1. 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

2. 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

3. 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

4. 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]

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

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

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

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

9. 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.

10. 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.

11. Kidney Ablation, technical issues
Central tumors

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

13. 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

14. 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

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

16. Kidney Ablation, technical issues
Anterior tumors; positioning

17. Kidney Ablation, technical issues
Anterior tumors; transhepatic approach 17

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

19. Kidney Ablation, technical issues
Tumors close to bowel; hydrodissection

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

21. Kidney Ablation, technical issues
Lower pole medial tumors
ureteral stent

22. 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.

23. 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

24. 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

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

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

27. 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%

28. Kidney Ablation, effectiveness
Venkatesan AM, Radiology 2011

29. 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

30. Post-ablation Care Labs CBC metabolic panel
Hct (40-54%), platelet ( /µL ), WBC (4-10 /µL)
metabolic panel
electrolytes, creatinin ( 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

31. 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

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

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

34. 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

35. Thank you