PMC3931632_01
Enhanced CT.. Notes: This enhanced CT shows a 13 cm right renal tumor that invades the pancreas (arrows), duodenum (arrowheads), and inferior vena cava (asterisk). The second part of the duodenum shows stenosis because of the protruding right renal tumor.. Abbreviation: CT, computed tomography.
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Computed tomography (CT) showed a large right renal tumor with a diameter of 13 cm that had invaded the second part of the duodenum and had involved multiple regional lymph nodes without distant metastasis (Figure 1).
PET scan.. Notes: Scan shows accumulation of FDG in the right renal tumor (arrows). Maximum SVU is >40.. Abbreviations: PET, positron emission tomography; FDG, fluorine-18-deoxyglucose; SUV, standardized uptake value.
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Positron emission tomography (PET) scans showed accumulation of fluorine-18-deoxyglucose in the tumor, with the maximum standardized uptake value being >40 (Figure 2).
Esophagogastroduodenoscopy image.. Note: Esophagogastroduodenoscopy reveals a red sessile tumor protruding into the second part of the duodenum (arrows), corresponding to the findings of CT (Figure 1).. Abbreviation: CT, computed tomography.
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Esophagogastroduodenoscopy detected direct invasion of the tumor into the second part of the duodenum with bleeding (Figure 3).
Histopathology of the biopsy specimen of duodenum.. Note: In the magnified encircled area, arrows show sarcomatoid tissue in the muscle layer of the duodenum.
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Biopsy of the protruding tumor revealed histologic features that were highly suggestive of sarcoma (Figure 4).
Enhanced CT at 5 weeks after starting treatment with axitinib.. Notes: Tumor degeneration is observed (black triangle). The lumen of the second part of the duodenum (arrowheads) is wider, due to tumor shrinkage compared with the pretreatment state. Three arrows show the head of the pancreas, and the asterisk shows inferior vena cava.. Abbreviation: CT, computed tomography.
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Attenuation of the tumor contrast uptake and enlargement of the duodenal lumen were observed on CT after 5 weeks of administration (Figure 5).
Macroscopic view of resected tissue.. Notes: (A) Shows necrotic tissue. (B) Shows sarcomatoid tissue invading pancreas (arrows).
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Pathological examination confirmed that the lesion was RCC with sarcomatoid differentiation with necrotic areas (pT4pN1M0, Fuhrman grade 4) (Figure 6).
Expressions of phosphorylate Akt (Ser-473).. Notes: (A) Expression of phosphorylated Akt (Ser-473) (60 kDa) and beta-actin (42 kDa) proteins in the primary tumor tissues using Western blotting. Each number corresponds to a case number, representative case of ccRCC, other RCC with sarcomatoid differentiation (sRCC1 and sRCC2), and present sRCC case. Patients of ccRCC and sRCC1/sRCC2 underwent nephrectomy before receiving any other therapy. Compared to ccRCC, tumor tissues of sRCCs showed higher expression of phosphorylated Akt (Ser-473). In the present sRCC case treated with presurgical axitinib, some tumor tissues of T4-2 and T4-3 showed an extremely lower expression of phosphorylated Akt (Ser-473) than T4-1, indicating that the T4-2 and T4-3 tissues were sensitive to axitinib. (B) Expression of phosphorylated Akt (Ser-473) in the primary tumors by densitometric analysis, as described previously. The data show the 95% confidence interval. Expression of phosphorylated Akt (Ser-473) was increased in sRCC tumor tissue (n=3; mean +- SD =8.66+-2.43) compared with those in ccRCC (n=5; 2.16+-0.47; P=0.0253).. Abbreviations: p, phosphorylated; M, marker; N, non-tumor tissue; n, number of the patients analyzed; T, primary tumor tissue with metastatic lesions; RCC, renal cell carcinoma; ccRCC, clear cell renal cell carcinoma; sRCC, renal cell carcinoma with sarcomatoid differentiation; SD, standard deviation.
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Akt (Ser-473) in the tumor was heterogeneous (Figures 7 and 8). Axitinib therapy (10 mg/day) was resumed because microscopic invasion was detected at the resection margin, and some of the tumor tissues showed viability and expression of phosphorylated Akt (Ser-473).
Representative immunohistochemistry in the primary tumor tissues for antiphosphorylated Akt (Ser-473) antibody.. Notes: Some of the tumor cells of ccRCC (A) showed brown staining in a membrane and cytoplasm, while many of the tumor cells did not. Most of the tumor cells of sRCC1 (B) and sRCC2 (C) showed moderate to strong staining. In the present sRCC case treated with presurgical axitinib, some of the tumor cells of T4-1 (D) showed weak reaction.. Abbreviations: ccRCC, clear cell renal cell carcinoma; sRCC, renal cell carcinoma with sarcomatoid differentiation.
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Akt (Ser-473) in the tumor was heterogeneous (Figures 7 and 8). Axitinib therapy (10 mg/day) was resumed because microscopic invasion was detected at the resection margin, and some of the tumor tissues showed viability and expression of phosphorylated Akt (Ser-473).