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Papillary Renal Cell Carcinoma Seeding along a Percutaneous Biopsy Tract

Authors:
  • Douglass Hainly Moir Pathology, Sydney, Australia

Abstract and Figures

We report a case of tumour seeding caused by percutaneous biopsy of a papillary renal cell carcinoma detected on pathological assessment of the partial nephrectomy specimen in a 50-year-old male. Whilst percutaneous biopsy of renal masses is considered to be safe and can be a valuable tool in the assessment of certain renal lesions, it is not without risks. This rare complication should be taken into consideration before contemplating its use in a patient.
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Case Report
Papillary Renal Cell Carcinoma Seeding along
a Percutaneous Biopsy Tract
Deanne Soares, Nariman Ahmadi, Oana Crainic, and John Boulas
Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, NSW 2050, Australia
Correspondence should be addressed to Deanne Soares; deanne.soares@gmail.com
Received  May ; Revised  July ; Accepted  July 
Academic Editor: Christian Pavlovich
Copyright ©  Deanne Soares et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
We report a case of tumour seeding caused by percutaneous biopsy of a papillary renal cell carcinoma detected on pathological
assessment of the partial nephrectomy specimen in a -year-old male. Whilst percutaneous biopsy of renal masses is considered
to be safe and can be a valuable tool in the assessment of certain renal lesions, it is not without risks. is rare complication should
be taken into consideration before contemplating its use in a patient.
1. Introduction
e use of percutaneous biopsies is useful in the diagnosis
and management of renal masses and of other abdominal
organs [,]. is has been found to be a safe and eective
tool with a complication rate of less than .% []. However,
a potential hazard of this procedure is tumour seeding, where
malignant cells are deposited along the needle tract, but this is
so rare in renal cell carcinoma (RCC) that its frequent use in
the assessment of indeterminate renal masses has therefore
been justied [,]. Here we present a case of RCC seeding
alongapreviouspercutaneousrenalbiopsytractnoted
on histopathological assessment of a partial nephrectomy
specimen.
2. Case Presentation
A -year-old male was referred to our institution for review
aer an incidental nding of a . cm enhancing lower
pole mass on the le kidney. is mass was rst noted on
ultrasound imaging as part of his investigations for symptoms
of bloating and constipation. A computed tomography scan
with intravenous contrast was then performed to further
characterise this lesion, which showed a low density but
mildly enhancing lesion. Magnetic resonance imaging (MRI)
was performed to exclude angiomyolipoma. It revealed a
 × mm le renal lower pole exophytic mass with a low
T signal suggesting the possibility of a renal cell carcinoma
(see Figure ). e patient then underwent an ultrasound-
guided biopsy of the mass to aid with diagnosis and assist
in management options. e lesion was rst accessed using
a -gauge needle with a coaxial sheath and  ne needle
aspiration (FNA) biopsies were performed. is was followed
by core biopsies using an -gauge core biopsy needle also
done with the coaxial sheath in place. Two passes were
made to obtain  cores, all embedded in  blocks. e core
sizes were  mm,  mm,  mm, mm,  mm, and  mm in
length. Pathological assessment of the FNA and core biopsy
specimens conrmed the presence of a low-grade neoplasm
consisting of closely packed cells with small rounded nuclei
forming clusters and some mucin lled tubules. Given this
nding, the patient underwent a subsequent open le partial
nephrectomy  weeks later. e procedure involved a lower
pole partial nephrectomy, with frozen section conrming
clear parenchymal margins. e perinephric fat over the
tumour was initially reected o during surgery and sent
separately with a marking suture placed where the fat was
adherent over the tumour site. ere was no tumour capsule
disruption or spillage or any other complication during the
procedure.
Macroscopically, there was a lobulated grey partly
necrotic, noncystic tumour measuring  × mm (see
Figure  showing the bisected specimen). Microscopically,
the lesion was well demarcated showing a complex papillary
Hindawi Publishing Corporation
Case Reports in Urology
Volume 2015, Article ID 925254, 4 pages
http://dx.doi.org/10.1155/2015/925254
Case Reports in Urology
T : Summary of reported cases of RCC seeding along a renal percutaneous biopsy tract.
Reference (year) Typ e of
tumour
Needle
calibre
(gauge)
Interval between
biopsy and seeding Size Description and location
Gibbons et al.
() []RCC   months cm Firm mass inferior to the
posterior part of the right th rib
Auvert et al.
() []Oncocytoma Did not
mention years cm Subcutaneous mass at biopsy site
Kiser et al.
() []
Papillary
RCC   month mm Nodule found when dissecting
Gerota’s fascia o psoas muscle
Wehl e and
Grabstald ()
[]
RCC  Not specied Not specied Flank mass at biopsy site
Shenoy et al.
() []RCC   months . cm Subcutaneous nodule
Giorgadze et al.
() []
Papillary
RCC
 (FNA)
 (Core) years  cm
Le retroperitoneal mass
extending posterior to the
abdominal aorta with possible
invasion into the psoas muscle
Mullins and
Rodriguez
() []
Papillary
RCC
 (FNA)
 (Core)  months . cm
Tumour invading the perirenal
fat within the previous biopsy
tract
Sainani et al.
() []
Papillary
RCC
 (FNA)
 (Core) years Up to . cm  retroperitoneal nodules and 
in the paraspinal musculature
F : Magnetic resonance imaging (MRI) showing a  × mm
le renal lower pole mass with a low T signal.
growth pattern (see Figure ). Immunochemically it was
strongly positive for both alpha-methyl CoA racemase and
CK. Histologically this was a type  papillary renal cell
carcinoma. During examination of the fat overlying the
tumour, viable tumour was noted seeding along the previous
percutaneous biopsy tract, with it growing within the brob-
lastic response that marked the biopsy tract (see Figures
and ). His recovery was uneventful and he was discharged
on day  postoperatively. He remained well  month aer his
procedure. Follow-up imaging will be sought.
3. Discussion
Tumour seeding in a biopsy tract has been well documented
in malignancies of solid organs such as in pancreatic and
lung adenocarcinoma as well as hepatocellular carcinoma
F : Macroscopic view of the partial nephrectomy specimen
demonstrating a  × mm well-demarcated tumour.
[]. However, the extension of a renal cell carcinoma along
a percutaneous biopsy tract is very rare with only a few
reported cases on this []. Gibbons et al. noted the
rst case of RCC tract seeding in ,  months aer
aspiration of a renal lesion using an -gauge needle [].
Tabl e  summarises all the previously reported cases of RCC
seeding along a renal percutaneous biopsy tract.
Up until , there were only  reported cases of RCC
tract seeding [] and in  there were further  cases
reported []. e size of the needle used during these
biopsies ranged from  to  gauges and were detected 
month to  years aer the initial biopsy was performed [].
A review by Herts and Baker in  found that needle tract
seeding from percutaneous renal mass biopsy is very rare
estimating the risk to be less than .% []. Nevertheless, this
is a potential risk and there have been some suggestions that
this risk is increased with the use of large gauge needles, more
Case Reports in Urology
F : High power view of the lesion demonstrating papillary
renalcellcarcinoma.
F : Fat overlying the tumour demonstrating papillary renal
cell carcinoma seeding along the previous percutaneous biopsy tract.
passes with the needle, and high tumour grade []. Also, the
use of coaxial biopsy technique, in which the biopsy specimen
is obtained with the use of an introducer sheath, has been
recommended in order to reduce the risk of tract seeding [].
In our case, this method was used and thus highlights the
fact that this does not completely eliminate the possibility of
tract seeding. Other technical recommendations to prevent
tumour seeding are to avoid multiple punctures of the tumour
capsule, to withdraw the needle under suction, and to wipe
the cores between passes []. In our case, both FNA and core
biopsies were done as the FNA sample was insucient and
 passes were made with the core biopsy needle which could
have contributed to the increased risk of seeding. Most of the
case reports do not specically mention the number of passes
made. In the case by Mullins and Rodriguez, there were 
passes made for FNA sampling and  passes made to obtain
the core samples. Also, there was no use of an introducer
sheath []. However, Sainani et al. reported the use of an
introducer sheath for the  FNA and  core samples they
obtained and yet found tumour seeding along the tract [].
is suggests that there might be other contributive factors
for tumour seeding along a percutaneous biopsy tract.
Seeding of tumour is when malignant cells are seen
growing along the path of a tract created by a needle usually
following diagnostic needling or a closed ablation procedure
F : High power view of the papillary renal cell carcinoma
seeding along the previous percutaneous biopsy tract.
and are highly site specic [,].isneedstobedistin-
guished from local recurrence, which is the development of
tumour at or in close proximity to the primary tumour usually
as a consequence of suboptimal treatment or microscopic
deposition of tumour cells in the surrounding tissue [,].
Diculties arise in histologically dierentiating the two when
a local recurrence incites a desmoplastic response to mimic a
healed needle track or when trying to identify a core tract on
sections that may not have been cut longitudinal to the axis
of the core. is leaves the delineation reliant on correlating
the site of the biopsy with the radiological images and
checking for tumour multifocality elsewhere in the tumour
bed. In one of the aforementioned cases, Giorgadze et al.
recognised the possibility that the retroperitoneal mass that
they found  years aer the biopsy could have been due
to recurrence rather than true seeding, given the presence
of lymphadenopathy []. In our case though, the presence
of tumour in fat is undoubtedly secondary to needle tract
seeding as it linearly follows the path of the needle (long and
narrow tract with radial extension from the long axis). In
addition to the cases in Tabl e , another case of cutaneous
seeding has also been reported aer biopsy of a pulmonary
metastatic deposit of RCC [], suggesting that the grade of
the tumour may also play a role in tract seeding. However,
several of the cases that have reported seeding in RCC,
including ours, have been low-grade papillary type which
is contrary to the suggestion that high grade tumours are
more likely to seed. A possible explanation of this is that
lower grade tumour cells can survive longer in the blood or
clot tract induced by the needle, due to its lower metabolic
requirements. Further studies are needed to investigate this.
In general terms, tract seeding will relate to the amount of
disruption of the tumour capsule (needle calibre and number
of punctures), pressure of egress at the puncture site (e.g.,
cystic masses or escaping haematoma), whether tumour cells
are dropped from the needle on its withdrawal (failure to
maintain negative pressure and burred needle tip), and the
ability of tumour cells to survive when deposited into a scar
[,,].Inthecaseofrenalcellcarcinoma,thereisapotential
for underrecognition of tract seeding unless the perinephric
fat is carefully histologically examined and the puncture site
is marked by the surgeon. Most pathologists, including those
Case Reports in Urology
at our institution, do a very thorough examination of the
tumourbutwithalimitedsamplingoftheoverlyingfatas
that is standard practice. Seeding of tumour along a needle
tractthoughwouldbeverydiculttondandwasvery
likelyachancediscoveryinourcase.israisesthequestion
of whether tumour tract seeding is underreported. is is
important in clinical practice because it has the potential to
upstage a tumour from a T to a T or T due to extension
into perinephric fat or into the abdominal wall and thus
potentially aect long-term survival.
Despite mixed reports about its diagnostic accuracy, the
practice of using percutaneous renal biopsies has increased
recently due to technological advances in imaging and
equipment used [].ishasledtoimprovementsinsafety
and decreased rates of complications further supporting its
use []. In this case, imaging results were consistent with a
papillary RCC and given the patient’s life expectancy of >
years, our recommendation was for him to have a partial
nephrectomy. However, the biopsy was done to overcome
patientreluctanceandfurtherstrengthenourcaseforsurgical
management, which is highly invasive and not without risks.
e aim of this paper is not to deter surgeons from the use of
renal biopsy but to simply add another element to consider
prior to its use and to make a case for improved patient
selection.
isisoneofonlyafewcontemporarycasereports
of RCC seeding along a percutaneous biopsy tract. Whilst
this complication is so rare that it does not warrant a need
to cease the use of percutaneous biopsy of renal masses,
it certainly highlights the possibility of tract seeding as a
potential hazard. As such, certain considerations, such as
appropriate patient selection, the use of correct equipment,
andsuitablebiopsytechnique,shouldbemadetominimise
the risk of this complication.
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.
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The demand for percutaneous needle biopsy is greater than ever before and with the majority of procedures requiring imaging guidance, radiologists have an increasingly important role in the diagnostic work-up of patients with suspected malignancy. All invasive procedures incur potential risks; therefore, clinicians should be aware of the most frequently encountered complications and have a realistic idea of their likelihood. Tumour seeding, whereby malignant cells are deposited along the tract of a biopsy needle, can have disastrous consequences particularly in patients who are organ transplant candidates or in those who would otherwise expect good long-term survival. Fortunately, tumour seeding is a rare occurrence, yet the issue invariably receives a high profile and is often regarded as a major contraindication to certain biopsy procedures. Although its existence is in no doubt, realistic insight into its likelihood across the spectrum of biopsy procedures and multiple anatomical sites is required to permit accurate patient counselling and risk stratification. This review provides a comprehensive overview of tumour seeding and examines the likelihood of this much feared complication across the range of commonly performed diagnostic biopsy procedures. Conclusions have been derived from an extensive analysis of the published literature, and a number of key recommendations should assist practitioners in their everyday practice.
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A 39-year-old man, who had undergone left nephrectomy for renal cell carcinoma of clear cell type, was noted to have a solitary nodular shadow in the right lung on chest X-ray. Percutaneous needle biopsy of the lung was performed via the right anterior chest wall and the histologic findings showed metastasis from renal carcinoma. Six month later, the patient presented with a cutaneous nodule at the site of puncture of the lung needle biopsy. Histological examination of a biopsy of the skin tumor revealed features of metastatic renal cell carcinoma of clear cell type. Surgical excision of the cutaneous nodule was performed, followed by radiotherapy at the site of the skin lesion on the chest wall. After treatment, the patient remains disease free after one year of follow-up. This case represents an unusual clinical presentation of metastatic renal cell carcinoma that appears to have been translocated to the skin by the needle biopsy.
Article
A case of tumor implantation along the needle tract 20 months after needle aspiration of a renal cell carcinoma is reported. This rare but possible complication of needle aspiration should not discourage its use in the evaluation of renal mass lesions. Needle aspiration should be reserved for those patients in whom the clinical findings, roentgenograms and sonography indicate a benign process (that is to confirm that the mass is benign).
Article
Fine needle aspiration biopsy yields a high rate of positive tissue with negligible local sequelae. We report the first instance known to us of Chiba needle tract seeding following this biopsy technique in a patient with renal malignancy.
Article
We report a case of tumor dissemination via needle aspiration of a solid hypovascular renal mass. This case emphasizes how needle aspiration of these masses does not always lead to proper management and may be detrimental to the patient.