Seeded Biopsy Tract Recurrence After Extirpative Surgery for Renal Cell Carcinoma

Abstract

Background: Renal mass biopsy (RMB) is an increasingly utilized modality in the work-up of patients with suspicious renal masses. Recurrence of renal cell carcinoma (RCC) from biopsy tract seeding is exceedingly rare in the literature. We report a case of such a phenomenon.

Case Presentation: Our patient is a 75-year-old Caucasian man and former smoker with a functionally solitary left kidney, initially worked up for gross hematuria and left flank pain. Imaging revealed hydronephrosis and a left renal mass, which was biopsied. Pathology analysis demonstrated clear cell RCC, and a left robotic radical nephrectomy was performed with negative surgical margins. Sixteen months postoperatively, imaging revealed multiple small masses along the biopsy tract, suspicious for recurrence. These were biopsied and pathology analysis confirmed recurrent clear cell RCC.

Conclusion: Despite its rarity, biopsy tract seeding is a serious complication of RMB. This warrants thorough counseling and shared decision making between providers and all patients with renal masses planning to undergo a RMB.

Introduction and Background

Renal mass biopsy (RMB) is commonly performed in the setting of suspicious renal masses, specifically when pathologic diagnosis would tailor therapy in select patient populations. With modern biopsy techniques, RMB is generally regarded as safe, with acceptable diagnostic yield and low complication rates. Among the potential complications is the theoretical risk of tumor seeding along the biopsy needle tract; however, only a handful of case reports exist in the contemporary literature. We report a case of tumor seeding and cancer recurrence along a biopsy tract in a patient with a history of clear cell renal cell carcinoma (RCC) in a functionally solitary kidney, after radical nephrectomy.

Presentation of Case

Clinical history

Our patient is a 75-year-old Caucasian man and former 7.5 pack-year smoker, with history of diabetes, chronic kidney disease, and a functionally solitary left kidney, who initially presented for intermittent gross hematuria and left flank pain. Ultrasonography, ordered by his primary care physician, showed left upper tract dilation and an incidental lesion, further characterized as a hyperdense left upper pole mass, on follow-up CT (Fig. 1). His examination was unremarkable. Additional imaging and close follow-up with urology were scheduled.

FIG. 1.

Preoperative imaging. Axial (top left) and coronal (top right) noncontrast CT images showing the 4.0 by 5.6 cm heterogeneously attenuating mass in the superior left kidney. Coronal (bottom left) and axial (bottom right) fluid-sensitive MRI sequences showing the same mass, measuring 5.0 by 3.7 cm, with heterogeneous signal and likely central necrosis.

Additional work-up

The following day he presented to the emergency department with severe left renal colic, worsened gross hematuria, and was found to have acute kidney injury, with a creatinine of 9.8 mg/dL (from baseline 2 mg/dL). Ultrasonography showed significantly worsened hydronephrosis and he was taken to the operating room for ureteral stent placement. A selective left cytology was sent at that time, which revealed rare reactive urothelial cells, but was otherwise nondiagnostic. His renal function slowly improved, and he was discharged on hospital day 4.

Follow-up MRI further characterized the suspicious mass, as shown in Figure 1. Subsequent CT of the chest ruled out pulmonary metastases. The patient was sent for RMB, which was performed with an 18-gauge needle through a percutaneous introducer to avoid multiple needle passes. Absorbable gelatin hemostatic foam was injected along the tract as the sheath was removed, as per standard practice within our interventional radiology department. Pathology analysis revealed clear cell RCC. The case was discussed with nephrology and the patient was thoroughly counseled. Given his functionally solitary kidney, the size and complexity of the mass, and the low likelihood of avoiding dialysis even with an effective partial nephrectomy, the decision was made to proceed with radical nephrectomy, and to begin hemodialysis postoperatively.

Primary treatment

The patient underwent robot-assisted laparoscopic radical nephrectomy and the final pathology analysis was pT3aNx Fuhrman grade 3 clear cell RCC with negative surgical margins (Fig. 3). No additional variant pathologic features were present. He did well postoperatively, was established on hemodialysis, and was started on an outpatient surveillance regimen.

FIG. 3.

Nephrectomy specimen pathology (upper two slides). H&E stained sections showing clear cell RCC. The left upper pane (4 × magnification) shows tumor extension into the pelvicaliceal system. The right upper pane (10 × magnification) shows WHO/ISUP grade 3 clear cell RCC (nucleoli conspicuous at 100 × magnification; not shown). Biopsy of needle tract recurrence (lower two slides). H&E stains in the lower left (2 × magnification) and lower right (20 × magnification) confirming metastatic clear cell RCC. H&E, hematoxylin and eosin; RCC, renal cell carcinoma; WHO/ISUP, World Health Organization/International Society of Urologic Pathologists.

Recurrence

Sixteen months after surgery, contrast CT imaging showed a cluster of enhancing masses along the prior site of the biopsy tract, suspicious for recurrent disease (Fig. 2). His case was discussed at an interdisciplinary tumor board meeting, and the decision was made to biopsy the lesions. Pathology analysis was consistent with clear cell RCC (Fig. 3). Planned adjuvant treatment includes surgical resection of the biopsy tract recurrences vs palliative radiation, pending patient preference.

FIG. 2.

Tumor recurrence. Preoperative left renal biopsy tract (upper left). Postoperative contrast-enhanced CT images show three enhancing masses along the biopsy tract (noted by arrows) in the left posterolateral abdominal wall, with a 2.5 cm by 1.6 cm mass in the subcutaneous fat (upper right), a 0.7 cm by 0.7 cm mass in the musculature (lower left), and a 1.4 cm by 0.4 cm mass along the retroperitoneal lining (lower right).

Discussion and Literature Review

Biopsy tract seeding of RCC remains a rare phenomenon with only a handful of cases in the literature and, as such, its true incidence is unknown. A 2007 review by Volpe et al.¹ demonstrated only six case reports of RCC biopsy tract seeding from 1977 to 2006. Most of this limited data describe microscopic seeding seen on histologic evaluation of surgical specimens. Even rarer are the accounts of clinical recurrence from biopsy seeding, as was the case with our patient.

An important technical component of modern-day RMBs is the use of a coaxial sheath or introducer. This allows the acquisition of multiple renal biopsies with a core needle while limiting the number of passes through the skin and intervening percutaneous tissue layers, thereby reducing the risk of tumor seeding.¹ A coaxial sheath was used for the RMB in our patient. One theoretical cause for the seeding is that the hemostatic foam injected along the tract experienced transient outward pressure from the adjacent renal parenchyma or collecting system. This may have forced a small amount of the foam out along the tract, allowing for seeding of tumor cells.

Despite the recommendation to use this biopsy technique to reduce risk, there are still reported cases of biopsy tract seeding. The largest contemporary single series of tract seeding was published in 2018 from a tertiary referral center in the United Kingdom. Overall, seven patients experienced tumor seeding along their biopsy tracts, as evidenced by postsurgical pathology analysis that showed tumor was present along the tract in the perinephric fat. Of the seven cases, six were papillary and one was clear cell RCC. The patient with clear cell RCC was the only one in the cohort with clinical evidence of macroscopic recurrence after partial nephrectomy, with final pathology analysis demonstrating positive surgical margins.²

The few remaining series are small, consisting of one or two patients each. A series of two cases included one patient who had clinical recurrence after biopsy and cryoablation, also with clear cell pathology.³ An additional case describes the partial nephrectomy of a papillary RCC with associated hematoma, and negative surgical margins at the index case. The patient recurred in the resection bed and completion nephrectomy showed concordant pathology. The authors cited the initial biopsy as the cause for the hematoma, and the hematoma as the source of the seeded metastases.⁴

Overall, there are few reported cases of biopsy tract seeding of RCC, a majority of which are microscopic, with even fewer cases of macroscopic recurrence. Intriguingly, a majority of seeding cases involved papillary RCC, although this observation is anecdotal, based on small sample sizes. Despite refined biopsy techniques, as utilization of RMB grows with each year, this potential risk must be appropriately acknowledged when discussing care options with renal mass patients considering RMB.

Conclusion

Tumor tract seeding and subsequent clinical recurrence are exceedingly rare. The true incidence of this complication, although unknown, is likely underreported especially in the setting of the increasing utilization of RMB in an era of targeted therapy. Although it should not dissuade providers from offering RMB to well-selected patients, it does underscore the importance of thorough counseling in the shared decision-making process.

Abbreviations Used

CT

computed tomography

H&E

hematoxylin and eosin

MRI

magnetic resonance imaging

RCC

renal cell carcinoma

RMB

renal mass biopsy

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Kidd LC, Okoro C, Kamat B, Peter A, Patel P, Reese AC (2020) Seeded biopsy tract recurrence after extirpative surgery for renal cell carcinoma, Journal of Endourology Case Reports 6:4, 512–515, DOI: 10.1089/cren.2020.0168.