Management of Residual or Recurrent Disease Following Thermal Ablation of Renal Cortical Tumors.

Justin Loloi,W Bruce Shingleton,Kamran Ahrar,Raymond J Leveillee,Surena F Matin,Jaime Landman,Jeffrey A Cadeddu,Benjamin R Lee,Ronald J Zagoria,Jay D Raman,Stephen Y Nakada

doi:10.15586/jkcvhl.2020.133

Abstract

Management of residual or recurrent disease following thermal ablation of renal cortical tumors includes surveillance, repeat ablation, or surgical extirpation. We present a multicenter experience with regard to the management of this clinical scenario. Prospectively maintained databases were reviewed to identify 1265 patients who underwent cryoablation (CA) or radiofrequency ablation (RFA) for enhancing renal masses. Disease persistence or recurrence was classified into one of the three categories: (i) residual disease in ablation zone; (ii) recurrence in the ipsilateral renal unit; and (iii) metastatic/extra-renal disease. Seventy seven patients (6.1%) had radiographic evidence of disease persistence or recurrence at a median interval of 13.7 months (range, 1–65 months) post-ablation. Distribution of disease included 47 patients with residual disease in ablation zone, 29 with ipsilateral renal unit recurrences (all in ablation zone), and one with metastatic disease. Fourteen patients (18%) elected for surveillance, and the remaining underwent salvage ablation (n = 50), partial nephrectomy (n = 5), or radical nephrectomy (n = 8). Salvage ablation was successful in 38/50 (76%) patients, with 12 failures managed by observation (3), tertiary ablation (6), and radical nephrectomy (3). At a median follow-up of 28 months, the actuarial cancer-specific survival and overall survival in this select cohort of patients was 94.8 and 89.6%, respectively.

Highlights

The widespread use of abdominal cross-sectional imaging has contributed to the observed increased incidence and detection of small renal masses (SRMs) [1, 2]
The American Urologic Association (AUA) guidelines highlight the standard of care for the management of SRMs, including partial or radical nephrectomy when feasible, with surveillance and thermal ablation as appropriate in certain patient cohorts [5]
The presence of contrast enhancement or lesion growth in the ipsilateral renal unit, including the ablation zone, was considered as evidence of radiographic local treatment failure. For those patients unable to receive contrast-based studies, evidence of residual or recurrent disease was confirmed by percutaneous renal mass biopsy (RMB)

Summary

Introduction

The widespread use of abdominal cross-sectional imaging has contributed to the observed increased incidence and detection of small renal masses (SRMs) [1, 2]. The American Urologic Association (AUA) guidelines highlight the standard of care for the management of SRMs, including partial or radical nephrectomy when feasible, with surveillance and thermal ablation as appropriate in certain patient cohorts [5]. Incorporation of renal tumor ablation into clinical practice requires an understanding of the incidence and patterns of recurrence, which can occur in up to 20% of patients, depending on tumor characteristics [7]. Several options have been proposed for the management of a failed ablative procedure, including surveillance, salvage ablation, and partial and radical nephrectomies [9, 10]. In particular for locally recurring RCC following cryoablation (CA), has been shown to be a feasible option with good outcomes and low complication rates [11]

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