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case_images: Whole body positron emission tomography-computed tomography before treatment.. (A-D) Whole body PET-CT showed that enlarged hypermetabolic mediastinum lymph nodes(SUVmax:9.2). (E-H) Whole body PET-CT showed that a highly metabolic irregular mass in right kidney with heterogeneous density (120 mm*108 mm, SUVmax:15.2) and the border demarcation between the masses and the liver were indistinct.. PET-CT: Positron emission tomography-computed tomography.
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case_images: To confirm the diagnosis and identify metastatic sites in the whole body, whole body positron emission tomography-computed tomography (PET-CT) was performed, which showed a highly metabolic irregular mass in right kidney with heterogeneous density (120mm*108 mm, SUVmax:15.2) and the border demarcation between the masses and the liver were indistinct, PET-CT also indicated that several hypermetabolic lymph nodes, including left supraclavicular lymph nodes (SUVmax:10.2), bilateral subclavicular lymph node(SUVmax:10.2), mediastinum lymph nodes (SUVmax:9.2), hilar lymph nodes (SUVmax:9.2), retroperitoneal lymph nodes (SUVmax:10.3), pelvic lymph nodes (SUVmax:15.8), lymph nodes located around the lower esophagus and spine (SUVmax:9.2); the soft tissue density shadows was seen in the inferior vena cava and right renal vein, with increased metabolism (SUVmax:13.5) (Figure 1).
case_images: Radiological evaluation before and after treatment.. (A) Abdominal MRI revealed irregular mass in right kidney with heterogeneous density and the soft tissue density shadows was seen in the inferior vena cava and right renal vein on 3 October 2022. (B) CT-SCAN revealed multiple enlarged mediastinum lymph node metastasis. (C) Abdominal MRI revealed irregular mass in right kidney with heterogeneous density significant reduction after two cycles of treatment. (D) CT-SCAN revealed significant mediastinum lymph node almost disappeared after two cycles treatment. (E) Abdominal MRI revealed irregular mass in right kidney with heterogeneous density continued reduction after four cycles of treatment. (F) CT-SCAN revealed significant mediastinum lymph node almost disappeared after four cycles of treatment.
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case_images: Abdominal magnetic resonance imaging (MRI) revealed a space-occupying lesion in the right kidney with multiple lymph node metastases compressing the right renal vein and inferior vena cava (Figure 2A). A computed tomography scan (CT-SCAN) revealed multiple mediastinum lymph node metastasis (Figure 2B). After two cycles of treatment, the patient obtained partial response with the mass in the right kidney significantly reduced and supraclavicular lymph nodes, bilateral subclavicular lymph nodes and mediastinum lymph nodes were almost invisible (Figure 2C & D). From October 2022 to January 2023, the patients received four cycles of treatment, and the assessment was still partial response (Figure 2E & E).
case_images: Staining images of PD-L1 expression (HE and IHC).. (A) HE staining images of PD-L1 expression. (B) IHC staining images of PD-L1 expression.. HE: Hematoxylin-eosin staining; IHC: Immunohistochemistry.
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case_images: TLE-1 and SMA proteins, while Desmin, CD99, S100 and FLY-1 proteins were negative. The Ki-67 index was 70%, and PD-L1 (SP263) and Her-2 expressions were negative (Figure 3).