Renal Ablation

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Pre-Procedure

Indications:
Renal cell carcinoma
• American Urological Association supports thermal ablation for T1a tumors which is <4 cm
• < 4 cm can be curable with one treatment
• T1b tumors: >4 cm but <7 cm - usually requires more probes and/or staging of the procedure
• Stage IV disease of metastasis who are not surgical candidates

Renal cell carcinoma:
• Slow growing tumor: on average, grows ~3 mm/year
• Rare to have metastasis when primary <4 cm

Contraindications:
• Life expectancy <12 months
• Uncorrectable coagulopathy
• No safe percutaneous window
• Invasion of renal vein or regional lymph node involvement- advanced stage.
• Active infection

Things to check:
• History and physical
• Labs- creatinine, INR, platelets
• Prior imaging- CT and/or MRI
• Consent for procedure and anesthesia

Procedure

Thermal ablation techniques:
• Cryoablation
• RFA
• Microwave
Data suggests RFA and cryoablation are similar in efficacy
Data on microwave is less robust

Cryoablation using combination CT and US guidance described below:
Positioning: prone or decubitus
Perform preliminary CT to confirm lesion position, size and adjacent structures.
Test probes in bowl or test tube of normal saline

US guidance for initial probe positioning
• For many patient's US guidance can be faster and more efficient for placement
• Helps evaluate the tumor in 3-D plane
• If using multiple probes, try and keep probes parallel

Once probes in final position using US guidance, confirm positioning with CT
• Evaluate probe position within the tumor
• Evaluate probe position with regards to adjacent structures: renal pelvis, ureter, lung, diaphragm, bowel, adrenal
• Evaluate ablation zone: 5-10 mm (consider full 10 mm margins if feasible)
• Probes no more than 2 cm apart
Opportunity to use protective maneuvers if needed such as hydrodissection

Ablate
• Cycles may vary with manufacturer
• 10 minute freeze with 8 minute active thaw - 2 cycles
• See cell death at -20° C
• Can visualize "ice ball" during freeze cycle
• Can turn on and off probes during freeze cycles to sculpt ablation zone
Remove probes when temperature reaches 10° C

Ice ball
• Seen at 0°C
• Approximates ablation zone; does not perfectly delineate lethal ablation zone
• Lethal isoderm is 2-3 mm within the ice ball


Post-Procedure

Complications:
• Flu-like symptoms (post-ablation syndrome) - fever, fatigue, myalgia. Manage conservatively with antipyretics. Common
• Hemorrhage
• Bowel injury
• Abscess formation/Infection
• Ureteral injury or stricture
• Genitofemoral nerve: anterolateral surface of psoas
• Lower intercostal nerve

Postprocedural care:
• Monitor patient for at least 2 hours
• Monitor for pain, bleeding, and adjacent structure injury such as pneumothorax
• Discharge home same day if hemodynamically stable, voiding and tolerating po intake
• Discharge medications: anti-inflammatories, antiemetics, and opioids for breakthrough pain
• Most patients will feel back to baseline within 8-10 days

Follow-up:
• Clinic visits with imaging before clinic
• Surveillance can vary
• Consider CT/MR at 3 and 6 months
• If disease free at 6 months, CT/MR at 12, 18 and 24 months
• If disease free at 24 months, CT/MR at 3, 4 and 5 years

Outcomes:
• T1a lesions treated with ablation similar to partial and radical nephrectomy
• > 95% cancer-specific 5 year survival with thermal ablation
• ~90% overall survival at 5 years with thermal ablation

Related Procedures

No related procedures.

 

References

[1] Xing M, Kokabi N, Zhang D, Ludwig JM, Kim HS. Comparative Effectiveness of Thermal Ablation, Surgical Resection, and Active Surveillance for T1a Renal Cell Carcinoma: A Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked Population Study. Radiology. 2018;288(1):81‐90. doi:10.1148/radiol.2018171407
[2] National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Kidney Cancer. Version 3.2018.
[3] Pierorazio PM, Johnson MH, Patel HD, et al. Management of Renal Masses and Localized Renal Cancer: Systematic Review and Meta-Analysis. J Urol. 2016;196(4):989‐999. doi:10.1016/j.juro.2016.04.081
[4] Gunn AJ, Gervais DA. Percutaneous ablation of the small renal mass-techniques and outcomes. Semin Intervent Radiol. 2014;31(1):33‐41. doi:10.1055/s-0033-1363841
[5] Uppot RN, Silverman SG, Zagoria RJ, Tuncali K, Childs DD, Gervais DA. Imaging-guided percutaneous ablation of renal cell carcinoma: a primer of how we do it. AJR Am J Roentgenol. 2009;192(6):1558‐1570. doi:10.2214/AJR.09.2582
[6] BackTable, LLC (Producer). (2017, November 1). Ep 15 – Renal Ablation Therapies [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

Join The Discussion

 

Demos

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Tools

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Literature

Literature is not yet available for this procedure.

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Journal of Kidney Cancer and VHL (Jun 2015)

Percutaneous Cryoablation for Renal Cell Carcinoma

Review of patient selection, theory, technique, and the advantages of percutaneous cryoablation for the treatment of small renal cancers.

Seminars in Interventional Radiology (Mar 2014)

Percutaneous Ablation of the Small Renal Mass-Techniques and Outcomes

A comparison of percutaneous ablation and partial nephrectomy for the treatment of small renal masses. Patient selection, preprocedural preparations, and specific ablation techniques are discussed in detail.

Seminars in Interventional Radiology (Jun 2014)

Renal Ablation Update

The purpose of this review article is to discuss the current ablative technologies available, briefly review their mechanisms of action, discuss technical aspects of each, and provide current data supporting their use.

American Journal of Roentgenology (Jun 2009)

Imaging Guided Percutaneous Ablation of Renal Cell Carcinoma: a Primer of How We Do It

Imaging-guided percutaneous renal ablation as a viable alternative to surgery and how to run a successful renal tumor ablation program.

 

Podcasts

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Dr. Mike Devane

Dr. Ahmed Kamel

Renal ablation therapies with Mike Devane MD and Ahmed Kamel MD, PhD, FSIR

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Treating Renal Masses Podcast with Dr. Arthur Caire

Dr. Arthure Caire

Dr. Shelby Bennett

Urologist Dr. Arthur Caire and IR Dr. Shelby Bennett discuss their approaches to treating renal masses, laparoscopic versus percutaneous ablation, follow-up imaging, and more.

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