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Percutaneous Ablation of Renal Cell Carcinoma (RCC)

Background

  • Incidence of renal cancer is 400’000 patients and mortality is 175’000 patients per year1
  • 90% of tumours in the kidney are renal cell carcinoma (RCC)2
  • Small tumours < 40 mm (T1a) account for 48-66% of all RCC2
  • 12% of RCC are currently being ablated, 88% are treated with surgery

Indications for Ablation

  • Not amenable to resection due to comorbidities
  • Limited renal function reserve (solitary kidney, bilateral tumours).
  • RCC stage T1a (limited to kidney and ≤ 40 mm)
  • High-risk patients with RCC stage T1b (limited to kidney and ≤ 70 mm)

Ablation technique

  • Perform biopsy before ablation (10-33% of biopsies reveal benign tumours2)
  • Cryoablation, MWA or RFA
  • Use ABLATE algorithm:
    • A, axial tumour diameter;
    • B, bowel proximity;
    • L, location within the kidney;
    • A, adjacency to the ureter;
    • T, touching renal sinus fat;
    • E, endophytic or exophytic position.3

Guidelines

  • European Society for Medical Oncology (ESMO): Ablation is an option in patients with small tumours and high surgical risk, compromised renal function or bilateral disease4
  • National Comprehensive Cancer Network (NCCN): Ablation can be considered for patients with T1 renal lesions5
  • American Society of Clinical Oncology (ASCO): Patients who are not indicated for surgery and where complete ablation can be achieved6
Evolution of treatment modalities

Quality Ablation of RCC with CAS-One IR - Reproducible and Standardized Treatments

  • Comprehensive treatment planning and assessment of risk factors (ABLATE algorithm)
  • Off-plane targeting enables treatment of lesions in difficult locations (kidney dome)
  • CT-fusion based ablation control for reliable assessment of technical success

Relevant Studies

Stage T1a RCC
  • Ablative treatments lead to significantly better renal cancer-specific survival than active surveillance8,9
  • Lower overall survival for ablation compared to resection10,11
  • No difference in cancer-specific survival (CSS) between ablation and resection8,10
  • Ablation leads to lower complication rates and shorter hospital stays than resection9,11
Stage T1b RCC
  • Partial nephrectomy (PN) and ablation are being increasingly used for T1b lesions
  • Small retrospective studies show no significant difference in CSS between PN and ablation12,13
  • Lower complication rates for ablation than PN12
Oligometastatic disease
  • 17% of patients present metastasis at the time of diagnosis and 25% develop metastasis after treatment
  • Surgical metastasectomy improves survival, ablation may be considered when resection is not feasible14
Comparison of ablative technique
  • No significant difference in CSS between cryoablation and MWA/RFA8

References

1. Bray, F. et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA. Cancer J. Clin. 68, 394–424 (2018).
2. Morris, C. S. et al. Society of Interventional Radiology Position Statement on the Role of Percutaneous Ablation in Renal Cell Carcinoma: Endorsed by the Canadian Association for Interventional Radiology and the Society of Interventional Oncology. J. Vasc. Interv. Radiol. 31, 189-194.e3 (2020).
3. Schmit, G. D. et al. ABLATE: A Renal Ablation Planning Algorithm. Am. J. Roentgenol. 202, 894–903 (2014).
4. Escudier, B. et al. Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann. Oncol. 30, 706–720 (2019).
5. Motzer, R. J. et al. NCCN Guidelines Insights: Kidney Cancer, Version 2.2020. J. Natl. Compr. Cancer Netw. 17, 1278–1285 (2019).
6. Finelli, A. et al. Management of small renal masses: American society of clinical oncology clinical practice guideline. Journal of Clinical Oncology vol. 35 668–680 (2017).
7. Huang, W. C. et al. Management of small kidney cancers in the new millennium contemporary trends and outcomes in a population-based cohort. JAMA Surg. 150, 664–672 (2015).
8. Uhlig, A. et al. Treatment for Localized T1a Clear Cell Renal Cell Carcinoma: Survival Benefit for Cryosurgery and Thermal Ablation Compared to Deferred Therapy. Cardiovasc. Intervent. Radiol. 41, 277–283 (2018).
9. Larcher, A. et al. Population-based assessment of cancer-specific mortality after local tumour ablation or observation for kidney cancer: a competing risks analysis. BJU Int. 118, 541–546 (2016).
10. Xing, M., Kokabi, N., Zhang, D., Ludwig, J. M. & Kim, H. S. Comparative effectiveness of thermal ablation, surgical resection, and active surveillance for T1a renal cell carcinoma: A surveillance, epidemiology, and end results (SEER)–Medicare-linked population study. Radiology 288, 81–90 (2018).
11. Talenfeld, A. D. et al. Percutaneous Ablation Versus Partial and Radical Nephrectomy for T1a Renal Cancer: A Population-Based Analysis. Ann. Intern. Med. 169, 69–77 (2018).
12. Caputo, P. A. et al. Cryoablation versus Partial Nephrectomy for Clinical T1b Renal Tumors: A Matched Group Comparative Analysis. Eur. Urol. 71, 111–117 (2017).
13. Thompson, R. H. et al. Comparison of partial nephrectomy and percutaneous ablation for cT1 renal masses. Eur. Urol. 67, 252–9 (2015).
14. Zaid, H. B. et al. Outcomes Following Complete Surgical Metastasectomy for Patients with Metastatic Renal Cell Carcinoma: A Systematic Review and Meta-Analysis. J. Urol. 197, 44–49 (2017)