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22 - Management of small renal masses
- from Section VI - Organ-specific cancers – renal cell carcinoma
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- By Mansi A. Saksena, Department of Radiology, Debra A. Gervais, Massachusetts General Hospital, Boston, Michael C. Soulen, University of Pennsylvania, Peter R. Mueller, Department of Radiology
- Edited by Jean-Francois H. Geschwind, Michael C. Soulen
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- Book:
- Interventional Oncology
- Published online:
- 05 September 2016
- Print publication:
- 22 September 2016, pp 203-213
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Summary
Approximately 61,560 new cases of renal cell carcinoma (RCC) were estimated to be diagnosed in the USA in 2015, with 14,080 cancer-related deaths attributed to cancers of the kidneys and the renal pelvis. More than one-half of these patients were diagnosed incidentally on cross-sectional imaging performed for non-related conditions. Increased incidental detection of small renal masses as well as advances in surgical techniques have led to development of nephron-sparing procedures for treatment in order to preserve renal function. Over the past decade, the options for the treatment of RCC have evolved to include radical nephrectomy as well as partial nephrectomy, laparoscopic nephrectomy and, in selected cases, percutaneous radiofrequency ablation (RFA), microwave ablation (MWA), and cryotherapy. Each therapy has unique clinical applications and benefits. This article illustrates various treatment modalities used in the therapy of RCC, with special emphasis on percutaneous ablative techniques.
Clinical overview
RCC accounts for 85% of all renal tumors and is slightly more common in men than in women (1.6:1.0). Symptomatic RCC usually presents with a triad of flank pain, hematuria, and a palpable abdominal mass. Hematuria, either gross or microscopic, in any patient usually warrants evaluation by a computed tomographic (CT) scan. Other non-specific symptoms include weight loss, anemia, or fatigue. However, almost one-half of patients are asymptomatic at diagnosis and have incidentally detected tumors on cross-sectional imaging. Certain genetic syndromes such as von Hippel–Lindau (VHL) disease increase the incidence of RCC (accounting for approximately 2% of cases of RCC). Other risk factors include smoking, hypertension, obesity, and end-stage renal disease resulting in dialysis.
Clear-cell RCC is the most common histological subtype and is associated with VHL syndrome and end-stage renal disease (Table 22.1). Other inherited forms include familial clear-cell RCC. Papillary RCC, when sporadic, has a prominent male preponderance and is associated with almost 90% 5-year survival rates prior to metastatic spread. Papillary RCC has a lesser incidence of metastases than clear-cell but, when metastatic, is harder to treat. Papillary RCC is also seen in end-stage renal disease and in several familial syndromes. Other less common cell types include chromophobe RCC and collecting-duct RCC.
3 - Diagnostic imaging pre- and post-ablation
- Edited by Andy Adam, University of London, Peter R. Mueller
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- Book:
- Interventional Radiological Treatment of Liver Tumors
- Published online:
- 23 December 2009
- Print publication:
- 11 December 2008, pp 44-73
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Summary
Introduction
Hepatic malignant tumors are common worldwide. Surgical resection and, in rare instances, liver transplantation represent the gold standard of management, offering a chance of cure in selected patients. The overall 3-year survival rate in patients with hepatocellular carcinoma (HCC) who undergo surgical resection is between 47.2% and 83.9%, and the overall 5-year survival rate in patients with colorectal liver metastases who undergo surgical resection is between 35% and 58%. However, curative resection is frequently precluded because of medical comorbidities that render patients inoperable. Less than 25% of patients with either primary HCC or colorectal liver metastases are candidates for surgical resection.
Since the 1990s, radiofrequency ablation (RFA) of primary and secondary hepatic malignancies has had promising results in local control of tumors. With advances in imaging modalities and refinements of ablation technique, as well as more powerful generators, the outcome of RFA for hepatic tumors has improved significantly in the past several years. RFA can achieve complete necrosis of the tumor without adverse effects on liver function. To date, RFA is considered a reasonable alternative for patients with four or fewer hepatic tumors that are less than 3–5 cm in diameter. The absolute contraindications of RFA include extrahepatic disease, life expectancy less than 6 months, other active malignant disease, cirrhosis or hepatic insufficiency, portal hypertension or portal vein thrombosis, altered mental status, age less than 18 years, pregnancy, severe pulmonary disease, active infection, and refractory coagulopathy.
33 - Percutaneous Renal Ablation
- from PART III - ORGAN-SPECIFIC CANCERS
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- By Mansi A. Saksena, Radiologist, Division of Abdominal Imaging and Intervention Department of Radiology Massachusetts General Hospital Boston, MA, Debra Gervais, Associate Professor, Radiology Massachusetts General Hospital Boston, MA, Peter R. Mueller, Professor, Radiology Director, Abdominal Imaging Massachusetts General Hospital Boston, MA
- Edited by Jean-François H. Geschwind, The Johns Hopkins University School of Medicine, Michael C. Soulen, University of Pennsylvania School of Medicine
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- Book:
- Interventional Oncology
- Published online:
- 18 May 2010
- Print publication:
- 15 September 2008, pp 400-412
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Summary
Approximately 38,890 new cases of renal cell carcinoma (RCC) were estimated to be diagnosed in the United States in 2006, with 12,840 cancer-related deaths attributed to cancers of the kidneys and the renal pelvis (1). More than one-half of these patients were diagnosed incidentally on cross-sectional imaging performed for non-related conditions (2). Increased incidental detection of small renal masses as well as advances in surgical techniques have led to development of nephron-sparing procedures for treatment in order to preserve renal function. Over the past decade, the options for the treatment of RCC have evolved to include radical nephrectomy as well as partial nephrectomy, laparoscopic nephrectomy and, in selected cases, percutaneous radiofrequency ablation (RFA) and cryotherapy. Each therapy has unique clinical applications and benefits. This article illustrates various treatment modalities used in the therapy of RCC with special emphasis on percutaneous ablative techniques.
CLINICAL OVERVIEW
RCC accounts for 85% of all renal tumors and is slightly more common in men than in women (1.6 to 1.0) (2). Symptomatic RCC usually presents with a triad of flank pain, hematuria and a palpable abdominal mass. Hematuria, either gross or microscopic, in any patient usually warrants evaluation by a computed tomographic (CT) scan. Other nonspecific symptoms include weight loss, anemia or fatigue. However, almost one-half the patients are asymptomatic at diagnosis and have incidentally detected tumors on cross-sectional imaging. Certain genetic syndromes such as von Hipple-Lindau (VHL) disease increase the incidence of RCC (accounting for approximately 2% of cases of RCC).
6 - The case for biopsy in the modern management of renal cancer
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- By Colin P. Cantwell, Division of Abdominal Imaging and Interventional Radiology, Department of Radiology and Harvard Medical School, Massachusetts, General Hospital, Boston, USA, Debra Gervais, Division of Abdominal Imaging and Interventional Radiology, Department of Radiology and Harvard Medical School, Massachusetts, General Hospital, Boston, USA, Peter R. Mueller, Division of Abdominal Imaging and Interventional Radiology, Department of Radiology and Harvard Medical School, Massachusetts, General Hospital, Boston, USA
- Edited by Uday Patel, St George's Hospital, London
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- Book:
- Carcinoma of the Kidney
- Published online:
- 08 August 2009
- Print publication:
- 06 December 2007, pp 112-125
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Summary
Introduction
In the past, focal renal biopsy had a limited role in the management of renal masses. Potential complications and an overestimated risk of seeding the biopsy tract dissuaded operators from biopsy, and when performed definitive results were uncommon. Hence, urologists presumed that solid renal lesions over 3 cm and complex cysts were predominantly renal cell carcinomas (RCC) and rarely performed biopsy before surgical procedures.
Attitudes have changed to renal biopsy for a number of reasons, firstly, histological techniques have become more reliable. The morphology, immunocytochemical, and genetic profiles of RCC and its subtypes have been better described. Immunohistochemistry and special stains and genetic test are available to help differentiate tumor subtypes. Oncocytoma, oncocytic cancers, RCC and fat poor angiomyolipomas (AML) can now be differentiated histologically. There has also been a downward-stage migration of renal tumors at diagnosis and a substantial fraction of contemporary solid renal masses are benign. In one study, 12.8% of solid renal masses were found to be benign. When stratified by size, the proportion of benign masses was 25% for masses smaller than 3 cm, 30% for masses smaller than 2 cm, and 44% for masses smaller than 1 cm. Furthermore, small solid benign renal masses cannot be reliably distinguished from malignant masses by means of imaging findings alone.