Scars hinder surgery for renal tumors that recur after cryoablation.
ANAHEIM, Calif.—Salvage surgery may be quite problematic for patients who experience recurrence of renal cell carcinoma following primary thermal ablation, researchers reported.
“Cryoablation, in particular, is associated with significant perinephric scarring and fibrosis that heavily impacts the technical ease of performing nephrectomy in a salvage situation,” said lead investigator Carvell T. Nguyen, MD, PhD, a urology resident at the Cleveland Clinic.
He and his colleagues studied 281 patients treated with thermal ablation for small renal tumors; of these, 103 underwent radiofrequency ablation (RFA) and 178 underwent cryoablation. Tumors recurred in the treated kidney in 25 RFA-treated patients and 16 cryoablation-treated patients. Eleven patients were not candidates for repeat thermal ablation. In this group, one patient received systemic therapy and one refused further treatment. Nine underwent attempted surgical excision.
Laparoscopic or open radical nephrectomy was possible in seven cases while open partial nephrectomy was attempted in five patients with post-ablative recurrence but was successful in only three cases. In the surgical salvage cases, perinephric fibrosis was much more extensive in patients who had undergone primary cryoablation compared to those who were initially treated with RFA. The 2 cases in which partial nephrectomy was not possible occurred in post-cryoablation patients.
Treatment of renal masses with thermal ablation is associated with higher recurrence rates compared with surgical excision, “so for a significant percentage of patients treated with thermal ablation, salvage therapy will be a reality,” Dr. Nguyen said. Urologists and patients need to consider this when discussing management options, he said.
Dr. Nguyen added: “Proper patient selection is important to ensure that the difficult clinical scenarios that we encountered are not a common occurrence for patients who experience recurrence after being treated with thermal ablation.”
Commenting on the new study, Jaime Landman, MD, director of minimally invasive urology at Columbia University in New York, said the study’s most remarkable finding was that only five (2%) of 281 subjects required salvage extirpative treatment. Study findings should be interpreted with caution because the re-treatment group was quite small, Dr. Landman pointed out, adding that “clearly, these [salvage] procedures will be challenging.”
At the conference, Dr. Landman presented findings of a study looking at the efficacy and complications of percutaneous and laparoscopic cryoablation for renal tumors. The study population consisted of 52 patients who underwent percutaneous cryoablation (PCA) and 35 who underwent laparoscopic cryoablation (LCA). After a mean follow-up of seven months, the LCA group had no recurrences whereas the PCA group had two (3.8%) after a mean follow-up of 16 months.
Compared with PCA-treated patients, LCA was associated with greater estimated blood loss (275 vs. 25 cc), higher transfusion rate (seven LCA patients required transfusion vs. none of the PCA patients), and more major complications (three in the LCA arm, none in the PCA arm).