2017 Resarch Forum

RBFM: C-2

Applicant: Christopher Spates MS III Principal Investigator: Tana Parker MD

Time is kidney: Clear cell renal cell carcinoma (CCRCC) incidental finding that evaded detection for over 22 months Christopher Spates MS III, Tana Parker MD

INTRODUCTION: Incidental findings of CCRCC are nothing new. With vast improvements in imaging technology and expanded use in emergency and trauma situations, the number of incidental findings likewise continues to increase. Patient prognosis often improves with the smaller the tumor is at time of detection. This case descries the finding of a larger than average renal “incidentaloma” and how it evaded detection by primary care physicians and urologists for over 22 months. P URPOSE: A 39 year old male presented to ED following violent assault. Chief complaints were extremity pain and facial abrasions. Past surgical history significant for frenulectomy 19 months prior to the assault. X-rays were unremarkable, and CT scans were deemed unnecessary at the time. The patient was discharged home with ibuprofen. At one week follow-up with PCP, the patient produced grossly bloody urine with visible clots. He was given a prescription for Bactrim and again sent home. Hours later the patient’s pain was unbearable and he became unable to void. He returned to the ED and had unremarkable initial labs. Abdominal CT showed 7cm right renal mass. Continuous bladder irrigation was initiated and the patient was admitted. Over the six day hospital course, ureteroscopy was performed with brush cytology collection and ureteral stent placement. Cytology of renal pelvis fluid was suspicious for malignancy. Within one month from initial presentation, a right radical nephrectomy was performed. The gross specimen was positive for clear cell renal cell carcinoma. Patient currently follows-up with a nephrologist and considers himself lucky for having received the violent assault, since it lead to the identification and treatment of his renal tumor. DISCUSSION: We propose additional research into benefits and drawbacks of Point-of-Care ultrasonography of the GU system before urologic procedures when pre-procedural urine dipsticks show blood. AIUM, in collaboration with AUA suggests renal ultrasound for hematuria. Expanded use of Point-of-Care ultrasound in the primary care setting following any abnormal urine dipstick, Urinalysis or markers of kidney function on routine blood tests should also be researched. Although multiple studies have shown the superiority of CT in the identification of small renal masses (<2cm), lower cost- per-procedure and absence of radiation exposure make ultrasound suitable as a routine screening modality. Improved outcomes are seen in patients with lower grade and smaller size cancer. Another important discussion highlighted by this case is the increasing number of incidental findings by CT in Trauma patients. Studies looking at frequency of, and appropriate documentation/action for incidental findings from Trauma patients at Kern Medical should be conducted. CONCLUSION: Our patient’s tumor was 7cm on CT and therefore could have been identified sooner by either US or CT. If either of our research proposals for US were in place, this patient’s tumor would have been identified sooner and at a smaller size. Earlier detection may have allowed for partial, rather than radical nephrectomy, leaving him with a greater kidney function. This case provides an opportunity to revisit clinical work-up of hematuria and proposes three additional research opportunities.