Treatment of renal adenocarcinoma by embolic occlusion of the renal circulation

Transcatheter obliteration of the renal artery by ethanol injection: experimental results

The sclerosing effect of the introduction of 95% ethanol into the renal artery was evaluated in eight rabbits and one pig. Longterm occlusion of the renal artery with ensuing infarction of the kidney could be produced by a small, easily tolerated dose. Several inherent drawbacks of currently used embolic sgents may be avoided with this technique, which is suggested for clinical trial.

Complications of the Gianturco coil in preoperative infarction of renal cell carcinoma

Percutaneous artery occlusion has been described for a multitude of clinical problems, including preoperative infarction of the kidney for renal cell carcinoma. The Gianturco wool coil provides a relatively new method for occlusion. Few complications with this device have been reported. We describe our experience with complications in 3 patients and discuss methods of their prevention.

Renal arterial embolization in cases of renal neoplasms. Own experiences

Observations of 17 embolizations of the renal artery carried out in cases of renal neoplasms are reported. In the light of intraoperative observations the optimal timing of the operation after embolization was established to be 48-72 hours. Attention is called to the possibility of complications in the form of spinal cord damage after renal arterial embolization.

Embolization for genitourinary disorders

Fourteen patients with various genitourinary disorders underwent arterial embolization. The procedure was useful in facilitating surgical removal of hypernephromas, in decreasing tumor-induced hypercalcemia, and in diminishing proteinuria secondary to renal failure. Patients with priapism due to excessive arterial inflow responded well. Results of embolization performed because of bleeding varied. When bleeding was localized to a single vessel or to an area supplied by such a vessel, embolization was successful. However, when hemorrhage was diffuse or due to multiple vessel inflow, arterial embolization was not entirely effective.

Splenic embolization

While transcatheter embolization of the spleen has shown promise in the treatment of a wide spectrum of disorders, the incidence of serious complications with this technique has limited its use as an alternative to operative splenectomy. In our institution 41 patients were treated with a modified technique involving partial splenic embolization, careful antibiotic prophylaxis, and adequate pain control. There was no mortality and only few instances of clinically significant complications: a splenic abscess in one patient, pancreatitis in one patient, severe pleural effusions in two patients, and pneumonia in five patients.

Therapeutic embolization with detachable balloons

In our first 18 months' clinical experience with embolization in the chest and abdomen using detachable balloons, successful results were obtained in 34 of 38 patients. One and 2-mm detachable silicone balloons, which can occlude vessels 4--8 mm in diameter, were employed. Prolonged balloon inflation was routinely achieved using iso-osmotic iodipamide meglumine as the filler and limiting inflation volumes to experimentally determined maximums. Improvements in introducer catheter design simplified delivery of the balloon into a variety of circulations. Detachable balloons are not suitable for all embolization purposes, and they are frequently used in conjunction with other agents. When used properly, balloons produce a permanent occlusion that is extremely selective and potentially reversible up to a certain point in the procedure. The balloon technique enables the angiographer to occlude vessels at distances of 2--10 mm beyond the introducer catheter, thus avoiding the need for subselective catheterization and minimizing the dangers of inadvertent embolization.

Hypernephroma embolisation--is it worthwhile?

Transcatheter embolisation was performed in 16 patients with hypernephroma, using either Oxycel, Gelfoam, or steel wire coil(s). Thirteen patients proceeded to early nephrectomy. Surgery was facilitated in four patients with large hypervascular tumours, three of whom had vena caval occlusion. Patients with small, or only moderately vascular tumours, did not benefit from the technique as assessed at nephrectomy. The technique was used as a palliative procedure in three patients, haematuria stopped in two, and abolition of high-output heart failure was achieved in one. Owing to the danger of this technique, it is suggested that its use be restricted to (a) rendering patients with large hypervascular tumours more suitable for surgery, and (b) in palliation of inoperable patients who have symptoms such as severe haematuria. The effect of the technique on survival time remains uncertain.

Percutaneous arterial embolization in the kidneys of dogs: a comparative study of eight different materials

Forty-one dogs were subjected to percutaneous arterial embolization of branches of the renal artery or its main trunk with or without prior injury to the kidney, with eight different materials, i.e., homologous blood clot, muscle, fat, fascia, barium sulphate, plain catgut, gelfoam and polyvinyl alcohol (Ivalon). From the immediate observations made, as well as the haemodynamic, angiographic and histological studies over a period ranging from 24 h to several weeks, it was concluded that Ivalon was the best material for arterial embolization.

Transcatheter embolization of the renal artery with bucrylate in renal carcinoma

In 5 patients with large renal carcinomas Bucrylate was injected into the renal artery. One to 3.5 ml Bucrylate were required to obtain occlusion of the arteries. At operation 14 to 38 days later the arteries were still occluded. One patient developed pulmonary embolism, other complications were of less importance. The main indication for the procedure is very large, highly vascularized carcinomas in the upper part of the kidney. Bucrylate seems to be a suitable embolus inducing agent.

Renal artery aneurysm: a complication of Gianturco coil embolization of renal adenocarcinoma

A complication of Gianturco coil infarction of a massive renal carcinoma with caval obstruction is presented. The immediate response was excellent but at 4 months the patient became hypertensive and potassium-depleted. A large aneurysm of the renal artery had developed at the site of the coils, necessitating nephrectomy.

Spontaneous regression of renal cell carcinoma metastases after preoperative embolization of primary tumor and subsequent nephrectomy

Preoperative arterial embolization and infarction of a large renal cell carcinoma followed by radical nephrectomy seven days later led to spontaneous regression of pulmonary metastases. However, a cerebral metastatic deposit manifested itself fourteen months after surgery, requiring craniotomy. Presently, the patient is alive and well with no evidence of disease twenty-one months after his original surgery. The immunologic implications of this favorable response to treatment are discussed, and immunologic testing of similar cases is encouraged.

Preoperative renal embolization as adjunct to radical nephrectomy

Radical nephrectomy preceded by preoperative renal artery embolization using Gianturco-Anderson-Wallace steel coils has objective value as determined by comparing records of 15 patients who had adjunctive embolization with 15 patients who did not. Embolization of the major renal artery facilitated surgery allowing initial renal vein ligation resulting in reduction of blood loss and operative time. The described experience and current literature review support adjunctive embolization and document minimal risk to the patient.

Transcatheter arterial embolization in urological tumors: the use of isobutyl-2-cyanoacrylate

Transcatheter arterial embolization is a useful technique to manage urological tumors. Herein we describe a new embolic material (isobutyl-2-cyanoacrylate) in 5 cases of renal cancer embolization and in 1 case of bilateral hypogastric embolization for bladder cancer hemorrhage. Isobutyl-2-cyanoacrylate provides a complete, distal and irreversible embolization, making it suitable material in cancer embolization.

Transcatheter arterial embolization of experimental hepatic tumours in the rat

After transcatheter arterial embolization with Spongostan (99.3% gelatin-similar to gelfoam) in a group of rats with experimental hepatic tumours, the angiographic and microscopic findings were compared with those in a group of rats with non-embolized liver tumours. Partial recanalization of the hepatic artery was demonstrated already after 2 to 6 days. Reduced vascularization of tumours could be demonstrated after embolization and in a few animals even decrease in tumour size. Microscopy revealed a significantly greater extent of tumour necrosis in embolized tumours of large size. Necrosis of normal liver tissue was found to a varying degree in the embolized rats, while no ischemic injury was evident in livers of most non-embolized animals.

Palliative embolization of arterial renal tumour supply. Results in 10 cases

Palliative occlusion of the arterial renal tumour supply was performed in 10 patients and the follow up is reported. Nine of the patients had no subsequent nephrectomy. Spongostan (99% gelatin) was used as the embolic material in 4 patients with the addition of steel coils in 2. Bucrylate was used in 6 cases. Six patients are alive with survival rates presently ranging from 3 to 24 months after embolization. Improvement of the survival time cannot be estimated but local symptoms such as hematuria and pain may be treated in those patients with renal tumours who are not considered for surgery.

Pre-operative arterial embolisation in renal carcinoma

Nephrectomy for carcinoma is often accompanied by moderate or severe bleeding but this may be reduced by prior occlusion of the renal artery. Embolisation with fresh autologous clot is rendered ineffective by rapid lysis. In vitro experiments showed that the clot could be stabilised by the addition of epsilon amino caproic acid (EACA). By injecting stabilised clot into the renal arterysatisfactory devascularisation of kidney and tumour was achieved in 10 patients.

Gel foam embolization of a functioning pheochromocytoma

For the first time, to our knowledge, a patient with a functioning pheochromocytoma was subjected to gel foam embolization for physiologic destruction of the tumor. The operation, 24 hours later, provided an uneventful anatomic removal of the infarcted tumor. Observation was considered as a possible alternative to surgical excision. Experience gained may allow testing of the validity of a nonoperative approach in selected cases.

Pre-operative balloon occlusion of the renal artery for radical nephrectomy

Six of 8 patients with renal tumours were successfully catheterised pre-operatively and the renal artery occluded by a Swan Ganz balloon tipped arterial catheter. At subsequent radical nephrectomy early ligation of the renal vein was readily accomplished and there was noticeable decrease in vascularity and engorgement of the kidney and its tumour.

Extensive renal involvement by renal cell carcinoma

Experience with the management of 3 cases of bilateral adenocarcinoma and 1 case of unilateral carcinoma in the solitary kidney is presented. Two patients died of metastases six and thirteen months postoperatively, while one is alive with metastases at fourteen months and another is alive without metastases at four months. The literature is reviewed, and the various treatments are discussed.

Cyanoacrylates in transcatheter renal embolization

Isobutyl-2-cyanoacrylate and N-butyl-2-cyanoacrylate were used in experimental trans-catheter embolization of rat kidneys and in two patients as preoperative embolization of renal carcinoma. The agents produced an efficient and lasting embolization, with no evident complication; however, their usage is difficult and an appropriate dosage is also difficult.

T and B lymphocyte levels in renal cancer patients: influence of preoperative transcatheter embolization and radical nephrectomy

The mean percentage of T and B lymphocytes in peripheral blood was tested in 6 patients with renal cancer before and after preoperative transcatheter embolization and radical nephrectomy. While no significant difference was found in B lymphocyte levels compared to those in healthy control subjects a clear impairment in circulating T lymphocyte levels was observed in renal cancer patients who had not been treated. This reduction in T lymphocyte levels persisted after embolization but there was a significant increase after radical nephrectomy.

Transcatheter arterial embolization of normal livers and experimental hepatic tumours in the rat

Transcatheter hepatic arterial embolization with Spongostan (99.3% gelatin) was performed in a group of normal rats. By repeat angiography could be demonstrated that arterial occlusions lasted for at least 1 to 8 days in most rats. Microscopy of these normal livers gave no evidence of parenchymatous liver injury. At postembolization angiography in a group of rats with experimental liver tumours it could be demonstrated that arterial supply of these tumours was temporarily completely arrested. Microscopy of some of these neoplasms revealed extensive necroses. The eventual future clinical applications of this procedure as an alternative to hepatic artery ligation is discussed.

Angiographic infarction of a large hypernephroma with a tissue adhesive for control of hematuria

A case of a large inoperable hypernephroma in a 69-year-old man is presented. Recurrent life-threatening hematuria was controlled successfully by transcatheter embolization and infarction of the tumor using a tissue adhesive called isobutyl 2-cyanoacrylate. The patient remained without hematuria for 18 months until death from extensive metastatic diseases. The advantages and disadvantages of tissue adhesive as an embolization material are discussed.

Therapeutic renal infarction

Pre-nephrectomy therapeutic renal infarction by injecting gelfoam into the renal artery was done in 10 patients with hypernephroma. This technique facilitates nephrectomy and decreases blood loss. A post-infarction syndrome characterized by flank pain, fever and nausea occurred in most patients. In addition, a dialysis patient underwent bilateral renal infarction with improvement of blood pressure control. Distal embolization of gelfoam occurred in this patient, resulting in significant gangrene of 1 foot.

Therapeutic embolization of symptomatic secondary renal tumors

A patient with colic and hematuria from renal involvement with osteogenic sarcoma who was palliated by percutaneous arterial embolization is described. While there has been much experience with embolization of primary renal tumors, this represents the first reported case of therapeutic embolization of a secondary renal tumor. Embolization is recommended as an adjunct to chemotherapy in the poor-risk patient with a symptomatic secondary renal tumor.

Arterial embolization for radical tumor resection

Two contemporary measures, selective transarterial embolization (Almgard et al. 1973) and controlled hypotensive anesthesia (Davis et al. 1974), have been combined in an effort to reduce the risk of operative bleeding in a case of massive bone and muscle resection of a highly vascular carcinoma lesion in the proximal third of the femur. This approach may be helpful in such cases.

Treatment of uncontrolled hypertension by therapeutic renal infarction

Certain hemodialysis patients need to be made anephric, either surgically or physiologically. Bilateral renal infarction with shredded absorbable gelatin sponge (Gelfoam) was performed on a woman with malignant hypertension being maintained on chronic center dialysis who was too great a surgical risk for bilateral nephrectomy. Peripheral embolization complicated the procedure resulting in a forefoot amputation for dry gangrene two months later. Her postinfarction peripheral plasma renins remained elevated, and she remained hypertensive but was more easily managed with fewer drugs. This technique has been successfully used by others in 1 patient with chronic renal failure and heavy proteinuria and another with hypertension and a solitary kidney. If, as in our case, postinfarction plasma renins remain elevated and hypertension persists, bilateral nephrectomy could be performed at a later date or infarction could be repeated.

Percutaneous transfemoral embolization of arterio-infundibular-venous fistula

An arterio-infundibular-venous fistula complicating partial nephrectomy was embolized successfully via transfemoral catheterization of the right renal artery using autologous muscle. The use of autologous material occluded this vascular malformation with preservation of renal function in the remaining portion of the kidney. The technique was lifesaving since this patient was in critical condition and could not tolerate an operation.

Intravascular occlusive therapy: use of interventional radiology in cancer patients

Selective transcatheter intravascular occlusion in the treatment of cancer patients is a valuable extension of interventional diagnostic radiology. Intra-arterial embolization may be performed with various substances, including autologous clot, autologous subcutaneous tissue, Gelfoam, and stainless steel coil. Clinical applications in cancer patients include control of gastrointestinal and genitourinary hemorrhage, preoperative reduction of tumor vascularity, control of local symptoms, and therapeutic reduction of tumor bulk. The technique has been used for preoperative and palliative treatment of neoplasms of the head and neck, kidney, liver, spleen, and soft tissue and bone. Transcatheter intravascular occlusion should be performed only by radiologists experienced in angiographic techniques. Inadvertent occlusion of a normal vessel and thromboembolism are possible complications.

The current status of angiography in the evaluation of cancer patients

Angiography has maintained a central role in the preoperative evaluation of patients with both benign and malignant tumors. A great deal of experience has accumulated with the method and the angiographic appearance of most tumors is well established. Although most cancer patients are first evaluated by less invasive techniques,angiography remains the most accurate method for the diagnosis of tumors of the liver and pancreas. In those patients in whom excision of a malignancy is considered, angiograms should be used preoperatively to assess both the resectability and curability of the lesion. In patients with carcinoma of the lung or esophagus invading the azygos vein or in patients with pancreatic carcinoma invading the visceral veins, needless radical operative procedures can be avoided. Finally, as angiographers are becoming more therapy-oriented, the palliative effects of selective arterial embolization with radioactive and infarcting materials are being evaluated.

Interventional radiology

Direct unencumbered visualization of areas of interest by image intensification combined with more invasive techniques of percutaneous puncture and angiography have extended the scope of the radiologist in the diagnosis and management of patients with neoplastic diseases. Percutaneous biopsies can be obtained more safely and with greater reliability from lesions of the lungs, skeleton, kidneys, liver, pancreas, and retroperitoneal lymph nodes. Intravascular therapy by arterial occlusion of the neoplasm has been employed to control hemorrhage, to decrease tumor mass, and preoperatively to facilitate surgical removal. The possibility of initiating an immune response to the ischemic neoplasm is also discussed.

Therapeutic ureteral obstruction and renal artery embolization

Two relatively unique techniques have been used in 4 cases to treat gross hematuria that might otherwise have resulted in nephrectomies. The techniques include ureteral obstruction with a Fogarty catheter and renal artery embolization.

Percutaneous catheter-aided infarction of renal tumors: a preliminary report

Three patients with moderate-sized cell carcinomas underwent percutaneous catheter-aided gelfoam embolization several days prior to an operation. Reduction of the vascular bed of the tumors shortened operative time and simplified the procedure. In the future these patients, along with others, will be followed to determine if reduction of tumor size by necrosis will alter the immune mechanism of the metastases. Even our small series and short followup illustrate that embolization is a simple and logical extension of diagnostic catheterization.