1. Percutaneous Ablation of Renal Masses R. Gaines Fricke University of Arkansas For Medical Sciences Interventional Oncology Service Line: RFS Practice Building

2.  Incidence  Renal cell carcinoma (RCC) accounts for 80-85% of all primary renal neoplasms in adults 1.  The incidence of RCC in the U.S. is approximately 63,000 new cases per year, resulting in nearly 14,000 deaths annually 1.  RCC is 50% more common in men than women 2.  Median age of 64 at diagnosis 2.  Mortality  The five-year survival rate of patients with RCC has steadily increased over the past 40years, from 50% in 1977, to 74% in 2011 1.  This increase is mostly attributed to earlier detection of smaller (T1a) neoplasms, usually as an incidental finding on cross sectional imaging. Renal Cell Carcinoma

3.  Risk Factors  Smoking 3  Obesity 4  Hypertension 5  Occupational Exposure (cadmium, asbestos, petroleum by products) 6  Approximately 3% of cases are genetic/familial 7 :  Von Hippel-Lindau: Clear cell RCC  Hereditary papillary RCC  Hereditary leiomyomatosis and RCC  Birt-Hogg-Dubé: Chromophobe RCC and oncocytomas  Tuberous Sclerosis: RCC and AML Renal Cell Carcinoma

4.  Clinical signs and symptoms  With increased use of cross sectional imaging, most presentations are incidental, shifting RCC from the “internist’s tumor” to the “radiologist’s tumor”.  Clinical presentation classically described as a triad of : hematuria, flank pain, and bulk symptoms or palpable mass.  Obstruction of testicular vein can lead to a symptomatic varicocele (usually on the left).  Systemic symptoms include fever, malaise, and weight loss.  Paraneoplastic symptoms may be due to PTH (hypercalcemia), renin (HTN), or erythropoietin (erythrocytosis). Renal Cell Carcinoma

5. Imaging and Staging  Initial diagnosis may be made using essentially any modality, including CT, MRI, PET, and Ultrasound.  Preoperative planning and staging is usually done via postcontrast CT or MRI, the latter typically being reserved for pregnant patients or those who can’t receive iodinated contrast. Renal Cell Carcinoma T3c T2T3a T3b T1

6. Treatment  Classically, the gold standard for treatment is radical nephrectomy.  However, more and more renal masses are discovered incidentally, and therefore tend to be smaller and lower grade.  This led to increased use of “nephron sparing” techniques such as partial nephrectomy, laparoscopic ablation (LA), and percutaneous ablation (PA). Renal Cell Carcinoma http://dx.doi.org/10.1016/S0140-6736(09)60229-4 http://dx.doi.org/10.1148/rg.304095134

7. Treatment (Cont.)  A number of patients will have significant comorbidities and will not be surgical candidates. For these people PA is a chance at curative treatment.  Moreover, as compared to LA, PA has been shown to have shorter procedure times, shorter hospital stay, lower major complication rates, lower cost, and overall equivalent success rates 8-12.  PA is therefore also preferentially used in patients who require nephron sparing technique such as those with a solitary kidney, multiple RCCs, or a heritable predisposition.  PA can also be used as a palliative treatment in patients with tumor-related hematuria. Renal Cell Carcinoma

8. Pre-Procedure Considerations  The majority of ablations can be performed as an outpatient.  An ideal candidate for ablation will have: 1. Renal mass 4cm or smaller (T1a). 2. No renal vein invasion or extension beyond the renal fascia. 3. Non-central location (reduced risk of vascular and collecting system injury). 4. Normal coagulation profile.  General anesthesia, deep sedation, or moderate sedation may be used. Percutaneous Ablation

9. Pre-Procedure Considerations Preablative biopsy :  The role of preablative biopsy varies by institution and remains somewhat controversial. Pros: - Avoids morbidity of ablation if there is a benign result: Some reports show between 13-37% of biopsied renal masses are benign 13-14. -Tissue diagnosis allows for tumor specific follow-up. Cons: - Periprocedural bleeding can obscure margins for subsequent ablation, especially if performed on same day. -Some argue results usually do not change clinical management 15. For instance, a solid mass with concerning imaging characteristics may still be treated despite a negative pathologic result. Percutaneous Ablation

10. Two most common methods: Percutaneous Ablation Radiofrequency Ablation (RFA) Delivers an RF current to the mass resulting in local frictional heating and tissue destruction/ coagulation necrosis 16. Cryoablation Rapid cooling via depressurization of a liquid gas (usually argon). This is thought to effect cell death by at least two methods: Ice crystal formation leading to cell rupture, and microvascular occlusion and ischemic injury from the subsequent thawing 17. http://dx.doi.org/10.1594/ecr2010/C-1302

11. Two most common methods: Radiofrequency Ablation (RFA) Cryoablation Percutaneous Ablation

12.  Complications Overall Specific Topic

13.  Evidence based outcomes Topic

14.  Conclusion Topic

15. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin. 2016; 66(1):7. Siegel RL, Ward E, Brawley O, et al. Cancer statistics, 2011: the impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin. 2011; 61(4):212. Cumberbatch MG, Rota M, Catto JW, et al. The role of tobacco smoke in bladder and kidney carcinogenesis: A comparison of exposures and meta-analysis of incidence and mortality risks. Eur Urol. 2016; 70m (3): 458. Adams KF, Leitzmann MF, Albanes D, et al. Body size and renal cell cancer incidence in a large US cohort study. Am J Epidmiol. 2008; 168 (3):268-77. Ljungberg B, Campbell SC, Choi HY, et al. The epidemiology of renal cell carcinoma. Eur Urol. 2011; 60(4):615-21. Mandel JS, McLaughlin JK, Schlehofer B, et al. International renal-cell cancer study IV. Int J Cancer 1995; 61(5):601. Rini B, Campbell SC, Escudier B. Renal Cell Carcinoma. Lancet 2009; 373 (9669): 1119-32. Kutikov A, Kunklw DA, Uzzo RG. Focal therapy for kidney cancer: a systematic review. Curr Opin Urol 2009; 19(2):149-53. Hinshaw JL, Shadid AM, Nakada SY, et al. Comparison of percutaneous and laparoscopic cryoablation for the treatment o solid renal masses. Am J Roentgenol 2008; 191(4):1159-1168. Badwan K, Maxwell K, Venkatesh R, et al. Comparison of laparoscopic and percutaneous cryoablation of renal tumors: a cost analysis. J Endourol 2008; 22(6):1275-77. Bandi G, Hedican SP, Nakada SY. Current practice patterns in the use of ablation technology for the management of small renal masses at academic centers in the United Stats. Urology 2008; 71(1):113-7. HuiGC, Tuncali K, Tatli S, et al. Comparison of percutaneous and surgical approaches to renal tumor ablation: meta-analysis of effectiveness and complication rates. J Vasc Interv Radiol 2008: 19(9): 1311-20. Frank I, Blute MI, Cheville JC, et al. Solid renal tumors: an analysis of pathlogical features related to tumor size. Ju Urol 2003; 170 (6) 2217-20. Tuncali K, vanSonnenberg E, Shankar S, et al. Evalutaion of patients referred for percutaneous ablation of renal tumors: importance of a preprocedural diagnosis. AJR 2004; 183(3):575-82. Zagoria RJ. Imaging of small renal masses: a medical success story. AJR 2000; 175 (4):945-55. Goldberg SN, Gazelle GS, Meuller PR. Thermal ablation therapy for focal malignancy: a unified approach to underlying principles, techniques, and diagnostic imaging guidance. Am J Roentgenol 2000; 174(2):323-331. Gage AA, Baust J. Mechanisms of tissue injury in cryosurgery. Cryobiology 1998; 37 (3): 171-86. References

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