NDP102: Paratesticular dedifferentiated liposarcoma : a rare case report
腎細胞癌併發針路徑轉移：案例報告及相關文獻回顧
陳冠宇1,2、陳順郎1,2、陳文榮1,2、謝佐宜1,2、楊旻鑫1,2、宋文瑋1,2、何承儒1,2、王紹全1,2
1中山醫學大學附設醫院泌尿科；2中山醫學大學醫學院
Renal cell carcinoma complicated with needle tract seeding: a case report and literature review
Kuan Yu Chen1,2, Sung Lang Chen1,2, Wen Jung Chen1,2, Tuzo Yi Hsieh1,2, Ming Hsin Yang1,2, Wen Wei Sung1,2, Cheng Ju Ho1,2, Shao Chuan Wang1,2
1Department of Urology, Chung Shan Medical University Hospital, Taichung, Taiwan. 2School of Medicine, Chung Shan Medical University Hospital, Taichung,
Introduction:
A renal mass biopsy is a minimally invasive procedure used to obtain tissue samples from renal masses, aiding in diagnosing and managing kidney tumors. Typically performed using either fine-needle aspiration or core needle biopsy, this procedure is crucial for differentiating between benign and malignant lesions, as well as determining the specific subtype of renal cell carcinoma (RCC). The biopsy technique and needle size choice are tailored to maximize diagnostic yield while minimizing risks. One of the rare but potential complications associated with renal mass biopsy is needle tract seeding, where tumor cells are inadvertently implanted along the biopsy needle path. This uncommon phenomenon is most frequently observed with papillary RCC (pRCC). Here we are going to present a case diagnosed with RCC with complication of needle tract seeding.
Case presentation:
This is a 91-year-old man with a history of chronic kidney disease, benign prostatic hyperplasia, hypertensive cardiovascular disease, and right chronic frontal-parietal-temporal subdural hemorrhage with midline shift, status post right parietal burr hole and external ventricle drain on 2014/01/14. This time, he suffered from abdominal pain and fever for 2 days and came to our emergency department for help on 2022-06-23. Covid-19 screening showed positive results. KUB plain film showed a diffuse distended bowel loop [Figure. 1]. Abdomen CT scan showed a 6.0 cm irregular contrast-enhancing mass in the right kidney, cT1bN0M0, suspicious renal cell carcinoma [Figure. 2]. Cytology of urine showed negative results. After management of his symptoms, he was referred to our urology outpatient department for consultation. Treatment choices including radical nephrectomy are suggested. The patient and the family were hesitant about the operation and asked for conservative treatment. After a full explanation of the possible risks, a renal mass biopsy was performed on 2022-08-29. Pathology confirmed renal cell carcinoma, favoring papillary renal cell carcinoma. The patient suffered from intermittent gross hematuria with acute urinary retention in September 2022. Cystoscopy on 2022-10-07 showed blood clots inside the bladder and gross hematuria from the right ureteral orifices. Follow-up Abdomen CT scan on 2022-10-10 showed size progression of the tumor with renal pelvis invasion, and perirenal space invasion [Figure.3-5]. A laparoscopic right radical nephrectomy was performed on 2022-10-18 after share-decision making with the patient and the family. Pathology showed papillary renal cell carcinoma, type 2, grade 2, pT3aNx. Adjuvant sunitinib and immune checkpoint inhibitors were suggested due to the high risk of the disease but the family refused. A newly found skin lesion at the right flank was noticed, excision biopsy was done on 2023-06-12 and confirmed metastatic renal cell carcinoma [Figure. 6-7]. Follow-up abdomen and chest CT scan showed suspicious liver, lung, and chest wall metastases [Figure. 8-10]. The patient is under regular follow-up and sunitinib treatment.Discussion:
Papillary renal cell carcinoma (pRCC) is the second most common subtype of renal cell carcinoma (RCC), accounting for about 10-15% of all RCC cases. pRCC can be further divided into two subtypes: Type 1 and Type 2. Type 1 is generally associated with a better prognosis, whereas Type 2 tends to be more aggressive and has a worse outcome. The potential for metastasis following a renal mass biopsy is a point of concern among clinicians. However, the risk is generally considered low. Several studies have evaluated the safety of renal mass biopsies and found that the rate of tumor seeding or metastasis is minimal [1][2]. In general, renal mass biopsies are deemed safe with respect to the risk of metastasis or needle tract seeding. Studies suggest that less than 0.01% of patients undergoing renal biopsies for RCC experience metastasis due to the procedure [3]. The literature consistently indicates that the benefits of renal mass biopsy, in terms of accurate diagnosis and guiding treatment, outweigh the potential risks. In contrast, Zhou et al [4] observed needle tract tumor seeding to perinephric tissue in six out of ninety-eight (6 %) renal cell carcinoma cases, and it was exclusively observed in pRCC (6/28, 21 %), with type 1 features, unifocal, small-sized (≤ 4 cm), and confined to the kidney. Renshaw et al. [5] reported that needle tract seeding has been documented in only 16 cases worldwide, with the majority occurring in pRCC patients. They found several risk factors related to needle tract seeding: multiple punctures, larger needle sizes (≥20 gauge), and the absence of a coaxial sheath were linked to higher seeding risks. Core needle biopsies also exhibited higher rates of seeding compared to fine-needle aspiration.
Conclusion:
In conclusion, while needle tract seeding is a serious but uncommon complication, it is critical to tailor biopsy approaches to reduce this risk, especially in pRCC. With careful technique and preventive strategies, the likelihood of seeding can be minimized, making renal mass biopsies a safe diagnostic tool.