IMAGE-GUIDED ABLATION OF RENAL TUMORS Servet Tatli MD Associate Professor of Radiology Harvard Medical School Department of Radiology Brigham and Women’s Hospital Uriner Sistemde GR: Renal tumorlerde lokal ablasyon 3/28/15 at 12:00-12:15, 15 min Salon A

Objectives Review current image-guided ablation techniques used in treatment of renal tumors Discuss technical issues that may arise during image-guided ablation of renal tumors with illustrated examples Nothing to disclose 2

Kidney Ablation, rationale Detection of increasing number of small incidental RCC’s necessitated development of less invasive treatment options to replace nephrectomy (partial or total) Percutenous, image-guided ablation methods are promising alternative techniques and particularly suit patients with solitary kidney nephron sparing ablation advanced age co-morbidities preventing surgery multiple RCC’s & heritable renal cancer syndromes

Kidney Ablation, tumor selection Not suitable patients uncorrected coagulopathy acute illness (sepsis) locally invasive tumors tumors with metastases Renal tumors more suitable for ablation small (3cm) peripheral / exophytic posteriorly situated inferior pole Challenging tumors large (> 5cm) central anterior location Role of preablation biopsy should be considered benign masses mimic malignancy on imaging 1/3 benign (2.2cm) [Tuncali K, AJR 2004]

Kidney Ablation, technical issues Positioning RPO or LPO on most cases 63 yow with a 5cm right renal cell carcinoma 5

Kidney Ablation, technical issues Large tumors 63 yow with a 5cm right renal cell carcinoma

Kidney Ablation, technical issues Large tumors 63 yow with a 5cm right renal cell carcinoma

Kidney Ablation, technical issues Large tumors 63 yow with a 5cm right renal cell carcinoma

Kidney Ablation, technical issues Multiple tumors; combine with nephrectomy 51-yom with a history of lymphoma and bilateral renal masses. The patient underwent right partial nephrectomy and pathology revealed rcc. Patient referred to us for nephron sparing percutaneus ablation.

Kidney Ablation, technical issues Multiple tumors; simultaneous ablation in both kidneys 51-yom with a history of lymphoma and bilateral renal masses. The patient underwent right partial nephrectomy and pathology revealed rcc. Patient referred to us for nephron sparing percutaneus ablation.

Kidney Ablation, technical issues Central tumors

Kidney Ablation, technical issues Central tumors 85-year-old  female  with  right-sided  RCC

Kidney Ablation, technical issues Cystic tumors or a tumor adjacent to a cyst 67-year-old  with  history  of  bilateral  renal  cell cancers.  Development  of  a  new  and  growing  1.3  cm  right  interpolar renal  tumor.  13

Kidney Ablation, technical issues Cystic tumors or a tumor adjacent to a cyst 75-year-old  woman  with  history  of  left  renal  cell carcinoma. 14

Kidney Ablation, technical issues Superior pole tumors 65 yof with an incidentally found right kidney mass proven to be RCC.

Kidney Ablation, technical issues Anterior tumors; positioning

Kidney Ablation, technical issues Anterior tumors; transhepatic approach 17

Kidney Ablation, technical issues Anterior tumors; manual displacement 60-yom with renal cell carcinoma referred for percutaneous cryoablation.

Kidney Ablation, technical issues Tumors close to bowel; hydrodissection

Kidney Ablation, technical issues Tumors close to bowel; instillation of room air or CO2 Venkatesan AM, Radiology 2011

Kidney Ablation, technical issues Lower pole medial tumors ureteral stent

Kidney Ablation, technical issues Nephron sparing ablation S/P nephrectomy 67-year-old  female  with  history of  metastatic  adenoid  cystic  carcinoma  of  the  parotid  gland, metastatic  to  the  kidneys,  previously  having  undergone  right nephrectomy,  but  left  kidney  also  found  to  have  multiple metastases.  Patient  has  undergone  prior  cryoablation  of  a  lower pole  left  renal  metastasis,  and  presents  for  cryoablation  of  a right  upper  pole  renal  metastasis.

Kidney Ablation, technical issues Nephron sparing ablation syndromes (VHL, familial RCC syndromes, Birth-Hogg-Dube) 45-year-old  female  with  Birt-Hogg-Dube  syndrome,  day one  post  cryoablation  of  left  upper  pole  cystic  renal  neoplasm, biopsy-proven  renal  cell  carcinoma. 23

Kidney Ablation, technical issues Recurrence / needle tract seeding 45-year-old  female  with  Birt-Hogg-Dube  syndrome,  day one  post  cryoablation  of  left  upper  pole  cystic  renal  neoplasm, biopsy-proven  renal  cell  carcinoma. Sainini N, Tatli S, JVIR 2013 24

Kidney Ablation, technical issues Tumors in transplant kidney 45 yom with a renal cell carcinoma in transplanted kidney

Kidney Ablation, technical issues Retroperitoneal renal cell carcinoma metastasis Retroperitoneal renal cell carcinoma metastasis near bowel 26

Kidney Ablation, effectiveness RFA, 90 /100 (90%) tumors underwent complete necrosis [Gervais DA, AJR 2005] Cryoablation [Tuncali, RSNA 2006] 62/63 (97%) secondary effectiveness, 95% in one session Meta-analysis for percutaneous vs. surgical approach [Hui, GC, JVIR, 2008] primary effectiveness percutaneous, 87% surgical, 94% secondary effectiveness percutaneous, 92% surgical, 95%

Kidney Ablation, effectiveness Venkatesan AM, Radiology 2011

Kidney Ablation, complications Few (3.6%) major (bleeding, abscess) lower than surgery percutaneous treatment group (3%) surgical treatment group (7%) [Hui, GC, JVIR 2008] Complications post-ablation syndrome (low-grade fever, pain, myalgia) hematuria (self-limited; rarely, bladder obstruction) perinephric hematoma thermal injury to adjacent structures ureter, genitofemoral nerve, psoas muscle, intestines, adrenal gland

Post-ablation Care Labs CBC metabolic panel Hct (40-54%), platelet (150-450 /µL ), WBC (4-10 /µL) metabolic panel electrolytes, creatinin (0.5-1.2 mg/dL), BUN, EGFR (>60) serum myoglobin (<100 ng/ml) mark elevation (>1000 μg/L) urine alkalinization with sodium bicarbonate 3 amps of 50 mEq in 1 L of D5W at 150 mL/hr) prophylactic alkalinization treatment of tumors adjacent muscular structures in patients with poor kidney function Nair RT, Radiology 2008 Frequently associated with CAD, RAD, carotid arterial disease 30

Post-ablation Care Next day morning imaging Imaging surveillance MRI, CECT baseline for follow up imaging residual tumor? complications? Imaging surveillance (every 3 months for the first year, 6 months for the second year, and yearly afterwards) recurrence? new tumors? extrarenal disease? Frequently associated with CAD, RAD, carotid arterial disease 31

Kidney Ablation, surveillance Expected post ablation imaging findings enhancement of the tumor 12 months 24 hrs 3 months 67 yom left renal cell carcinoma

Kidney Ablation, postablation surveillance Granulation tissue mimicking needle tract seeding Lokken et al, AJR 2007

Conclusion Percutaneous image-guided ablation of kidney neoplasm is safe and effective It is minimally invasive treatment option alternative to surgery Appropriate patient, ablation method, and guidance modality selection, and post-ablation surveillance are important factors for satisfactory results with fewer complication

Thank you