Laparoscopic Cryoablation for Renal Cell Carcinoma: 100-Month Oncologic Outcomes.

PURPOSE: With the incidence of renal cell carcinoma on the rise treatment options for the small renal mass have broadened. Cryoablation is increasingly used as a therapeutic option for renal tumors in select cases. However, studies with long-term oncologic outcomes are sparse. We evaluated the long-term oncologic outcomes of laparoscopic renal mass cryoablation. MATERIALS AND METHODS: We reviewed our laparoscopic cryoablation database for patients treated with laparoscopic cryoablation from October 1997 to February 2005. Patients with less than 3 months of followup were excluded from study. Patient and tumor characteristics, and perioperative outcomes, including complications, were recorded. Recurrence-free, cancer specific and overall survival was analyzed using Kaplan-Meier curves. RESULTS: A total of 142 tumors in 138 consecutive patients were treated with laparoscopic cryoablation. Mean age of the cohort was 66.35 years. Of the patients 99 (71.7%) were male and 39 (28.3%) were female. Mean body mass index was 29.15 kg/m(2) and median ASA score was 3. A solitary kidney was present in 23 patients (16.2%). Mean tumor size on cross-sectional imaging was 2.4 cm. The mean preoperative and postoperative estimated glomerular filtration rate was 66.72 and 61.00 ml per minute, respectively. The postoperative estimated glomerular filtration rate was determined at a mean ± SD of 15.17 ± 10.99 months of followup. The median R.E.N.A.L. nephrometry score was 5. Of the 142 tumors 100 were diagnosed as renal cell carcinoma after histopathological examination of the biopsy specimen. At 3, 5 and 10 years in patients diagnosed with renal cell carcinoma estimated recurrence-free survival was 91.4%, 86.5% and 86.5%, estimated cancer specific survival was 96.8%, 96.8% and 92.6%, and estimated overall survival was 88.7%, 79.1% and 53.8%, respectively. Mean followup was 98.8 ± 54.2 months in those diagnosed with renal cell carcinoma. Mean time to recurrence was 2.3 years. The latest experienced recurrence was 4.4 years after laparoscopic cryoablation. There was a postoperative complication rate of 10.6% with a total of 15 complications. CONCLUSIONS: Laparoscopic cryoablation achieves good long-term oncologic outcomes for localized small renal masses. It can safely be used in patients who cannot undergo or are unwilling to accept the risks of partial nephrectomy. Mean time to recurrence was 2.3 years and all recurrences developed within 4.4 years of initial treatment.

Laparoscopic vs percutaneous cryoablation for the small renal mass: 15-year experience at a single center.

OBJECTIVE: To analyze our 15-year experience with small renal masses ablation and present oncologic and functional outcomes of laparoscopic cryoablation (LCA) and percutaneous cryoablation (PCA). MATERIALS AND METHODS: We identified patients who underwent LCA (n = 275) or PCA (n = 137) for small renal masses between 1997 and 2012. Differences in overall survival (OS) and recurrence-free survival (RFS) were analyzed using a log-rank test. Cox proportional hazard ratios model was used to determine factors that predicted OS. Fit proportional hazard risk ratios were also calculated to determine if there were any factors that affected tumor recurrence. RESULTS: Tumor sizes were equal between the 2 groups; however, tumors in the PCA group were more complex. The overall (7.27% and 7.29%) and major complications (0.7% and 3.6%) were similar. The estimated probability of 5-year OS for LCA and PCA was 89% and 82%, respectively. The estimated probability of the 5-year RFS for LCA and PCA was 79% and 80%, respectively. Heart disease (hazard ratio, 2.15; 95% confidence interval, 1.35-3.41; P = .001) and history of disease recurrence (hazard ratio, 2.49; 95% confidence interval, 1.60-3.86; P = .001; P <.0001) were predictors of death. The median follow-up time for the LCA group (4.41 years [1.67-6.91 years]) was longer than the PCA group (3.15 years [1.37-4.08 years]; P = .0001). CONCLUSION: We found no significant difference in OS or RFS at 5 years between the 2 groups. Tumor size and anterior location affected local recurrence rates, and these factors should be taken into consideration when choosing the appropriate treatment plan. RENAL nephrometry score or type of cryoablation was not associated with tumor recurrence.

Probe ablation as salvage therapy for renal tumors in von Hippel-Lindau patients: the Cleveland Clinic experience with 3 years follow-up.

BACKGROUND: To evaluate the efficacy and safety of probe ablative therapy as salvage treatment for renal tumor in von Hippel-Lindau (VHL) patients after previous partial nephrectomy (PN). METHODS: Medical records of VHL patients undergoing probe ablative treatment for renal tumors from March 2003 to January 2010 at our institution were retrospectively analyzed. RESULTS: Fourteen VHL patients who were submitted to salvage probe ablative therapy were included in the analysis. Twelve patients (85%) had a solitary kidney. Overall, 33 tumors were ablated by either percutaneous cryoablation (P-Cryo) (n of procedures = 13), radiofrequency ablation (RFA) (n = 14), and laparoscopic cryoablation (L-Cryo) (n = 3). Average maximal renal tumor diameter was 2.6 ± 1 cm. Average ablation time was 18.3 ± 2.1 minutes for P-Cryo, 36.7 ± 17 minutes for RFA, and 17.3 ± 4 minutes for L-Cryo. All procedures were successfully completed without transfusions and intraoperative complications. No early postoperative complications were recorded. Postoperative decline in renal function was minimal and not clinically significant. With a mean follow-up of 37.6 months (range 12-82), 4 patients had a suspicious recurrence on computed tomography/magnetic resonance imaging (CT/MRI) scan and in 3 of them a re-ablation was performed. Actuarial overall and cancer-specific survivals were 92% and 100%, respectively. CONCLUSIONS: Probe ablative therapy seems to represent a suitable treatment option for VHL patients with a previous history of PN as it offers a repeatable operation, with a high technical success rate and causing minor changes in renal function.

Image guided percutaneous probe ablation for renal tumors in 65 solitary kidneys: functional and oncological outcomes.

PURPOSE: We evaluated the oncological and functional outcomes of computerized tomography guided percutaneous cryotherapy or radio frequency ablation of kidney tumors in patients with a solitary kidney. MATERIALS AND METHODS: We reviewed the medical charts of patients with a solitary kidney who underwent percutaneous probe ablation for renal masses at our institution from April 2002 through March 2010. Followup consisted of computerized tomography or magnetic resonance imaging 1 day postoperatively, at 3, 6 and 12 months, and annually thereafter. Serum creatinine and estimated glomerular filtration rate were used to measure renal function. The cryotherapy and radio frequency ablation groups were compared for demographics, the 2-year actuarial survival rate and renal function. RESULTS: Overall 65 patients were included in this retrospective analysis, of whom 29 (44.6%) underwent cryotherapy and 36 (55.4%) underwent radio frequency ablation. Median followup was 15.1 (IQR 4.4 to 32.9) and 38.8 months (13.8 to 50.7), respectively. The 2 groups were comparable in median age, body mass index, American Society of Anesthesiologists score, tumor size and preoperative estimated glomerular filtration rate. The 3 primary treatment failures, including 1 after cryotherapy and 2 after radio frequency ablation, were successfully re-treated with thermal ablation. There were 14 recurrences after radio frequency ablation and 3 after cryotherapy. Two-year actuarial overall, cancer specific, recurrence-free and metastasis-free survival rates for cryotherapy vs radio frequency ablation were 89% vs 93%, 100% vs 96%, 69% vs 58% and 86% vs 91%, respectively. For each group no significant decrease in renal functional parameters was found at the latest followup visit. CONCLUSIONS: Computerized tomography guided percutaneous probe ablation represents a safe treatment option in surgical patients at high risk with a solitary kidney. It provides low morbidity, acceptable short-term cancer control and minimal clinical impact on postoperative renal function.

Synchronized real-time ultrasonography and three-dimensional computed tomography scan navigation during percutaneous renal cryoablation in a porcine model.

AIM: To investigate the accuracy of percutaneous cryoablation for kidney tumors performed under combined real-time ultrasonography (US) and three-dimensional (3D) CT scan navigation in a porcine model. MATERIALS AND METHODS: After percutaneously injecting 2 to 6 tumor mimic lesions in 11 pigs, a CT scan was performed and digital data were saved into a navigation system (Real-Time Virtual Sonography [RVS]) that allows 3D reconstruction and synchronization with real-time US images. The cryoprobe was guided percutaneously into the kidney tumor mimic, and ice ball formation was monitored continuously during cryoablation using the RVS system. Kidneys were harvested and sent for gross pathologic and histopathologic analysis at days 0, 15, and 30 postoperatively. RESULTS: Thirty-five renal tumor mimics were created and treated by percutaneous cryotherapy; tumor mimic locations were as follows: 16 tumors (46%) in the lower pole, 14 (40%) in the central region, and 5 (14%) in the upper pole. Eleven tumor mimics (31%) were intraparenchymal, and 24 (69%) subcapsular. The synchronization between the CT scan 3D reconstructed images and real-time US was successful in all cases. The mean tumor size was 2 cm (range, 1.2-4 cm). Mean cryonecrosis size was 3.3, 3.7, and 2.8 cm at days 0, 15, and 30, respectively. Three (8.5%) positive margins were found on the macroscopic and microscopic analysis. CONCLUSIONS: RVS imaging system synchronizing real-time US with preoperative CT scan is a feasible and safe technique for percutaneous probe ablation of kidney tumors.

Stereotactic percutaneous cryoablation for renal tumors: initial clinical experience.

PURPOSE: Percutaneous imaging guided tumor ablation has an increasingly prominent role as minimally invasive treatment for renal tumors. Precise cryoprobe placement is essential for successful ablation. CT-Nav is a novel stereotactic surgical navigation system with the potential to achieve precise percutaneous cryoprobe placement while decreasing radiation exposure compared to conventional computerized tomography guided procedures. MATERIALS AND METHODS: We performed a prospective pilot study to evaluate the technical feasibility, safety and accuracy of the system during renal cryoablation. Patients with enhancing renal masses amenable to renal cryoablation underwent preoperative computerized tomography with a preplaced tracking sensor taped to the body. Using a stereroscopic infrared camera the tracking sensor was located 3-dimensionally and a tracking handle was used to guide the cryoprobe percutaneously based on preoperative preloaded computerized tomography. Demographic and perioperative data were added prospectively to an institutional review board approved database. Immediately after cryoprobe placement computerized tomography was repeated to confirm placement accuracy. RESULTS: A total of 13 tumors in 10 patients were successfully cryoablated with the novel navigational system. Mean tumor size was 2.2 cm. Preoperative biopsy revealed renal cell carcinoma in 9 cases. Mean operative time was 155 minutes. No intraoperative or postoperative complications were noted. Mean length of stay was 9.5 hours. Mean targeting registration error was 4.2 mm. CONCLUSIONS: Stereotactic percutaneous cryoablation for renal tumors offers the potential for safe, precise needle placement.

Hemorrhagic cholecystitis as a complication of anticoagulant therapy: role of CT in its diagnosis.

Hemorrhage within the gallbladder lumen is a rare but potentially fatal complication of acute cholecystitis. Concomitant anticoagulant therapy increases the chances of hemorrhage. In this case report we describe one such case which showed active extravasation of the contrast into the lumen of the gallbladder. Early diagnosis of this potentially fatal condition is important to facilitate urgent surgical treatment.

Correlation of radiographic imaging and histopathology following cryoablation and radio frequency ablation for renal tumors.

PURPOSE: Followup after radio frequency ablation and cryotherapy for small renal lesions lacks pathological analysis. The definition of successful tumor ablation has been the absence of contrast enhancement on posttreatment magnetic resonance imaging or computerized tomography. We hypothesized that adding post-ablation kidney biopsy would help confirm treatment success. MATERIALS AND METHODS: From April 2002 to March 2006 a total of 109 renal lesions in 88 patients were ablated with percutaneous radio frequency ablation and from September 1997 to January 2006 a total of 192 lesions in 176 patients were treated with laparoscopic cryoablation. Patients were followed with radiographic imaging and post-ablation biopsy at 6 months. RESULTS: Radiographic success at 6 months was 85% (62 cases) and 90% (125) for radio frequency ablation and cryoablation, respectively. At 6 months 134 lesions (45%) were biopsied and success in the radio frequency ablation cohort decreased to 64.8% (24 cases), while cryoablation success remained high at 93.8% (91). Six of 13 patients (46.2%) with a 6-month positive biopsy after radio frequency ablation demonstrated no enhancement on posttreatment magnetic resonance imaging or computerized tomography. In patients treated with cryoablation all positive biopsies revealed posttreatment enhancement on imaging just before biopsy. CONCLUSIONS: We observed a poor correlation between radiographic imaging and pathological analysis. We recommend post-radio frequency ablation followup biopsy due to the significant risk of residual renal cell cancer without radiographic evidence, although to our knowledge the clinical significance of these viable cells remains to be determined. In contrast, radiographic images of renal lesions treated with cryotherapy appeared to correlate adequately with corresponding histopathological findings in our series.

Percutaneous radiofrequency ablation of tumor in transplanted kidney.

Treatment options for tumors in allograft kidneys include radical nephrectomy or nephron-sparing surgery. Nephron-sparing procedures relieve the patient of the necessity of immediate dialysis. Partial nephrectomy is technically challenging and potentially difficult because of existing comorbidities and adhesions from previous surgery. Probe ablation is technically simpler and is associated with lower morbidity, shorter hospitalization, and reduced convalescence compared with open partial nephrectomy of a renal allograft. We present an interesting case with a synchronous finding of a papillary renal cancer in a native and allograft kidney, in which the allograft tumor was treated with percutaneous radiofrequency ablation.

Probe-ablative nephron-sparing surgery: cryoablation versus radiofrequency ablation.

Over the past decade, a number of probe ablative therapies have emerged for the treatment of patients with localized renal tumors. Cryoablation and radiofrequency ablation (RFA) have been studied in the greatest detail. We present the results of 164 laparoscopic cryoablations and 82 percutaneous RFAs performed in our institution and compare them retrospectively in terms of complications, impact on renal function, follow-up imaging, and oncologic outcomes. Comparison of cryotherapy versus RFA revealed that mean tumor size was similar (2.56 cm vs 2.51 cm); however, the cryoablation group had a greater number of anteriorly located tumors (39% vs 10%), as well as fewer central tumors (6% vs 37%) and fewer solitary kidneys (24% vs 49%). Mean thermal treatment time was 19.3 minutes versus 32.2 minutes in the cryoablation and RFA groups, respectively. Radiologic evidence of tumor recurrence or persistence of disease was noted in 3 patients (1.8%) who underwent cryoablation and in 9 (11.1%) who were treated with RFA. All of have been successfully treated with repeat ablation/nephrectomy, or they are currently under observation. Complication rates were minimal in both groups; no significant impact on mean serum creatinine levels was noted. Cancer-specific survival following cryotherapy was 98% at a median follow-up of 3 years and 100% for RFA at 1-year median follow-up. Cryoablation and RFA are developmental nephron-sparing options. Early results are encouraging for both forms of probe ablation in terms of early oncologic control, preservation of renal function, and low complication rates. Longer-term oncologic data are necessary so that the true value of these treatment modalities can be determined.

Colonic abnormalities on CT in adult hospitalized patients with Clostridium difficile colitis: prevalence and significance of findings.

OBJECTIVE: The purpose of this study was to determine the prevalence of an abnormal colon on CT in adult inpatients with Clostridium difficile colitis, compare the clinical presentation of these patients, and determine whether CT findings predicted the need for surgical treatment. MATERIALS AND METHODS: Over a 21-month period, 152 of 572 inpatients with C. difficile colitis were identified and had CT scans performed within 2 weeks of the diagnosis. These were independently and retrospectively reviewed by two reviewers. Those with colonic wall thickness greater than 4 mm were considered positive (CT-positive patients) and were further reviewed for specific findings in the colon. All 152 patients with CT scans were also retrospectively reviewed using the hospital information system for certain clinical parameters, admitting diagnoses, and reasons for scanning. The following were compared using several statistical tests: clinical parameters in CT-positive and CT-negative patients and surgical and nonsurgical groups to determine if positive scans or surgical treatment could be clinically predicted; specific CT findings in CT-positive patients to see if an association was found with clinical parameters or surgical treatment; and admitting diagnoses and reasons for scanning in scanned and unscanned populations to see which patients were more likely to undergo CT. RESULTS: Seventy-six (50%) of 152 scanned hospitalized patients with C. difficile colitis were CT-positive. These patients most often had segmental involvement (50 [66%] of 76 patients), with the rectum (60 [82%] of 73 patients) and sigmoid colon (61 [82%] of 74 patients) most often affected. Positive scans were associated with increased WBC, abdominal pain, and diarrhea. Patients with signs and symptoms of infection or abdominal complaints were more likely to be scanned. No statistical correlation was found between specific CT findings and clinical parameters or clinical parameters and patients requiring surgery. There was no predictive value of specific CT findings for surgical treatment. CONCLUSION: Half of the patients scanned had an abnormal CT, with segmental colonic disease more common than diffuse. Positive scans were more likely in patients with leukocytosis, abdominal pain, and fever. Specific CT findings did not correlate with clinical parameters and could not predict surgical treatment.

Prospective preoperative determination of mucinous pancreatic cystic neoplasms.

BACKGROUND: Optimal management of pancreatic cystic neoplasms includes identification and resection of mucinous neoplasms. This study was performed to assess the accuracy of preoperative variables in determining a mucinous lesion. METHODS: Patients referred for a cystic neoplasm were prospectively assessed by presenting symptoms, blinded radiologic review, and endoscopic ultrasound-guided cyst aspirate analysis. Patients who were symptomatic, or had aspirate findings of a mucinous neoplasm were resected. RESULTS: Eighty-seven patients were enrolled over a 22-month period ending in December 2001. There were 56 (64%) women and 31 (36%) men, with a mean age of 63 (27-86) years. Thirty-five (40%) patients were resected including 24 (69%) women and 11 (31%) men with a mean age of 58 years. Twenty-eight (80%) patients who had resection were symptomatic. Specimen histology included 18 (51%) mucinous neoplasms, 8 (23%) serous neoplasms, 4 (11%) ductal or neuroendocrine carcinomas, and 3 (9%) pseudocysts. The positive predictive value (PPV) for cyst-aspirate extracellular mucin (83%) was significant in predicting a mucinous neoplasm (P =.009). No other aspirate variables (amylase, carcinoembryonic antigen, CA15-3, viscosity), or patient characteristics were predictive of final histology. Diagnostic agreement between all 3 radiologists was 8% (P =.98). At a median follow-up of 12 months, no patients who were observed required resection. CONCLUSIONS: Patients with suspected pancreatic cystic neoplasms can be selectively treated on the basis of symptoms and cyst-aspirate mucin analysis. Symptomatic and mucin containing lesions should be resected.