Journal of Kidney Cancer and VHL 2015; 2(3): 105-113. Doi: http://dx.doi.org/10.15586/jkcvhl.2015.34
Review Article
Percutaneous Cryoablation for Renal Cell Carcinoma
Tsitskari Maria1, Christos Georgiades1,2
1Vascular & Interventional Radiology, American Medical Center, Nicosia, Cyprus; 2Johns Hopkins University, Baltimore, USA.
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.
Received: 05 May 2015; Accepted after revision: 07 June 2015; Published: 09 June 2015.
Author
for correspondence: Tsitskari Maria MD, MSc, Vascular & Interventional Radiology, American Medical Center, Nicosia, Cyprus. E-mail: [email protected]
How to cite: Maria T, Georgiades C. Percutaneous Cryoablation for Renal Cell Carcinoma. Journal of Kidney Cancer and VHL 2015;2(3):105-113. Doi: http://dx.doi.org/10.15586/jkcvhl.2015.34
Renal cell carcinoma (RCC) is the most
common type of kidney cancer in adults and the third most common malignancy of
the urinary tract. With the advance and increasing use of cross sectional imaging
techniques more cases of RCC are detected at an early stage and when they are
clinically occult (1). Surgical
resection has been considered the standard of care for patients with localized
RCC with partial nephrectomy traditionally being the intervention of choice. Despite this, most patients undergo radical
nephrectomy, as the availability of physicians able to perform partial
nephrectomy has not kept up with demand.
The increased incidence of small renal masses resulted in the
development of nephron sparing surgical techniques aiming at preserving renal
function. Partial nephrectomy when feasible, either open or laparoscopic, is
considered now the gold standard treatment for this subgroup of patients (2). Many
patients however are poor surgical candidates, due to old age, the presence of
comorbidities, multiple tumors, or compromised renal function. All of the above
facilitated the introduction of less invasive ablative techniques as an
alternative to extirpative surgical
Figure 1.
The physics of cryoablation. Ex-vivo
appearance of the formed ice-ball on a Cryoprobe (a). In human tissue the
margin of the ice-ball represents the zero degree (Celsius) isotherm, which is
not lethal. As the argon gas drops in
pressure it cools substantially and absorbs energy (Q), which is carried away
by the warmed gas and released in the room (inert gas). D is the diameter of the visible ice ball (b).
The pressurized argon is released inside the probe (no gas is released
in the patient). As the pressure drops
it cools forming the ice-ball. The
lethal ablation zone is 3-5 mm inside the visible ice-ball (c).
Current Literature on Percutaneous Cryoablation
Figure 2. Schematic representation of the relevant isotherms
during renal cryoablation. The temperature precipitously increases with
distance from the probe. The temperature plot is shown in the upper portion of
the figure. The 0o C isotherm is visible and represents the margin
of the ‘‘ice-ball,’’ which is not lethal. Lethal temperature for renal tissue
is -20-25o C. This isotherm is not visible and resides at a certain
distance within the visible ‘‘ice-ball.’’ For effective cryoablation, the
nonvisible lethal isotherm must cover the entire target lesion (arrowhead).
Note the ‘‘ghost’’ (dark line spearing the target lesion) of the removed
cryoprobe as the tissue is still frozen and not collapsed.
Cryoablation seems to offer some
advantages over RFA and other thermal ablation techniques for renal masses.
Imaging guidance (CT) allows direct visualization of the ice ball,
permitting more precise monitoring of the ablation zone (6). It also allows the simultaneous use and
synergy of more than one probe, thus sculpting the ice-ball. Additionally
investigators showed that cryoablation has a reduced risk of thermal injury to
the collecting system for centrally located tumors (11). This was also recently
confirmed by Rosenberg et al. in a series of 41 patients with ice balls
overlapping the renal sinus by 6 mm or more (12). A meta-analysis of reported cryoablation vs
RFA for small renal masses was published by Kunkle and Uzzo in October 2007
(5). They analyzed the results from
forty-seven studies including 1375 renal masses. The meta-analysis demonstrated
that repeat ablation was performed more often after RFA (8.5% vs. 1.5%) and the
rates of local tumor progression (which includes initial subtotal treatment and
late local recurrence) were significantly higher for RFA compared with
cryoablation, 12.9% vs. 5.2%, respectively.
Atwell et al. in 2012 studied 445 tumors measuring 3.0 cm or smaller
treated with thermal ablation (256 tumors were treated with RFA and 189 tumors
were treated with cryoablation). They suggested that the two methods are
equally effective, having similar major complications and technical success,
although cryoablation may be more efficacious for central tumors near the renal
hilum (13).
Figure 3.
Determination of the lethal cryoablation zone during an animal experiment. The ice-ball is indicated by the dashed line
on the CT (A), the blue line on the
histopathological slide (B) and the
arrow on the gross specimen (C). The lethal ablation zone is smaller than the
ice-ball and indicated by the green line on the histopathological slide (B).
On the gross specimen (c), the lethal zone appears as a red circle
inside the ice-ball. In this experiment,
the distance between the visible ice- ball and the lethal ablation zone was
determined to be about 3 mm (23).
Different studies compared the efficacy
of percutaneous and laparoscopic approaches for cryoablation. An analysis of
the literature on renal cryoablation from 1966 to 2010 in which 28 laparoscopic
studies were compared with 14 percutaneous studies (in total, 1447 tumors) did
not show a significant difference in terms of rate of residual tumors (p =
0.25) or rate of recurrent tumor (p = 0.44). The patient groups were comparable
in terms of age, tumor size, and duration of follow-up (14).
There are several retrospective studies
supporting the short and midterm outcome and efficacy of percutaneous renal cryoablation.
Atwell et al. retrospectively reviewed 93 tumors treated with percutaneous
cryoablation, with a mean size of 34 mm. They reported technical success rate
of 96% with local tumor control in 95% of tumors and 1 case of local tumor
progression seen on follow-up (15). In
previous studies with smaller series of patients other authors reported local
control rates ranging from 83% - 95% based on short term follow up (16, 17, 18,
19). In a prospective study, Buy et al.
reviewed 120 tumors with a mean size of 26 mm. They reported a technical
success rate of 94% with two tumors requiring second session of cryoablation
(either due to recurrence or residual tumor) with disease free survival rate at
1 year of 96.7% (20).
Figure 4.
Coronal reformatted, CT of the left kidney (A)
showing a central biopsy proven renal cell carcinoma (arrows). The intra-procedural coronal image shows the
5 cryyoprobes resulting in a lower density ice-ball (B, arrows). Three month
follow up CT (C) shows complete lack
of enhancement of the necrotic tumor (arrows).
Patient selection
Follow up
Figure 5. Contrast enhanced, CT scan before cryoablation
with axial (A) and coronal (B) reformations show T1a stage
exophytic tumor (white arrows). Contrast
enhanced, CT scan at 9 months post-cryoablation with axial (C) and coronal (D)
reformations show no mass enhancement, confirming complete necrosis of the
tumor. The inflammatory rim (white
arrowheads) is noted representing the edge of the ablation zone and not
residual disease.
Percutaneous ablation of renal tumors under imaging guidance is now a widely accepted nephron sparing curative treatment option for patients who are poor surgical candidates or patients who wish to avoid surgery. These recommendations are supported by prospective, long-term studies (5-year) (21). Treatment failure and local recurrence are uncommon, comparable to that of partial-nephrectomy and do not preclude repeat treatment. In addition, cryoablation appears to be safer than any surgical option. Based on these data, patients with tumors that are stage 1A or B amenable to percutaneous cryoablation, should be offered the option of percutaneous, image guided cryoablation (or thermal ablation).
Conflicts of Interest
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Mueller P, Gervais DA. Long-Term Oncologic Outcomes After Radiofrequency
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G, Hale J, Myles J, Novick AC. Renal cryosurgery: experimental evaluation of
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