Image guided radiofrequency ablation for small renal masses

Local recurrence of renal cell carcinoma successfully treated with fusion imaging-guided percutaneous thermal ablation

Image-guided thermal ablations are increasingly applied in the treatment of renal cancers, under the guidance of ultrasound (US) or computed tomography (CT). Fusion imaging allows exploitation of the strengths of all imaging modalities simultaneously, eliminating or minimising the weaknesses of every single modality. We present a case of a 68-year-old patient treated using US/CT fusion imaging to guide radiofrequency ablation for local recurrence of renal cell carcinoma undetectable by ultrasound.

Active surveillance and focal ablation for small renal masses: a better solution for comorbid patients

The natural history of small renal masses (SRM) is still not well understood and they are frequently incidentally diagnosed in elderly patients. Therefore, there is a need for less invasive options sparing the patient from the side-effects related to conventional surgical treatment. PubMed and Medline database search was performed to look for new findings on active surveillance and focal therapy for SRM. Sixty-one articles published between 2002 and 2018 were selected for the purpose of the review. There is growing evidence confirming the safety of active surveillance in patients at surgical risk and there appears to be a satisfactory intermediate-term outcome of focal treatment of SRM. In the group of elderly patients with a decreased life expectancy active surveillance appears to be the most appropriate approach. The future of minimally invasive therapy appears bright, especially with the improvement of new imaging modalities.

Long-Term Survival after Percutaneous Radiofrequency Ablation of Pathologically Proven Renal Cell Carcinoma in 100 Patients

PURPOSE

To determine the long-term survival of patients treated with percutaneous radiofrequency (RF) ablation for pathologically proven renal cell carcinoma (RCC).

MATERIALS AND METHODS

In this single-center retrospective study, 100 patients with 125 RCCs (100 clear-cell, 19 papillary, and 6 chromophobe) 0.8-8 cm in size treated with RF ablation were evaluated at a single large tertiary-care center between 2004 and 2015. Technical success, primary and secondary technique efficacy, and pre- and postprocedural estimated glomerular filtration rate (eGFR) at 3-6 months and 2-3 years were recorded. Overall survival, cancer-specific survival, and local tumor progression-free survival were calculated by Kaplan-Meier survival curves. Complications were classified per the Clavien-Dindo system. Statistical testing was done via χ² tests for proportions and paired t test for changes in eGFR. Statistical significance was set at α = 0.05.

RESULTS

Overall technical success rate was 100%, and primary and secondary technique efficacy rates were 90% and 100%, respectively. Median follow-up was 62.8 months, ranging from 1 to 120 months. The 10-year overall, cancer-specific, and local progression-free survival rates were 32%, 86%, and 92%, respectively. The number of ablation probes used was predictive of residual unablated tumor (P < .001). There were no significant changes in preprocedure vs 2-3-years postprocedure eGFR (65.2 vs 62.1 mL/min/1.73 m²; P = .443). There was a 9% overall incidence of complications, the majority of which were grade I.

CONCLUSIONS

Image-guided percutaneous RF ablation of RCCs is effective at achieving local control and preventing cancer-specific death within 10 years from initial treatment.

Current opinion in urology 2017: focal therapy of small renal lesions

PURPOSE OF REVIEW

With the increasing incidence of small renal masses (SRMs), ablative technologies are becoming more commonly utilized. With any nascent treatment modality, outcomes literature needs to be constantly re-evaluated. The purpose of this review is to revisit the most updated literature regarding the safety and efficacy of ablative treatments of renal lesions.

RECENT FINDINGS

Recent literature demonstrates that small renal tumor ablation is safe and effective. Although it does not have the same oncological efficacy of surgical extirpation, local recurrence-free survival has consistently shown to be around 90%. Cryoablation and radiofrequency ablation have longer-term data demonstrating durable responses. Microwave ablation and irreversible electroporation are promising modalities with longer-term data coming. Complication rates and procedural morbidity of ablation are consistently lower than for partial nephrectomy.

SUMMARY

Image-guided focal ablation is a valuable tool in the management of SRMs. Although it does not have the same efficacy of surgical extirpation, with the ability to perform repeat procedures and salvage surgery if necessary, oncologic outcomes are comparable to those of upfront surgery. Ultimately, longer-term studies and prospective trials are needed to further elucidate these modalities.

Role of R.E.N.A.L. Nephrometry Score in Laparoscopic Partial Nephrectomy

Background:

Preoperative anatomical scoring system is conducive to comparison between treatment options and evaluation of postoperative outcomes in patients with small renal tumors. This study aimed to evaluate the clinical application efficacy of the R.E.N.A.L. nephrometry score (RNS) in predicting perioperative outcomes in patients with renal tumor who underwent laparoscopic partial nephrectomy (LPN).

Methods:

The clinical data of 139 patients with renal tumors who underwent LPN between 2009 and 2015 were collected and analyzed. Patients were divided into three groups according to their RNS (low, moderate, and high). Clinical characteristics including perioperative variables, complications, and RNS were compared to evaluate the differences between the three groups. Multivariable logistic regression analysis was used to analyze the risk factors of postoperative complications.

Results:

According to the RNS, there were 74, 50, and 15 patients in the low, moderate, and high RNS groups, respectively. There were significant differences in estimated blood loss (EBL; χ² = 7.285, P = 0.026), warm ischemia time (WIT; χ² = 13.718, P = 0.001), operation time (OT; χ² = 6.882, P = 0.032), perioperative creatinine clearance change (PCCC; χ² = 6.206, P = 0.045), and number of patients with complications (NPC; P = 0.002) among the three groups. The values for EBL, WIT, OT, PCCC, and NPC for patients in the high RNS group were higher than those for patients in the low RNS group. After adjustment for OT, WIT, and EBL, RNS was statistically significantly associated with the risk of postoperative complications in a multivariable logistic regression model (odds ratio = 1.541, 95% confidence interval: 1.059–2.242, P = 0.024).

Conclusions:

The RNS is a valuable tool for evaluating the complexity of renal tumor anatomy. It can aid surgeons in preoperative decision-making concerning management therapy. Future multicenter, large sample size studies are warranted for evaluating its predicting performance of perioperative outcomes.

[Percutaneous renal ablation: Pre-, per-, post-interventional evaluation modalities and adapted management]

OBJECTIVES

Ablative treatment (AT) rise is foreseen, validation of steps to insure good proceedings is needed. By looking over the process of the patient, this study evaluates the requirements and choices needed in every step of the management.

METHODS

We searched MEDLINE^®, Embase^®, using (MeSH) words and we looked for all the studies. Investigators graded the strength of evidence in terms of methodology, language and relevance.

RESULTS

Explanations of AT proposal rather than partial nephrectomy or surveillance have to be discussed in a consultation shared by urologist and interventional radiologist. Per-procedure choices depend on predictable ballistic difficulties. High volume, proximity of the hilum or of a risky organ are in favor of general anesthesia, cryotherapy and computed tomography/magnetic resonance imaging (CT/MRI). Percutaneous approach should be privileged, as it seems as effective as the laparoscopic approach. Early and delayed complications have to be treated both by urologist and radiologist. Surveillance by CT/MRI insure of the lack of contrast-enhanced in the treated area. Patients and tumors criteria, in case of incomplete treatment or recurrence, are the key of the appropriate treatment: surgery, second session of AT, surveillance.

CONCLUSION

AT treatments require patient's comprehension, excellent coordination of the partnership between urologist and radiologist and relevant choices during intervention.

Tips and tricks for a safe and effective image-guided percutaneous renal tumour ablation

Abstract

Image-guide thermal ablations are nowadays increasingly used to provide a minimally invasive treatment to patients with renal tumours, with reported good clinical results and low complications rate. Different ablative techniques can be applied, each with some advantages and disadvantages according to the clinical situation. Moreover, percutaneous ablation of renal tumours might be complex in cases where there is limited access for image guidance or a close proximity to critical structures, which can be unintentionally injured during treatment. In the present paper we offer an overview of the most commonly used ablative techniques and of the most important manoeuvres that can be applied to enhance the safety and effectiveness of percutaneous image-guided renal ablation. Emphasis is given to the different technical aspects of cryoablation, radiofrequency ablation, and microwave ablation, on the ideal operating room setting, optimal image guidance, application of fusion imaging and virtual navigation, and contrast enhanced ultrasound in the guidance and monitoring of the procedure. Moreover, a series of protective manoeuvre that can be used to avoid damage to surrounding sensitive structures is presented. A selection of cases of image-guided thermal ablation of renal tumours in which the discussed technique were used is presented and illustrated.

Teaching points

• Cryoablation, radiofrequency and microwave ablation have different advantages and disadvantages.

• US, CT, fusion imaging, and CEUS increase an effective image-guidance.

• Different patient positioning and external compression may increase procedure feasibility.

• Hydrodissection and gas insufflation are useful to displace surrounding critical structures.

• Cold pyeloperfusion can reduce the thermal damage to the collecting system.

Precision surgery and genitourinary cancers

The landscape of the surgical management of urologic malignancies has dramatically changed over the past 20 years. On one side, better diagnostic and prognostic tools allowed better patient selection and more reliable surgical planning. On the other hand, the implementation of minimally invasive techniques and technologies, such as robot-assisted laparoscopy surgery and image-guided surgery, allowed minimizing surgical morbidity. Ultimately, these advances have translated into a more tailored approach to the management of urologic cancer patients. Following the paradigm of "precision medicine", contemporary urologic surgery has entered a technology-driven era of "precision surgery", which entails a range of surgical procedures tailored to combine maximal treatment efficacy with minimal impact on patient function and health related quality of life. Aim of this non-systematic review is to provide a critical analysis of the most recent advances in the field of surgical uro-oncology, and to define the current and future role of "precision surgery" in the management of genitourinary cancers.

US-guided percutaneous laser ablation of refractory metastatic retroperitoneal lesions: A care-compliant case report

RATIONALE

Retroperitoneal metastatic lymph node is rare but severe, which has important structures like the gastrointestinal tract and large blood vessels around and may challenge excision, inducing serious complications like hemorrhage, intestinal adhesion, and even death after injury.

PATIENT CONCERNS

We described the case of a 60-year-old man with a history of right liver resection in 2010, pulmonary wedge resection in 2012, and transarterial chemoembolization twice in 2014, in which the postoperative pathology suggested the mixed liver cancer, and poorly differentiated lung cancer from liver metastasis.

DIAGNOSES

Preoperative magnetic resonance (MR) imaging scan showed a refractory retroperitoneal metastatic lymph node.

INTERVENTIONS

Then this patient repeatedly received 4 ablations with US-guided laser ablation within a month.

OUTCOMES

After 4 ablations due to residual tumor, MR, and CT images of 5-month follow-up showed the partial response. No obvious side effects were discovered in this case during these procedures.

LESSONS

This suggested US-guided laser ablation appears to be a useful technique for retroperitoneal metastatic lymph node with poor general condition or those refusing surgical therapy.