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Haroon M, Sathiadoss P, Hibbert RM, Jeyaraj SK, Lim C, Schieda N. Imaging considerations for thermal and radiotherapy ablation of primary and metastatic renal cell carcinoma. Abdom Radiol (NY) 2021; 46:5386-5407. [PMID: 34245341 DOI: 10.1007/s00261-021-03178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 10/20/2022]
Abstract
Ablative (percutaneous and stereotactic) thermal and radiotherapy procedures for management of both primary and metastatic renal cell carcinoma are increasing in popularity in clinical practice. Data suggest comparable efficacy with lower cost and morbidity compared to nephrectomy. Ablative therapies may be used alone or in conjunction with surgery or chemotherapy for treatment of primary tumor and metastatic disease. Imaging plays a crucial role in pre-treatment selection and planning of ablation, intra-procedural guidance, evaluation for complications, short- and long-term post-procedural surveillance of disease, and treatment response. Treatment response and disease recurrence may differ considerably after ablation, particularly for stereotactic radiotherapy, when compared to conventional surgical and chemotherapies. This article reviews the current and emerging role of imaging for ablative therapy of renal cell carcinoma.
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Bertolotto M, Campo I, Sachs C, Ciabattoni R, Cicero C, Drudi FM, Derchi LE, Cova MA. Contrast-enhanced ultrasound after successful cryoablation of benign and malignant renal tumours: how long does tumour enhancement persist? J Med Imaging Radiat Oncol 2021; 65:272-278. [PMID: 33547767 DOI: 10.1111/1754-9485.13149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/07/2020] [Accepted: 01/04/2021] [Indexed: 01/20/2023]
Abstract
INTRODUCTION To investigate how long successfully ablated tumours take to become completely avascular at CEUS after cryoablation. METHODS Ninety-five patients had percutaneous cryoablation of 103 renal tumours investigated at CEUS on post-operative day one. If the lesion was avascular, a contrast-CT/MR was scheduled six months after the procedure, while CEUS was repeated if the lesion still displayed enhancement, until the disappearance of intralesional vascularity. Technical success was defined when the tumour was covered completely by the ablation zone. Technique efficacy was assessed at six months of follow-up. RESULTS Technical efficacy was obtained for 101/103 cryoablations, 56% of which (57/101) were avascular on post-operative day one. After one week, two weeks, one month 83%, 91% and 100% of these 101 lesions, respectively, were avascular. Two tumours were unsuccessfully treated. They displayed persistent intralesional vascularity at CEUS one month after the procedure. CONCLUSIONS After cryoablation, obtaining CEUS before one month may be misleading. When technical efficacy is obtained, disappearance of intralesional enhancement is observed within two weeks in the majority of cases (91%), but can persist until one month. Identification of tumour enhancement after one month may be concerning for residual viable tumour.
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Affiliation(s)
- Michele Bertolotto
- Department of Radiology, University of Trieste, Ospedale di Cattinara, Trieste, Italy
| | - Irene Campo
- Department of Radiology, Ospedale Civile di Conegliano, ULSS 2 Marca Trevigiana, Conegliano (TV), Italy
| | - Camilla Sachs
- S.C. Radiologia Pordenone - Sacile, Azienda sanitaria Friuli Occidentale (ASFO), Pordenone (PN), Italy
| | - Riccardo Ciabattoni
- Department of Radiology, University of Trieste, Ospedale di Cattinara, Trieste, Italy
| | - Calogero Cicero
- Department of Radiology, Ospedale San Bassiano, Bassano del Grappa (VI), Italy
| | - Francesco Maria Drudi
- Department of Radiology, University Sapienza of Rome, Policlinico Umberto I, Roma, Italy
| | - Lorenzo E Derchi
- Department of Health Sciences (DISSAL), University of Genoa, Emergency Radiology, Policlinico San Martino IST, Genova, Italy
| | - Maria Assunta Cova
- Department of Radiology, University of Trieste, Ospedale di Cattinara, Trieste, Italy
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van Oostenbrugge TJ, Langenhuijsen JF, Oosterwijk E, Boerman OC, Jenniskens SF, Oyen WJG, Fütterer JJ, Mulders PFA. Follow-up imaging after cryoablation of clear cell renal cell carcinoma is feasible using single photon emission computed tomography with 111In-girentuximab. Eur J Nucl Med Mol Imaging 2019; 47:1864-1870. [PMID: 31768601 PMCID: PMC7299921 DOI: 10.1007/s00259-019-04613-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 11/11/2019] [Indexed: 11/24/2022]
Abstract
Purpose Detection of residual or recurrent vital renal tumor on follow-up (FU) cross-sectional imaging after ablative therapy is challenging. The specific and high expression levels of carbonic anhydrase IX (CAIX) in clear cell renal cell carcinoma (ccRCC) makes it a suitable target for imaging using radiolabeled anti-CAIX antibody girentuximab. The objective of this study was to evaluate the feasibility of targeted FU imaging 1 month after cryoablation of ccRCC using single photon emission computed tomography (SPECT) after 111In-labeled girentuximab administration. Methods In this prospective study 16 patients underwent 111In-girentuximab-SPECT before MR-guided renal cryoablation between February 2015 and September 2018. In case of tumor targeting 111In-girentuximab-SPECT was repeated 1 month following MR-guided cryoablation. Presence of residual or recurrent vital tumor was assessed on contrast-enhanced cross-sectional imaging during further FU. The standard FU imaging protocol consisted of MRI/CT scans at 1, 3, 6, 12, and 18 months and annually thereafter. Results A total of 10 (63%) patients showed positive tumor targeting on 111In-girentuximab-SPECT before cryoablation and 9 ( 56%) were eligible to undergo FU SPECT. Of the 9 111In-girentuximab-SPECT FU scans, 8 (89%) were considered negative. One (11%) scan showed uptake suggestive for residual vital tumor. Six months after treatment, FU CT showed contrast enhancement suggestive for residual/recurrent disease in the ablated zone at the site of the 111In-girentuximab uptake after treatment. During a mean FU of 21 months (range 1–33) no other cases with residual/recurrent disease were detected. Conclusion FU imaging with 111In-girentuximab-SPECT is feasible after ccRCC cryoablation and may contribute to early detection of residual or recurrent disease.
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Affiliation(s)
- Tim J van Oostenbrugge
- Department of Urology, Radboud University Medical Center, 6500, HB, Nijmegen, the Netherlands. .,Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Johan F Langenhuijsen
- Department of Urology, Radboud University Medical Center, 6500, HB, Nijmegen, the Netherlands
| | - Egbert Oosterwijk
- Department of Urology, Radboud University Medical Center, 6500, HB, Nijmegen, the Netherlands
| | - Otto C Boerman
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sjoerd F Jenniskens
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wim J G Oyen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Jurgen J Fütterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter F A Mulders
- Department of Urology, Radboud University Medical Center, 6500, HB, Nijmegen, the Netherlands
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Fraisse G, Colleter L, Peyronnet B, Khene ZE, Mandoorah Q, Soorojebally Y, Bourgi A, De La Taille A, Roupret M, De Kerviler E, Desgrandchamps F, Bensalah K, Masson-Lecomte A. Peri-operative and local control outcomes of robot-assisted partial nephrectomy vs percutaneous cryoablation for renal masses: comparison after matching on radiological stage and renal score. BJU Int 2018; 123:632-638. [PMID: 30153399 DOI: 10.1111/bju.14530] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To compare the oncological outcomes of percutaneous cryoablation (PCA) vs robot-assisted partial nephrectomy (RAPN) for the treatment of T1 renal tumours. PATIENTS AND METHODS We conducted a retrospective study in all patients treated by RAPN or PCA for malignant renal tumours in one of four centres between 2009 and 2016. Tumours were paired one by one using radiological tumour stage and RENAL nephrometry score (package matchit, R software version 3.2.2). Malignancy was confirmed by biopsy for all patients in the PCA group. Patient characteristics before and after matching and oncological results were compared between the two groups. Cox regression, adjusted for age, treatment type, histological type and margins, was used to identify factors associated with time to local recurrence. Positive margins were defined histologically in the RAPN group and radiologically in the PCA group. RESULTS A total of 647 patients were identified; 470 underwent RAPN and 177 underwent PCA. After matching, there was no significant difference between the two groups (RAPN, n = 177; PCA, n = 177) with regard to tumour stage, RENAL nephrometry score, tumour size (27.6 vs 25.9 mm; P = 0.07) and gender ratio. Patients in the PCA group remained significantly older (69.9 vs 59.8 years; P < 0.001). The absolute recurrence rate was 2.8% in the RAPN group vs 8.4% in the PCA group (P = 0.03). The 5-year recurrence-free survival rate was 85% in the PCA group vs 95% in the RAPN group (log-rank P = 0.02). In multivariate analysis, the presence of positive margins and the type of treatment were the two factors significantly associated with local recurrence (P < 0.001 and P = 0.046, respectively). CONCLUSION The local recurrence rate after PCA was significantly higher than after RAPN for T1 renal tumours. Incomplete treatment was the main criterion associated with recurrence. The recurrence rate may have been overestimated in the PCA group because of closer radiological follow-up in these patients.
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Affiliation(s)
- Guillaume Fraisse
- Urology Department, Saint Louis Academic Hospital, Paris Diderot Université, Paris, France
| | - Loïc Colleter
- Radiology Department, Saint Louis Hospital, APHP, Université Paris Diderot, Paris, France
| | | | | | - Qusay Mandoorah
- GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Yanish Soorojebally
- INSERMU955Eq07, Urology Department, Henri Mondor Academic Hospital, Créteil, France
| | - Ali Bourgi
- INSERMU955Eq07, Urology Department, Henri Mondor Academic Hospital, Créteil, France
| | | | - Morgan Roupret
- GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Eric De Kerviler
- Radiology Department, Saint Louis Hospital, APHP, Université Paris Diderot, Paris, France
| | | | - Karim Bensalah
- Urology Department, Rennes Academic Hospital, Rennes, France
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Bertolotto M, Siracusano S, Cicero C, Iannelli M, Silvestri T, Celia A, Guarise A, Stacul F. Cryotherapy of Renal Lesions: Enhancement on Contrast-Enhanced Sonography on Postoperative Day 1 Does Not Imply Viable Tissue Persistence. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:301-310. [PMID: 27914172 DOI: 10.7863/ultra.16.02061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 05/23/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To investigate whether persistent enhancement detected on contrast-enhanced sonography at postoperative day 1 (early contrast-enhanced sonography) after cryoablation of renal tumors implies the presence of residual viable tumor tissue, defined as residual enhancing tissue on reference imaging (computed tomography or magnetic resonance imaging) performed 6 months after the procedure. METHODS Seventy-four patients with percutaneous cryoablation of renal tumors had early contrast-enhanced sonography from November 2011 to August 2015. Two independent readers evaluated early contrast-enhanced sonographic findings and contrast-enhanced sonographic investigations performed 1 month after cryoablation of lesions that displayed enhancement on early contrast-enhanced sonography. They scored intralesional enhancement in 4 groups: no enhancement, few intralesional vessels, focal enhancing areas, and diffuse enhancement. Inter-reader agreement in evaluating lesion vascularity on early contrast-enhanced sonography was assessed with weighted κ statistics. Computed tomography or magnetic resonance imaging performed 6 months after the treatment was the reference procedure for assessing the absence or presence of residual disease. RESULTS Inter-reader agreement in assessing intratumoral vascularization on early contrast-enhanced sonography was very good (κ = 0.90). Enhancement was absent for both readers in 33 of 74 cases; only a few intralesional vessels were visible in 21; whereas diffuse or focal enhancement was present in 13. In the remaining 7 patients, there were differences. Four lesions with focal enhancement on early contrast-enhanced sonography and 1 that was considered avascular had residual tumors on reference imaging. Ablation was successful in the remaining 69 of 74 patients (93%). CONCLUSIONS After cryoablation, intratumoral enhancement on early contrast-enhanced sonography does not imply tumor cell viability.
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Affiliation(s)
- Michele Bertolotto
- Department of Radiology, University of Trieste, Ospedale di Cattinara, Trieste, Italy
| | - Salvatore Siracusano
- Department of Urology, University of Verona, Policlinico G. B. Rossi, Verona, Italy
| | - Calogero Cicero
- Department of Radiology, Ospedale San Bassiano, Bassano del Grappa, Italy
| | - Mariano Iannelli
- Department of Radiology, University of Trieste, Ospedale di Cattinara, Trieste, Italy
| | - Tommaso Silvestri
- Department of Urology, University of Trieste, Ospedale di Cattinara, Trieste, Italy
| | - Antonio Celia
- Department of Urology, Ospedale San Bassiano, Bassano del Grappa, Italy
| | - Alessandro Guarise
- Department of Radiology, Ospedale San Bassiano, Bassano del Grappa, Italy
| | - Fulvio Stacul
- S. C. Radiologia Ospedale Maggiore, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Trieste, Trieste, Italy
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Non-Surgical Ablative Therapy for Management of Small Renal Masses-Current Status and Future Trends. Indian J Surg Oncol 2017; 8:39-45. [PMID: 28127181 DOI: 10.1007/s13193-016-0598-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022] Open
Abstract
A large number of small renal masses (SRMs) with size less than 4 cm are being identified due to advances in diagnostic imaging. As the natural history of these tumours remains unknown, there is no reliable way to predict their behaviour or future growth. Although, partial nephrectomy is the gold standard for treatment of these tumours, ablative non-surgical therapies such as cryoablation and radiofrequency ablation provide a less invasive option of treatment with comparable oncological outcomes. In this systematic review, the principle, indications, methods of treatment, oncological control, complication and renal function of ablative therapies are critically reviewed. Cryotherapy utilizes the principle of inducing tissue destruction by freezing and thawing using argon and helium gasses, respectively. Radiofrequency ablation (RFA) works on the principle of tissue heating. Ablative treatments are particularly useful in the elderly patients, those with comorbidities or in patients with SRMs in solitary kidneys or renal impairment. Ablative therapies have less procedure-related complications and have promising medium-term oncological outcome. Longer-term results are accumulating. Cryotherapy may be a better modality for oncological control than RFA. Ablative therapy has emerged as a viable treatment options for SRMs with recurrence free survival rates approaching that of extirpative surgery. However, there is no consensus in the literature on the best selection criteria and this needs further refinement. Prospective long-term data with regards to oncological control is still needed.
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Zondervan PJ, Wagstaff PGK, Desai MM, de Bruin DM, Fraga AF, Hadaschik BA, Köllermann J, Liehr UB, Pahernik SA, Schlemmer HP, Wendler JJ, Algaba F, de la Rosette JJMCH, Laguna Pes MP. Follow-up after focal therapy in renal masses: an international multidisciplinary Delphi consensus project. World J Urol 2016; 34:1657-1665. [PMID: 27106492 PMCID: PMC5114314 DOI: 10.1007/s00345-016-1828-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/04/2016] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To establish consensus on follow-up (FU) after focal therapy (FT) in renal masses. To formulate recommendations to aid in clinical practice and research. METHODS Key topics and questions for consensus were identified from a systematic literature research. A Web-based questionnaire was distributed among participants selected based on their contribution to the literature and/or known expertise. Three rounds according to the Delphi method were performed online. Final discussion was conducted during the "8th International Symposium on Focal Therapy and Imaging in Prostate and Kidney Cancer" among an international multidisciplinary expert panel. RESULTS Sixty-two participants completed all three rounds of the online questionnaire. The panel recommended a minimum follow-up of 5 years, preferably extended to 10 years. The first FU was recommended at 3 months, with at least two imaging studies in the first year. Imaging was recommended biannually during the second year and annually thereafter. The panel recommended FU by means of CT scan with slice thickness ≤3 mm (at least three phases with excretory phase if suspicion of collecting system involvement) or mpMRI. Annual checkup for pulmonary metastasis by CT thorax was advised. Outside study protocols, biopsy during follow-up should only be performed in case of suspicion of residual/persistent disease or radiological recurrence. CONCLUSIONS The consensus led to clear FU recommendations after FT of renal masses supported by a multidisciplinary expert panel. In spite of the low level of evidence, these recommendations can guide clinicians and create uniformity in the follow-up practice and for clinical research purposes.
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Affiliation(s)
- P J Zondervan
- Department of Urology, AMC University Hospital, PO box 22660, 1100DD, Amsterdam, The Netherlands.
| | - P G K Wagstaff
- Department of Urology, AMC University Hospital, PO box 22660, 1100DD, Amsterdam, The Netherlands
| | - M M Desai
- Department of Urology, Keck School of Medicine USC, Los Angeles, CA, USA
| | - D M de Bruin
- Department of Urology, AMC University Hospital, PO box 22660, 1100DD, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, AMC University Hospital, Amsterdam, The Netherlands
| | - A F Fraga
- Department of Urology, Centro Hospitalar do Porto, Porto, Portugal
| | - B A Hadaschik
- Department of Urology, University Hospital Heidelberg, Heidelberg, Germany
| | - J Köllermann
- Department of Pathology, Sana Klinikum Offenbach, Offenbach, Germany
| | - U B Liehr
- Department of Urology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - S A Pahernik
- Department of Urology, University Hospital Heidelberg, Heidelberg, Germany
| | - H P Schlemmer
- Department of Urology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - J J Wendler
- Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - F Algaba
- Department of Pathology, Fundació Puigvert, Barcelona, Spain
| | - J J M C H de la Rosette
- Department of Urology, AMC University Hospital, PO box 22660, 1100DD, Amsterdam, The Netherlands
| | - M P Laguna Pes
- Department of Urology, AMC University Hospital, PO box 22660, 1100DD, Amsterdam, The Netherlands
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Zondervan PJ, Buijs M, de la Rosette JJ, van Delden O, van Lienden K, Laguna MP. Cryoablation of small kidney tumors. Int J Surg 2016; 36:533-540. [PMID: 27500963 DOI: 10.1016/j.ijsu.2016.06.049] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 06/04/2016] [Accepted: 06/19/2016] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Cryoablation (CA) has been broadly used mostly in the treatment of small renal masses (SRMs). The present review aims to define the current role of CA in the treatment of SRMs by assessing clinical indications and outcomes. METHOD A comprehensive review on patient selection, procedural details, perioperative complications, and short/long-term oncological and functional outcomes was conducted. For each section, a take-home message was formulated with level of evidence (LoE) according to Cochrane collaboration. RESULTS Age and comorbidity drive the choice of ablation in SRMs, although hospital setting also influences the decision. Technically in adequate CA or first post-CA control occurs in 3-5% of laparoscopic cryoablation (LCA) or percutaneous cryoablation (PCA) series. Meta-analysis does not evidence differences in the rate of residual tumor per person-year between the approaches (0.033 LCA vs. 0.046 PCA, p = 0.25). Perioperative complications (8-25%) are erratically reported. LCA has significantly lower likelihood of complications than minimally invasive partial nephrectomy (MIPN). Systematic reviews indicate 30-month local tumor progression rate of 8.5% for LCA in renal cell carcinoma but low metastatic progression (1-4.4%). Few LCA long-term follow-up series (mean/media 48-98 months) report recurrence-free survival (RFS) and cancer-specific survival (CSS) ranges of 80-100%. For PCA, Kaplan-Meier local disease-free survival (DFS) of 95.6% at 3-5 years [32] and 5-year overall survival and local RFS of 86.3% were reported. The decrease in renal function after CA is minimal, and the only risk factor associated is the basal estimated glomerular filtration rate (eGFR). CONCLUSION LoE 3a/b confirms lower CA perioperative complication rate and higher local progression rate than those for MIPN. CA preserves postoperative renal functional, without any evidence of differences in mid-/long-term follow-up compared to nephron sparing surgery.
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Affiliation(s)
- P J Zondervan
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M Buijs
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J J de la Rosette
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - O van Delden
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - K van Lienden
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M P Laguna
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Leão RRN, Richard PO, Jewett MAS. Indications for biopsy and the current status of focal therapy for renal tumours. Transl Androl Urol 2016; 4:283-93. [PMID: 26816831 PMCID: PMC4708239 DOI: 10.3978/j.issn.2223-4683.2015.06.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The increased detection of small renal masses (SRMs) has focused attention on their uncertain natural history. The development of treatment alternatives and the discovery of biologically targeted drugs have also raised interest. Renal mass biopsies (RMBs) have a crucial role as they provide the pathological, molecular and genetic information needed to classify these lesions and guide clinical management. The improved accuracy has improved our knowledge of the behaviour of different tumour histologies and opened the potential for risk-adapted individualized treatment approaches. To date, studies have demonstrated that percutaneous ablation is an effective therapy with acceptable outcomes and low risk in the appropriate clinical setting. Although partial nephrectomy (PN) is still considered the standard treatment for SRM, percutaneous ablation is increasingly being performed and if long-term efficacy is sustained, it may have a wider application for SRMs after biopsy characterization.
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Affiliation(s)
- Ricardo R N Leão
- Department of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Patrick O Richard
- Department of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Michael A S Jewett
- Department of Surgery (Urology) and Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and the University of Toronto, Toronto, Ontario, Canada
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Nielsen TK, Østraat Ø, Andersen G, Høyer S, Graumann O, Borre M. Computed Tomography Contrast Enhancement Following Renal Cryoablation—Does it Represent Treatment Failure? J Endourol 2015; 29:1353-60. [DOI: 10.1089/end.2015.0405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
| | - Øyvind Østraat
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Gratien Andersen
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Høyer
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Ole Graumann
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Borre
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark
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11
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Sanz E, Hevia V, Arias F, Fabuel JJ, Álvarez S, Rodríguez-Patrón R, Gómez V, Díez-Nicolás V, González-Gordaliza C, Burgos FJ. Contrast-enhanced ultrasound (CEUS): an excellent tool in the follow-up of small renal masses treated with cryoablation. Curr Urol Rep 2015; 16:469. [PMID: 25404183 DOI: 10.1007/s11934-014-0469-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Strict imaging follow-up is mandatory after cryoablation of small renal masses (SRMs). Although it uses ionizing radiation and nephrotoxic iodinated contrast, computed tomography (CT) is still the gold standard test. Contrast-enhanced ultrasound (CEUS) is a novel technique that informs in real time about renal perfusion avoiding radiation and nephrotoxicity. The objective of this study is to compare outcomes between CEUS and CT in the follow-up of SRMs treated with cryoablation, as well as to assess degree of agreement between them. This is a prospective observational study (May 2012 to December 2013) comparing CEUS and CT in 16 patients with SRMs cryoablated. The on-going protocol of the study includes a CT and CEUS 3 months after treatment and then every 6 months during 5 years. Local relapse was defined as the presence of contrast enhancement in the mass. All the CEUS were performed by a single experienced observer (E.S.). Degree of agreement was measured with kappa index. CEUS detected contrast enhancement in three patients (3/16, 18.8%) and CT in two patients (2/16, 12.5%). Degree of agreement between CEUS and CT, according to Landis-Koch classification, was 0.76 (CI 0.33-1.19; p = 0.0165), which is excellent and higher than expected by random. Sensitivity of the test is 93.75% (15/16). Median time of follow-up after cryoablation is 22 months (15.5-36.5). CEUS has an excellent agreement with CT and a high sensitivity in the follow-up of SRMs treated with cryosurgery, demonstrating its usefulness. Due to these encouraging results, it could become a reference test in the near future for monitoring SRMs after ablative treatment.
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Affiliation(s)
- Enrique Sanz
- Urology Department, Hospital Universitario Ramón y Cajal, Alcalá University, Madrid, Spain
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12
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Percutaneous Cryoablation for Renal Cell Carcinoma. J Kidney Cancer VHL 2015; 2:105-113. [PMID: 28326265 PMCID: PMC5345531 DOI: 10.15586/jkcvhl.2015.34] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 06/07/2015] [Indexed: 01/20/2023] Open
Abstract
Renal cell carcinoma (RCC) is the most common type of kidney cancer in adults. Nephron sparing resection (partial nephrectomy) has been the “gold standard” for the treatment of resectable disease. With the widespread use of cross sectional imaging techniques, more cases of renal cell cancers are detected at an early stage, i.e. stage 1A or 1B. This has provided an impetus for expanding the nephron sparing options and especially, percutaneous ablative techniques. Percutaneous ablation for RCC is now performed as a standard therapeutic nephron-sparing option in patients who are poor candidates for resection or when there is a need to preserve renal function due to comorbid conditions, multiple renal cell carcinomas, and/or heritable renal cancer syndromes. During the last few years, percutaneous cryoablation has been gaining acceptance as a curative treatment option for small renal cancers. Clinical studies to date indicate that cryoablation is a safe and effective therapeutic method with acceptable short and long term outcomes and with a low risk, in the appropriate setting. In addition it seems to offer some advantages over radio frequency ablation (RFA) and other thermal ablation techniques for renal masses.
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Durack JC, Richioud B, Lyon J, Solomon SB. Late emergence of contrast-enhancing fat necrosis mimicking tumor seeding after renal cryoablation. J Vasc Interv Radiol 2014; 25:133-7. [PMID: 24365507 DOI: 10.1016/j.jvir.2013.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 06/29/2013] [Accepted: 07/02/2013] [Indexed: 11/16/2022] Open
Abstract
Defining radiographic treatment success after percutaneous renal ablation is challenging due to variable ablation zone imaging findings over time. The present report describes two cases of progressively more evident enhancing soft-tissue nodules in the perinephric fat more than 2 years after cryoablation. Despite features concerning for tumor recurrence on computed tomography and magnetic resonance imaging, biopsies revealed fat necrosis in both cases. Renal ablation zone soft-tissue nodules can appear long after ablation, enhance with contrast medium, mimic applicator tract or ablation zone tumor seeding, and may require biopsy for confirmation of benignity.
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Affiliation(s)
- Jeremy C Durack
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065.
| | | | - James Lyon
- San Diego Imaging, Sharp Memorial Hospital, San Diego, California
| | - Stephen B Solomon
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065
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Iannuccilli JD, Grand DJ, Dupuy DE, Mayo-Smith WW. Percutaneous ablation for small renal masses-imaging follow-up. Semin Intervent Radiol 2014; 31:50-63. [PMID: 24596440 DOI: 10.1055/s-0033-1363843] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Image-guided percutaneous thermal ablation is a safe and effective nephron-sparing alternative to surgical resection for the treatment of small renal tumors. Assessment of treatment efficacy relies heavily on interval follow-up imaging after treatment. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) both play a pivotal role in evaluating the treatment zone, identifying residual tumor, and detecting early and delayed procedure-related complications. This article discusses a surveillance imaging protocol for patients who undergo percutaneous thermal ablation of renal tumors, and also illustrates the typical appearances of both successfully treated tumors and residual disease on contrast-enhanced CT or MRI. In addition, it discusses the imaging appearance of potential early and delayed treatment-related complications to facilitate their prompt detection and management.
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Affiliation(s)
- Jason D Iannuccilli
- Department of Diagnostic Imaging, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, Rhode Island
| | - David J Grand
- Department of Diagnostic Imaging, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Damian E Dupuy
- Department of Diagnostic Imaging, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, Rhode Island
| | - William W Mayo-Smith
- Department of Diagnostic Imaging, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, Rhode Island
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El Dib R, Nascimento Junior P, Kapoor A. An alternative approach to deal with the absence of clinical trials: a proportional meta-analysis of case series studies. Acta Cir Bras 2013; 28:870-6. [DOI: 10.1590/s0102-86502013001200010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 11/13/2013] [Indexed: 11/22/2022] Open
Affiliation(s)
- Regina El Dib
- Sao Paulo State University, Brazil; McMaster University, Canada
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Chalasani V, Martinez CH, Lim D, Abdelhady M, Chin JL. Surgical cryoablation as an option for small renal masses in patients who are not ideal partial nephrectomy candidates: intermediate-term outcomes. Can Urol Assoc J 2013; 4:399-402. [PMID: 21191499 DOI: 10.5489/cuaj.954] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE There has been increasing interest in surveillance and ablative techniques for small renal masses (SRM), given the increasing number being diagnosed at smaller sizes. Of the currently available ablative techniques, radiofrequency ablation and cryoablation have been the popular ones. We describe our intermediate-term outcomes with using cryoablation for SRM in patients who were not ideal candidates for partial nephrectomy. MATERIALS AND METHODS Nineteen patients treated with cryoablation were included. Patients with renal lesions <4 cm were considered for cryoablation, and all patients were treated between 2002 and 2007. Access was either laparoscopic (transperitoneal) or via open surgical techniques. From 2002 to 2004, the CryoCare System (Endocare, Inc., Irvine, CA) was used, with probe sizes ranging from 3 to 5 mm. Before 2004, the SeedNet system (Galil Medical, Arden Hills, MN) was used, with 17-gauge (1.47 mm) IceRod cryoneedles. Recurrence-free survival (RFS) and overall survival (OS) were calculated using Kaplan Meier methodology. RESULTS The mean age was 56.7 years. The mean tumour size was 2.6 cm (range 1.2-4.0 cm). There were no intraoperative or postoperative complications in the 19 patients. One patient has been lost to follow-up; mean follow up was 41.6 months (range 7-84 months) in the cohort. Recurrence, defined as either increase in size of lesion or enhancement on follow-up imaging, was seen in 4 patients. There was 1 non-cancer specific death, and 1 cancer specific death. CONCLUSIONS The 4-year RFS rate and OS rate were 83.6% and 94.1%, respectively, in patients with SRM who were unsuitable for partial nephrectomy.
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Affiliation(s)
- Venu Chalasani
- Division of Urology, University of Western Ontario, London, ON
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Barwari K, Wijkstra H, van Delden OM, de la Rosette JJ, Laguna MP. Contrast-enhanced ultrasound for the evaluation of the cryolesion after laparoscopic renal cryoablation: an initial report. J Endourol 2013; 27:402-7. [PMID: 23092215 DOI: 10.1089/end.2012.0400] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Stringent radiological follow-up is essential after renal tumor ablation. Drawbacks of postablation follow-up by contrast-enhanced computed tomography (CECT) are the associated ionizing radiation and nephrotoxic contrast agent. Contrast-enhanced ultrasound (CEUS) has shown potential to demonstrate microvasculature without using either ionizing radiation or toxic contrast agent. We assessed the concordance of enhancement patterns of CEUS and CECT/MRI in cryolesion assessment after laparoscopic renal cryoablation (LCA). METHODS From 01/2006 to 01/2009, a CEUS was performed before and after LCA (3 and 12 months) in addition to regular CECT/MRI. Using an enhancement score (0=no enhancement, 1=rim enhancement, 2=diffuse enhancement, 3=localized enhancement, 4=no enhancement defect), the cryolesion was assessed by both modalities, and concordance of enhancement score was assessed. RESULTS In total, 45 tumors were included (29 biopsy proven renal cell carcinoma (RCC), mean size 2.66 cm). One cryoablation failed, resulting in a nonenhancing cryolesion apart from the persisting renal tumor. There were no postablation recurrences during the study period. Pre-LCA: Both modalities were available in 26 cases. In 20 out of 26, there was concordance of enhancement score (77%, all cases score 3 or 4). Three months: Both modalities were available in 32 cases. Enhancement score corresponded in 23 out of 32 cases (72%). Seven cases showed enhancement on CECT/MRI ("1" in six cases, "4" in one case) with enhancement score "0"on CEUS. Two cases showed enhancement on CEUS without enhancement on CECT/MRI (specificity 92%, negative predictive value [NPV] 77%). Except one case, all enhancement resolved on subsequent imaging. Twelve months: Both modalities were available in 21 tumors. Enhancement score corresponded in 19 out of 21 cases (91%). Two cases showed enhancement on CEUS without enhancement on CECT/MRI (specificity 90%, NPV 100%). CONCLUSION This pilot study shows that CEUS is a safe imaging technique with high concordance of enhancement score between CEUS and CECT/MRI. While cross-sectional imaging seems sensible to demonstrate successful ablation at first follow-up, CEUS might be used to diminish the burden of contrast-enhanced cross-sectional imaging in the long-term follow-up.
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Affiliation(s)
- Kurdo Barwari
- Department of Urology, AMC University Hospital, University of Amsterdam, Amsterdam, The Netherlands.
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Abstract
Thermoablation (TA) has become an increasingly popular treatment for small renal masses (SRMs). Although long-term outcomes are not currently reported, TA may have a role in being an alternative to radical or partial nephrectomy. This review gives a broad overview of TA and discusses current controversies in the field.
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Affiliation(s)
- Phillip H Abbosh
- Division of Urology, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Volpe A, Finelli A, Gill IS, Jewett MA, Martignoni G, Polascik TJ, Remzi M, Uzzo RG. Rationale for Percutaneous Biopsy and Histologic Characterisation of Renal Tumours. Eur Urol 2012; 62:491-504. [DOI: 10.1016/j.eururo.2012.05.009] [Citation(s) in RCA: 187] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 05/03/2012] [Indexed: 12/18/2022]
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Hétet JF, Colls P, Pocholle P, Chauveau P, Barré C. Cryothérapie des tumeurs rénales par approche laparoscopique. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.fpurol.2011.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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El Dib R, Touma NJ, Kapoor A. Cryoablation vs radiofrequency ablation for the treatment of renal cell carcinoma: a meta-analysis of case series studies. BJU Int 2012; 110:510-6. [PMID: 22304329 DOI: 10.1111/j.1464-410x.2011.10885.x] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
UNLABELLED Study Type - Therapy (systematic review). Level of Evidence 2b What's known on the subject? and What does the study add? The oncological success of partial nephrectomy in the treatment of small renal masses is well established. However, partial nephrectomy has largely supplanted the radical approach. In the last decade, laparoscopy has been adopted as the new surgical approach for the treatment of renal cell carcinoma. Laparoscopy offers the advantage of lower analgesic use, shorter hospital stay, and quicker recovery time. More recently, ablative technologies have been investigated as an alternative to laparoscopic partial nephrectomy. These techniques can often be performed percutaneously in the radiology suite, or laparoscopically without the need for hilar clamping. However, only the cryoablation and radiofrequency ablation modalities have had widespread use with several series reporting short to intermediate results. This review shows that both cryoablation and radiofrequency ablation are promising therapies in patients with small renal tumours (<4 cm), who are considered poor candidates for more involved surgery. OBJECTIVE • To determine the current status of the literature regarding the clinical efficacy and complication rates of cryoablation vs radiofrequency ablation in the treatment of small renal tumours. METHODS • A review of the literature was conducted. There was no language restriction. Studies were obtained from the following sources: MEDLINE, EMBASE and LILACS. • Inclusion criteria were (i) case series design with more than one case reported, (ii) use of cryoablation or radiofrequency ablation, (iii) patients with renal cell carcinoma and, (iv) outcome reported as clinical efficacy. • When available, we also quantified the complication rates from each included study. • Proportional meta-analysis was performed on both outcomes with a random-effects model. The 95% confidential intervals were also calculated. RESULTS • Thirty-one case series (20 cryoablation, 11 radiofrequency ablation) met all inclusion criteria. • The pooled proportion of clinical efficacy was 89% in cryoablation therapy from a total of 457 cases. There was a statistically significant heterogeneity between these studies showing the inconsistency of clinical and methodological aspects. • The pooled proportion of clinical efficacy was 90% in radiofrequency ablation therapy from a total of 426 cases. There was no statistically significant heterogeneity between these studies. • There was no statistically significant difference regarding complications rate between cryoablation and radiofrequency ablation. CONCLUSIONS • This review shows that both ablation therapies have similar efficacy and complication rates. • There is urgency for performing clinical trials with long-term data to establish which intervention is most suitable for the treatment of small renal masses.
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Affiliation(s)
- Regina El Dib
- Botucatu School of Medicine, UNESP - Univ Estadual Paulista, Botucatu, Brazil.
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Tsivian M, Kim CY, Caso JR, Rosenberg MD, Nelson RC, Polascik TJ. Contrast enhancement on computed tomography after renal cryoablation: an evidence of treatment failure? J Endourol 2012; 26:330-5. [PMID: 22070179 DOI: 10.1089/end.2011.0337] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Renal cryoablation has gained popularity as a treatment option for localized renal masses. Treatment success is typically defined by the absence of contrast enhancement on follow-up imaging. We investigate the evolution of lesions that demonstrate contrast enhancement on CT after renal cryoablation. PATIENTS AND METHODS Retrospective review of records of laparoscopic and percutaneous cryoablation (LCA and PCA) was performed, identifying records with postoperative radiographic enhancement. Imaging studies were reviewed and radiographic (pre- and post-contrast Hounsfield units, pattern and location of enhancement) and clinical data including follow up were collected. RESULTS One hundred and seventy-two cryoablation procedures were analyzed. Of these, 30 (17.4%) showed enhancement on follow-up CT. In 28 cases, contrast enhancement was demonstrated on the first postoperative study. Seven patients underwent salvage treatments. Spontaneous resolution of enhancement was noted in 17 (56.7%) cases. No association was found between enhancement pattern (diffuse/nodular/rim) and resolution. Of lesions enhancing >35 HU, only 14.3% resolved spontaneously. Delayed enhancement (after negative imaging studies) occurred in two patients; both underwent salvage treatments. CONCLUSIONS Most of the time, contrast-enhancements after cryoablation are evident on the first follow-up imaging study. More than 50% of these resolve spontaneously, and only one of four patients need salvage treatment. Delayed appearance of enhancement after previously negative imaging and highly enhancing lesions (>35 HU) are unlikely to resolve and should be considered suspicious for local recurrence or incomplete ablation. Further investigation is warranted to reach a consensus on a radiographic definition of local recurrence after renal cryoablation.
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Affiliation(s)
- Matvey Tsivian
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
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Contemporary Management of Small Renal Masses. Eur Urol 2011; 60:501-15. [DOI: 10.1016/j.eururo.2011.05.044] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 05/23/2011] [Indexed: 02/07/2023]
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Lagerveld BW, van Horssen P, Laguna MP, van den Wijngaard JP, Siebes M, Wijkstra H, de la Rosette JJ, Spaan JA. Gradient Changes in Porcine Renal Arterial Vascular Anatomy and Blood Flow After Cryoablation. J Urol 2011; 186:681-6. [DOI: 10.1016/j.juro.2011.03.146] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Indexed: 11/28/2022]
Affiliation(s)
- Brunolf W. Lagerveld
- Department of Urology, St. Lucas Andreas Hospital and Onze Lieve Vrouwe Gasthuis, Academic Medical Centre, University of Amsterdam, The Netherlands
- Department of Urology, Academic Medical Centre, University of Amsterdam, The Netherlands
| | - Pepijn van Horssen
- Department of Biomedical Engineering and Physics, Academic Medical Centre, University of Amsterdam, The Netherlands
| | - M. Pilar Laguna
- Department of Urology, Academic Medical Centre, University of Amsterdam, The Netherlands
| | | | - Maria Siebes
- Department of Biomedical Engineering and Physics, Academic Medical Centre, University of Amsterdam, The Netherlands
| | - Hessel Wijkstra
- Department of Urology, Academic Medical Centre, University of Amsterdam, The Netherlands
| | | | - Jos A.E. Spaan
- Department of Biomedical Engineering and Physics, Academic Medical Centre, University of Amsterdam, The Netherlands
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Deodhar A, Monette S, Single GW, Hamilton WC, Thornton R, Maybody M, Coleman JA, Solomon SB. Renal tissue ablation with irreversible electroporation: preliminary results in a porcine model. Urology 2010; 77:754-60. [PMID: 21111458 DOI: 10.1016/j.urology.2010.08.036] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Revised: 07/07/2010] [Accepted: 08/21/2010] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the histopathologic and computed tomography imaging features associated with irreversible electroporation (IRE) ablation performed in normal porcine kidneys. IRE is a nonthermal ablative tool that uses direct electrical pulses to create permanent "pores" in cell membranes and cell death. It does not affect the extracellular matrix. METHODS Fifteen female swine were treated with IRE using acute (<24 hours), subacute (36 hours), and chronic (3 weeks) treatment settings. Unipolar IRE applicators were placed under CT guidance. The renal pelvis/calyx was included in 18 ablations. Imaging and histopathologic follow-up were performed. RESULTS A total of 29 ablations (19 acute, 4 subacute, and 6 chronic) were created. Acute/subacute ablations showed complete cortical necrosis without intervening live cells. The pelvic epithelium was necrotic with urothelial sloughing; pelvic extracellular matrix was intact. Chronic ablations showed cortical fibrosis, regenerating renal pelvic epithelium and intact pelvic extracellular matrix. No thermal injury, renal pelvic, or blood vessel injury was seen. Immediate postprocedure CT imaging demonstrated a hypodense nonenhancing lesion that persisted at 1 week. Of the 6 chronic lesions, 4 showed complete resolution at 3 weeks on imaging. No collecting system damage was seen. CONCLUSIONS This preliminary porcine study demonstrates the nonthermal and connective tissue sparing mechanism of action of IRE. These features may protect against collecting system damage after IRE ablation of renal tissue. IRE could therefore play an important role in ablation of centrally located renal tumors.
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Affiliation(s)
- Ajita Deodhar
- Interventional Radiology and Image Guided Therapies, Suite H118, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Allen BC, Remer EM. Percutaneous cryoablation of renal tumors: patient selection, technique, and postprocedural imaging. Radiographics 2010; 30:887-900. [PMID: 20631358 DOI: 10.1148/rg.304095134] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Percutaneous cryoablation of renal tumors requires a number of important steps for success and relies heavily on imaging for treatment planning, intraprocedural guidance and monitoring, detection of untreated tumor, and surveillance for disease progression. Imaging-guided percutaneous cryoablation has several advantages over laparoscopic cryoablation. In particular, computed tomography (CT) and magnetic resonance (MR) imaging allow global evaluation of the ablation zone and an accurate depiction of the treatment margin. Ultrasonography allows real-time guidance of probe placement but cannot help depict ice ball formation as accurately as CT or MR imaging. Multiphasic CT or MR imaging should be performed at structured intervals following ablation. Treated tumors are expected to decrease in size over time, and lesion growth and internal or nodular enhancement are suspicious for tumor recurrence or progression. Complications include probe site pain, hematoma, incomplete ablation, and recurrent tumor. Current limitations of percutaneous cryoablation include the inability to control hemorrhage without intraarterial access and a lack of long-term follow-up data. Nevertheless, percutaneous cryoablation is an effective choice for minimally invasive nephron-sparing treatment of renal tumors.
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Affiliation(s)
- Brian C Allen
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
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Survey of Endourology. J Endourol 2010. [DOI: 10.1089/end.2010.1528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Klingler HC, Susani M. Focal Therapy and Imaging in Prostate and Kidney Cancer: Renal Biopsy Protocols Before and After Focal Therapy. J Endourol 2010; 24:701-5. [DOI: 10.1089/end.2009.0526] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Martin Susani
- Department of Pathology, Medical University of Vienna, Vienna, Austria
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Rioja J, Tzortzis V, Mamoulakis C, Laguna M. Crioterapia de tumores renales: estado actual y desarrollos contemporáneos. Actas Urol Esp 2010. [DOI: 10.1016/j.acuro.2009.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ateş F, Akyol I, Sildiroglu O, Kucukodaci Z, Soydan H, Karademir K, Baykal K. Preoperative imaging in renal masses: does size on computed tomography correlate with actual tumor size? Int Urol Nephrol 2010; 42:861-6. [DOI: 10.1007/s11255-010-9707-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2009] [Accepted: 01/12/2010] [Indexed: 10/19/2022]
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A critical analysis of the actual role of minimally invasive surgery and active surveillance for kidney cancer. Eur Urol 2009; 57:223-32. [PMID: 19853989 DOI: 10.1016/j.eururo.2009.10.023] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Accepted: 10/13/2009] [Indexed: 12/28/2022]
Abstract
CONTEXT The incidence of renal cell carcinomas (RCCs) has increased steadily-most rapidly for small renal masses (SRMs). Paralleling the changing face of RCC in the past 2 decades, new, less invasive surgical options have been developed. Laparoscopic radical nephrectomy (LRN) is an established procedure for the treatment of RCC. Treatment of SRMs includes open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), thermal ablation, and active surveillance. OBJECTIVE To present an overview of minimally invasive treatment options and data on surveillance for kidney cancer. EVIDENCE ACQUISITION Literature and meeting abstracts were searched using the terms renal cell carcinoma, minimally invasive surgery, laparoscopic surgery, thermal ablation, surveillance, and robotic surgery. The articles with the highest level of evidence were identified with the consensus of all the collaborative authors and reviewed. EVIDENCE SYNTHESIS Renal insufficiency, as measured by the glomerular filtration rate, occurs more often after radical nephrectomy than partial nephrectomy (PN). OPN and LPN show comparable results in long-term oncologic outcomes. The treatment modality for SRMs should therefore be nephron-sparing surgery (NSS). In select patients, thermal ablation or active surveillance of SRMs is an alternative. CONCLUSIONS LRN has become the standard of care for most organ-confined tumours not amenable to NSS. Amongst NSS options, PN is the treatment of choice, yet remains underutilised in the community. Initial data during its learning curve revealed that LPN had higher urologic morbidity. However, current emerging data indicate that in experienced hands, LPN has shorter ischaemia times, a lower complication rate, and equivalent long-term oncologic and renal functional outcomes, yet with decreased patient morbidity compared to OPN. Robotic partial nephrectomy is being explored at select centres, and cryotherapy and radiofrequency ablation are options for carefully selected tumours. Active surveillance is an option for selected high-risk patients. Percutaneous needle biopsy is likely to gain increasing relevance in the management of small renal tumours.
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Abstract
Advances in imaging techniques (CT and MRI) and widespread use of imaging especially ultrasound scanning have resulted in a dramatic increase in the detection of small renal masses. While open partial nephrectomy is still the reference standard for the management of these small renal masses, its associated morbidity has encouraged clinicians to exploit the advancements in minimally invasive ablative techniques. The last decade has seen the rapid development of laparoscopic partial nephrectomy and novel ablative techniques such as, radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU), and cryoablation (CA). In particular, CA for small renal masses has gained popularity as it combines nephron-sparing surgery with a minimally invasive approach. Studies with up to 5-year followup have shown an overall and cancer-specific 5-year survival of 82% and 100%, respectively. This manuscript will focus on the principles and clinical applications of cryoablation of small renal masses, with detailed review of relevant literature.
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