Percutaneous ablation

of renal cell carcinoma

Where do we stand now?

Sanja Stojanović, Spasić Aleksandar

Clinical Center of Vojvodina / Center for Radiology
Novi Sad Serbia
 Renal cell carcinoma

• approximately less than 4 % of all new cancers

in the western world
• The detection rate has been increasing in
recent years
• Incidental finding
 Which RCCs are we speaking about

• T1
– T1a: tumour confined to kidney, <4 cm
– T1b: tumour confined to kidney, >4 cm but <7 cm
• T2:
• T3:
• T4:
 4 cm
Treated area

deployment of thermal energy

ELECTRODES
How to enlarge area of ablation
 Hyperthermic ablation
in depth understanding of the mechanism

Thermal conduction from small

heating zone

Mechanism of celullar injury

Central zone – necrosis

Periphery - sublethal

Immune activation – antigen

presentation

Chu CF, Dupuy D. Thermal ablation of tumours: biological mechanisms and advances in therapy. Cancer; 2014.
 Cryoablation

Liquefied gases (Argon)

-20 to -40°C
1cm beyond the lesion

Mechanism of cellular injury

Even better immune activation

- sometime inactivation

Chu CF, Dupuy D. Thermal ablation of tumours: biological mechanisms and advances in therapy. Cancer; 2014.
 Immunomodulation

Often too weak

to completely
overcome disease

Synergy with ablation

- imunnoadjuvants

Chu CF, Dupuy D. Thermal ablation of tumours: biological mechanisms and advances in therapy. Cancer; 2014.
 Partial Thermal
Nephrectomy Ablation
PATIENT SELECTION BIAS
- Patients that are not fit or are not willing to undergo surgical treatment

- Active surveilance only for those patients with cT1a RCC that cannot undergo
percutaneous treatment
 Partial Thermal
Nephrectomy Ablation

• Armamentorium
• Lethal mechanism
• Immunomodulation
• Pathology
• Image guidance
 RF

CRYO

Cornelis FH et al. A Comparative Study of Ablation Boundary Sharpness After Percutaneous Radiofrequency, Cryo-,
Microwave, and Irreversible Electroporation Ablation in Normal Swine Liver and Kidneys. CIRSE; 2017.
Biopsy - mandatory

Percentage Survival
Fuhrman grading

18G needle Disease Specific Survival (months)

Metastases
Multiple subtypes of RCC
T1a – 7%
Byopsy ˃˃ Pathology ˃˃ Ablation
RCC 3-4cm – 11%
Further therapy by oncologists
Comparisson with other modalities (PN)
Patient selection
• Small renal mass: T1a;
T1b ?

• Comorbid conditions
• Advanced age
• Single kidney
• Multiple masses (VHL)
 Ideal lesion for RF

• Small (≤ 3cm/4cm?)

• Posterior

• Exophytic

• Far away from critical

structures
 Multiple tumours

Proximity of colon Proximity of spleen

Proximity of hilus
- pyeloureter
- vascular
 Image guidance
CT

US – inferior control
ablation induced artifacts

MRI – robust equipement

availibility
 colon
Hydrodissection
to push away structures in close proximity
RCC infusion of liquid

One needle Two needles

 Complications

Hemorrhage (thinner or thicker needles)

– Subcapsular
– Retroperitoneal

Hematuria
– Central locations
– Cryoablation better tolerated by pyelocaliceal wall
– Pyeloperfusion (cold or warmed liquids)
Atwell TD et al. Percutaneous Ablation of Renal Masses Measuring 3.0 cm and Smaller: Comparative Local Control and
Complications After Radiofrequency Ablation and Cryoablation. AJR; 2013.
Prediction
of complications

% Major Complication
Radius
Exophytic/endophytic
Nearness to collecting system
Anterior/posterior 4-6 7-9
R.E.N.A.L. Score
10 - 12

Location relative to polar lines

Schmit GD et al. Usefulness of R.E.N.A.L. Nephrometry Scoring System for Predicting Outcomes and Complications of Percutaneous Ablation of
751 Renal Tumors. J.Urology; 2013.
 10 - 12

% Local Failure
7-9
4-6

Radius Months Post Treatment

Exophytic/endophytic
Nearness to collecting system
Anterior/posterior
Prediction
Location relative to polar lines of local success
Approach Skin landmark
Antenna position

90° angle
RF or PN
Single kidney / multiple RCC
- Renal reserve

- Partial nephrectomy or
thermal ablation ?

- Control of complications
 T1a lesion

26mm lesion Position 1 Position 2 After ablation

 Control sectional imaging
- 4 weeks after ablation – rest of the ablated tumour
- after 3, 6, 9 or 12 months – institution protocol

- US: “liquid” complications (Hydronephrosis, Collections...) ˃˃ CT/MRI

3 months 1 year 2 years

 Follow up

• Early follow up – imaging not recommended unless

complication (bleeding..) suspected

• Late follow up - no consensus on chosen modality

– Comparation to preoperative imaging
– Lack of enhancement
– Decrease in size of the ablative zone
– Peripheral enhancement (usualy disappears after 6 months)
– Recurrent tumor versus inflammatory changes
-- New baseline after 6 months
 Conclusion

- Guidelines
- T1a(b) tumours

- Biopsy

- Pursuing excellence in technique and

understanding of lethal mechanisms
- Learning curve
Thank you for your attention!
Thank you for your attention!