Clinicopathological and Genomic Analysis of a Chinese ccRCC Patient with Multiple Morphologies and Rapid Progression : A Case Report

Clinicopathological and Genomic Analysis of a Chinese ccRCC Patient with Multiple Morphologies and Rapid Progression : A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Clinicopathological and Genomic Analysis of a Chinese ccRCC Patient with Multiple Morphologies and Rapid Progression : A Case Report Jing Yang, Junyun Wang, Yunshi Liang, Jianfei Wang, Jin Xv, Guorong Liu, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-108093/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Renal cell carcinoma (RCC) with sarcomatoid differentiation and multiple metastases is highly aggressive RCC with poor prognosis. However, there are not sufficient report on the genetic alterations and tumor immune microenviroment (TIME) of RCC with complex pathological morphology and aggressive behavior. Case presentation : A rare Chinese RCC case with complex pathological morphology and multiple subcutaneous and soft tissue metastases was reported. The clinical manifestations, histomorphology, immunophenotype and follow-up data were collected and analyzed. We performed target region sequencing and immunohistochemistry staining in different morphological regions of the primary tumor and the peritoneal metastasis. Microscopically, this primary tumor was composed of three different histological variations, including ccRCC like region, eosinophilic papillary structure and sarcomatoid differentiation. The peritoneal metastasis partially showed rhabdoid differentiation. IHC staining didn’t display positivity for characteristic markers. IHC for inflammatory cells showed that CD8+T cells and tumor associated neutrophils (TANs) were significantly increased in the sarcomatous areas and peritoneal metastatic tumor. Genomic analysis indicated that VHL mutations were present in all types of pathological regions and peritoneal metastatic tumor. Therefore, the pathological diagnosis of high-grade ccRCC with sarcomatoid differentiation was established. Additionally , we also found SETD2 , TP53 and PDGFRA mutations were observed in sarcomatoid tumor area, whereas BRCA2, ATR, CYLD , YAP1 and COL5A3 mutations were specifically detected in peritoneal metastases. These findings are rather striking because some genes e.g., ATR serine/threonine kinase ( ATR ) and Hippo signaling ( YAP1 ), PI3K-Akt signaling ( PDGFRA ) and T cell receptor signaling ( COL5A3 ) were previously reported to be very rare in ccRCC patients. Conclusions : Using next-generation sequencing and TIME analysis, multiple low-frequency mutant genes including PDGFRA, ATR, YAP1 and COL5A3 and increased CD8+ T cells and neutrophils were detected in this rare Chinese ccRCC. These findings potentially provide new evidence and molecular markers for accurately assessing the biological behavior of ccRCC. Pathology ccRCC sarcomatoid differentiation multiple morphologies molecular features tumor microenvironment Figures Figure 1 Figure 1 Figure 1 Figure 1 Figure 2 Figure 2 Figure 2 Figure 2 Figure 3 Figure 3 Figure 3 Figure 3 Figure 4 Figure 4 Figure 4 Figure 4 Introduction Renal Cell Carcinoma (RCC) is the most common malignant tumor of kidney with an estimated 403,262 new incidences and 175,098 deaths globally in 2018 and the overall incidence rate has been increasing over the past decade [ 1 , 2 ]. Clear cell renal cell carcinoma (ccRCC) accounts forཞ75% of kidney cancer diagnoses of RCC [ 3 ].ccRCC has long been known to be a highly heterogeneous tumor including morphological heterogeneity and intratumoral genomic heterogeneity. The former is mainly reflected in diverse histological architectural patterns with clear cells or eosinophilic cells [ 4 ]. These tumor heterogeneities resulted in variable biological behavior of ccRCC, ranging from low-proliferating localized tumors to highly aggressive metastatic neoplasms. Although the overall survival of ccRCC is good with a 5-year survival rate of 70%, approximately 25% of ccRCC patients show distant metastasis at the first diagnosis [ 5 ]. Thus, accurate assessing the tumor prognosis is important to guide therapeutic intervention and follow-up strategies. Currently, prognosis evaluation of ccRCC is mainly on the basis of tumor stage and grade. There are also several morphological parameters associated with poor prognosis, such as tumor necrosis, rhabdoid and sarcomatoid differentiation [ 6 ]. Studies showed that the 5-year survival rate of the tumor with sarcomatoid differentiation is 15–22% and the median survival for tumors with rhabdoid morphology is 8–31 months [ 7 , 8 ]. As we known, genetic alterations play a critical role in the tumor initiation, progression and evolution. With the rapid development of gene sequencing technology, researchers discovered that VHL, PBRM1, SETD2 and BAP1 are the most commonly mutated genes of ccRCC [ 9 ]. Among these genes, BAP1 -mutant tumors are typically high-grade and are associated with poor outcome [ 10 ]. Mutation in SETD2 is also associated with poor prognosis of ccRCC [ 11 ]. Recently, the research from Samra Turajlic et al. identified genetic diversity and chromosomal complexity as determinants of patient outcome [ 12 ]. Moreover, an integrative genomic study of Chinese ccRCCs revealed that the gene mutation landscape in Chinese cohort is different from TCGA dataset, demonstrating significantly higher mutation frequencies in CSMD3 and TMPRSS13 [ 13 ]. Therefore, to explore the molecular markers related to ccRCC prognosis in Chinese population is meaningful and important. In addition, increasing studies indicated that tumor microenvironment (TME) plays an important role in tumor progression, immune escape and drug-resistance [ 14 ]. Tumor-associated neutrophils (TANs) and lymphocytes (TILs) are the main components of inflammatory in TME [ 15 ]. A study from Song et al. showed that neutrophils are favorably recruited to the RCC cells to promote the RCC migration and invasion [ 16 ]. In another study the author developed an architectural pattern-based grading model for ccRCC prognosis evaluation including the intratumoral inflammatory reaction patterns [ 4 ]. Herein, we reported a rare Chinese RCC with complicated morphology, extensive metastasis and extremely aggressive behavior. A comprehensive analysis including histopathology, gene alterations and TIME was performed to explore the factors related with aggressive behavior and poor prognosis. Case Presentation The patient was a 56-year-old Chinese man accidentally detected a kidney mass by abdominal ultrasound in outer hospital due to repeated hiccups in August, 2019. Then the patient was referred to our hospital for further diagnosis and treatment in September, 2019. No family tumor history was mentioned and no clinical symptoms were presented, such as flank pain, fever and gross hematuria, nevertheless his weight had lost about 5 kilograms since the onset. Physical examination found that multiple subcutaneous soft nodules located in head, face, neck, waist, abdomen, chest, back and limbs with the diameter from 0.8-1.5cm, without redness, swelling, ulceration and purulence. The enhanced computed tomography (CT) of abdomen revealed an uneven-density mass in the upper pole of the right kidney and multiple uneven-density nodules in abdominal cavity, abdominal wall, retroperitoneum, pelvic cavity, bilateral groin, bilateral psoas muscles, iliopsoas and gluteal muscles, front abdominal wall, back and hip subcutaneous and around the anus (Fig. 1A1, A4 and B4). The kidney mass was measured with the size of 46mm×42mm×39mm and shown low-density and no-enhanced necrotic area in portal phase (Fig. 1A2). Another low-density nodule was found in the lower pole of the right kidney with the size of 29.74 × 22.70 × 21.77 mm (Fig. 1A3). Chest enhanced CT showed no metastasis in the lungs, but there were multiple enlarged stuck nodules in the mediastinum, bilateral armpits and anterior chest wall, which was considered as metastases (Fig. 1B1-B3). A peritoneal metastatic node was removed for frozen-section (yellow triangle) (Fig.1C). Then, a right radical 3D laparoscopic nephrectomy plus peritoneal nodule biopsy was performed. The patient returned to the hospital for review 1 month after surgery and was admitted oral Pazopanib treatment (200mg per tablet, qd) on Oct 13th, 2019. During the treatment of Pazopanib, the patient was getting better physically. Unfortunately, the patient died 1 month later due to excessive medication arbitrarily. The entire course of his clinical treatment is illustrated in Supplementary Fig. 1. Pathological findings Macroscopic findings Grossly, the tumor protruding from the renal cortex was confined within the renal parenchyma and measured to be 4.5 × 4.0 × 4.0 cm. The cross-section showed a yellowish and spherical neoplasm in the upper pole of the right kidney. The border with the kidney is sharp. Focal hemorrhage and necrosis were identified. In addition, a few dense gray-white nodes were detected in the renal capsule, the perinephric adipose tissue and peritoneum, and their diameter was about 0.3-1.0 cm (Supplementary Fig. 1). Histopathological and immunohistochemical (IHC) findings Microscopic evaluation of the renal tumor showed the tumor was multi-nodular and separated by fibrous tissue. The tumor histology was very complicated with three different histological morphologies, including conventional ccRCC like region, eosinophilic papillary structure and sarcomatoid (spindle) differentiation (Fig. 2A). In ccRCC like region, the pattern of growth was predominantly solid, with formation of nest and acinar patterns separated by the stroma that was characteristically endowed with a prominent network of small, thin-walled blood vessels (Fig. 2Aa1). The area of eosinophilic papillary structure was composed of papillae formed by delicate fibrovascular cores that contain foamy macrophages. Most of these tumor cells showed abundant eosinophilic cytoplasm with occasional small nuclei (Fig. 2Ab1). The sarcomatoid area was lack of distinct borders with the area of clear cells which transition zone between them could be seen. In this region, some little abscesses with lots of neutrophils and tumor necrosis were observed (Fig. 2Ac1). In addition, histopathological examination of the peritoneum node revealed epithelioid sheets of cells exhibiting great pleomorphism and frequent mitoses (Fig. 2B). These tumor cells with eccentric nuclei and abundant eosinophilic cytoplasm resembled rhabdomyoblasts, which was designated as rhabdoid differentiation (Fig. 2B1). To identify the specific subtype of this tumor, we completed serious of IHC staining in the primary kidney tumors and peritoneal metastatic node. These immunostainings showed that CK8/18 and EMA were diffuse or patchy strong positivity in the classical ccRCC like area and eosinophilic papillary area (Fig. 2Aa2-3, 2Ab2-3), while their expressions were reduced in the sarcomatoid area and peritoneal metastatic node (Fig. 2Ac2-3, 2B2-3). To the opposite, vimentin was expressed more intensely and diffusely in the sarcomatoid area and peritoneal metastatic node (Fig. 2Aa4-Ac4, 2B4). Carbonic anhydrase Ⅸ (CA-Ⅸ) was present strongly and diffusely in the intact membranous distribution in the clear cells and those tumor cells in the eosinophilic papillary area, which was negative in sarcomatoid cells (Fig. 2Aa5-Ac5, 2B5). Tumor cells in these four lesions were negative for CD10, CK7, CD117, PAX8, MelanA, HMB45, SMA, Myogenin, Syn, CgA and ALK and retained SMARCB1 (INI-1) expression. The immunostaining summary information could be seen in Supplementary Table 1. Tumor immune microenvironment (TIME) analysis of different regions Due to numerous inflammatory cells accumulating in the sarcomatoid area and peritoneal metastatic node, we further detected the status of the immune tumor microenvironment via the IHC staining of LCA, CD8, CD4 and MPO and evaluated inflammatory cells in the ccRCC like region, sarcomatoid area and peritoneal metastatic tumor, respectively. We found that lymphocytes were mostly distributed in the border of different morphological tumor node, but not in the center of lesion, while the distribution of neutrophils had no zonal (Fig. 3A). The number of TILs infiltrating on the border of sarcomatoid area was significantly more than the ccRCC like region (p=0.0144, Fig. 3Aa2-b2 and 3C). Amount of CD8+ T cells in the sarcomatous area and peritoneal metastasis tumor were significantly more than ccRCC (p sarcomatoid/ccRCC <0.0001, p peritonael / ccRCC <0.0001, Fig.3Aa-b4, 3B4 and 3E). The number of CD4+ T cells in the peritonaeul tumor was slightly higher than ccRCC area and sarcomatous area (p peritonael/ccRCC =0.0161, p peritonael/sarcomatoid =0.0161, Fig.3Aa3-b3, 3B3 and 3D). It implies that CD8+ T cells preferred infiltrating into the high grade RCC compared with CD4+ T cells. Moreover, neutrophils were more enriched in the sarcomatous areas and peritoneal tumor than ccRCC like region (p sarcomatoid/ccRCC <0.0001, p sarcomatoid/peritonae <0.0001, Fig. 3Aa5-b5, 3B5 and 3F). Gene mutation analysis with target capture sequencing To confirm the accurate subtype of tumor and further reveal the underlying molecular mechanism related heterogeneous morphology and extremely aggressive biological behavior, genomic profiling of the four distinct morphology tissue slides from resected tumor specimens was achieved by using target capture sequencing with a designed panel of 620 key cancer-related genes (GloriousMed Clinical Laboratory Co., Shanghai, China). The distribution of somatic mutations (SNV, InDel) among four different morphological tissues from this patient are summarized in a Venn diagram (Fig. 4A). The most common VHL mutations in ccRCC were detected in all of them, including primary and peritoneal metastatic foci (Fig. 4B). Therefore, we identified this patient as a high-grade clear cell renal cell carcinoma (ccRCC) with with sarcomatoid differentiation and systemic multiple metastases (pT3aN1M1). Further analysis indicated tumor of eosinophilic papillary area carries the fewest number and types of mutated genes among all tumor tissues, only VHL and BAP1 mutation, suggesting that these two genes might be early events in ccRCC tumorigenesis. From the perspective of genomic changes, eosinophilic morphology tumor seems to occur in the earliest stage of the disease due to the minimum number of driver gene alterations and mutation types. Notably, histone modification gene SETD2 mutations were detected in all of tumor regions except for eosinophilic papillary area, suggesting SETD2 could play an important role in ccRCC progression. Remarkably, the genetic alterations in sarcomatoid regions are similar to those in clear cell carcinoma areas, both sharing some identical gene mutations such as VHL (p. R64fs), SETD2 (p.N1628T), SMAD4 (p.Q534fs*3), and PTPRT (p.A696V). BAP1 variant P190R and ATM variant E1199 deletion were observed only in conventional clear cell carcinomas, whereas there were exclusive TP53 variant A347G and PDGFRA variant S890 frameshift deletion in sarcomatoid-like tumor, hinting that TP53 and PDGFRA may play a significant role in the sarcomatoid transformation from ccRCC morphology. BRCA2 and ATR involved in DNA damage response pathway, NF-kappa B signaling gene CYLD and Hippo signaling gene YAP1 , protein digestion and absorption gene COL5A3 were specifically detected in peritoneal metastatic node but not in other primary areas (Fig. 4B). Besides, the tumor mutation burden (TMB) value of the four tumor areas present some certain regularities. The higher the grade, the higher the TMB value, as expected, the worse the prognosis, especially with sarcomatoid lesions. The TMB of peritoneal metastatic tumor was higher than the primary tumor (Fig. 4C). The TMB evidence also supports that tumor of eosinophilic papillary area and ccRCC area occurred at the early stage, then the tumor developed into the sarcomatoid morphology, and lastly metastasized to multiple organs including the peritoneum. The last main thing is that this patient harbored several somatic mutations of certain genes including histone methyltransferase SETD2 (SET domain containing 2), ATR serine/threonine kinase ( ATR ), ATM serine/threonine kinase ( ATM ) and TP53 associated with DNA damage response signaling and Hippo signaling ( YAP1 ), PI3K-Akt signaling ( PDGFRA ) and T cell receptor signaling ( COL5A3 ) (Fig. 4B), some of which contribute to the development of the RCC in light of previous data [9, 17, 18]. Discussion This is a really complex, difficult and rare RCC case even though it was identified high- grade advanced ccRCC with sarcomatoid differentiation by gene sequencing finally. But making an accurate pathological diagnosis for this case is very difficult in the beginning because it presented complicated pathological morphology as mentioned before and lacked the expression of characteristic immune markers. For example, a classical ccRCC marker CD10 was negative in all of tumor areas. Meanwhile, we excluded chromophobe renal cell carcinoma (ChRCC), MiT family translocation carcinoma, renal medullary carcinoma and ALK rearrangement-associated RCC because of the lack of CK7, CD117, MelanA, HMB45, TFE3 and ALK expression and retaining SMARCB1 (INI-1) expression. Additionally, we also excluded clear cell papillary RCC due to the staining pattern of CA-Ⅸ without the basolateral positivity. As mentioned above, this tumor was highly invasive and metastasis had occurred in the multiple parts of the body including subcutaneous, soft tissue, lymph nodes and so on at the beginning of diagnosis. Sarcomatoid differentiation in the primary tumor was undoubtedly one of the important reasons of its high aggressiveness. Published data showed that this feature is found in 5–8% of ccRCC, 8–9% of ChRCC, and 2–3% of PRCC [ 19 – 22 ]. Additionally, in the context of the current 2016 WHO classification system, tumors in the unclassified RCC (uRCC) category can be those with a combination of features of more than one recognized subtype, with mucin production or with unrecognized epithelial cell subtypes, low- or high-grade unclassified oncocytic neoplasms, and other unclassifiable renal tumors [ 23 ]. Sarcomatoid differentiation is also included in the morphology spectrum of uRCC. Some research data from a few relatively large series of uRCC suggest a comparably poor or worse outcome than high-stage ccRCC [ 24 ]. Hence, it is critical to determine the tumor subtype and explore the underlying molecular mechanism of highly aggressive biological behavior via target gene sequencing in four different tumor areas including metastatic foci In this study, we detected VHL mutations in all of tumor areas including the primary tumor with three different morphologies and metastasis. It confirmed that this tumor was ccRCC and its different components are originated from the same progenitor cell. Because of huge tumor heterogeneity, the mutation profiles between in situ foci and metastases are varied, especially for driver mutations. BRCA2 and ATR involved in DNA damage response pathway, NF-kappa B signaling gene CYLD and Hippo-YAP signaling gene YAP1 , protein digestion and absorption gene COL5A3 was specifically detected in peritoneal metastatic node but not in other primary areas, indicating that these gene mutations might play an important role in promoting tumor metastasis. Importantly, the alterations (especially deleterious gene mutations) of DDR genes exhibited potential value of predicting response to immune checkpoint inhibitors for metastatic RCC patients [ 25 ]. Given the key role of these signaling pathways in the feature of DNA repair, cell proliferation and metastasis, these mutations might contribute to this patient’s rapid progression and high aggressiveness. It was reported that patients with sarcomatoid carcinoma have a poorer prognosis than classical ccRCC [ 8 , 26 ], therefore uncovering the genomic characterization of sarcomatoid transformation in ccRCC is vital. The most altered pathways of sarcomatoid RCC (sRCC) involved VHL (72%), chromatin remodeling genes (72%), MTOR pathway (50%), DNA repair (30%), and the Hippo-YAP pathway (20%) [ 27 ]. The research from Wang Z and colleagues indicated more mutations in TP53, PTEN and RELN occurred in sRCC compared with ccRCC [ 28 ]. In addition, tyrosine kinase PDGFR-α ( PDGFRA ) gain of function mutations play a crucial role in RCC pathogenesis. Higher expression of tyrosine kinase receptor PDGFRα was observed in the sRCC part (81.2%) in comparison with the epithelial part (43.7%) and more common mutation of PDGFRA in a subset sRCC cases where sarcomatoid differentiation showed overexpression of this proteins [ 29 ]. In this study, SETD2 variant N1628T, TP53 variant A347G and PDGFRA variant S890 frameshift deletion were detected in sarcomatoid-like tumor, which may be the intrinsic cause of sarcoma tumor progression and suggested that patient can benefit from the imatinib drug. This example among others provides a model of how oncogenic activation of tyrosine kinase maintains the highly aggressive clinicopathological features and poor prognosis. The tumor microenvironment consisting of several cellular and extracellular matrix components is closely related to the outcome of tumor progression by promoting tumor growth, tumor invasion as well as metastatic growth [ 30 ]. In immune cell TME compartments of RCC, studies indicated that subdivided macrophages and T cells are the main immune cells [ 31 , 32 ]. In July 2018 Wang et al. described a new RCC subtype, namely the inflamed pan-RCC subtype (IS) and revealed that IS RCCs are enriched for Tregs, NK cells, neutrophils, macrophages, B-cells, TH1 cells, and CD8 + T cells and are importantly associated with poor prognosis and poor survival [ 33 ]. Some papers also reported that the immune microenvironment of RCC is unique compared with other solid tumors [ 2 ]. Resected RCC tumors are usually wide-spread infiltrated by CD8 + T cells and an increased level of infiltrating CD8 + T cells is associated with worse outcome in RCC [ 34 ], while in the other solid tumors infiltrating CD8 + T cells are associated with a better prognosis[ 35 ]. In our study, CD8 + T cells and tumor associated neutrophils (TANs) significantly increased in the more aggressive tumor components (sarcomatous area and peritoneal metastasis tumor) compared with ccRCC. It explained the highly aggressive biological behavior from the modification of tumor microenvironment (TME) and suggested that the patient may benefit from immunotherapy due to extensive infiltrated of CD8 + T cells and neutrophils. Further data are needed to determine whether CD8 + T cell density might be a biomarker for immunotherapy. This study has several limitations, including its small sample size, lack of transcriptome analysis due to insufficient quality of RNA and non-coding gene analysis. Despite the limitations, based on molecular features and TIME analysis, we have identified a rare Chinese case of ccRCC with sarcomatoid differentiation, extensive tumor metastasis and poor prognosis. Furthermore, multiple low-frequency mutant genes including PDGFRA , ATR , YAP-1 and COL5A3 , activated tumor infiltrating CD8 + cells and increased neutrophils were detected in this study, which provided genetic explanation of the highly heterogeneous nature of ccRCC and poor prognosis. These findings provide new evidence and potential for accurately assessing the biological behavior of ccRCC. Conclusions Using next-generation sequencing and TIME analysis, multiple low-frequency mutant genes including PDGFRA, ATR, YAP1 and COL5A3 , activated infiltrating CD8 + T cells and increased neutrophils were detected in a rare Chinese ccRCC with sarcomatoid differentiation and extremely aggressive biological behavior. These findings potentially provide new evidence and molecular markers for accurately assessing the biological behavior of ccRCC. Abbreviations RCC renal cell carcinoma; ccRCC clear cell renal cell carcinoma; sRCC sarcomatoid renal cell carcinoma; TIME tumor immune microenvironment; TME tumor microenvironment; TANs tumor associated neutrophils; TMB tumor mutation burden; SETD2 SET domain containing 2; ATR ataxia telangiectasia and Rad3 related; ATM Ataxia–telangiectasia mutated; IHC immunohistochemistry Declarations Acknowledgment This work was supported by the National Natural Science Foundation of China (grant no. 81702796) Authors’ contributions Jing Yang and Junyun Wang conceived the study. Yehui Chen is the corresponding author. Jing Yang obtained samples and performed the pathology review. Yunshi Liang, Jin Xv and Zhaoliang Tang completed pathological diagnosis, data collection and analysis. Jinxiang Zhang and Hong Yuan collected clinic history data and followed up. Guorong Liu and Xiubo Li performed IHC staining. Yunhai Huang evaluated the results of the computed tomography (CT). Junyun Wang performed the bioinformatic analysis. Jing Yang, Junyun Wang and Jianfei Wang analyzed and interpreted the data. JingYang and Junyun Wang wrote the first manuscript, which was reviewed by all coauthors. Funding The authors have no funding to disclose Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request Ethics approval and consent to participate The present study was approved by the ethics committee of Guangzhou First People’s Hospital and adhered to the tenets of the Declaration of Helsinki. Consent for publication Patient signed an informed consent for publication of the case report. Competing interests The authors declare that they have no competing interests. References Znaor A, Lortet-Tieulent J, Laversanne M, Jemal A, Bray F. International variations and trends in renal cell carcinoma incidence and mortality. Eur Urol. 2015;67(3):519–30. 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The entire course of his clinical treatment is illustrated as timeline figure. In August, 2019, a kidney mass detected by abdominal ultrasound in outer hospital due to repeated hiccups. In September, 2019, the patient was referred to our hospital for further diagnosis and treatment. His weight had lost about 5Kg since the onset, and systematic multiple metastases were found by the enhanced computed tomography (CT). On September 4th, 2019, a right radical 3D laparoscopic nephrectomy plus peritoneal nodule biopsy was performed. On Oct 13th, 2019, the patient returned to the hospital for review 1 month after surgery and was admitted oral Pazopanib treatment (200mg per tablet, qd). During the treatment of Pazopanib, the patient was getting better physically. After nearly two months of follow-up, the patient died on November 26th, 2019. FigureS1timeline.tif Supplementary Fig. 1. The entire course of his clinical treatment is illustrated as timeline figure. In August, 2019, a kidney mass detected by abdominal ultrasound in outer hospital due to repeated hiccups. In September, 2019, the patient was referred to our hospital for further diagnosis and treatment. His weight had lost about 5Kg since the onset, and systematic multiple metastases were found by the enhanced computed tomography (CT). On September 4th, 2019, a right radical 3D laparoscopic nephrectomy plus peritoneal nodule biopsy was performed. On Oct 13th, 2019, the patient returned to the hospital for review 1 month after surgery and was admitted oral Pazopanib treatment (200mg per tablet, qd). During the treatment of Pazopanib, the patient was getting better physically. After nearly two months of follow-up, the patient died on November 26th, 2019. FigureS1timeline.tif Supplementary Fig. 1. The entire course of his clinical treatment is illustrated as timeline figure. In August, 2019, a kidney mass detected by abdominal ultrasound in outer hospital due to repeated hiccups. In September, 2019, the patient was referred to our hospital for further diagnosis and treatment. His weight had lost about 5Kg since the onset, and systematic multiple metastases were found by the enhanced computed tomography (CT). On September 4th, 2019, a right radical 3D laparoscopic nephrectomy plus peritoneal nodule biopsy was performed. On Oct 13th, 2019, the patient returned to the hospital for review 1 month after surgery and was admitted oral Pazopanib treatment (200mg per tablet, qd). During the treatment of Pazopanib, the patient was getting better physically. After nearly two months of follow-up, the patient died on November 26th, 2019. FigureS1timeline.tif Supplementary Fig. 1. The entire course of his clinical treatment is illustrated as timeline figure. In August, 2019, a kidney mass detected by abdominal ultrasound in outer hospital due to repeated hiccups. In September, 2019, the patient was referred to our hospital for further diagnosis and treatment. His weight had lost about 5Kg since the onset, and systematic multiple metastases were found by the enhanced computed tomography (CT). On September 4th, 2019, a right radical 3D laparoscopic nephrectomy plus peritoneal nodule biopsy was performed. On Oct 13th, 2019, the patient returned to the hospital for review 1 month after surgery and was admitted oral Pazopanib treatment (200mg per tablet, qd). During the treatment of Pazopanib, the patient was getting better physically. After nearly two months of follow-up, the patient died on November 26th, 2019. SupplementaryTable1.docx SupplementaryTable1.docx SupplementaryTable1.docx SupplementaryTable1.docx CAREchecklist20201104.pdf CAREchecklist20201104.pdf CAREchecklist20201104.pdf CAREchecklist20201104.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-108093","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":4753880,"identity":"d7bbde97-4b75-4859-9e28-88b29927ee2a","order_by":0,"name":"Jing Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYBACNvnHx3//4LGR42dvIFILH0NagjSDTJqxZM8BIrXIMeQYSDPYHE7cMCOBWIcxHDAwLshhTtwg+XjjDYYam2jCWhgbEpJnnGEz3i6dVmzBcCwtt4GgFmaGAwd4e3hkd87OMZNgbDhMhBY2xsYG3n8SjBtuniFWCw8zMzMPj4Hihhs8xGqRANozgycBGMhAvyQQ4xf5GfzfGD7w/AdG5eGNNz7U2BDWggwMJBJIUQ7RQqqOUTAKRsEoGBkAAGyZOq3Cm1diAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-1730-9795","institution":"South China University of Technology","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Yang","suffix":""},{"id":4753881,"identity":"e38bb9d4-38ff-4e04-b437-019e715d8a87","order_by":1,"name":"Junyun Wang","email":"","orcid":"https://orcid.org/0000-0003-0573-7856","institution":"Beijing Institute of Genomics Chinese Academy of Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Junyun","middleName":"","lastName":"Wang","suffix":""},{"id":4753882,"identity":"daa4c346-3378-4748-b23c-2430ab269955","order_by":2,"name":"Yunshi Liang","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yunshi","middleName":"","lastName":"Liang","suffix":""},{"id":4753883,"identity":"68a93aa5-7430-4e78-a084-66a8e8b3cb27","order_by":3,"name":"Jianfei Wang","email":"","orcid":"","institution":"GloriousMed Clinical Laboratory(Shanghai) Co. Ltd)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jianfei","middleName":"","lastName":"Wang","suffix":""},{"id":4753884,"identity":"79f9c8cf-3823-4f3e-a749-f8f2fac04ef7","order_by":4,"name":"Jin Xv","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Xv","suffix":""},{"id":4753885,"identity":"fa9e5a61-af00-4ffd-84f2-04ebc01b6161","order_by":5,"name":"Guorong Liu","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Guorong","middleName":"","lastName":"Liu","suffix":""},{"id":4753886,"identity":"124b2a8c-e146-4419-aee3-d1992eb95672","order_by":6,"name":"Xiubo Tang","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiubo","middleName":"","lastName":"Tang","suffix":""},{"id":4753887,"identity":"b20f0376-6a68-4368-98f8-96b3a0b7e313","order_by":7,"name":"Zhaoliang Tang","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhaoliang","middleName":"","lastName":"Tang","suffix":""},{"id":4753888,"identity":"10f035b8-9fdb-4b1d-876e-63ef5f600fae","order_by":8,"name":"Jinxiang Zhang","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jinxiang","middleName":"","lastName":"Zhang","suffix":""},{"id":4753889,"identity":"7bc03ffd-0bf2-4b4f-bd6e-fa5b1d77c31f","order_by":9,"name":"Yunhai Huang","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yunhai","middleName":"","lastName":"Huang","suffix":""},{"id":4753890,"identity":"2c4d1ec5-4964-4854-a781-53b091943919","order_by":10,"name":"Hong Yuan","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Yuan","suffix":""},{"id":4753891,"identity":"ec3e1362-24ed-48bd-8e51-b74e3bbe80df","order_by":11,"name":"Yehui Chen","email":"","orcid":"","institution":"Guangzhou First People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yehui","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2020-11-13 18:03:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-108093/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-108093/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":3697904,"identity":"2df020d1-a37d-4488-b963-b032865a3fba","added_by":"auto","created_at":"2020-11-19 16:23:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8557363,"visible":true,"origin":"","legend":"The entire course of his clinical treatment is illustrated and contrast-enhanced computed tomography in portal phase of the thoraco-abdomen. (A1-A4) Abdomen enhanced CT showed an uneven-density mass (black arrow) in the upper pole of the right kidney and multiple uneven-density nodules abdominal cavity, abdominal wall, retroperitoneum, pelvic cavity, bilateral groin, bilateral psoas muscles, iliopsoas and gluteal muscles, front abdominal wall, back and hip subcutaneous (red arrow) and around the anus. (A3) Another low-density nodule was found in the lower pole of the right kidney (blue arrow). (B1-B3) Chest enhanced CT showed multiple enlarged stuck nodules formed a huge irregular mass (yellow arrow) in the mediastinum and a metastatic nodule was in the anterior chest wall (red triangle). (C) A peritoneal metastatic node was removed for frozen-section (yellow triangle).","description":"","filename":"OnlineFigure1.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/c997c7c12a26dd459d98939a.Png"},{"id":3697895,"identity":"8e7de40d-d521-45b9-b0d1-53ba1cd4d30c","added_by":"auto","created_at":"2020-11-19 16:23:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8557363,"visible":true,"origin":"","legend":"The entire course of his clinical treatment is illustrated and contrast-enhanced computed tomography in portal phase of the thoraco-abdomen. (A1-A4) Abdomen enhanced CT showed an uneven-density mass (black arrow) in the upper pole of the right kidney and multiple uneven-density nodules abdominal cavity, abdominal wall, retroperitoneum, pelvic cavity, bilateral groin, bilateral psoas muscles, iliopsoas and gluteal muscles, front abdominal wall, back and hip subcutaneous (red arrow) and around the anus. (A3) Another low-density nodule was found in the lower pole of the right kidney (blue arrow). (B1-B3) Chest enhanced CT showed multiple enlarged stuck nodules formed a huge irregular mass (yellow arrow) in the mediastinum and a metastatic nodule was in the anterior chest wall (red triangle). (C) A peritoneal metastatic node was removed for frozen-section (yellow triangle).","description":"","filename":"OnlineFigure1.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/69f10d1c252360af638ade96.Png"},{"id":3697880,"identity":"a6350748-c497-45b9-aa7a-5a41c3d55abc","added_by":"auto","created_at":"2020-11-19 16:23:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8557363,"visible":true,"origin":"","legend":"The entire course of his clinical treatment is illustrated and contrast-enhanced computed tomography in portal phase of the thoraco-abdomen. (A1-A4) Abdomen enhanced CT showed an uneven-density mass (black arrow) in the upper pole of the right kidney and multiple uneven-density nodules abdominal cavity, abdominal wall, retroperitoneum, pelvic cavity, bilateral groin, bilateral psoas muscles, iliopsoas and gluteal muscles, front abdominal wall, back and hip subcutaneous (red arrow) and around the anus. (A3) Another low-density nodule was found in the lower pole of the right kidney (blue arrow). (B1-B3) Chest enhanced CT showed multiple enlarged stuck nodules formed a huge irregular mass (yellow arrow) in the mediastinum and a metastatic nodule was in the anterior chest wall (red triangle). (C) A peritoneal metastatic node was removed for frozen-section (yellow triangle).","description":"","filename":"OnlineFigure1.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/a0e36d0deef9fe682e724417.Png"},{"id":3697887,"identity":"f1b1f8ae-6108-4b3d-92b5-be69e1891fb9","added_by":"auto","created_at":"2020-11-19 16:23:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8557363,"visible":true,"origin":"","legend":"The entire course of his clinical treatment is illustrated and contrast-enhanced computed tomography in portal phase of the thoraco-abdomen. (A1-A4) Abdomen enhanced CT showed an uneven-density mass (black arrow) in the upper pole of the right kidney and multiple uneven-density nodules abdominal cavity, abdominal wall, retroperitoneum, pelvic cavity, bilateral groin, bilateral psoas muscles, iliopsoas and gluteal muscles, front abdominal wall, back and hip subcutaneous (red arrow) and around the anus. (A3) Another low-density nodule was found in the lower pole of the right kidney (blue arrow). (B1-B3) Chest enhanced CT showed multiple enlarged stuck nodules formed a huge irregular mass (yellow arrow) in the mediastinum and a metastatic nodule was in the anterior chest wall (red triangle). (C) A peritoneal metastatic node was removed for frozen-section (yellow triangle).","description":"","filename":"OnlineFigure1.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/2f279104673ef375d3b92d50.Png"},{"id":3697906,"identity":"3288430d-e076-47b9-82a5-9b941be15130","added_by":"auto","created_at":"2020-11-19 16:23:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4841036,"visible":true,"origin":"","legend":"Pathological morphologies and immunohistochemistry staining of renal cell carcinoma and peritoneal tumoral node.\n (A)Low magnification of the renal cell carcinoma. Scale bar=2000mm.Yellow line exhibited the clear-cell carcinoma; Red line exhibited the eosinophilic papillary area; Blue line exhibited the sarcomatous change area; Black line exhibited the normal renal tissue. (Aa1) RCC with the morphology of classical ccRCC. Scale bar=50mm;(Aa2-a7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in classical ccRCC area. (Ab1) RCC with eosinophilic papillary structure, Scale bar=50mm. (Ab2-b7) Immunostaining for CK8/18, EMA, vimentin, CAIX, AMACR and Ki67 in papillary area (Ac1) RCC with sarcomatoid (spindle) cells and clear nucleolus. Scale bar=50mm. (Ac2-7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in sarcomatous area, Scale bar=50mm.\n(B)Low magnification of the peritoneal tumoral node. Scale bar=2000mm. (B1) Peritoneal tumor with spindle cells and rhabdoid cells. Scale bar=50mm. (B2-7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in peritoneal tumoral node.\n","description":"","filename":"OnlineFigure2.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/981c131f21e6627dcf2e699f.Png"},{"id":3697897,"identity":"16f65289-c0d1-42d5-8156-524e138d3d29","added_by":"auto","created_at":"2020-11-19 16:23:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4841036,"visible":true,"origin":"","legend":"Pathological morphologies and immunohistochemistry staining of renal cell carcinoma and peritoneal tumoral node.\n (A)Low magnification of the renal cell carcinoma. Scale bar=2000mm.Yellow line exhibited the clear-cell carcinoma; Red line exhibited the eosinophilic papillary area; Blue line exhibited the sarcomatous change area; Black line exhibited the normal renal tissue. (Aa1) RCC with the morphology of classical ccRCC. Scale bar=50mm;(Aa2-a7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in classical ccRCC area. (Ab1) RCC with eosinophilic papillary structure, Scale bar=50mm. (Ab2-b7) Immunostaining for CK8/18, EMA, vimentin, CAIX, AMACR and Ki67 in papillary area (Ac1) RCC with sarcomatoid (spindle) cells and clear nucleolus. Scale bar=50mm. (Ac2-7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in sarcomatous area, Scale bar=50mm.\n(B)Low magnification of the peritoneal tumoral node. Scale bar=2000mm. (B1) Peritoneal tumor with spindle cells and rhabdoid cells. Scale bar=50mm. (B2-7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in peritoneal tumoral node.\n","description":"","filename":"OnlineFigure2.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/201ec69dd7739cceccdc0b8a.Png"},{"id":3697882,"identity":"09847368-3800-4284-829c-b1e88df10100","added_by":"auto","created_at":"2020-11-19 16:23:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4841036,"visible":true,"origin":"","legend":"Pathological morphologies and immunohistochemistry staining of renal cell carcinoma and peritoneal tumoral node.\n (A)Low magnification of the renal cell carcinoma. Scale bar=2000mm.Yellow line exhibited the clear-cell carcinoma; Red line exhibited the eosinophilic papillary area; Blue line exhibited the sarcomatous change area; Black line exhibited the normal renal tissue. (Aa1) RCC with the morphology of classical ccRCC. Scale bar=50mm;(Aa2-a7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in classical ccRCC area. (Ab1) RCC with eosinophilic papillary structure, Scale bar=50mm. (Ab2-b7) Immunostaining for CK8/18, EMA, vimentin, CAIX, AMACR and Ki67 in papillary area (Ac1) RCC with sarcomatoid (spindle) cells and clear nucleolus. Scale bar=50mm. (Ac2-7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in sarcomatous area, Scale bar=50mm.\n(B)Low magnification of the peritoneal tumoral node. Scale bar=2000mm. (B1) Peritoneal tumor with spindle cells and rhabdoid cells. Scale bar=50mm. (B2-7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in peritoneal tumoral node.\n","description":"","filename":"OnlineFigure2.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/bc3a676d8f06105695229851.Png"},{"id":3697889,"identity":"fdce8ff8-279b-4604-a85e-a5b35cd3d579","added_by":"auto","created_at":"2020-11-19 16:23:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4841036,"visible":true,"origin":"","legend":"Pathological morphologies and immunohistochemistry staining of renal cell carcinoma and peritoneal tumoral node.\n (A)Low magnification of the renal cell carcinoma. Scale bar=2000mm.Yellow line exhibited the clear-cell carcinoma; Red line exhibited the eosinophilic papillary area; Blue line exhibited the sarcomatous change area; Black line exhibited the normal renal tissue. (Aa1) RCC with the morphology of classical ccRCC. Scale bar=50mm;(Aa2-a7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in classical ccRCC area. (Ab1) RCC with eosinophilic papillary structure, Scale bar=50mm. (Ab2-b7) Immunostaining for CK8/18, EMA, vimentin, CAIX, AMACR and Ki67 in papillary area (Ac1) RCC with sarcomatoid (spindle) cells and clear nucleolus. Scale bar=50mm. (Ac2-7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in sarcomatous area, Scale bar=50mm.\n(B)Low magnification of the peritoneal tumoral node. Scale bar=2000mm. (B1) Peritoneal tumor with spindle cells and rhabdoid cells. Scale bar=50mm. (B2-7) Immunostaining for CK8/18, EMA, Vimentin, CAIX, AMACR and Ki67 in peritoneal tumoral node.\n","description":"","filename":"OnlineFigure2.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/2c9a4df7cd945381adc1ca1d.Png"},{"id":3697908,"identity":"202643e9-df11-45b4-8e53-3de21c1af527","added_by":"auto","created_at":"2020-11-19 16:23:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3499663,"visible":true,"origin":"","legend":"Distribution and statistical results of lymphocytes and neutrophils in kidney tumor and peritoneal node. (A)Low magnification for the distribution of lymphocytes and neutrophils in HE sections of renal tumor. Scale bar=2000mm. \n(Aa1-a5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in ccRCC area, respectively. HE Scale bar=50mm; IHC Scale bar=100mm. (Ab1-b5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in sarcomatous area, respectively. HE Scale bar=50mm; IHC Scale bar=100mm; \n(B1-B5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in the peritoneal node, respectively. HE Scale bar=50mm; IHC Scale bar=100mm\n(C-F) Statistical results of TILs, CD8+ T cells, CD4+ T cells and neutrophils distributed in these three areas. Ordinary one-way ANOVA was taken. * P＜0.05.\n","description":"","filename":"OnlineFigure3.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/e38f1bf434b66850a7c73e6a.Png"},{"id":3697899,"identity":"a8d09f9e-5e02-4c03-94bc-0e742e3b6d68","added_by":"auto","created_at":"2020-11-19 16:23:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3499663,"visible":true,"origin":"","legend":"Distribution and statistical results of lymphocytes and neutrophils in kidney tumor and peritoneal node. (A)Low magnification for the distribution of lymphocytes and neutrophils in HE sections of renal tumor. Scale bar=2000mm. \n(Aa1-a5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in ccRCC area, respectively. HE Scale bar=50mm; IHC Scale bar=100mm. (Ab1-b5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in sarcomatous area, respectively. HE Scale bar=50mm; IHC Scale bar=100mm; \n(B1-B5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in the peritoneal node, respectively. HE Scale bar=50mm; IHC Scale bar=100mm\n(C-F) Statistical results of TILs, CD8+ T cells, CD4+ T cells and neutrophils distributed in these three areas. Ordinary one-way ANOVA was taken. * P＜0.05.\n","description":"","filename":"OnlineFigure3.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/072138321ec1db4f1e57cc18.Png"},{"id":3697884,"identity":"7be9fcfe-f004-4158-8a2d-f3aedad6f655","added_by":"auto","created_at":"2020-11-19 16:23:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3499663,"visible":true,"origin":"","legend":"Distribution and statistical results of lymphocytes and neutrophils in kidney tumor and peritoneal node. (A)Low magnification for the distribution of lymphocytes and neutrophils in HE sections of renal tumor. Scale bar=2000mm. \n(Aa1-a5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in ccRCC area, respectively. HE Scale bar=50mm; IHC Scale bar=100mm. (Ab1-b5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in sarcomatous area, respectively. HE Scale bar=50mm; IHC Scale bar=100mm; \n(B1-B5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in the peritoneal node, respectively. HE Scale bar=50mm; IHC Scale bar=100mm\n(C-F) Statistical results of TILs, CD8+ T cells, CD4+ T cells and neutrophils distributed in these three areas. Ordinary one-way ANOVA was taken. * P＜0.05.\n","description":"","filename":"OnlineFigure3.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/931166176b959b1a9f08effa.Png"},{"id":3697891,"identity":"8c217d94-1864-42cb-8abb-759b68de52d6","added_by":"auto","created_at":"2020-11-19 16:23:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3499663,"visible":true,"origin":"","legend":"Distribution and statistical results of lymphocytes and neutrophils in kidney tumor and peritoneal node. (A)Low magnification for the distribution of lymphocytes and neutrophils in HE sections of renal tumor. Scale bar=2000mm. \n(Aa1-a5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in ccRCC area, respectively. HE Scale bar=50mm; IHC Scale bar=100mm. (Ab1-b5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in sarcomatous area, respectively. HE Scale bar=50mm; IHC Scale bar=100mm; \n(B1-B5) H\u0026E and immunohistochemistry staining for LCA, CD4, CD8, MPO in the peritoneal node, respectively. HE Scale bar=50mm; IHC Scale bar=100mm\n(C-F) Statistical results of TILs, CD8+ T cells, CD4+ T cells and neutrophils distributed in these three areas. Ordinary one-way ANOVA was taken. * P＜0.05.\n","description":"","filename":"OnlineFigure3.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/20fe9dfc250e38536a0c6e28.Png"},{"id":3697909,"identity":"4aadfe88-d88c-4d8e-92af-b1486964fa50","added_by":"auto","created_at":"2020-11-19 16:23:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1014313,"visible":true,"origin":"","legend":"Genetic mutations profile in the patient’s different lesions. (A)The distribution of somatic mutations (SNV, InDel) in conventional ccRCC area, eosinophilic papillary carcinoma area, sarcomatoid tumor area and peritoneal metastatic tumor was illustrated in Venn diagram. (B) Somatic mutations of RCC characteristics-associated genes and pathways in the patient’s four distinct tumor lesions. (C) The shift of TMB value was shown in different tumor areas.","description":"","filename":"OnlineFigure4.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/b44c3f7240711144f326937d.Png"},{"id":3697900,"identity":"1d8a9f35-9ee5-4279-b1a2-0b84aef32b41","added_by":"auto","created_at":"2020-11-19 16:23:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1014313,"visible":true,"origin":"","legend":"Genetic mutations profile in the patient’s different lesions. (A)The distribution of somatic mutations (SNV, InDel) in conventional ccRCC area, eosinophilic papillary carcinoma area, sarcomatoid tumor area and peritoneal metastatic tumor was illustrated in Venn diagram. (B) Somatic mutations of RCC characteristics-associated genes and pathways in the patient’s four distinct tumor lesions. (C) The shift of TMB value was shown in different tumor areas.","description":"","filename":"OnlineFigure4.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/8a3d3d2760662b46e1ec8e4e.Png"},{"id":3697892,"identity":"f2910621-cc7f-44f8-8057-87fa9159669a","added_by":"auto","created_at":"2020-11-19 16:23:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1014313,"visible":true,"origin":"","legend":"Genetic mutations profile in the patient’s different lesions. (A)The distribution of somatic mutations (SNV, InDel) in conventional ccRCC area, eosinophilic papillary carcinoma area, sarcomatoid tumor area and peritoneal metastatic tumor was illustrated in Venn diagram. (B) Somatic mutations of RCC characteristics-associated genes and pathways in the patient’s four distinct tumor lesions. (C) The shift of TMB value was shown in different tumor areas.","description":"","filename":"OnlineFigure4.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/7a50acef1d77c437a0c7a342.Png"},{"id":3697885,"identity":"9fb837c7-0e07-4c33-b5cd-b10816a1341b","added_by":"auto","created_at":"2020-11-19 16:23:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1014313,"visible":true,"origin":"","legend":"Genetic mutations profile in the patient’s different lesions. (A)The distribution of somatic mutations (SNV, InDel) in conventional ccRCC area, eosinophilic papillary carcinoma area, sarcomatoid tumor area and peritoneal metastatic tumor was illustrated in Venn diagram. (B) Somatic mutations of RCC characteristics-associated genes and pathways in the patient’s four distinct tumor lesions. (C) The shift of TMB value was shown in different tumor areas.","description":"","filename":"OnlineFigure4.Png","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/67be3a716ee700f34778066c.Png"},{"id":13616783,"identity":"b99b3f91-6a99-4eee-aa77-6a37c50d386e","added_by":"auto","created_at":"2021-09-17 06:51:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":17292649,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/23386830-83aa-41ca-a6fd-f7b934f5aacd.pdf"},{"id":3697903,"identity":"4ff64d59-728e-470d-97ec-73de7879d993","added_by":"auto","created_at":"2020-11-19 16:23:30","extension":"tif","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":186934412,"visible":true,"origin":"","legend":"Supplementary Fig. 1. The entire course of his clinical treatment is illustrated as timeline figure. In August, 2019, a kidney mass detected by abdominal ultrasound in outer hospital due to repeated hiccups. In September, 2019, the patient was referred to our hospital for further diagnosis and treatment. His weight had lost about 5Kg since the onset, and systematic multiple metastases were found by the enhanced computed tomography (CT). On September 4th, 2019, a right radical 3D laparoscopic nephrectomy plus peritoneal nodule biopsy was performed. On Oct 13th, 2019, the patient returned to the hospital for review 1 month after surgery and was admitted oral Pazopanib treatment (200mg per tablet, qd). During the treatment of Pazopanib, the patient was getting better physically. After nearly two months of follow-up, the patient died on November 26th, 2019.","description":"","filename":"FigureS1timeline.tif","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/202682491d401ca3014747c8.tif"},{"id":3697894,"identity":"f4fa39c5-1571-4d86-8533-1a28bb9af8ab","added_by":"auto","created_at":"2020-11-19 16:23:28","extension":"tif","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":186934412,"visible":true,"origin":"","legend":"Supplementary Fig. 1. The entire course of his clinical treatment is illustrated as timeline figure. In August, 2019, a kidney mass detected by abdominal ultrasound in outer hospital due to repeated hiccups. In September, 2019, the patient was referred to our hospital for further diagnosis and treatment. His weight had lost about 5Kg since the onset, and systematic multiple metastases were found by the enhanced computed tomography (CT). On September 4th, 2019, a right radical 3D laparoscopic nephrectomy plus peritoneal nodule biopsy was performed. On Oct 13th, 2019, the patient returned to the hospital for review 1 month after surgery and was admitted oral Pazopanib treatment (200mg per tablet, qd). During the treatment of Pazopanib, the patient was getting better physically. After nearly two months of follow-up, the patient died on November 26th, 2019.","description":"","filename":"FigureS1timeline.tif","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/fcec964aa8a043bce1416c55.tif"},{"id":3697886,"identity":"5ea1c035-37be-4de4-8d59-5d2b89b8c093","added_by":"auto","created_at":"2020-11-19 16:23:22","extension":"tif","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":186934412,"visible":true,"origin":"","legend":"Supplementary Fig. 1. The entire course of his clinical treatment is illustrated as timeline figure. In August, 2019, a kidney mass detected by abdominal ultrasound in outer hospital due to repeated hiccups. In September, 2019, the patient was referred to our hospital for further diagnosis and treatment. His weight had lost about 5Kg since the onset, and systematic multiple metastases were found by the enhanced computed tomography (CT). On September 4th, 2019, a right radical 3D laparoscopic nephrectomy plus peritoneal nodule biopsy was performed. On Oct 13th, 2019, the patient returned to the hospital for review 1 month after surgery and was admitted oral Pazopanib treatment (200mg per tablet, qd). During the treatment of Pazopanib, the patient was getting better physically. After nearly two months of follow-up, the patient died on November 26th, 2019.","description":"","filename":"FigureS1timeline.tif","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/354e49479ff2b23e8fc3ebea.tif"},{"id":3697879,"identity":"b407680c-4551-4c63-bf86-c5b2c19937fe","added_by":"auto","created_at":"2020-11-19 16:23:22","extension":"tif","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":186934412,"visible":true,"origin":"","legend":"Supplementary Fig. 1. The entire course of his clinical treatment is illustrated as timeline figure. In August, 2019, a kidney mass detected by abdominal ultrasound in outer hospital due to repeated hiccups. In September, 2019, the patient was referred to our hospital for further diagnosis and treatment. His weight had lost about 5Kg since the onset, and systematic multiple metastases were found by the enhanced computed tomography (CT). On September 4th, 2019, a right radical 3D laparoscopic nephrectomy plus peritoneal nodule biopsy was performed. On Oct 13th, 2019, the patient returned to the hospital for review 1 month after surgery and was admitted oral Pazopanib treatment (200mg per tablet, qd). During the treatment of Pazopanib, the patient was getting better physically. After nearly two months of follow-up, the patient died on November 26th, 2019.","description":"","filename":"FigureS1timeline.tif","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/c9f0ea7ebfa2514b09faf8da.tif"},{"id":3697905,"identity":"e9e08100-dcbf-49d7-936a-bdf95ad8eca8","added_by":"auto","created_at":"2020-11-19 16:23:34","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13932,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/c84e10448967b2ea8daeb152.docx"},{"id":3697896,"identity":"4beb370c-e551-4c06-a0f8-00c494de981c","added_by":"auto","created_at":"2020-11-19 16:23:28","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13932,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/e485a1a187165dcf2ffcacad.docx"},{"id":3697888,"identity":"e10d8c7c-a7c0-493d-bd37-00a6861ba73b","added_by":"auto","created_at":"2020-11-19 16:23:23","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13932,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/a03d3bb95295343a6385abfb.docx"},{"id":3697881,"identity":"d0e13c29-a12b-4ce9-a97e-53024dd2c1ab","added_by":"auto","created_at":"2020-11-19 16:23:23","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13932,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/10f54045fdeec79d1640a5f1.docx"},{"id":3697907,"identity":"1d42baba-bdcd-46c4-b616-a8b35269286e","added_by":"auto","created_at":"2020-11-19 16:23:34","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":596394,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklist20201104.pdf","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/b762f73e8cce6d4cb66417f4.pdf"},{"id":3697898,"identity":"bcde0e3f-62c4-4ec0-8603-4d97c95620d7","added_by":"auto","created_at":"2020-11-19 16:23:29","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":596394,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklist20201104.pdf","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/8fce850a5ee85eefbb4a49c4.pdf"},{"id":3697890,"identity":"86155483-f192-4ed3-81d0-dcc5eb72402d","added_by":"auto","created_at":"2020-11-19 16:23:24","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":596394,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklist20201104.pdf","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/63901f5a94b45e2b64c13bc1.pdf"},{"id":3697883,"identity":"768dd116-6b0a-4cf2-94ca-9f9cd40827a9","added_by":"auto","created_at":"2020-11-19 16:23:23","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":596394,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklist20201104.pdf","url":"https://assets-eu.researchsquare.com/files/rs-108093/v1/9b82061b771045ed6a70c657.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eClinicopathological and Genomic Analysis of a Chinese ccRCC Patient with Multiple Morphologies and Rapid Progression : A Case Report\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eRenal Cell Carcinoma (RCC) is the most common malignant tumor of kidney with an estimated 403,262 new incidences and 175,098 deaths globally in 2018 and the overall incidence rate has been increasing over the past decade [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Clear cell renal cell carcinoma (ccRCC) accounts forཞ75% of kidney cancer diagnoses of RCC [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].ccRCC has long been known to be a highly heterogeneous tumor including morphological heterogeneity and intratumoral genomic heterogeneity. The former is mainly reflected in diverse histological architectural patterns with clear cells or eosinophilic cells [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These tumor heterogeneities resulted in variable biological behavior of ccRCC, ranging from low-proliferating localized tumors to highly aggressive metastatic neoplasms. Although the overall survival of ccRCC is good with a 5-year survival rate of 70%, approximately 25% of ccRCC patients show distant metastasis at the first diagnosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Thus, accurate assessing the tumor prognosis is important to guide therapeutic intervention and follow-up strategies.\u003c/p\u003e \u003cp\u003eCurrently, prognosis evaluation of ccRCC is mainly on the basis of tumor stage and grade. There are also several morphological parameters associated with poor prognosis, such as tumor necrosis, rhabdoid and sarcomatoid differentiation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Studies showed that the 5-year survival rate of the tumor with sarcomatoid differentiation is 15\u0026ndash;22% and the median survival for tumors with rhabdoid morphology is 8\u0026ndash;31\u0026nbsp;months [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs we known, genetic alterations play a critical role in the tumor initiation, progression and evolution. With the rapid development of gene sequencing technology, researchers discovered that \u003cem\u003eVHL, PBRM1, SETD2\u003c/em\u003e and \u003cem\u003eBAP1\u003c/em\u003e are the most commonly mutated genes of ccRCC [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Among these genes, \u003cem\u003eBAP1\u003c/em\u003e-mutant tumors are typically high-grade and are associated with poor outcome [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Mutation in \u003cem\u003eSETD2\u003c/em\u003e is also associated with poor prognosis of ccRCC [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Recently, the research from Samra Turajlic et al. identified genetic diversity and chromosomal complexity as determinants of patient outcome [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, an integrative genomic study of Chinese ccRCCs revealed that the gene mutation landscape in Chinese cohort is different from TCGA dataset, demonstrating significantly higher mutation frequencies in \u003cem\u003eCSMD3\u003c/em\u003e and \u003cem\u003eTMPRSS13\u003c/em\u003e [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, to explore the molecular markers related to ccRCC prognosis in Chinese population is meaningful and important.\u003c/p\u003e \u003cp\u003eIn addition, increasing studies indicated that tumor microenvironment (TME) plays an important role in tumor progression, immune escape and drug-resistance [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Tumor-associated neutrophils (TANs) and lymphocytes (TILs) are the main components of inflammatory in TME [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A study from Song et al. showed that neutrophils are favorably recruited to the RCC cells to promote the RCC migration and invasion [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In another study the author developed an architectural pattern-based grading model for ccRCC prognosis evaluation including the intratumoral inflammatory reaction patterns [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHerein, we reported a rare Chinese RCC with complicated morphology, extensive metastasis and extremely aggressive behavior. A comprehensive analysis including histopathology, gene alterations and TIME was performed to explore the factors related with aggressive behavior and poor prognosis.\u003c/p\u003e "},{"header":"Case Presentation","content":"\u003cp\u003eThe patient was a 56-year-old Chinese man accidentally detected a kidney mass by abdominal ultrasound in outer hospital due to repeated hiccups in August, 2019. Then the patient was referred to our hospital for further diagnosis and treatment in September, 2019. No family tumor history was mentioned and no clinical symptoms were presented, such as flank pain, fever and gross hematuria, nevertheless his weight had lost about 5 kilograms since the onset. Physical examination found that multiple subcutaneous soft nodules located in head, face, neck, waist, abdomen, chest, back and limbs with the diameter from 0.8-1.5cm, without redness, swelling, ulceration and purulence. The enhanced computed tomography (CT) of abdomen revealed an uneven-density mass in the upper pole of the right kidney and multiple uneven-density nodules in abdominal cavity, abdominal wall, retroperitoneum, pelvic cavity, bilateral groin, bilateral psoas muscles, iliopsoas and gluteal muscles, front abdominal wall, back and hip subcutaneous and around the anus (Fig. 1A1, A4 and B4). The kidney mass was measured with the size of 46mm\u0026times;42mm\u0026times;39mm and shown low-density and no-enhanced necrotic area in portal phase (Fig. 1A2). Another low-density nodule was found in the lower pole of the right kidney with the size of 29.74 \u0026times; 22.70 \u0026times; 21.77 mm (Fig. 1A3). Chest enhanced CT showed no metastasis in the lungs, but there were multiple enlarged stuck nodules in the mediastinum, bilateral armpits and anterior chest wall, which was considered as metastases (Fig. 1B1-B3). A peritoneal metastatic node was removed for frozen-section (yellow triangle) (Fig.1C). Then, a right radical 3D laparoscopic nephrectomy plus peritoneal nodule biopsy was performed. The patient returned to the hospital for review 1 month after surgery and was admitted oral Pazopanib treatment (200mg per tablet, qd) on Oct 13th, 2019. During the treatment of Pazopanib, the patient was getting better physically. Unfortunately, the patient died 1 month later due to excessive medication arbitrarily. The entire course of his clinical treatment is illustrated in Supplementary Fig. 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePathological findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMacroscopic findings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGrossly, the tumor protruding from the renal cortex was confined within the renal parenchyma and measured to be 4.5 \u0026times; 4.0 \u0026times; 4.0 cm. The cross-section showed a yellowish and spherical neoplasm in the upper pole of the right kidney. The border with the kidney is sharp. Focal hemorrhage and necrosis were identified. In addition, a few dense gray-white nodes were detected in the renal capsule, the perinephric adipose tissue and peritoneum, and their diameter was about 0.3-1.0 cm (Supplementary Fig. 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHistopathological and immunohistochemical (IHC) findings \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMicroscopic evaluation of the renal tumor showed the tumor was multi-nodular and separated by fibrous tissue. The tumor histology was very complicated with three different histological morphologies, including conventional ccRCC like region, eosinophilic papillary structure and sarcomatoid (spindle) differentiation (Fig. 2A). In ccRCC like region, the pattern of growth was predominantly solid, with formation of nest and acinar patterns separated by the stroma that was characteristically endowed with a prominent network of small, thin-walled blood vessels (Fig. 2Aa1). The area of eosinophilic papillary structure was composed of papillae formed by delicate fibrovascular cores that contain foamy macrophages. Most of these tumor cells showed abundant eosinophilic cytoplasm with occasional small nuclei (Fig. 2Ab1). The sarcomatoid area was lack of distinct borders with the area of clear cells which transition zone between them could be seen. In this region, some little abscesses with lots of neutrophils and tumor necrosis were observed (Fig. 2Ac1). In addition, histopathological examination of the peritoneum node revealed epithelioid sheets of cells exhibiting great pleomorphism and frequent mitoses (Fig. 2B). These tumor cells with eccentric nuclei and abundant eosinophilic cytoplasm resembled rhabdomyoblasts, which was designated as rhabdoid differentiation (Fig. 2B1).\u003c/p\u003e\n\u003cp\u003eTo identify the specific subtype of this tumor, we completed serious of IHC staining in the primary kidney tumors and peritoneal metastatic node. These immunostainings showed that CK8/18 and EMA were diffuse or patchy strong positivity in the classical ccRCC like area and eosinophilic papillary area (Fig. 2Aa2-3, 2Ab2-3), while their expressions were reduced in the sarcomatoid area and peritoneal metastatic node (Fig. 2Ac2-3, 2B2-3). To the opposite, vimentin was expressed more intensely and diffusely in the sarcomatoid area and peritoneal metastatic node (Fig. 2Aa4-Ac4, 2B4). Carbonic anhydrase Ⅸ (CA-Ⅸ) was present strongly and diffusely in the intact membranous distribution in the clear cells and those tumor cells in the eosinophilic papillary area, which was negative in sarcomatoid cells (Fig. 2Aa5-Ac5, 2B5). Tumor cells in these four lesions were negative for CD10, CK7, CD117, PAX8, MelanA, HMB45, SMA, Myogenin, Syn, CgA and ALK and retained SMARCB1 (INI-1) expression. The immunostaining summary information could be seen in Supplementary Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTumor immune microenvironment (TIME) analysis of different regions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to numerous inflammatory cells accumulating in the sarcomatoid area and peritoneal metastatic node, we further detected the status of the immune tumor microenvironment via the IHC staining of LCA, CD8, CD4 and MPO and evaluated inflammatory cells in the ccRCC like region, sarcomatoid area and peritoneal metastatic tumor, respectively. We found that lymphocytes were mostly distributed in the border of different morphological tumor node, but not in the center of lesion, while the distribution of neutrophils had no zonal (Fig. 3A). The number of TILs infiltrating on the border of sarcomatoid area was significantly more than the ccRCC like region (p=0.0144, Fig. 3Aa2-b2 and 3C). Amount of CD8+ T cells in the sarcomatous area and peritoneal metastasis tumor were significantly more than ccRCC (p\u003csub\u003esarcomatoid/ccRCC\u003c/sub\u003e\u0026lt;0.0001, p\u003csub\u003eperitonael / ccRCC\u003c/sub\u003e\u0026lt;0.0001, Fig.3Aa-b4, 3B4 and 3E). The number of CD4+ T cells in the peritonaeul tumor was slightly higher than ccRCC area and sarcomatous area (p\u003csub\u003eperitonael/ccRCC\u003c/sub\u003e =0.0161, p\u003csub\u003eperitonael/sarcomatoid\u003c/sub\u003e =0.0161, Fig.3Aa3-b3, 3B3 and 3D). It implies that CD8+ T cells preferred infiltrating into the high grade RCC compared with CD4+ T cells. Moreover, neutrophils were more enriched in the sarcomatous areas and peritoneal tumor than ccRCC like region (p\u003csub\u003esarcomatoid/ccRCC\u003c/sub\u003e\u0026lt;0.0001, p\u003csub\u003esarcomatoid/peritonae\u003c/sub\u003e\u0026lt;0.0001, Fig. 3Aa5-b5, 3B5 and 3F).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGene mutation analysis with target capture sequencing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo confirm the accurate subtype of tumor and further reveal the underlying molecular mechanism related heterogeneous morphology and extremely aggressive biological behavior, genomic profiling of the four distinct morphology tissue slides from resected tumor specimens was achieved by using target capture sequencing with a designed panel of 620 key cancer-related genes (GloriousMed Clinical\u0026nbsp;Laboratory\u0026nbsp;Co., Shanghai, China). The distribution of somatic mutations (SNV, InDel) among four different morphological tissues from this patient are summarized in a Venn diagram (Fig. 4A).\u003c/p\u003e\n\u003cp\u003eThe most common\u003cem\u003e VHL\u003c/em\u003e mutations in ccRCC were detected in all of them, including primary and peritoneal metastatic foci (Fig. 4B). Therefore, we identified this patient as a high-grade clear cell renal cell carcinoma (ccRCC) with with sarcomatoid differentiation and systemic multiple metastases (pT3aN1M1). Further analysis indicated tumor of eosinophilic papillary area carries the fewest number and types of mutated genes among all tumor tissues, only \u003cem\u003eVHL \u003c/em\u003eand \u003cem\u003eBAP1\u003c/em\u003emutation, suggesting that these two genes might be early events in ccRCC tumorigenesis. From the perspective of genomic changes, eosinophilic morphology tumor seems to occur in the earliest stage of the disease due to the minimum number of driver gene alterations and mutation types. Notably, histone modification gene \u003cem\u003eSETD2\u003c/em\u003e mutations were detected in all of tumor regions except for eosinophilic papillary area, suggesting SETD2 could play an important role in ccRCC progression.\u003c/p\u003e\n\u003cp\u003eRemarkably, the genetic alterations in sarcomatoid regions are similar to those in clear cell carcinoma areas, both sharing some identical gene mutations such as \u003cem\u003eVHL\u003c/em\u003e(p. R64fs), \u003cem\u003eSETD2\u003c/em\u003e(p.N1628T), \u003cem\u003eSMAD4\u003c/em\u003e(p.Q534fs*3), and\u003cem\u003e PTPRT\u003c/em\u003e(p.A696V). \u003cem\u003eBAP1\u003c/em\u003e variant P190R and \u003cem\u003eATM\u003c/em\u003e variant E1199 deletion were observed only in conventional clear cell carcinomas, whereas there were exclusive \u003cem\u003eTP53\u003c/em\u003e variant A347G and \u003cem\u003ePDGFRA\u003c/em\u003e variant S890 frameshift deletion in sarcomatoid-like tumor, hinting that \u003cem\u003eTP53\u003c/em\u003e and \u003cem\u003ePDGFRA\u003c/em\u003e may play a significant role in the sarcomatoid transformation from ccRCC morphology. \u003cem\u003eBRCA2\u003c/em\u003e and \u003cem\u003eATR\u003c/em\u003e involved in DNA damage response pathway, NF-kappa B signaling gene \u003cem\u003eCYLD\u003c/em\u003e and Hippo signaling gene \u003cem\u003eYAP1\u003c/em\u003e, protein digestion and absorption gene \u003cem\u003eCOL5A3\u003c/em\u003e were specifically detected in peritoneal metastatic node but not in other primary areas (Fig. 4B).\u003c/p\u003e\n\u003cp\u003eBesides, the tumor mutation burden (TMB) value of the four tumor areas present some certain regularities. The higher the grade, the higher the TMB value, as expected, the worse the prognosis, especially with sarcomatoid lesions. The TMB of peritoneal metastatic tumor was higher than the primary tumor (Fig. 4C). The TMB evidence also supports that tumor of eosinophilic papillary area and ccRCC area occurred at the early stage, then the tumor developed into the sarcomatoid morphology, and lastly metastasized to multiple organs including the peritoneum.\u003c/p\u003e\n\u003cp\u003eThe last main thing is that this patient harbored several somatic mutations of certain genes including histone methyltransferase \u003cem\u003eSETD2 \u003c/em\u003e(SET domain containing 2), ATR serine/threonine kinase (\u003cem\u003eATR\u003c/em\u003e), ATM serine/threonine kinase (\u003cem\u003eATM\u003c/em\u003e) and \u003cem\u003eTP53\u003c/em\u003e associated with DNA damage response signaling and Hippo signaling (\u003cem\u003eYAP1\u003c/em\u003e), PI3K-Akt signaling (\u003cem\u003ePDGFRA\u003c/em\u003e) and T cell receptor signaling (\u003cem\u003eCOL5A3\u003c/em\u003e) (Fig. 4B), some of which contribute to the development of the RCC in light of previous data [9, 17, 18].\u003c/p\u003e"},{"header":"Discussion","content":" \u003cp\u003eThis is a really complex, difficult and rare RCC case even though it was identified high- grade advanced ccRCC with sarcomatoid differentiation by gene sequencing finally. But making an accurate pathological diagnosis for this case is very difficult in the beginning because it presented complicated pathological morphology as mentioned before and lacked the expression of characteristic immune markers. For example, a classical ccRCC marker CD10 was negative in all of tumor areas. Meanwhile, we excluded chromophobe renal cell carcinoma (ChRCC), MiT family translocation carcinoma, renal medullary carcinoma and ALK rearrangement-associated RCC because of the lack of CK7, CD117, MelanA, HMB45, TFE3 and ALK expression and retaining SMARCB1 (INI-1) expression. Additionally, we also excluded clear cell papillary RCC due to the staining pattern of CA-Ⅸ without the basolateral positivity. As mentioned above, this tumor was highly invasive and metastasis had occurred in the multiple parts of the body including subcutaneous, soft tissue, lymph nodes and so on at the beginning of diagnosis. Sarcomatoid differentiation in the primary tumor was undoubtedly one of the important reasons of its high aggressiveness. Published data showed that this feature is found in 5\u0026ndash;8% of ccRCC, 8\u0026ndash;9% of ChRCC, and 2\u0026ndash;3% of PRCC [\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Additionally, in the context of the current 2016 WHO classification system, tumors in the unclassified RCC (uRCC) category can be those with a combination of features of more than one recognized subtype, with mucin production or with unrecognized epithelial cell subtypes, low- or high-grade unclassified oncocytic neoplasms, and other unclassifiable renal tumors [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Sarcomatoid differentiation is also included in the morphology spectrum of uRCC. Some research data from a few relatively large series of uRCC suggest a comparably poor or worse outcome than high-stage ccRCC [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Hence, it is critical to determine the tumor subtype and explore the underlying molecular mechanism of highly aggressive biological behavior via target gene sequencing in four different tumor areas including metastatic foci\u003c/p\u003e \u003cp\u003eIn this study, we detected \u003cem\u003eVHL\u003c/em\u003e mutations in all of tumor areas including the primary tumor with three different morphologies and metastasis. It confirmed that this tumor was ccRCC and its different components are originated from the same progenitor cell.\u003c/p\u003e \u003cp\u003eBecause of huge tumor heterogeneity, the mutation profiles between in situ foci and metastases are varied, especially for driver mutations. \u003cem\u003eBRCA2\u003c/em\u003e and \u003cem\u003eATR\u003c/em\u003e involved in DNA damage response pathway, NF-kappa B signaling gene \u003cem\u003eCYLD\u003c/em\u003e and Hippo-YAP signaling gene \u003cem\u003eYAP1\u003c/em\u003e, protein digestion and absorption gene \u003cem\u003eCOL5A3\u003c/em\u003e was specifically detected in peritoneal metastatic node but not in other primary areas, indicating that these gene mutations might play an important role in promoting tumor metastasis. Importantly, the alterations (especially deleterious gene mutations) of DDR genes exhibited potential value of predicting response to immune checkpoint inhibitors for metastatic RCC patients [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Given the key role of these signaling pathways in the feature of DNA repair, cell proliferation and metastasis, these mutations might contribute to this patient\u0026rsquo;s rapid progression and high aggressiveness.\u003c/p\u003e \u003cp\u003eIt was reported that patients with sarcomatoid carcinoma have a poorer prognosis than classical ccRCC [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], therefore uncovering the genomic characterization of sarcomatoid transformation in ccRCC is vital. The most altered pathways of sarcomatoid RCC (sRCC) involved \u003cem\u003eVHL\u003c/em\u003e (72%), chromatin remodeling genes (72%), MTOR pathway (50%), DNA repair (30%), and the Hippo-YAP pathway (20%) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The research from Wang Z and colleagues indicated more mutations in \u003cem\u003eTP53, PTEN\u003c/em\u003e and \u003cem\u003eRELN\u003c/em\u003e occurred in sRCC compared with ccRCC [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In addition, tyrosine kinase PDGFR-α (\u003cem\u003ePDGFRA\u003c/em\u003e) gain of function mutations play a crucial role in RCC pathogenesis. Higher expression of tyrosine kinase receptor PDGFRα was observed in the sRCC part (81.2%) in comparison with the epithelial part (43.7%) and more common mutation of \u003cem\u003ePDGFRA\u003c/em\u003e in a subset sRCC cases where sarcomatoid differentiation showed overexpression of this proteins [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In this study, \u003cem\u003eSETD2\u003c/em\u003e variant N1628T, \u003cem\u003eTP53\u003c/em\u003e variant A347G and \u003cem\u003ePDGFRA\u003c/em\u003e variant S890 frameshift deletion were detected in sarcomatoid-like tumor, which may be the intrinsic cause of sarcoma tumor progression and suggested that patient can benefit from the imatinib drug. This example among others provides a model of how oncogenic activation of tyrosine kinase maintains the highly aggressive clinicopathological features and poor prognosis.\u003c/p\u003e \u003cp\u003eThe tumor microenvironment consisting of several cellular and extracellular matrix components is closely related to the outcome of tumor progression by promoting tumor growth, tumor invasion as well as metastatic growth [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In immune cell TME compartments of RCC, studies indicated that subdivided macrophages and T cells are the main immune cells [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In July 2018 Wang et al. described a new RCC subtype, namely the inflamed pan-RCC subtype (IS) and revealed that IS RCCs are enriched for Tregs, NK cells, neutrophils, macrophages, B-cells, TH1 cells, and CD8\u0026thinsp;+\u0026thinsp;T cells and are importantly associated with poor prognosis and poor survival [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Some papers also reported that the immune microenvironment of RCC is unique compared with other solid tumors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Resected RCC tumors are usually wide-spread infiltrated by CD8\u0026thinsp;+\u0026thinsp;T cells and an increased level of infiltrating CD8\u0026thinsp;+\u0026thinsp;T cells is associated with worse outcome in RCC [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], while in the other solid tumors infiltrating CD8\u0026thinsp;+\u0026thinsp;T cells are associated with a better prognosis[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In our study, CD8\u0026thinsp;+\u0026thinsp;T cells and tumor associated neutrophils (TANs) significantly increased in the more aggressive tumor components (sarcomatous area and peritoneal metastasis tumor) compared with ccRCC. It explained the highly aggressive biological behavior from the modification of tumor microenvironment (TME) and suggested that the patient may benefit from immunotherapy due to extensive infiltrated of CD8\u0026thinsp;+\u0026thinsp;T cells and neutrophils. Further data are needed to determine whether CD8\u0026thinsp;+\u0026thinsp;T cell density might be a biomarker for immunotherapy.\u003c/p\u003e \u003cp\u003eThis study has several limitations, including its small sample size, lack of transcriptome analysis due to insufficient quality of RNA and non-coding gene analysis. Despite the limitations, based on molecular features and TIME analysis, we have identified a rare Chinese case of ccRCC with sarcomatoid differentiation, extensive tumor metastasis and poor prognosis. Furthermore, multiple low-frequency mutant genes including \u003cem\u003ePDGFRA\u003c/em\u003e, \u003cem\u003eATR\u003c/em\u003e, \u003cem\u003eYAP-1\u003c/em\u003e and \u003cem\u003eCOL5A3\u003c/em\u003e, activated tumor infiltrating CD8\u0026thinsp;+\u0026thinsp;cells and increased neutrophils were detected in this study, which provided genetic explanation of the highly heterogeneous nature of ccRCC and poor prognosis. These findings provide new evidence and potential for accurately assessing the biological behavior of ccRCC.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eUsing next-generation sequencing and TIME analysis, multiple low-frequency mutant genes including \u003cem\u003ePDGFRA, ATR, YAP1\u003c/em\u003e and \u003cem\u003eCOL5A3\u003c/em\u003e, activated infiltrating CD8\u0026thinsp;+\u0026thinsp;T cells and increased neutrophils were detected in a rare Chinese ccRCC with sarcomatoid differentiation and extremely aggressive biological behavior. These findings potentially provide new evidence and molecular markers for accurately assessing the biological behavior of ccRCC.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003erenal cell carcinoma;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eccRCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eclear cell renal cell carcinoma;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003esRCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esarcomatoid renal cell carcinoma;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTIME\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etumor immune microenvironment;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTME\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etumor microenvironment;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTANs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etumor associated neutrophils;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTMB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etumor mutation burden;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSETD2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSET domain containing 2;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eataxia telangiectasia and Rad3 related;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAtaxia\u0026ndash;telangiectasia mutated;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eimmunohistochemistry\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Natural Science Foundation of China (grant no. 81702796)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJing Yang and Junyun Wang conceived the study. Yehui Chen is the corresponding author. Jing Yang obtained samples and performed the pathology review. Yunshi Liang, Jin Xv and Zhaoliang Tang completed pathological diagnosis, data collection and analysis. Jinxiang Zhang and Hong Yuan collected clinic history data and followed up. Guorong Liu and Xiubo Li performed IHC staining. Yunhai Huang evaluated the results of the computed tomography (CT). Junyun Wang performed the bioinformatic analysis. Jing Yang, Junyun Wang and Jianfei Wang analyzed and interpreted the data. JingYang and Junyun Wang wrote the first manuscript, which was reviewed by all coauthors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no funding to disclose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr /\u003e The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was approved by the ethics committee of Guangzhou First People\u0026rsquo;s Hospital and adhered to the tenets of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient signed an informed consent for publication of the case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr /\u003e The authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZnaor A, Lortet-Tieulent J, Laversanne M, Jemal A, Bray F. 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Nat Rev Cancer. 2012;12(4):298\u0026ndash;306.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ccRCC, sarcomatoid differentiation, multiple morphologies, molecular features, tumor microenvironment","lastPublishedDoi":"10.21203/rs.3.rs-108093/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-108093/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Renal cell carcinoma (RCC) with sarcomatoid differentiation and multiple metastases is highly aggressive RCC with poor prognosis. However, there are not sufficient report on the genetic alterations and tumor immune microenviroment (TIME) of RCC with complex pathological morphology and aggressive behavior.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e: A rare Chinese RCC case with complex pathological morphology and multiple subcutaneous and soft tissue metastases was reported. The clinical manifestations, histomorphology, immunophenotype and follow-up data were collected and analyzed. We performed target region sequencing and immunohistochemistry staining in different morphological regions of the primary tumor and the peritoneal metastasis. Microscopically, this primary tumor was composed of three different histological variations, including ccRCC like region, eosinophilic papillary structure and sarcomatoid differentiation. The peritoneal metastasis partially showed rhabdoid differentiation. IHC staining didn’t display positivity for characteristic markers. IHC for inflammatory cells showed that CD8+T cells and tumor associated neutrophils (TANs) were significantly increased in the sarcomatous areas and peritoneal metastatic tumor. Genomic analysis indicated that \u003cem\u003eVHL\u003c/em\u003e mutations were present in all types of pathological regions and peritoneal metastatic tumor. Therefore, the pathological diagnosis of high-grade ccRCC with sarcomatoid differentiation was established. Additionally\u003cem\u003e,\u003c/em\u003e we also found \u003cem\u003eSETD2\u003c/em\u003e, \u003cem\u003eTP53\u003c/em\u003e and \u003cem\u003ePDGFRA\u003c/em\u003e mutations were observed in sarcomatoid tumor area, whereas \u003cem\u003eBRCA2, ATR,\u003c/em\u003e \u003cem\u003eCYLD\u003c/em\u003e, \u003cem\u003eYAP1\u003c/em\u003e and\u003cem\u003e COL5A3\u003c/em\u003e mutations were specifically detected in peritoneal metastases. These findings are rather striking because some genes e.g., ATR serine/threonine kinase (\u003cem\u003eATR\u003c/em\u003e) and Hippo signaling (\u003cem\u003eYAP1\u003c/em\u003e), PI3K-Akt signaling (\u003cem\u003ePDGFRA\u003c/em\u003e) and T cell receptor signaling (\u003cem\u003eCOL5A3\u003c/em\u003e) were previously reported to be very rare in ccRCC patients.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Using next-generation sequencing and TIME analysis, multiple low-frequency mutant genes including PDGFRA, ATR, YAP1 and COL5A3 and increased CD8+ T cells and neutrophils were detected in this rare Chinese ccRCC. These findings potentially provide new evidence and molecular markers for accurately assessing the biological behavior of ccRCC.\u003c/p\u003e","manuscriptTitle":"Clinicopathological and Genomic Analysis of a Chinese ccRCC Patient with Multiple Morphologies and Rapid Progression : A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-11-19 16:23:18","doi":"10.21203/rs.3.rs-108093/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"338174cb-4614-4283-b587-7851c57c508c","owner":[],"postedDate":"November 19th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":1135317,"name":"Pathology"}],"tags":[],"updatedAt":"2020-11-19T16:23:19+00:00","versionOfRecord":[],"versionCreatedAt":"2020-11-19 16:23:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-108093","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-108093","identity":"rs-108093","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}