Trans-arterial embolization of renal cell carcinoma: a systematic review and meta-analysis

PURPOSE

To evaluate if trans-arterial embolization (TAE) of the primary tumor in patients with renal cell carcinoma (RCC) improves symptomatology such as pain and hematuria or oncologic outcomes such as progression-free survival (PFS) and overall survival (OS).

MATERIALS AND METHODS

The systematic review search included PubMed, Ovid/MEDLINE, and Embase for full-text English articles including randomized and non-randomized prospective trials as well as prospective and retrospective case series. To be included, prospective trials needed ≥ 25 patients in each arm while case series and retrospective chart reviews required at least two patients. Evaluated outcomes included PFS, OS, change in tumor size, improvements in pain, improvements in hematuria, and adverse events (AEs).

RESULTS

1327 articles were retrieved and screened. Nine studies met inclusion criteria (retrospective case series, n = 8; non-randomized prospective trial, n = 1) which included 237 patients (M = 156 (65.8%); F = 56 (23.6%); gender unreported = 25 (10.5%); mean age: 69.4 (range: 38-87)) with a mean tumor diameter of 9.3 cm (5.2-10.5). When reported, the TNM stages were stage I (n = 10), II (n = 18), III (n = 36), and IV (n = 121). 60 patients were treated for pain and hematuria. After TAE, pain improved in 59 patients (98.3%) and hematuria improved in 57 patients (95%). A meta-analysis for improvements in pain and hematuria demonstrated an event rate of pain improvement of 0.952 (0.788-0.990; p < 0.001) and an event rate for hematuria improvement of 0.923 (0.809-0.971; p < 0.001). Median OS ranged from 1 to 39 months but only one study reported PFS (10.5 months). Only one study demonstrated a statistically significant improvement in OS with TAE when compared with patients that did not undergo TAE (p = 0.02). A reduction in tumor size was only achieved in 17 patients (17/49; 34.7%) limiting evaluation. AEs included fever (n = 115/237; 48.5%), flank pain (n = 72/237; 30.4%), nausea (n = 58/237; 24.5%), hematuria (n = 12/237; 5.1%), hypertension (n = 12/237; 5.1%), reduced GFR (n = 6/237; 2.5%), hematoma (n = 6/237,2.5%), and ileus (n = 3/237; 1.3%).

CONCLUSION

TAE monotherapy of the primary tumor in patients with RCC improves symptomatology such as pain and hematuria with an acceptable safety profile.

Transarterial embolization of renal cell carcinoma as an adjunctive therapy prior to cryoablation: a propensity score matching analysis

PURPOSE

We aimed to assess the safety and effectiveness of transarterial embolization (TAE) prior to percutaneous cryoablation (PCA) in the management of renal cell carcinoma (RCC) compared with PCA alone using a propensity score matching analysis to minimize confounding factors.

METHODS

A retrospective review of all PCAs performed for renal masses identified 9 patients who underwent TAE prior to PCA. These patients were matched in a 2:1 ratio with patients who underwent PCA only using age, gender, and tumor size to create the propensity score model for matching. Other demographic, clinical, and outcomes data were collected.

RESULTS

The TAE+PCA group included 5 males and 4 females with a mean age of 67.9 years and mean tumor diameter of 51.7 mm. The PCA only group included 11 males and 7 females with a mean age of 66.8 years and mean tumor diameter of 46.2 mm. No significant differences in these propensity score matched characteristics were identified. Further, the groups had no significant differences in tumor geometry (P = 0.831), R.E.N.A.L. nephrometry scores (P = 0.144), or comorbidity indices (P = 0.392). TAE was technically successful and without complication in all cases. PCA was technically successful in 8 of 9 patients in the TAE+PCA group and in 14 of 18 patients in the PCA only group (P = 0.483). No significant differences in the rate of complications (P = 0.483), change in eGFR (P = 0.691), or change in hematocrit (P = 0.152) were identified between the two groups.

CONCLUSION

TAE of RCC prior to PCA is safe and technically feasible; however, no objective benefits over PCA alone were identified by propensity score matching analysis. Due to small sample size and limitations of the study, no definite conclusions should be drawn. Larger, prospective studies of this therapeutic approach are warranted.

Imaging the renal mass: a historical review

A matter of months after Roentgen's landmark discovery in 1895, Roentgen's rays were focused on diseases and disorders of the urinary tract, specifically the kidney. At the dawn of the 20th century, urologists in the United States and around the world quickly recognized that by using a variety of metal stylets and radiopaque contrast agents, such as silver salts, the upper urinary tract, namely the ureter, pelvis, and calyces, could be depicted with radiography. Renal cysts and tumors were diagnosed on the basis of deformities in the kidney. Retrograde pyelography dominated the imaging evaluation of the kidney until the discovery of a safe intravenous method for urinary tract imaging (ie, intravenous pyelography). Pioneers and pathfinders in the field of contrast media development and radiologic procedures helped give radiologists the lead role in the work-up of renal masses, an area where urologists once held forth. The subspecialty of uroradiology was born in the middle of the 20th century. Intravenous urography, nephrotomography, and diagnostic angiography with pharmacologic manipulation followed by cyst or mass puncture and biopsy yielded unrivaled specificity for the diagnosis and staging of benign and malignant renal masses. The advent of cross-sectional and multiplanar imaging and the profound effects they had and continue to have on the discovery and characterization of renal masses has been detailed in the pages of Radiology since the 1920s. Ultrasonography, nuclear imaging, computed tomographic scanning, magnetic resonance imaging, and positron emission tomography each have made a claim to a part of the imaging algorithm of modern uroradiologic practice.

Renal cell carcinoma metastases to the pancreas: value of arterial phase imaging at MDCT

BACKGROUND

The pancreas is an increasingly recognized site of renal cell carcinoma metastases. It is important to determine the optimal MDCT protocol to best detect RCC metastases to the pancreas.

PURPOSE

To compare the rate of detection of renal cell carcinoma metastases to the pancreas between arterial and portal venous phase MDCT.

MATERIAL AND METHODS

A retrospective review of CTs of the abdomen yielded six patients with metastatic RCC to the pancreas. Five of six patients had pathologically proven clear cell RCC. Two blinded reviewers independently reported the number of pancreatic lesions seen in arterial and venous phases. Each lesion was graded as definite or possible. The number of lesions was determined by consensus review of both phases. Attenuation values were obtained for metastatic lesions and adjacent normal pancreas in both phases.

RESULTS

There were a total of 24 metastatic lesions to the pancreas. Reviewer 1 identified 20/24 (83.3%) lesions on the arterial phase images and 13/24 (54.2%) lesions on the venous phase. Seventeen of 20 (85.0%) arterial lesions were deemed definite and 9/13 (69.2%) venous lesions were definite. Reviewer 2 identified 19/24 (79.2%) lesions on the arterial phase and 14/24 (58.3%) on the venous phase. Seventeen of 19 (89.5%) arterial lesions were definite and 7/14 (50%) venous lesions were definite. Mean attenuation differential between lesion and pancreas was 114 HU and 39 HU for arterial and venous phases, respectively (P<0.0001).

CONCLUSION

Detection of RCC metastases to the pancreas at MDCT is improved using arterial phase imaging compared to portal venous phase imaging.

Sternal metastasis as an initial presentation of renal cell carcinoma: a case report

Renal cell carcinoma accounts for 85% of all solid renal tumors in adults. Nearly one quarter of patients has distant metastasis at presentation while another 50% develop metastasis during follow-up. A small percentage of these are solitary metastasis. We report here a case of solitary bone sternal metastasis as an initial presentation of clear-cell renal cell carcinoma in a 56-year-old woman. The prognosis for patients with metastasized renal cell carcinoma is poor; treatment of metastasis is usually palliative and designed to provide comfort and pain relief. Palliative nephrectomy may be considered for control of symptoms. Radical nephrectomy associated with metastatic bone tumor resection is being tested to improve functional status and survival, especially when metastasis involves supporting bones.