HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hall, W. H. Articles by White, R. W. d. Search for Related Content PubMed PubMed Citation Articles by Hall, W. H. Articles by White, R. W. d. Social Bookmarking                      What's this?

Combined Embolization and Percutaneous Radiofrequency Ablation of a Solid Renal Tumor

¹ Department of Radiology, University of California Davis Medical Center, 4860 Y St., Ste. 3100, Sacramento, CA 95817.
² Department of Urology, University of California Davis Medical Center, Sacramento, CA 95817.

Received September 3, 1999; accepted after revision November 1, 1999.

 
Address correspondence to J. P. McGahan.

Introduction

Top Introduction Subject and Methods Discussion References

 
Renal cell carcinoma is the most common primary parenchymal malignancy of the kidney and accounts for 2% of all new cancers annually in the United States, with approximately 30,000 new cases per year [1]. Therapy usually consists of radical nephrectomy, depending on tumor extent and presence of regional or distant metastases. Small (<4 cm) solitary unilateral lesions may be amenable to nephron-sparing surgery or partial nephrectomy. The standard treatment for small malignant tumors in patients with a solitary kidney is partial nephrectomy. Improved surgical techniques have increased patient survival [2]. We describe a patient whose multiple medical problems precluded surgical resection of a small renal cell carcinoma in a solitary left kidney. Instead, this patient was referred for radiofrequency (RF) ablation of her lesion.

Subject and Methods

Top Introduction Subject and Methods Discussion References

 
A 67-year-old woman with a solitary left kidney presented with a solid heterogeneously enhancing 2.5 x 3.0 cm mass that was suggestive of malignancy at the superior pole of her kidney (Fig. 1A). The mass was incidentally discovered on a thoracic CT scan obtained for the evaluation of chronic pulmonary disease. The patient had previously undergone a right nephrectomy in 1961 for nephrolithiasis. This patient's multiple medical problems, including systemic lupus erythematosus and rheumatoid arthritis (both requiring chronic steroid therapy [prednisone, 5 mg/day]) and chronic obstructive pulmonary disease, caused by a long history of smoking, made her a poor candidate for surgery. Renal function tests revealed a blood urea nitrogen level of 13 mg/dl (normal range, 8-22 mg/dl) and a serum creatinine level of 0.9 mg/dl (normal range, 0.5-1.3 mg/dl). All hematologic tests revealed normal findings except for a hemoglobin level of 11.8 g/dl (normal range, 12-16 g/dl). Therefore, RF ablation of the mass was proposed. Before RF ablation, a sonographically guided biopsy of the mass was performed, which confirmed renal cell carcinoma. The patient provided informed consent for the biopsy and all subsequent portions of the tumor ablation. Because the biopsy samples contained a significant amount of blood, we decided to perform selective embolization of the tumor before RF ablation.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —67-year-old woman with chronic lung disease and solitary left kidney. CT scan of abdomen obtained with IV contrast material shows small hypervascular lesion (arrows) at upper pole of left kidney.

A left renal arteriogram revealed the hypervascularity of the tumor, typical of renal cell carcinoma (Fig. 1B). Under fluoroscopic guidance, a 3-French microcatheter was coaxially inserted into an interlobar branch of the left renal artery entering the tumor (Fig. 1C). Then 300 µm of polyvinyl alcohol particles was injected to stop blood flow. An arteriogram revealed complete occlusion of the interlobar branch, with no evidence of additional arterial feeding branches (Fig. 1D).

View larger version (156K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —67-year-old woman with chronic lung disease and solitary left kidney. Left renal arteriogram shows hypervascular lesion (arrows) at upper pole of left kidney.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —67-year-old woman with chronic lung disease and solitary left kidney. Selective left renal angiogram shows interlobar arterial branch supplying tumor (arrow).

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —67-year-old woman with chronic lung disease and solitary left kidney. Angiogram obtained after embolization shows vascular stump (arrow) with no evidence of feeding vessels.

After embolization, the patient underwent CT. Two grounding pads for the RF electrocautery unit (RF 2000 Generator; Radio Therapeutics, Mountain View, CA) were placed on the patient's thighs. Using sonographic and CT guidance, a 15-gauge LeVeen RF needle (Radio Therapeutics) was percutaneously introduced into the tumor via a left posterior approach below the 12th rib (Fig. 1E). Three RF applications were performed, gradually ramping power to a maximum of 60 W/4 min, 60 W/3 min 30 sec, and 50 W/5 min, until rise in impedance of each application prevented further treatment. The patient's recovery was uneventful and she was discharged from the hospital the next morning.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E. —67-year-old woman with chronic lung disease and solitary left kidney. Abdominal CT scan obtained after renal angiogram shows prongs of RF needle (arrow) that was placed in renal lesion using posterior approach, with patient in prone position. Needle was inserted in direction of arrow.

Eight weeks later, a follow-up CT scan revealed an avascular area at the superior pole of the kidney in the region of the previously embolized and ablated tumor (Fig. 1F). Three months after treatment, a percutaneous biopsy of this region was performed under combined sonographic and CT guidance. Five passes with a 22-gauge needle and three passes with an 18-gauge needle were performed. Pathologic findings revealed fibrous tissue and necrotic cellular debris with no evidence of malignancy.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1F. —67-year-old woman with chronic lung disease and solitary left kidney. Follow-up contrast-enhanced abdominal CT scan obtained 8 weeks after E shows avascular area (arrows) at upper pole of left kidney, in region of previous treatment.

Discussion

Top Introduction Subject and Methods Discussion References

 
Renal cell carcinoma is the most common primary renal parenchymal malignancy in the United States. It is most common after the fifth decade of life and has a male-female ratio of about 1.5:1 [1]. Treatment usually requires surgical resection. The 5-year survival for patients with localized disease (stages I, II, and IIIA) is from 40% to 90%, and patients with stage I lesions generally have an excellent prognosis [2]. In our patient, partial nephrectomy was initially considered. However, because of her multiple medical problems, our patient would have been subject to unacceptable surgical risks. Therefore, RF ablation was performed.

Percutaneous RF ablation was first used for the treatment of hepatic neoplasms in animal models [3]. Later, the technique was effectively used for the treatment of primary and secondary liver tumors [4, 5]. RF ablation has also shown promise in the treatment of other tumors in the body. Potential complications include needle-track seeding with tumor, hematoma, infection, and skin necrosis. To reduce the risk of seeding, heating of the track has been proposed to ablate any remaining tumor cells. Moreover, modern imaging techniques combined with newer RF devices and needles allow precise RF treatment without significant damage to surrounding tissue.

Recently, RF ablation of small unilateral renal cell carcinomas has been proposed as an alternative to more invasive procedures such as partial or radical nephrectomy [6, 7]. To our knowledge, only one other case report describes this technique. This report, by McGovern et al. [8], describes an 84-year-old woman with a 3-cm renal cell carcinoma that was treated with a cooled-tip RF needle and without embolization. This patient recovered well and had no recurrence at 3 months after treatment [8]. These cases illustrate that RF ablation has the advantage of decreased morbidity compared with that of partial or total nephrectomy. Additionally, RF ablation can be performed with conscious sedation and a relatively short hospitalization. (Our patient was discharged less than 24 hr after the procedure and required less than 1 week of recuperation.) The 5-year cancer-specific survival for nephron-sparing procedures such as partial nephrectomy compares favorably with the results of radical nephrectomy for small (<3.5 cm) unilateral early-stage tumors [2]. It is premature to speculate on our patient's 5-year survival, but initial follow-up CT and biopsy results are encouraging. Our experience suggests that similar results might be expected with a less invasive procedure such as RF ablation. Moreover, RF ablation may be a safe and effective treatment for selected patients with renal cell carcinoma. We are encouraged by the preliminary results in this patient's case and look forward to hearing from other researchers.

References

Top Introduction Subject and Methods Discussion References

 

1. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA Cancer J Clin 1999;49:8 -31[Abstract/Free Full Text]
2. Elson PJ, Witte RS, Trump DL. Prognostic factors for survival in patients with recurrent or metastatic renal cell carcinoma. Cancer Res 1988;48:7310 -7313[Medline]
3. McGahan JP, Browning PD, Brock JM, et al. Hepatic ablation using radiofrequency electrocautery. Invest Radiol 1990;25:267 -270[Medline]
4. Goldberg SN, Gazelle GS, Solbiati L, et al. Ablation of liver tumors using percutaneous RF therapy. AJR 1998;170:1023 -1028[Free Full Text]
5. Solbiati L, Ierace T, Goldberg SN, et al. Percutaneous US-guided radiofrequency tissue ablation of liver metastases: treatment and follow-up in 16 patients. Radiology 1997;1202:195 -203
6. Zlotta AR, Wildschutz T, Raviv G, Peny MO, et al. Radiofrequency interstitial tumor ablation (RITA) is a possible new modality for treatment of renal cancer: ex vivo and in vivo experience. J Endourol 1997;11:251 -258[Medline]
7. Polascik TJ, Hamper U, Lee BR, et al. Ablation of renal tumors in a rabbit model with interstitial saline-augmented radiofrequency energy: preliminary report of a new technology. Urology 1999;53:465 -472[Medline]
8. McGovern FJ, Wood BJ, Goldberg SN, Mueller PR. Radiofrequency ablation of renal cell carcinoma via image guided needle electrodes. J Urol 1999;161:599 -600[Medline]

CiteULike

Complore

Connotea

Del.icio.us

Digg

Reddit

Technorati

This article has been cited by other articles:

				J. P. McGahan, K. M. Ro, C. P. Evans, and L. M. Ellison Efficacy of transhepatic radiofrequency ablation of renal cell carcinoma. Am. J. Roentgenol., May 1, 2006; 186(5 Suppl): S311 - S315. [Abstract] [Full Text] [PDF]

				D. A. Gervais, F. J. McGovern, R. S. Arellano, W. S. McDougal, and P. R. Mueller Radiofrequency Ablation of Renal Cell Carcinoma: Part 1, Indications, Results, and Role in Patient Management over a 6-Year Period and Ablation of 100 Tumors Am. J. Roentgenol., July 1, 2005; 185(1): 64 - 71. [Abstract] [Full Text] [PDF]

				A. Hines-Peralta and S. N. Goldberg Review of Radiofrequency Ablation for Renal Cell Carcinoma Clin. Cancer Res., September 15, 2004; 10(18): 6328S - 6334S. [Abstract] [Full Text] [PDF]

				I. Chang, I. Mikityansky, D. Wray-Cahen, W. F. Pritchard, J. W. Karanian, and B. J. Wood Effects of Perfusion on Radiofrequency Ablation in Swine Kidneys Radiology, May 1, 2004; 231(2): 500 - 505. [Abstract] [Full Text] [PDF]

				W. W. Mayo-Smith, D. E. Dupuy, P. M. Parikh, J. A. Pezzullo, and J. J. Cronan Imaging-Guided Percutaneous Radiofrequency Ablation of Solid Renal Masses: Techniques and Outcomes of 38 Treatment Sessions in 32 Consecutive Patients Am. J. Roentgenol., June 1, 2003; 180(6): 1503 - 1508. [Abstract] [Full Text] [PDF]

				D. A. Gervais, F. J. McGovern, R. S. Arellano, W. S. McDougal, and P. R. Mueller Renal Cell Carcinoma: Clinical Experience and Technical Success with Radio-frequency Ablation of 42 Tumors Radiology, February 1, 2003; 226(2): 417 - 424. [Abstract] [Full Text] [PDF]

				Y. Miao, Y. Ni, H. Bosmans, J. Yu, J. Vaninbroukx, S. Dymarkowski, H. Zhang, and G. Marchal Radiofrequency Ablation for Eradication of Renal Tumor in a Rabbit Model by Using a Cooled-tip Electrode Technique Ann. Surg. Oncol., September 1, 2001; 8(8): 651 - 657. [Abstract] [Full Text] [PDF]

				A. J. Aschoff, A. Sulman, M. Martinez, J. L. Duerk, M. I. Resnick, G. T. MacLennan, and J. S. Lewin Perfusion-Modulated MR Imaging--Guided Radiofrequency Ablation of the Kidney in a Porcine Model Am. J. Roentgenol., July 1, 2001; 177(1): 151 - 158. [Abstract] [Full Text] [PDF]

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hall, W. H. Articles by White, R. W. d. Search for Related Content PubMed PubMed Citation Articles by Hall, W. H. Articles by White, R. W. d. Social Bookmarking                      What's this?