This is a real challenge case.  I will try to give my thought about this case and hopefully it will be helpful. I look forward to hearing other opinions and final answers. It will be also helpful to know the tumor pathologic stage (fat or renal vein invasion) and metastasis  Thanks.

1、嗜酸细胞腺瘤？NO: There are certainly morphologic features of oncocytoma, but other features (focal papillary, true cytologic atypia and number of mitoses and atypical mitoses, necrosis and huge size all against diagnosis of oncocytoma. About 5% oncocytoma could have focal cytologic atypia or giant degenerating cells, but papillary and many mitoses, and tumor necrosis are not seen in a benign oncocytoma.   

2、嫌色细胞癌嗜酸细胞亚型？Some people would agree with this diagnosis.  I think it is not, again because of focal papillary and marked cytologic atypia and mitoses are not usually seen in eosinophilic type chromophobe RCC

3、颗粒细胞型透明细胞癌？NO. The growth and vascular patterns are not that of a clear cell RCC with granular cells.

4、恶性嗜酸细胞腺瘤？NO. most people would not use this terminology anymore.

5. 还是腺瘤内有腺癌呢？This is a very interesting theory and it is certainly possible. It could be either transformation to a carcinoma (if we agree) from a oncocytoma or possibly a hybrid (mixed) oncocytom-chromophobe RCC.

6. I also think it is possible that it is a tubulopapillary RCC with eosinophilic cells.

7. For practical reason, the best diagnosis might be: unclassified RCC (oncocytic malignant RCC).

I don’t think immunostains will be particularly helpful because the heterogeneity of this tumor and overlapping staining profiles of most markers. Cytogenetic and chromosome analysis might be the only way to get a more definite diagnosis.  

 嗜酸型嫌色性肾细胞癌大体常棕黄色，胞浆可以细颗粒状，但有核周空晕。

颗粒细胞型透明细胞癌瘤细胞异型更明显，腺管乳头结构，常能见到不等量的透明细胞。

至于嗜酸细胞腺瘤，不会有病理核分裂和大片坏死。

应该是恶性，叫个什么名字好呢？ 嗜酸细胞腺瘤恶变？

 可以诊断颗粒性肾细胞癌

1.管状、巢状和乳头状结构混合

2.坏死

3.细胞多形，核仁明显，易见病理性核分裂

腺瘤恶变