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case_images: (a) Abdominal CT scan revealed a 65 mm x 60 mm tumor (red arrow) in the right kidney. (b-d) Thoracic CT scan of the chest showed multiple lung tumors (yellow arrows). Among them, the 35 mm hilar mass (d) was indistinguishable as either primary lung cancer or lung metastasis of RCC.
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case_images: CT showed a right renal tumor measuring 65 mm x 60 mm (Fig. 1a) and multiple lung tumors (Fig. 1b-d). Among the multiple lung tumors in chest CT images, the 35 mm lung hilar mass (Fig. 1d) was indistinguishable as either primary lung cancer or lung metastasis of RCC.
case_images: (a) The surgical specimen from radical nephrectomy shows a tumor with a solid and yellow appearance on the cut surface. (b) Microphotograph of the renal tumor with hematoxylin and eosin staining reveals clear or granular eosinophilic cytoplasm. Scale bar: 100 mum. (c) The surgical specimen of the thoracoscopic lung lobectomy revealed a tumor with a solid and yellow appearance similar to the renal tumor on the cut surface. (d) The microphotograph of the lung metastasis with hematoxylin and eosin staining also showed clear or granular eosinophilic cytoplasm, resembling that of the renal tumor. Scale bar: 100 mum.
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case_images: We performed right radical nephrectomy, and subsequent pathological examination confirmed the diagnosis of clear cell RCC, G2>G3, INFa, v1, ly0, pT1b (Fig. 2a,b). However, pathological examination of the resected mass revealed it was a lung metastasis of RCC (Fig. 2c,d).
case_images: Optical coherence tomography images show that subretinal fluid (white arrows) was present in the right (a) and left (b) eyes before topical steroid therapy for Vogt-Koyanagi-Harada disease-like uveitis. 60 days after topical steroid treatment, the right (c) and left (d) subretinal fluid were resolved.
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case_images: Simultaneously, the patient experienced blurry vision, and an eye examination by an ophthalmologist showed bilateral subretinal fluid, which is typically observed in acute VKH-like uveitis (Fig. 3a,b). His bilateral subretinal fluid was resolved and visual symptoms were improved (Fig. 3c,d), after which nivolumab was resumed while continuing the use of steroid eye drops.
case_images: Immunohistochemical findings of primary RCC (a-e) and lung metastasis (f-j). The scale bar on all images is 200 mum. HLA-DR4 expression is observed more strongly in the lung metastasis than in primary RCC (a, f: PD-L1 immunostaining, b, g: Melan-A immunostaining, c, h: tyrosinase immunostaining, d, i: ARMC9 immunostaining, e, j: HLA-DR4 immunostaining).
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case_images: The expression of PD-L1 and these melanocyte proteins was not detected in both primary RCC (Fig. 4a-d) and lung metastasis (Fig. 4f-i). However, we found that HLA-DR4 expression was significantly higher in the lung metastases than in the primary RCC (Fig. 4e,j).