Thermal Ablation For Renal Cell Carcinoma Research Articles

Predictors for complication in renal cancer surgery: a national register study.

Nationwide register data provide unique opportunities for real-world assessment of complications from different surgical methods. This study aimed to assess incidence of, and predictors for, post-operative complications and to evaluate 90-day mortality following different surgical procedures and thermal ablation for renal cell carcinoma (RCC). All patients undergoing surgical treatment and thermal ablation for RCC in Sweden during 2015-2019 were identified from the National Swedish Kidney Cancer Register. Frequencies and types of post-operative complications were analysed. Logistic regression models were used to identify predictors for 90-day major (Clavien-Dindo grades III-V) complications, including death. The overall complication rate was 24% (1295/5505), of which 495 (8.7%) were major complications. Most complications occurred following open surgery, of which bleeding and infection were the most common. Twice as many complications were observed in patients undergoing open surgery compared to minimally invasive surgery (20% vs. 10%, P < 0.001). Statistically significant predictors for major complications irrespective of surgical category and technique were American society of anesthiologists (ASA) score, tumour diameter and serum creatinine. Separating radical and partial nephrectomy, surgical technique remained a significant risk factor for major complications. Most complications occurred within the first 20 days. The overall 90-day readmission rate was 6.2%, and 30- and 90-day mortality rates were 0.47% and 1.5%, respectively. In conclusion, bleeding and infection were the most common major complications after RCC surgery. Twice as many patients undergoing open surgery suffer a major post-operative complication as compared to patients subjected to minimally invasive surgery. General predictors for major complications were ASA score, tumour size, kidney function and surgical technique.

Nephron sparing surgery in von Hippel-Lindau associated renal cell carcinoma; clinicopathological long-term follow-up

We evaluated the clinicopathological outcome of von Hippel-Lindau (VHL)-patients who had mainly undergone nephron sparing surgery (NSS) for renal cell carcinoma (RCC) when the tumour diameter has reached 4.0cm. Multiple, bilateral RCC with high recurrence rates and subsequent repeated interventions, followed by increasing risk for end-stage renal failure and metastases is characteristic for VHL. NSS is widely used for VHL-associated RCC at 3.0cm cut-off. 54 VHL patients underwent NSS, nephrectomy or thermal ablation for RCC. We analysed time to second treatment, overall and cancer specific survival, intra- and post-operative data as well as tumour characteristics. We also examined the effects of delaying removal of RCC to 4.0cm cut-off. Median follow-up was 67months. 54 patients underwent 97 kidney treatments. 96% of first and 67% of second interventions comprised of NSS. 0% metastases were observed in the group with largest tumour size ≤4cm. The probability for second surgery was 21%, at 5years and 42% at 10years. Median time to second NSS was 149.6months. The overall and cancer specific survival rate was 96.5 and 100% at 5-year follow-up, and 82.5 and 90.5% respectively at 10-year follow-up. Median delay to second NSS at 4.0cm cut-off versus 3.0cm was 27.8months. NSS was both successfully used in first and second surgery and to some extent even in third surgery. By following a strict surveillance protocol it is possible to support a 4.0cm-threshold strategy for NSS, based on the assumption that delaying time to second NSS prevents patients from premature renal failure.

Assessing Outcomes in Probe Ablative Therapies for Small Renal Masses

The increasing incidence of renal-cell carcinoma can be largely attributed to the increased detection of small renal masses (SRMs) via abdominal imaging. These lesions tend to have a slow rate of growth and low malignant potential, and hence, minimally invasive treatments and active surveillance have been developed for these low-risk tumors to minimize treatment-related morbidity. Radiofrequency ablation and cryotherapy are the principal less-invasive approaches, and their initial oncologic efficacy and complication profiles have been favorable. Suboptimal definition of the relevant outcomes of treatment, a dearth of prospective and randomized data, and relatively short follow-up in the context of the natural history of SRMs pose challenges in the assessment of the efficacy and outcomes of thermal ablation of renal-cell carcinoma. Better pretreatment characterization of the biology of these tumors, more effective real-time treatment monitoring, and standardization of outcome definitions and follow-up are needed to better clarify the effectiveness and role of these treatments. This review highlights these potential pitfalls in the assessment of outcomes of probe ablation of SRMs.

Reporting Standards for Percutaneous Thermal Ablation of Renal Cell Carcinoma

WITH the increasing incidence of renal cell carcinoma (RCC) in the United States and the increasing proportion of patients with tumors detected at an early stage (1–5), nephron-sparing approaches are becoming more popular. These alternatives to radical nephrectomy include partial nephrectomy, wedge resection, and, more recently, in situ thermal ablation. Five-year survival rates after partial nephrectomy are equivalent to those after radical nephrectomy (6–8), supporting the rationale of in situ tumor destruction to further reduce morbidity and invasiveness. In situ thermal destruction of RCC uses techniques that destroy tumor tissue through heating (eg, radiofrequency [RF] ablation, microwave ablation, laser interstitial therapy, high-intensity focused ultrasound [US]) or freezing (eg, cryotherapy). Each of these techniques relies on controlled energy delivery to minimize collateral damage to normal renal parenchyma and other surrounding structures. In the United States, RF ablation and cryoablation are currently the most widely used techniques for in situ RCC destruction. Thermal ablation of RCC may be performed percutaneously, laparoscopically, or through open surgery. Our current understanding of the role of percutaneous thermal ablation in the management of primary RCC is limited by a paucity of prospective studies (9,10). Given the relative newness of this technology, most series to date report short-term or midterm outcomes, with no reports extending to 5 years of survival outcomes. No randomized trials have been performed to date comparing thermal ablation against a gold standard (ie, partial nephrectomy) or against other thermal ablation techniques. The optimal size range of RCC amenable to thermal ablation has not been clearly defined and is closely related to anatomic factors that influence the ability to deposit sufficient thermal dose to coagulate tissue, including proximity to major vessels and the urinary collecting system, which can act as a heat sink. The kidney has approximately four times the blood flow of the liver, so convective heat loss during thermal ablation is potentially significant (11). The role of percutaneous thermal ablation compared with laparoscopic or open thermal ablation also remains a topic of controversy. The combination of thermal ablation with other imageguided therapies (eg, transcatheter embolization) and adjuvant therapies such as chemotherapy and antiangiogenic agents for larger RCCs in patients who are poor operative candidates is another potential use of this technique. Although most recent reports of percutaneous RCC ablation have involved RF ablation, other ablation technologies are now available with percutaneous applicators (eg, cryoablation, microwave, laser interstitial therapy), and reporting standards should be uniform for all forms of energy-based ablation. This document provides recommended reporting standards for physicians performing percutaneous thermal ablation of primary RCC and will serve as a template in the design of clinical trials to further evaluate this technology. From the Section of Vascular and Interventional Radiology, Department of Radiology (T.W.I.C.), New York University School of Medicine, New York, New York; Department of Radiology (S.F.M.), University of Western Ontario, Peterborough Regional Health Center, Peterborough, Ontario, Canada; Department of Radiology, Gastrointestinal/Genitourinary Division (D.A.G.), Massachusetts General Hospital; Department of Radiology (S.N.G.), Beth Israel Deaconess Medical Center, Boston; Department of Radiology (C.J.G.), Lahey Clinic Medical Center, Burlington; Department of Radiology (D.A.P.), University of Massachusetts Memorial Health Care, Worcester, Massachusetts; Department of Radiology (T.B.K.), University of California San Diego Medical Center, San Diego, California; Department of Radiology (D.S.), The Reading Hospital and Medical Center, Reading, Pennsylvania; and Department of Radiology (J.F.C.), University of Colorado Health Sciences Center, Denver, Colorado. Received June 19, 2006; revision requested June 19; final revision received June 29; and accepted July 3. Address correspondence to T.W.I.C., c/o Tricia McClenny, Society of Interventional Radiology, 3975 Fair Ridge Dr, Suite 400 North, Fairfax, VA 22033; E-mail: mcclenny@sirweb.org

Reporting Standards for Percutaneous Thermal Ablation of Renal Cell Carcinoma

WITH the increasing incidence of renal cell carcinoma (RCC) in the United States and the increasing proportion of patients with tumors detected at an early stage (1–5), nephron-sparing approaches are becoming more popular. These alternatives to radical nephrectomy include partial nephrectomy, wedge resection, and, more recently, in situ thermal ablation. Five-year survival rates after partial nephrectomy are equivalent to those after radical nephrectomy (6–8), supporting the rationale of in situ tumor destruction to further reduce morbidity and invasiveness. In situ thermal destruction of RCC uses techniques that destroy tumor tissue through heating (eg, radiofrequency [RF] ablation, microwave ablation, laser interstitial therapy, high-intensity focused ultrasound [US]) or freezing (eg, cryotherapy). Each of these techniques relies on controlled energy delivery to minimize collateral damage to normal renal parenchyma and other surrounding structures. In the United States, RF ablation and cryoablation are currently the most widely used techniques for in situ RCC destruction. Thermal ablation of RCC may be performed percutaneously, laparoscopically, or through open surgery. Our current understanding of the role of percutaneous thermal ablation in the management of primary RCC is limited by a paucity of prospective studies (9,10). Given the relative newness of this technology, most series to date report short-term or midterm outcomes, with no reports extending to 5 years of survival outcomes. No randomized trials have been performed to date comparing thermal ablation against a gold standard (ie, partial nephrectomy) or against other thermal ablation techniques. The optimal size range of RCC amenable to thermal ablation has not been clearly defined and is closely related to anatomic factors that influence the ability to deposit sufficient thermal dose to coagulate tissue, including proximity to major vessels and the urinary collecting system, which can act as a heat sink. The kidney has approximately four times the blood flow of the liver, so convective heat loss during thermal ablation is potentially significant (11). The role of percutaneous thermal ablation compared with laparoscopic or open thermal ablation also remains a topic of controversy. The combination of thermal ablation with other imageguided therapies (eg, transcatheter embolization) and adjuvant therapies such as chemotherapy and antiangiogenic agents for larger RCCs in patients who are poor operative candidates is another potential use of this technique. Although most recent reports of percutaneous RCC ablation have involved RF ablation, other ablation technologies are now available with percutaneous applicators (eg, cryoablation, microwave, laser interstitial therapy), and reporting standards should be uniform for all forms of energy-based ablation. This document provides recommended reporting standards for physicians performing percutaneous thermal ablation of primary RCC and will serve as a template in the design of clinical trials to further evaluate this technology. From the Section of Vascular and Interventional Radiology, Department of Radiology (T.W.I.C.), New York University School of Medicine, New York, New York; Department of Radiology (S.F.M.), University of Western Ontario, Peterborough Regional Health Center, Peterborough, Ontario, Canada; Department of Radiology, Gastrointestinal/Genitourinary Division (D.A.G.), Massachusetts General Hospital; Department of Radiology (S.N.G.), Beth Israel Deaconess Medical Center, Boston; Department of Radiology (C.J.G.), Lahey Clinic Medical Center, Burlington; Department of Radiology (D.A.P.), University of Massachusetts Memorial Health Care, Worcester, Massachusetts; Department of Radiology (T.B.K.), University of California San Diego Medical Center, San Diego, California; Department of Radiology (D.S.), The Reading Hospital and Medical Center, Reading, Pennsylvania; and Department of Radiology (J.F.C.), University of Colorado Health Sciences Center, Denver, Colorado. Received June 19, 2006; revision requested June 19; final revision received June 29; and accepted July 3. Address correspondence to T.W.I.C., c/o Tricia McClenny, Society of Interventional Radiology, 3975 Fair Ridge Dr, Suite 400 North, Fairfax, VA 22033; E-mail: mcclenny@sirweb.org