Ablación del cáncer renal por radiofrecuencia

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Abstract

Introducción: El tratamiento estándar de las masas renales de pequeño tamaño es la nefrectomía parcial, que ha demostrado unos resultados oncológicos semejantes a la nefrectomía radical. Recientemente se han desarrollado técnicas de ablación como la radiofrecuencia y la crioterapia, con el fin de minimizar los efectos secundarios de la resección quirúrgica convencional. En este artículo, revisamos la técnica de ablación mediante radiofrecuencia. Material y métodos: Para esta revisión se ha utilizado la base de datos Medline introduciendo los términos “renal radiofrequency ablation”. Resultados: Se analizan los diferentes sistemas que existen en el mercado para la aplicación de radiofrecuencia. Se describen las técnicas de aplicación (abierta, laparoscópica y percutánea), observando una tendencia clara a la aplicación de forma percutánea. En los estudios clínicos publicados existen ya series de pacientes con seguimientos a medio plazo (3 años) en los que se demuestra unos resultados oncológicos semejantes a los de las técnicas de resección clásicas y con un índice de complicaciones menor. Conclusiones: La ablación de tumores renales con radiofrecuencia ha demostrado ser un tratamiento eficaz y con mínimas complicaciones. Sin embargo, hasta que no existan seguimientos a largo plazo, se debe utilizar únicamente en pacientes seleccionados.

Translated abstract

Introduction: Standard treatment for small renal masses is partial nephrectomy, which has shown oncological results similar to radical nephrectomy. Ablation procedures such as radiofrequency and cryotherapy have recently been developed in order to minimize the side effects of conventional surgical excision. This article reviews radiofrequency ablation. Materials and methods: For this review, a search was made in the Medline database using the term “renal radiofrequency ablation”. Results: The different currently marketed systems for delivery of radiofrequency energy are examined. The different delivery approaches (open, laparoscopic, and percutaneous) are described. A trend towards use of the percutaneous approach was seen. Published clinical studies already include patient series with mid-term follow-ups (3 years) showing oncological outcomes similar to conventional resection procedures with fewer complications. Conclusions: Renal tumor radiofrequency ablation has proved to be an effective treatment with minimal complications. However, it should only be used in selected patients until longer follow-up studies are available.

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Most cited references 84

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Rising incidence of renal cell cancer in the United States.

W. Chow, S Devesa, J Warren … (1999)

Clinical surveys have revealed that incidental detection of renal cell carcinoma is rising because of increased use of imaging procedures. To examine incidence, mortality, and survival trends of renal cell and renal pelvis cancers by age, sex, race, and tumor stage at diagnosis. Calculation of age-adjusted incidence and mortality rates, along with 5-year relative survival rates, using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. Patients diagnosed as having kidney cancer from 1975 through 1995 in the 9 geographic areas covered by tumor registries in the SEER program, which represent about 10% of the US population. Incidence, mortality, and 5-year relative survival rates by time periods. The age-adjusted incidence rates for renal cell carcinoma between 1975 and 1995 for white men, white women, black men, and black women were 9.6, 4.4, 11.1, and 4.9 per 100000 person-years, respectively. The corresponding rates for renal pelvis cancer were 1.5, 0.7, 0.8, and 0.5 per 100000 person-years. Renal cell cancer incidence rates increased steadily between 1975 and 1995, by 2.3% annually among white men, 3.1 % among white women, 3.9% among black men, and 4.3% among black women. Increases were greatest for localized tumors but were also seen for more advanced and unstaged tumors. In contrast, the incidence rates for renal pelvis cancer declined among white men and remained stable among white women and blacks. Although 5-year relative survival rates for patients with renal cell cancer improved among whites but not among blacks, kidney cancer mortality rates increased in all race and sex groups. Increasing detection of presymptomatic tumors by imaging procedures, such as ultrasonography, computed tomography, and magnetic resonance imaging, does not fully explain the upward incidence trends of renal cell carcinoma. Other factors may be contributing to the rapidly increasing incidence of renal cell cancer in the United States, particularly among blacks.

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Nephron sparing surgery for renal tumors: indications, techniques and outcomes.

R G Uzzo, A C Novick (2001)

A contemporary review of the indications, techniques and outcomes is presented for nephron sparing approaches to solid renal masses, emphasizing their role for the treatment of renal cell carcinoma. We also reviewed the evolving role of minimally invasive forms of parenchymal sparing renal surgery. MEDLINE and CANCERLIT computerized literature searches, and manual bibliographic reviews were performed to identify published peer reviewed articles pertaining to nephron sparing surgery or partial nephrectomy from 1980 to 2000. Pertinent articles were collated and reviewed. Nephron sparing surgery is increasingly being used to treat patients with solid renal lesions. The technical success rate of nephron sparing surgery is excellent, and operative morbidity and mortality are low. For renal cell carcinoma long-term cancer-free survival is comparable to that after radical nephrectomy, particularly for low stage disease. The overall incidence of local recurrence is low at 0% to 10%. For tumors 4 cm. or less local recurrence rates are even less at 0% to 3%. The risk of local recurrence depends primarily on the initial local pathological tumor stage. The reported incidence of multifocal renal cell carcinoma is approximately 15% and it also depends on tumor size, histology and stage. The risk of multifocal disease is low at less than 5% when the maximal diameter of the primary tumor is 4 cm. or less. Recent advances in renal imaging limit the radiographic evaluation necessary when planning complex nephron sparing approaches. Three-dimensional, volume rendered computerized tomography integrates all of the necessary information previously obtained by conventional computerized tomography, angiography, venography and pyelography into a single preoperative test, allowing better operative planning with maximal preservation of unaffected parenchyma in the remnant kidney. Minimally invasive modalities of tumor resection or destruction should be reserved for highly select patients and await improvements in technology, standardization of technique and long-term outcomes data before they may be completely integrated options. Nephron sparing surgery provides effective therapy for patients in whom preservation of renal function is a relevant clinical consideration. The importance of meticulous operative technique for achieving acceptable oncological and functional outcomes is emphasized. Accumulating data in appropriately select patients suggest a long-term functional advantage gained by the maximal preservation of unaffected renal parenchyma without sacrificing cancer control.

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Radiofrequency ablation of renal cell carcinoma: part 1, Indications, results, and role in patient management over a 6-year period and ablation of 100 tumors.

Hugh F. McGovern, W Scott McDougal, R. S. P. Mueller … (2005)

The objectives of our article are to review our experience with radiofrequency ablation of renal cell carcinoma and to assess size and location as predictors of the ability to achieve complete necrosis by imaging criteria. Over a 6-year period, 100 renal tumors in 85 patients underwent radiofrequency ablation at a single institution. The absence of enhancement on CT or MRI after radiofrequency ablation was interpreted as complete coagulation necrosis. Results were analyzed by tumor size and location using multivariate analysis. A p value of 0.05 or less was considered significant. All 52 small (3 cm) and all 68 exophytic tumors underwent complete necrosis regardless of size, although many large tumors (> 3 cm) required a second ablation session. Using multivariate analysis, we found that both small size (p < 0.0001) and noncentral location (p = 0.0049) proved to be independent predictors of complete necrosis after a single ablation session. Location was a significant predictor (p = 0.015) of complete necrosis after any number of sessions, whereas size showed a strong trend (p = 0.059) toward predicting success after any number of sessions. Complications were either self-limited or readily treated and included hemorrhage (major, n = 2; minor, n = 3), inflammatory track mass (n = 1), transient lumbar plexus pain (n = 2), ureteral injury (n = 2), and skin burns (n = 1). Radiofrequency ablation is a promising minimally invasive therapy for renal cell carcinoma in patients who are not good operative candidates. Small size and noncentral location are favorable tumor characteristics, although large tumors can sometimes be successfully treated with multiple ablation sessions.