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Chaurasia A, Singh S, Homayounieh F, Gopal N, Jones EC, Linehan WM, Shyn PB, Ball MW, Malayeri AA. Complications after Nephron-sparing Interventions for Renal Tumors: Imaging Findings and Management. Radiographics 2023; 43:e220196. [PMID: 37384546 PMCID: PMC10323228 DOI: 10.1148/rg.220196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/20/2022] [Accepted: 01/10/2023] [Indexed: 07/01/2023]
Abstract
The two primary nephron-sparing interventions for treating renal masses such as renal cell carcinoma are surgical partial nephrectomy (PN) and image-guided percutaneous thermal ablation. Nephron-sparing surgery, such as PN, has been the standard of care for treating many localized renal masses. Although uncommon, complications resulting from PN can range from asymptomatic and mild to symptomatic and life-threatening. These complications include vascular injuries such as hematoma, pseudoaneurysm, arteriovenous fistula, and/or renal ischemia; injury to the collecting system causing urinary leak; infection; and tumor recurrence. The incidence of complications after any nephron-sparing surgery depends on many factors, such as the proximity of the tumor to blood vessels or the collecting system, the skill or experience of the surgeon, and patient-specific factors. More recently, image-guided percutaneous renal ablation has emerged as a safe and effective treatment option for small renal tumors, with comparable oncologic outcomes to those of PN and a low incidence of major complications. Radiologists must be familiar with the imaging findings encountered after these surgical and image-guided procedures, especially those indicative of complications. The authors review cross-sectional imaging characteristics of complications after PN and image-guided thermal ablation of kidney tumors and highlight the respective management strategies, ranging from clinical observation to interventions such as angioembolization or repeat surgery. Work of the U.S. Government published under an exclusive license with the RSNA. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available in the Online Learning Center. See the invited commentary by Chung and Raman in this issue.
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Affiliation(s)
- Aditi Chaurasia
- From the Urologic Oncology Branch, National Cancer Institute,
National Institutes of Health, Bethesda, Md (A.C., N.G., W.M.L., M.W.B.);
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, 10 Center Dr 1C352, Bethesda, MD 20892 (S.S., F.H.,
E.C.J., A.A.M.); and Division of Abdominal Imaging and Intervention, Department
of Radiology, Brigham and Women’s Hospital, Harvard Medical School,
Boston, Mass (P.B.S.)
| | - Shiva Singh
- From the Urologic Oncology Branch, National Cancer Institute,
National Institutes of Health, Bethesda, Md (A.C., N.G., W.M.L., M.W.B.);
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, 10 Center Dr 1C352, Bethesda, MD 20892 (S.S., F.H.,
E.C.J., A.A.M.); and Division of Abdominal Imaging and Intervention, Department
of Radiology, Brigham and Women’s Hospital, Harvard Medical School,
Boston, Mass (P.B.S.)
| | - Fatemeh Homayounieh
- From the Urologic Oncology Branch, National Cancer Institute,
National Institutes of Health, Bethesda, Md (A.C., N.G., W.M.L., M.W.B.);
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, 10 Center Dr 1C352, Bethesda, MD 20892 (S.S., F.H.,
E.C.J., A.A.M.); and Division of Abdominal Imaging and Intervention, Department
of Radiology, Brigham and Women’s Hospital, Harvard Medical School,
Boston, Mass (P.B.S.)
| | - Nikhil Gopal
- From the Urologic Oncology Branch, National Cancer Institute,
National Institutes of Health, Bethesda, Md (A.C., N.G., W.M.L., M.W.B.);
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, 10 Center Dr 1C352, Bethesda, MD 20892 (S.S., F.H.,
E.C.J., A.A.M.); and Division of Abdominal Imaging and Intervention, Department
of Radiology, Brigham and Women’s Hospital, Harvard Medical School,
Boston, Mass (P.B.S.)
| | - Elizabeth C. Jones
- From the Urologic Oncology Branch, National Cancer Institute,
National Institutes of Health, Bethesda, Md (A.C., N.G., W.M.L., M.W.B.);
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, 10 Center Dr 1C352, Bethesda, MD 20892 (S.S., F.H.,
E.C.J., A.A.M.); and Division of Abdominal Imaging and Intervention, Department
of Radiology, Brigham and Women’s Hospital, Harvard Medical School,
Boston, Mass (P.B.S.)
| | - W. Marston Linehan
- From the Urologic Oncology Branch, National Cancer Institute,
National Institutes of Health, Bethesda, Md (A.C., N.G., W.M.L., M.W.B.);
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, 10 Center Dr 1C352, Bethesda, MD 20892 (S.S., F.H.,
E.C.J., A.A.M.); and Division of Abdominal Imaging and Intervention, Department
of Radiology, Brigham and Women’s Hospital, Harvard Medical School,
Boston, Mass (P.B.S.)
| | - Paul B. Shyn
- From the Urologic Oncology Branch, National Cancer Institute,
National Institutes of Health, Bethesda, Md (A.C., N.G., W.M.L., M.W.B.);
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, 10 Center Dr 1C352, Bethesda, MD 20892 (S.S., F.H.,
E.C.J., A.A.M.); and Division of Abdominal Imaging and Intervention, Department
of Radiology, Brigham and Women’s Hospital, Harvard Medical School,
Boston, Mass (P.B.S.)
| | - Mark W. Ball
- From the Urologic Oncology Branch, National Cancer Institute,
National Institutes of Health, Bethesda, Md (A.C., N.G., W.M.L., M.W.B.);
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, 10 Center Dr 1C352, Bethesda, MD 20892 (S.S., F.H.,
E.C.J., A.A.M.); and Division of Abdominal Imaging and Intervention, Department
of Radiology, Brigham and Women’s Hospital, Harvard Medical School,
Boston, Mass (P.B.S.)
| | - Ashkan A. Malayeri
- From the Urologic Oncology Branch, National Cancer Institute,
National Institutes of Health, Bethesda, Md (A.C., N.G., W.M.L., M.W.B.);
Department of Radiology and Imaging Sciences, Clinical Center, National
Institutes of Health, 10 Center Dr 1C352, Bethesda, MD 20892 (S.S., F.H.,
E.C.J., A.A.M.); and Division of Abdominal Imaging and Intervention, Department
of Radiology, Brigham and Women’s Hospital, Harvard Medical School,
Boston, Mass (P.B.S.)
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Koebe SD, Curci NE, Caoili EM, Triche BL, Dreyfuss LD, Allen GO, Brace CL, Davenport MS, Abel EJ, Wells SA. Contrast-enhanced CT immediately following percutaneous microwave ablation of cT1a renal cell carcinoma: Optimizing cancer outcomes. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:2674-2680. [PMID: 35278110 DOI: 10.1007/s00261-022-03481-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate the effect of intra-procedural contrast-enhanced CT (CECT) and same-session repeat ablation (SSRA) on primary efficacy, the complete eradication of tumor after the first ablation session as confirmed on first imaging follow-up, of clinically localized T1a (cT1a) renal cell carcinoma (RCC). METHODS 398 consecutive patients with cT1a RCC were treated with cryoablation between 10/2003 and 12/2017, radiofrequency (RFA) or microwave ablation (MWA) between 1/2010 and 12/2017. SSRA was performed for residual tumor identified on intra-procedural CECT. Kruskal-Wallis and Pearson's chi-squared tests were performed to assess differences in continuous and categorical variables, respectively. Multivariate linear regression was used to determine predictors for primary efficacy and decline in estimated glomerular filtration rate. RESULTS 347 consecutive patients (231 M, mean age 67.5 ± 9.1 years) were included. Median tumor diameter was smaller [2.5 vs 2.7 vs 2.6 (p = 0.03)] and RENAL Nephrometry Score (NS) was lower [6 vs 7 vs 7 (p = 0.009] for MWA compared to the RFA and cryoablation cohorts, respectively. Primary efficacy was higher in the MWA cohort [99.4% (170/171)] compared to the RFA [91.4% (85/93)] and cryoablation [92.8% (77/83)] cohorts (p = 0.001). Microwave ablation and SSRA was associated with higher primary efficacy on multivariate linear regression (p = 0.01-0.03). CONCLUSION MWA augmented by SSRA, when residual tumor is identified on intra-procedural CECT, may improve primary efficacy for cT1a RCC.
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Affiliation(s)
- Samuel D Koebe
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Nicole E Curci
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Elaine M Caoili
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Leo D Dreyfuss
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | - Glenn O Allen
- Department of Radiology, University of Wisconsin, Madison, WI, USA
| | - Christopher L Brace
- Department of Radiology, University of Wisconsin, Madison, WI, USA
- Department of Biomedical Engineering, University of Wisconsin, Madison, WI, USA
| | | | - E Jason Abel
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Urology, University of Wisconsin, Madison, WI, USA
| | - Shane A Wells
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
- Department of Radiology, University of Wisconsin, Madison, WI, USA.
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/376. 600 Highland Avenue, Madison, WI, 53792, USA.
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Krieger JR, Lee FT, McCormick T, Ziemlewicz TJ, Hinshaw JL, Wells SA, Laeseke PE, Stratchko L, Alexander M, Hedican SP, Best SL, Borza T, Nakada SY, Abel EJ. Microwave Ablation of Renal Cell Carcinoma. J Endourol 2021; 35:S33-S37. [PMID: 34499558 DOI: 10.1089/end.2020.1078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Management options for small renal masses include active surveillance, partial nephrectomy, radical nephrectomy, and thermal ablation. For tumors typically ≤3 cm in size, thermal ablation is a good option for those desiring an alternative to surgery or active surveillance, especially in patients who are considered high surgical risk. We favor microwave ablation because of the more rapid heating, higher temperatures that overcome the heat sink effect of vessels, reproducible cell kill, and a highly visible ablation zone formed by water vapor that corresponds well to the zone of necrosis. For central tumors, we favor cryoablation because of the slower formation of the ablation zone and less likelihood of damage to the collecting system. With microwaves, it is important to monitor the ablation zone in real time (ultrasound is the best modality for this purpose), avoid direct punctures of the collecting system, and to place probes tangential to the collecting system to avoid burning open a persistent tract between the urothelium and extrarenal spaces or causing strictures. The surgical steps described in this video cover our use of high-frequency jet ventilation with general anesthesia to minimize organ motion, initial imaging and targeting, probe insertion, hydrodissection (a technique that enables displacement of adjacent structures), the ablation itself, and finally our dressing. Postoperative cares typically consist of observation with a same-day discharge or an overnight stay. Follow-up includes a magnetic resonance imaging abdomen with and without contrast, chest X-ray, and laboratories (basic metabolic panel, complete blood count, and C-reactive protein) 6 months postablation. Overall, percutaneous microwave ablation is an effective and safe treatment option for renal cell carcinoma in both T1a and T1b tumors in selected patients with multiple studies showing excellent oncologic outcomes when compared with partial and radical nephrectomy.
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Affiliation(s)
- Jordan R Krieger
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Fred T Lee
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Timothy McCormick
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Timothy J Ziemlewicz
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - J Louis Hinshaw
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Shane A Wells
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Paul E Laeseke
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Lindsay Stratchko
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Marci Alexander
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sean P Hedican
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sara L Best
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Tudor Borza
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Stephen Y Nakada
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - E Jason Abel
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
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