PMC8571253_01
(a) Plain X-ray Lumbosacral spine showing 6 lumbar vertebrae, to aid in marking level per operatively. (b) Sagittal MRI lumbosacral spine showing rectangular mass at L3-4 level, isointense on T1 and T2, and mild homogenous contrast uptake. (Level counted taking X-ray into consideration). (c) Axial MRI at L4 level, showing well-defined homogenously enhancing mass, extending toward left neural foramina (marked with yellow arrow), displacing the cauda equina to the right side (marked in red).
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F1
The plain X-rays only showed lumbarization of S1 [Figure 1a]. T1, and mildly homogeneously enhanced with contrast; it measured 2.5 cm craniocaudally and 1.5 cm anteroposteriorly [Figure 1b and c]. The bone scan and the CT of the chest/abdomen/ pelvic demonstrated no additional metastatic RCC lesions.
(a) Peroperative image showing caudal pole dissected (marked with yellow arrow) (b) tumor adherent to nerve roots (marked with blue arrow). (c) Specimen after piecemeal excision.
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F2
The caudal pole was readily skeletonized from the cauda equina, but was adherent to the L3 nerve root exiting through the left L3/L4 foramen; it was sacrificed [Figure 2a]. The cranial pole was removed in a piecemeal fashion, leaving multiple particulate remnant adherent to various nerve roots [Figure 2b and c].
(a) Photomicrograph of Hematoxylin and Eosin stain showing polygonal cells with hyperchromatic nuclei, scanty cytoplasm arranged in alveolar pattern (marked with *) typical of clear cell carcinoma, (b) PAX 8 immunostaining showing distinct nuclear reactivity characteristic of renal origin and (c) CAM 5.2 antibody immunostaining for CK8 showing diffuse positivity thus verifying epithelial origin. All images are x100 original magnification.
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F3
The tumor's histological features were consistent with metastatic renal cell carcinoma, as were the results of immunohistochemical stains (i.e., positive for PAX8 and Cam5.2) [Figure 3a-c].