Local Recurrence of Renal Cancer After Surgery: Prime Time for Percutaneous Thermal Ablation?

Current strategies to diagnose and manage of positive surgical margins and local recurrence after partial nephrectomy

Objective

No standard strategy for diagnosis and management of positive surgical margin (PSM) and local recurrence after partial nephrectomy (PN) are reported in literature. This review aims to provide an overview of the current strategies and further perspectives on this patient setting.

Methods

A non-systematic review of the literature was completed. The research included the most updated articles (about the last 10 years).

Results

Techniques for diagnosing PSMs during PN include intraoperative frozen section, imprinting cytology, and other specific tools. No clear evidence is reported about these methods. Regarding PSM management, active surveillance with a combination of imaging and laboratory evaluation is the first option line followed by surgery. Regarding local recurrence management, surgery is the primary curative approach when possible but it may be technically difficult due to anatomy resultant from previous PN. In this scenario, thermal ablation (TA) may have the potential to circumvent these limitations representing a less invasive alternative. Salvage surgery represents a valid option; six studies analyzed the outcomes of nephrectomy on local recurrence after PN with three of these focused on robotic approach. Overall, complication rates of salvage surgery are higher compared to TA but ablation presents a higher recurrence rate up to 25% of cases that can often be managed with repeat ablation.

Conclusion

Controversy still exists surrounding the best strategy for management and diagnosis of patients with PSMs or local recurrence after PN. Active surveillance is likely to be the optimal first-line management option for most patients with PSMs. Ablation and salvage surgery both represent valid options in patients with local recurrence after PN. Conversely, salvage PN and radical nephrectomy have fewer recurrences but are associated with a higher complication rate compared to TA. In this scenario, robotic surgery plays an important role in improving salvage PN and radical nephrectomy outcomes.

Theoretical Evaluation of Microwave Ablation Applied on Muscle, Fat and Bone: A Numerical Study

(1) Background: Microwave ablation (MWA) is a common tumor ablation surgery. Because of the high temperature of the ablation antenna, it is strongly destructive to surrounding vital tissues, resulting in high professional requirements for clinicians. The method used to carry out temperature observation and damage prediction in MWA is significant; (2) Methods: This work employs numerical study to explore temperature distribution of typical tissues in MWA. Firstly, clinical MWA based on isolated biological tissue is implemented. Then, the Pennes models and microwave radiation physics are established based on experimental parameters and existing related research. Initial values and boundary conditions are adjusted to better meet the real clinical materials and experimental conditions. Finally, clinical MWA data test this model. On the premise that the model is matched with clinical MWA, fat and bone are deduced for further heat transfer analysis. (3) Results: Numerical study obtains the temperature distribution of biological tissue in MWA. It observes the heat transfer law of ablation antenna in biological tissue. Additionally, combined with temperature threshold, it generates thermal damage of biological tissues and predicts the possible risks in MWA; (4) Conclusions: This work proposes a numerical study of typical biological tissues. It provides a new theoretical basis for clinically thermal ablation surgery.

Renal cell carcinoma: The role of radical surgery on different patterns of local or distant recurrence

INTRODUCTION

With the increasing reliance on targeted therapies and immunotherapy, no standard management strategy is today available for the treatment of locally, distant, or both renal cell carcinoma (RCC) recurrences, and their surgical treatment seems to play a crucial role. We report the 20-year experience of our center evaluating the short- and long-term outcomes of patients undergone surgical resection of RCC recurrences, and the possible role of repeated surgical resections of RCC recurrences.

MATERIALS AND METHODS

From January 1999 to January 2019, 40 patients underwent surgical resection of isolated locally recurrent RCC (iLR-RCC-group), locally recurrent RCC associated with the presence of distant recurrence (LR-DR-RCC-group), and distant-only recurrent RCC (DR-RCC-group). Data regarding pre-, intra-, post-operative course, and follow-up, prospectively collected in an institutional database, were retrospectively analyzed and compared.

RESULTS

iLR-RCC-group was composed of 9 patients, LR-DR-RCC-group of 6 patients, and DR-RCC-group of 25 patients. The recurrence rate was 55.6% (5/9 patients) in iLR-RCC-group, 50% (3/6 patients) in LR-DR-RCC-group, and 44% (11/25) patients in DR-RCC-group, p = 0.830. 3/5 (60%) patients in iLR-RCC-group, 2/3 (66.7%) patients in LR-DR-RCC-group, and 7/11 (63.6%) patients in DR-RCC group underwent to almost one further local treatments of their recurrences, respectively (p = 0.981). No differences in the mean disease-free survival (p = 0.384), overall survival (OS) (p = 0.881), and cancer-specific survival (p = 0.265) were reported between the three groups. In DR-RCC-group, patients who underwent further local treatments of new recurrences presented a longer OS: 150.7 versus 66.5 months (p = 0.004).

CONCLUSIONS

A surgical resection of RCC recurrences should be always taken in consideration, also in metastatic patients and/or in those who have already undergone surgery of previous RCC recurrence, whenever radicality is still possible, because this approach may offer a potentially long survival.

Long-Term Follow-Up Outcomes after Percutaneous US/CT-Guided Radiofrequency Ablation for cT1a-b Renal Masses: Experience from Single High-Volume Referral Center

Image-guided thermal ablations are increasingly applied in the treatment of renal cancers, under the guidance of ultrasound (US) or computed tomography (CT). Sometimes, multiple ablations are needed. The aim of the present study was to evaluate the long-term results in patients with renal mass treated with radiofrequency ablation (RFA) with both US and CT, with a focus on the multiple ablations rate. 149 patients (median age 67 years) underwent RFA from January 2008 to June 2015. Median tumor diameter was 25 mm (IQR 17–32 mm). Median follow-up was 54 months (IQR 44–68). 27 (18.1%) patients received multiple successful ablations, due to incomplete ablation (10 patients), local tumor progression (8 patients), distant tumor progression (4 patients) or multiple tumor foci (5 patients), with a primary and secondary technical efficacy of 100%. Complications occurred in 13 (8.7%) patients (6 grade A, 5 grade C, 2 grade D). 24 patients died during follow-up, all for causes unrelated to renal cancer. In conclusion, thermal ablations with the guidance of US and CT are safe and effective in the treatment of renal tumors in the long-term period, with a low rate of patients requiring multiple treatments over the course of their disease.

Percutaneous microwave ablation therapy of renal cancer local relapse after radical nephrectomy: a feasibility and efficacy study

Renal cell carcinoma (RCC) local recurrence after radical nephrectomy is uncommon. When feasible, surgical removal remains the primary treatment strategy; nevertheless, local RCC relapse management is controversial, and less invasive procedures may represent an attractive option to achieve oncologic control. The aim of our study was to assess the feasibility, safety, and clinical outcomes of image-guided percutaneous microwave ablation (MWA) for RCC local recurrence in patients initially treated with nephrectomy with curative intent. 10 consecutive patients underwent CT-guided percutaneous MWA of a total of 10 retroperitoneal nodules. Inclusion criteria were: histologically verified retroperitoneal metastases, previous radical nephrectomy, lesion no larger than 3 cm, no other metastatic site elsewhere. All the procedures were performed under moderate sedation choosing the most favorable patient decubitus. If deemed necessary, pneumodissection was induced before ablation. After the antenna placement inside the target lesion, thermal ablation was achieved by maintenance of a power of 100 W for a total time between 2 and 4 min. All patients were observed overnight and discharged the following day if clinically stable. Technical success was obtained in 100% of patients. One patient was re-treated to complete oncologic response with repeat MWA. No major complications were observed. No patients demonstrated local recurrence at a mean follow-up of 26 months. MWA is a safe and effective treatment strategy for loco-regional relapse of RCC following radical nephrectomy. This technique may represent a valuable approach for patients who are not eligible for surgery.

Image-guided laser ablation in the treatment of recurrence of renal tumours: technique and preliminary results

Abdominal recurrences of renal cell carcinoma (RCC) after surgery might represent a challenge for treatment, often requiring difficult surgeries or anticipated systemic therapy. Our aim is to illustrate a novel application of laser ablation for the treatment of abdominal recurrences of RCC. Patients with abdominal recurrences of renal cancer were treated under ultrasound/computed tomography guidance with a diode laser inserted into the lesion through a thin 21-G needle. A fixed 3-W power protocol was used, changing the illumination time according to lesion dimension and shape. Also, technical success, technical efficacy, local tumour progression, and major and minor complications were retrospectively analysed. Three patients were treated with image-guided laser ablation for abdominal recurrences of RCC. In all cases, it was possible to perform ablation as preoperatively planned and all three nodules (size of 6, 8, and 12 mm) were completely ablated with no evidence of residual enhancement after 6 weeks at contrast-enhanced CT. No minor or major complications were observed. No local tumour progression was reported up to 12 months from ablation. Image-guided laser ablation holds the potential to offer a minimally invasive treatment to patients with abdominal recurrence of RCC. Further studies are needed to evaluate the clinical role of this technique.

Cone-Beam CT-Assisted Ablation of Renal Tumors: Preliminary Results

INTRODUCTION

Renal ablation is a recognized treatment modality for small renal masses. Cone-beam CT (CBCT) has been recently used in interventional oncology as a promising new guidance device, but this technology still needs to be validated for renal ablations. We aimed to assess the technical success of CBCT applications in renal ablative treatments.

MATERIALS AND METHODS

Between March 2016 and June 2018, 14 patients (mean age 69, range 54-83, 7F, 7M) underwent 21 renal ablations for histologically proven renal cell carcinoma (RCC). All treatments were performed with ultrasound (US) and CBCT guidance under general anesthesia in a dedicated angiography room setting. CBCT was mainly used to assess needle placement and to exclude complications at the end of the procedure. In two small lesions (< 1 cm), pre-acquired CBCT was co-registered with real-time US to obtain a US-CBCT fusion image guidance for tumor ablation.

RESULTS

Whether used alone or in combination with other imaging modalities, CBCT was proven to be technically successful in all 21 procedures to guide or assist tumor ablation. A primary technical efficacy of thermal ablation was achieved in 19/21 ablations (90.1%) at 1 month. Mean procedure duration was 100.2 min (range 160-64). Mean length of hospital stay was 2 days (range 1-10 days). All patients are still under active surveillance for a mean follow-up of 14.5 months (range 4-26 months).

CONCLUSIONS

CBCT for renal ablation guidance is a viable tool. Larger series are needed to compare it to MDCT.

Systematic Review of the Management of Local Kidney Cancer Relapse

CONTEXT

Management of locally recurrent renal cancer is complex.

OBJECTIVE

In this systematic review we analyse the available literature on the management of local renal cancer recurrence.

EVIDENCE ACQUISITION

A systematic search (PubMed, Web of Science, CINAHL, Clinical Trials, and Scopus) of English literature from 2000 to 2017 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

EVIDENCE SYNTHESIS

The search identified 1838 articles. Of those, 36 were included in the evidence synthesis. The majority of the studies identified were retrospective and not controlled. Local recurrence after thermal ablation (TA) may be managed with repeat TA. Alternatively, salvage nephrectomy is possible. However, a higher rate of complications should be expected than after primary nephrectomy. Salvage nephrectomy and TA represent treatment options for local recurrence after partial nephrectomy. Local retroperitoneal recurrence after radical nephrectomy is ideally treated with surgical resection, for which minimally invasive approaches might be applicable to select patients. For large recurrences, addition of intraoperative radiation may improve local control. Local tumour destruction appears to be more beneficial than systemic therapy alone for local recurrences.

CONCLUSIONS

Management of local renal cancer relapse varies according to the clinical course and prior treatments. The available data are mainly limited to noncontrolled retrospective series. After nephron-sparing treatment, TA represents an effective treatment with low morbidity. For local recurrence after radical nephrectomy, the low-level evidence available suggests superiority of surgical excision relative to systemic therapy or best supportive care. As a consequence, surgery should be prioritised when feasible and applicable.

PATIENT SUMMARY

In renal cell cancer, the occurrence and management of local recurrence depend on the initial treatment. This cancer is a disease with a highly variable clinical course. After initial organ-sparing treatment, thermal ablation offers good cancer control and low rates of complications. For recurrence after radical nephrectomy, surgical excision seems to provide the best long-term cancer control and it is superior to medical therapy alone.

The efficacy and safety of microwave ablation in patients with retroperitoneal metastases

BACKGROUND

Retroperitoneal metastases are common, and most present with symptoms; however, treatments for this condition are limited. This retrospective study verified the efficacy and safety of microwave ablation (MWA) in retroperitoneal metastases patients.

METHODS

Patients with pathologically confirmed malignant carcinoma and imaging showing retroperitoneal metastases were enrolled and underwent MWA. The end-points included objective response rate, time to local progression (TTLP), overall survival, visual analogue scale (VAS) score, dose of morphine pre- and post-ablation and complications.

RESULTS

Twenty-three patients were enrolled. The mean tumour diameter was 3.6 cm. Altogether, 29 tumour sites in 23 patients were ablated during 23 procedures; technical success was achieved in all 23 patients. The objective response and disease control rates were 95.7% and 100.0%, respectively. The mean TTLP and median OS were 22.8 months (95% CI: 16.1-29.6 months) and 10.6 months (95% CI: 7.4-13.8 months), respectively. In 13 patients with symptoms, the VAS values before ablation and 48 h, 1 month, 2 months, 3 months and 6 months after ablation were 5.38, 2.77 (p = 0.015), 2.15 (p = 0.001), 2.17 (p = 0.001), 1.40 (p = 0.000) and 1.71 (p = 0.006), respectively. The corresponding morphine doses were 76.9 mg, 70.7 mg (p = 0.584), 50.7 mg (p = 0.031), 55.0 mg (p = 0.097), 46.0 mg (p = 0.057) and 40.0 mg (p = 0.363), respectively. No ablation-associated mortality was observed. Major complications, minor complications and adverse events were observed in eight (34.8%), five (21.7%) and four (17.4%) patients, respectively.

CONCLUSION

MWA for the treatment of retroperitoneal metastases was effective and the complications were common.

Percutaneous laser ablation: a new contribution to unresectable high-risk metastatic retroperitoneal lesions?

BACKGROUND & AIMS

Metastasis in retroperitoneal lymph nodes is one of the signs of advanced stage or terminal stage of malignancy. We performed a trial to assess the safety and efficacy of ultrasonography (US)-guided local neodymium-doped yttrium aluminum garnet (Nd:YAG) laser ablation for metastatic lymph nodes in the retroperitoneal region.

METHODS

We evaluated 4 cases of retroperitoneal metastatic lymph nodes treated using US-guided Nd:YAG laser ablation. Additionally, we reviewed the PubMed database for articles on thermal ablation of retroperitoneal lesions until March 2016, without language limitations.

RESULTS

In our study, all lesions were nearly completely ablated with mild discomfort, including pain and fever at the 3-month follow-up. In the literature review, a total of 398 patients with 491 retroperitoneal tumors were identified, and complications after the procedure included enterovesical fistula, fecal incontinence, and hematoma.

CONCLUSIONS

Percutaneous laser ablation could be a theoretically promising approach for retroperitoneal metastatic lesions. ClinicalTrials.gov number: NCT02822053.

Surgical Management of Local Recurrences of Renal Cell Carcinoma

Surgical resection either in the form of radical nephrectomy or in the form of partial nephrectomy represents the mainstay options in the treatment of kidney cancer. In most instances, resecting the tumor bearing kidney or the tumor itself provides durable cancer specific survival rates. However, recurrences may rarely develop in the renal fossa or remnant kidney. Despite its rarity, locally recurrent RCC is a challenging condition in terms of the possible management options and relatively poor prognosis. If technically feasible, wide surgical excision and ensuring negative surgical margins are the most effective treatment options. Repeat surgeries (completion nephrectomy, excision of locally recurrent tumor, or repeat partial nephrectomy) may often be complicated, and perioperative morbidity is a major concern. Open approach has been extensively applied in this context and 5-year cancer specific survival rates have been reported to be around 50%. The roles of minimally invasive surgical options (laparoscopic and robotic approach) and nonsurgical alternatives (cryoablation, radiofrequency ablation) have yet to be described. In selected patients, surgical resection may have to be complemented with (neo)adjuvant radiotherapy or medical treatment.