August Case of the Month
Authors: Elvira A. Allakhverdieva, BA, Medical Student, MD Candidate Class of 2017, Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT; Igor Latich, MD, Assistant Professor, Vascular and Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale New Haven Hospital, New Haven, CT; and Keith Quencer, MD, Clinical Instructor, Vascular and Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale New Haven Hospital, New Haven, CT
1. Why did you select this case for submission?
Renal cell carcinoma represents up to 85% of primary renal neoplasms. It occurs predominantly in the sixth and seventh decade of life. Majority of this patient population have a number of medical comorbidities, including heart disease, which necessitates anticoagulation therapy. Use of anticoagulation therapy is one of the relative contraindications for percutaneous renal biopsy. Therefore, these patients become poor candidates for tissue biopsy and staging of the disease. For those with intracaval extension of renal cell carcinoma (RCC), there is an option of intravascular intervention and biopsy of the mass. Even though it is relatively safe and successful approach, there are limited number of reports describing this technique. We chose this topic with the main goal of educating providers about alternative options for their patients diagnosed with RCC and who cannot undergo percutaneous renal biopsy.
2. What should readers learn from this case?
The case describes basics of diagnosis, staging, and biopsy techniques of RCC. In addition, it provides information for relative contraindications for RCC percutaneous biopsy approach and indications for renal artery embolization in the setting of RCC.
3. What did you learn from working on the case?
Working on this case, helped me to learn and understand RCC diagnosis, pathology, and complexity of disease staging. Tissue biopsy is a must and individual approach to a patient is highly desirable. Providing alternative approach to tissue biopsy helps patients to avoid number of devastating complications and get necessary treatment in a timely manner. Despite the fact that intravascular approach is not widely used, it could potentially become a standard biopsy technique in certain patient population.
4. How did guidance from senior staff at your institution impact your learning and case development?
Without mentorship, one can easily succumb to a failure. I had two great mentors, Dr. Keith Quencer and Dr. Igor Latich, who provided me with support and guidance in process of writing this case. They were not only a great source of information, but also a great inspiration on the road of becoming a well-rounded physician. I have chosen to become a radiologist and successfully matched at University of Miami Diagnostic Radiology program. I am planning to continue my research in the field of radiology, grow as a physician and become a mentor to my future colleagues.
5. Why did you choose Case in Point for submission of your case?
Case in Point is a trusted and well respected information source for many medical providers. We wanted our case to have informational value and be a part of the body of literature, which people trust and rely on when making clinical decisions.
6. Are you a regular reader of Case in Point? What are your favorite types of cases?
I am a frequent reader of Case in Point. It is one of the first online recourses that I use to find interesting cases and learn new techniques. I enjoy the question-answer format which aids in better comprehension and memory retention. All cases have their uniqueness, but interventional radiology cases fall under my favorites.
7. What else should we know about the case that you’d like to share?
Biopsy of intraluminal extension of the tumor can be helpful in establishing the diagnosis and staging of RCC with extension to IVC. The details of endovascular approach are the following: right common femoral vein was accessed and a sheath was placed; digital angiography of the inferior vena cava was performed confirming the large intraluminal mass extending from the right renal vein into the IVC; the filling defects were seen on the venogram used as target landmarks for biopsy. Samples were taken with myocardial forceps. The patient tolerated the procedure well, but more importantly, had no clinical signs of the bleeding.