 68 per minute. His vitals signs are
otherwise unremarkable. No other abnormalities are noted through physical
examination, except a few brown skin fibrous plaque on his face. Radiologic
examinations reveal a 5.5 cm solid mass at his left kidney. His right kidney is
unremarkable. Cardiac sonographic examination reveal multiple
well-circumscribed myocardial mass in the left ventricle. Biopsy of the renal
mass reveal distorted vessles with thick walls, scattered adipose tissue and
bundles of spindle cells. There is no evidence of cytological atypia or
necrosis. Immunohistochemistry studies reveal the spindle cells are positive
for vimentin and desmin. Mutation of what gene is likely associated with his
condition?
A. MET
B. PAX6
C. TSC2
D. VHL
E. WT-1
4. A 63-year-old man
presents with left flank pain for 6 months. He denies any history of trauma.
His has a history of stage I colon cancer 10 years ago, that was resected.
Physical examination reveals a vaguely palpable left abdominal mass. There is
no evidence of hepatosplenomegaly. His laboratory results are within normal
range. CT scan reveal a 15 cm well circumscribed solid mass at left kidney.
Biopsy of the mass reveal cords of cells with small round to oval nuclei and
abundant eosinophilic granular cytoplasm. No cytological atypia or necrosis is
seen. These cells show patchy reactivity to CK7 and are negative for colloid
iron stain, CK20. What is most likely the diagnosis?
A. Adult Wilms tumor
B. Chromophobe renal
cell carcinoma
C. Metastatic colon
adenocarcinoma
D. Oncocytoma
E. Urothelial
carcinoma of renal pelvis
5. Use this case for next three questions.
A 42-year-old woman presents with fatigue and progressive abdominal distention
for 3 months. She has lost 20 lb unintentionally. She does not have flank or
abdominal pain, bowel habit change or hematuria. She was diagnosed with a
neuroendocrine tumor of pancreas that was treated with surgery. Physical
examination reveals a tender mass at left upper abdomen. No lymphadenopathy,
hepatosplenomegaly are noted. Laboratory studies reveal a hemoglobin of 5.5
g/dL (normal 12-16 g/dL). Her other laboratory test results are within normal
range. CT scan reveal an 18 cm solid mass at her left kidney. Biopsy of the
mass reveal nests of cells with clear cytoplasm and enlarged irregular nuclei
with various sizes and darkness of chromatin. Very fine vessels are seen
surrounding these nests. Immunohistochemistry studies reveal positive
reactivity to both cytokeratin and vimentin, but negative for CD56 and
chromogranin. What is most likely the diagnosis?
A. Clear cell renal
cell carcinoma
B. Chromophobe renal
cell carcinoma
C. Metastatic pancreatic
neuroendocrine tumor
D. Oncocytoma
E. Urothelial
carcinoma of renal pelvis
6. A 42-year-old
woman presents with fatigue and progressive abdominal distention for 3 months.
She has lost 20 lb unintentionally. She does not have flank or abdominal pain,
bowel habit change or hematuria. She was diagnosed with a neuroendocrine tumor
of pancreas that was treated with surgery. Physical examination reveals a
tender mass at left upper abdomen. No lymphadenopathy, hepatosplenomegaly are
noted. Laboratory studies reveal a hemoglobin of 5.5 g/dL (normal 12-16 g/dL).
Her other laboratory test results are within normal range. CT scan reveal an 18
cm solid mass at her left kidney. Biopsy of the mass reveal nests of cells with
clear cytoplasm and enlarged irregular nuclei with various sizes and darkness
of chromatin. Very fine vessels are seen surrounding these nests.
Immunohistochemistry studies reveal positive reactivity to both cytokeratin and
vimentin, but negative for CD56 and chromogranin. What genetic mutation is
likely detected in this lesion?
A. MET
B. PAX6
C. TSC2
D. VHL
E. WT-1
7. A 42-year-old
woman presents with fatigue and progressive abdominal distention for 3 months.
She has lost 20 lb unintentionally. She does not have flank or abdominal pain,
bowel habit change or hematuria. She was diagnosed with a neuroendocrine tumor
of pancreas that was treated with surgery. Physical examination reveals a
tender mass at left upper abdomen. No lymphadenopathy, hepatosplenomegaly are
noted. Laboratory studies reveal a hemoglobin of 5.5 g/dL (normal 12-16 g/dL).
Her other laboratory test results are within normal range. CT scan reveal an 18
cm solid mass at her left kidney. Biopsy of the mass reveal nests of cells with
clear cytoplasm and enlarged irregular nuclei with various sizes and darkness
of chromatin. Very fine vessels are seen surrounding these nests.
Immunohistochemistry studies reveal positive reactivity to both cytokeratin and
vimentin, but negative for CD56 and chromogranin. What genetic background is
most likely associated with her presentations?
A. Birt-Hogg-Dubé
syndrome
B. Hereditary
papillary renal carcinoma
C. Tuberous
sclerosis
D. von
Hippel-Lindau syndrome
E. WAGR syndrome
8. A 77-year-old
woman presents with slowing enlarged anterior neck for 6 months. She denies
history of voice change, fever or weight loss. She has a history of certain
type of kidney tumor 35 years ago that was treated with nephrectomy. Physical
examination reveal a slightly enlarged thyroid. No enlarged lymph nodes are
seen. Her laboratory test results are within normal range. Sonographic
examination of her thyroid reveal a 1.5 cm nodule in the right lobe. Core
biopsy reveal nests of cells with small nuclei and clear cytoplasm. No nuclear
groove or inclusions are seen. Delicate capillaries are seen surrounding these
nests. There is no definitive evidence of invasion. Immunohistochemistry
studies reveal these cells are positive for cytokeratin, but negative for
thyroglobulin, TTF-1, calcitonin and parathyroid hormones. What is the most
likely diagnosis?
A. Follicular
adenoma
B. Medullary
carcinoma
C. Metastatic renal
cell carcinoma
D. Multinodular
goiter
E. Papillary
carcinoma of thyroid
9. Use this case for next two questions. A
69-year-old woman presents with fever and productive cough with yellowish
sputum for 1 week. She denies other symptoms. She has stage I colonic adenocarcinoma
and was treated colectomy 10 years ago. She does not smoke nor drink alcohol. Physical
examination reveals a temperature at 38.5 °C, heart rate at 98, and respiratory
rate at 25. No other abnormalities are noted. Her laboratory results including
liver and renal function tests are within normal range, except slightly
elevated white cells with normal differential. Chest X-ray reveal a 2.5 cm nodule
at the periphery area of right lower lobe. Biopsy of the nodule reveal nests of
atypical cells with eosinophilic granular cytoplasm, slightly pleomorphic
nuclei with perinuclear halo. No intercellular bridges or squamous pears are
seen. These cells are positive for colloid iron. Per immunohistochemistry
studies, these cells are positive for CK7 but negative for CK20 and TTF1. What should
be done next for her?
A. Broad spectrum
antibiotics
B. Image studies
for chest, abdomen and pelvis
C. Molecular studies
for EGFR mutation
D. Serum test for
HIV infection
E. Sputum culture
10. A 69-year-old
woman presents with fever and productive cough with yellowish sputum for 1
week. She denies other symptoms. She has stage I colonic adenocarcinoma and was
treated colectomy 10 years ago. She does not smoke nor drink alcohol. Physical
examination reveals a temperature at 38.5 °C, heart rate at 98, and respiratory
rate at 25. No other abnormalities are noted. Her laboratory results including
liver and renal function tests are within normal range, except slightly
elevated white cells with normal differential. Chest X-ray reveal a 2.5 cm nodule
at the periphery area of right lower lobe. Biopsy of the nodule reveal nests of
atypical cells with eosinophilic granular cytoplasm, slightly pleomorphic
nuclei with perinuclear halo. No intercellular bridges or squamous pears are
seen. These cells are positive for colloid iron. Per immunohistochemistry
studies, these cells are positive for CK7 but negative for CK20 and TTF1. What is
most likely the diagnosis?
A. Adenocarcinoma of
lung
B. Metastatic chromophobe
renal cell carcinoma
C. Metastatic colon
adenocarcinoma
D. Pulmonary abscess
E. Squamous cell carcinoma
of lung
11. Use this case for next two questions. A
72-year-old woman presents with fatigue, loin pain and hematuria for 3 months.
She has a history of spontaneous pneumothorax, hypertension, atherosclerosis
and coronary artery disease. She was diagnosed with adenocarcinoma of left lung
and was treated with surgery and chemotherapy 5 years ago. Physical examination
is unremarkable except multiple skin tags. Her CBC a hemoglobin at 11 g/dL
(normal 12-16 g/dL), and urinalysis reveals approximately 15 red cell/high
power field (normal less than 4/HPF). Her lab results are otherwise
unremarkable. CT scan reveal a 1.5 cm well circumscribed lesion at the upper
pole of left kidney. Core biopsy reveal nest of cells with small to
intermediate sized round to oval nuclei and eosinophilic granular cytoplasm
with perinuclear halo. Scarring tissue is focally seen. There is no evidence of
necrosis. These cells are positive for colloid iron. Immunohistochemistry
studies reveal diffuse reactivity to CK7, but not TTF1. What is most likely the
diagnosis?
A. Clear cell renal
cell carcinoma
B. Chromophobe
renal cell carcinoma
C. Metastatic adenocarcinoma
of lung
D. Oncocytoma
E. Urothelial
carcinoma of renal pelvis
12. A 72-year-old
woman presents with fatigue, loin pain and hematuria for 3 months. She has a
history of spontaneous pneumothorax, hypertension, atherosclerosis and coronary
artery disease. She was diagnosed with adenocarcinoma of left lung and was
treated with surgery and chemotherapy 5 years ago. Physical examination is
unremarkable except multiple skin tags. Her CBC a hemoglobin at 11 g/dL (normal
12-16 g/dL), and urinalysis reveals approximately 15 red cell/high power field
(normal less than 4/HPF). Her lab results are otherwise unremarkable. CT scan
reveal a 1.5 cm well circumscribed lesion at the upper pole of left kidney.
Core biopsy reveal nest of cells with small to intermediate sized round to oval
nuclei and eosinophilic granular cytoplasm with perinuclear halo. Scarring
tissue is focally seen. There is no evidence of necrosis. These cells are
positive for colloid iron. Immunohistochemistry studies reveal diffuse
reactivity to CK7, but not TTF1. Abnormality of what gene is likely to be seen
in this lesion?
A. BHD mutation
B. MET mutation
C. Xp11
translocation
D. VHL mutation
E. WT-1 mutation
13. Use this case for next two questions. A
77-year-old woman presents with vague left flank discomfort for 3 months. She denies
any history of trauma. She has history of papillary carcinoma of thyroid at age
of 45, and was treated with total thyroidectomy and hormone replacement.
Physical examination and laboratory tests are within normal range. CT scan
reveal a 7.2 cm poorly circumscribed solid mass at the lower pole of the left
kidney. Core biopsy reveal finger-like growth with fibrovascular core lined by
cuboid cells with moderate atypia. The lining cells have no nuclear inclusion
or grooves. Clusters of foamy histiocytes and foci of calcification or necrosis
are seen. Immunohistochemistry studies reveal negative reactivity to
thyroglobulin and TTF-1. What is the most likely diagnosis?
A. Chromophobe renal
cell carcinoma
B. Metastatic papillary
carcinoma of thyroid
C. Papillary adenoma
D. Papillary renal
cell carcinoma
E. Urothelial
carcinoma of renal pelvis
14. A 77-year-old woman
presents with vague left flank discomfort for 3 months. She denies any history
of trauma. She has history of papillary carcinoma of thyroid at age of 45, and
was treated with total thyroidectomy and hormone replacement. Physical
examination and laboratory tests are within normal range. CT scan reveal a 7.2 cm
poorly circumscribed solid mass at the lower pole of the left kidney. Core
biopsy reveal finger-like growth with fibrovascular core lined by cuboid cells
with moderate atypia. The lining cells have no nuclear inclusion or grooves. Clusters
of foamy histiocytes and foci of calcification or necrosis are seen. Immunohistochemistry
studies reveal negative reactivity to thyroglobulin and TTF-1. Abnormality of
what gene is likely to be seen in this lesion?
A. BHD
B. MET
C. TSC2
D. VHL
E. WT-1
15. A 57-year-old
woman presents with right flank pain for a month. She denies history of trauma
or hematuria. Physical examination and laboratory studies are unremarkable. Sonographic
examination reveals a 5.5 cm well circumscribed mass at the central portion of
her right kidney. No other abnormalities are noted. Biopsy of the mass reveal
solid cords and nests of atypical cells with marked pleomorphism and scan
cytoplasm. Whole body scan reveals no other tumors. What is most likely the
diagnosis?
A. Angiomyolipoma
B. Chromophobe renal
cell carcinoma
C. Collecting duct
carcinoma
D. Papillary renal
cell carcinoma
E. Urothelial
carcinoma of renal pelvis
16. Use this case for next two questions. A
69-year-old man presents with painless hematuria for 2 weeks. He has no other
symptoms. His past medical history is unremarkable. He was coal miner for 40
years before retirement. He has been smoking cigarette 1 and a half pack a day
for 50 years, and occasionally drink beers and tequila. Physical examination is
unremarkable. His CBC is within normal range. Urinalysis reveals more than 15
red blood cells/high power field (normal < 4 RBCs/HPF). Markedly atypical
epithelial cell are seen. CT scan reveal a 1.5 cm mass at the mid portion of
his left kidney. Retrograde pyelogram demonstrates filling defect in left
pelvis. Cystoscopic and ureteroscopic examinations with multiple biopsies show
no evidence of neoplasms. Biopsy of the left kidney mass reveal finger like
growth with fibrovascular core covered by multiple layers of squamoid cells
with marked cytological atypia and active mitosis. Necrosis are seen focally.
What is the most likely diagnosis?
A. Clear cell renal
cell carcinoma
B. Chromophobe renal
cell carcinoma
C. Collecting duct
carcinoma
D. Papillary renal
cell carcinoma
E. Urothelial
carcinoma of renal pelvis
17. A 69-year-old man
presents with painless hematuria for 2 weeks. He has no other symptoms. His
past medical history is unremarkable. He was coal miner for 40 years before
retirement. He has been smoking cigarette 1 and a half pack a day for 50 years,
and occasionally drink beers and tequila. Physical examination is unremarkable.
His CBC is within normal range. Urinalysis reveals more than 15 red blood cells/high
power field (normal < 4 RBCs/HPF). Markedly atypical epithelial cell are
seen. CT scan reveal a 1.5 cm mass at the mid portion of his left kidney. Retrograde
pyelogram demonstrates filling defect in left pelvis. Cystoscopic and
ureteroscopic examinations with multiple biopsies show no evidence of neoplasms.
Biopsy of the left kidney mass reveal finger like growth with fibrovascular
core covered by multiple layers of squamoid cells with marked cytological
atypia and active mitosis. Necrosis are seen focally. What is the most likely findings
by UroVysion study in this patient?
A. Aneuploidy of chromosomes
3, 7, 17, and loss of the 9p21
B. BHD mutation
C. Deletion of VHL
D. Mutation of MET
E. Xp11
translocation
18. Use this case for next two questions. A
2-year-old boy presents with fever and decreased activity for 3 days. His past
medical history is unremarkable. Physical examination reveal a 7 cm mass at the
right upper abdomen. The mass is slightly firm and non-movable. His CBC reveals
a hemoglobin at 7.5 g/dL (normal 11.5-14.5 g/dL). No other abnormal laboratory
test results are noted. CT scan reveal a poorly demarcated mass in his right
kidney. His left kidney is unremarkable. A right nephrectomy was performed. Pathological
examination of the mass reveal scatter irregular glandular structures lined by cells
with irregular dark nuclei, nests of epithelioid cells with large irregular
nuclei and scant cytoplasm, in a fibrotic background. Necrosis is focally seen.
Per immunohistochemistry studies, all the cells are positive WT-1 and negative
to S-100. What is the most likely diagnosis?
A. Collecting duct
carcinoma
B. Neuroblastoma
C. Xp11
translocation renal cell carcinoma
D. Urothelial
carcinoma of renal pelvis
E. Wilms tumor
19. A 2-year-old boy
presents with fever and decreased activity for 3 days. His past medical history
is unremarkable. Physical examination reveal a 7 cm mass at the right upper
abdomen. The mass is slightly firm and non-movable. His CBC reveals a
hemoglobin at 7.5 g/dL (normal 11.5-14.5 g/dL). No other abnormal laboratory
test results are noted. CT scan reveal a poorly demarcated mass in his right
kidney. His left kidney is unremarkable. A right nephrectomy was performed. Pathological
examination of the mass reveal scatter irregular glandular structures lined by cells
with irregular dark nuclei, nests of epithelioid cells with large irregular
nuclei and scant cytoplasm, in a fibrotic background. Necrosis is focally seen.
Per immunohistochemistry studies, all the cells are positive WT-1 and negative
to S-100. Abnormality of what gene is likely to be seen in this lesion?
A. BHD
B. MET
C. TSC2
D. VHL
E. WT-1
Back to contents
Comments
Post a Comment