1.
Embolytic therapy
(1)
Renal artery embolization
(1)
Renal artery embolization
: Renal artery embolization can be used for palliative treatment of renal tumors to relieve clinical symptoms and improve quality of life.
1)
Indications
(1) pain due to renal tumor; (2) hemorrhagic events associated with renal tumor, such as renal tumor rupture or bleeding after partial nephrectomy and hematuria; (3) pre-surgical embolization of some large, blood-rich renal tumors: it is not routinely recommended because its benefit in terms of prolonging patient survival, reducing intraoperative bleeding, and decreasing postoperative complications is unclear.
2)
Contraindications
: ① Uncorrectable coagulopathy; ② Severe infection.
(iii) Significant reduction in peripheral blood leukocytes and platelets (not an absolute contraindication, e.g., in hypersplenism): leukocytes <3.0×109/L and platelets <50×109/L; (iv) Severe renal dysfunction.
3)
Key points of the operation procedure
(1) Renal arteriography, usually using the Seldinger method, is performed by percutaneous puncture of the femoral artery or radial artery, and the catheter is placed in the renal artery for digital subtraction angiography (DSA) and, if necessary, adrenal arteriography to search for collateral blood supply. (2) Carefully analyze the angiographic manifestations to clarify the location, size, number and blood supplying arteries of the tumor. ③Embolization of the tumor blood supply artery is performed. For bleeding after partial nephrectomy, embolization should be performed as much as possible super-selected to the relevant vessels, paying attention to the preservation of normal renal units.
(4) Postoperative complications: post-embolization syndrome is the most common adverse reaction after renal artery embolization, mainly manifested as fever, pain, nausea and vomiting. It is caused by local tissue ischemia and necrosis after embolization of renal artery, and most patients can recover completely after symptomatic treatment.
(2)
Pulmonary metastasis embolism
The lung is the most common site of metastasis for renal tumors, and some patients with renal tumors have hemoptysis as the first symptom. Bronchial artery embolization can be used to treat pulmonary metastases, prevent complications associated with pulmonary metastases, and improve the quality of survival.
1)
Indications
(1) pain due to lung metastases, such as pleural metastases; (2) dyspnea due to lung metastases, such as airway compression stenosis; (3) hemorrhagic events related to lung metastases, such as hemoptysis, hemothorax, etc.
2)
Contraindications
(1) Uncorrectable coagulopathy; (2) Severe infection.
③ Significant reduction in peripheral blood leukocytes and platelets (not an absolute contraindication, e.g. in hypersplenism): leukocytes <3.0×109/L and platelets <50×109/L; ④ Severe renal dysfunction.
3)
Key points of the operation procedure
The catheter is placed in the bronchial artery and DSA is performed. If necessary, intercostal arteries can be used to find collateral blood supply. (2) Carefully analyze the imaging performance to clarify the location, size, number and blood supplying artery of the tumor. (3) Super-select the tumor-supplying artery for embolization, paying attention to avoid the spinal artery. ④For metastatic non-clear cell carcinoma, chemoembolization of bronchial artery can be considered.
4)
Postoperative complications
Post-embolization syndrome is the most common adverse reaction after bronchial artery embolization, mainly manifesting as fever, pain, cough, and hemoptysis. It occurs because of local tissue ischemia and necrosis caused by embolization, and most patients can recover completely after symptomatic treatment.
(3)
Embolization of liver metastases
The liver is also a common site of metastasis for renal tumors. Selective hepatic artery embolization can be used to treat liver metastases, prevent deterioration of liver function, and improve the quality of survival.
1)
Contraindications
: ① Uncorrectable coagulopathy; ② Severe infection.
(iii) Significant reduction in peripheral blood leukocytes and platelets (not an absolute contraindication, such as in hypersplenism): leukocytes <3.0×109/L and platelets <50×109/L; (iv) Severe renal dysfunction; (v) Severe liver dysfunction (Child-Pugh grade C), including jaundice, hepatic encephalopathy, refractory ascites, or hepatorenal syndrome.
2)
Key points of the procedure
(1) Hepatic arteriography, usually using the Seldinger method, with percutaneous puncture of the femoral artery, catheter placed in the celiac trunk or common hepatic artery for DSA, should include the arterial, parenchymal, and venous phases; superior mesenteric arteriography should be performed, with attention to finding collateral blood supply. (2) Carefully analyze the imaging performance to clarify the site, size, number and blood supplying artery of the tumor. ③Hepatic artery embolization: super-select to tumor blood supply artery for embolization. ④For metastatic non-clear cell carcinoma, hepatic artery chemoembolization can be considered.
3)
Postoperative complications
Post-embolization syndrome is the most common adverse reaction after hepatic artery embolization, mainly manifesting as fever, pain, nausea, vomiting, and transient liver function abnormalities. It is caused by local ischemia and necrosis after embolization of the hepatic artery, and most patients can recover completely after symptomatic treatment.
2.
Ablation therapy
Ablative therapy has been widely used in recent years to give some patients with renal cell carcinoma who do not undergo or tolerate surgical resection a chance for radical treatment.
Ablative therapy is a type of treatment that uses physical or chemical methods to directly kill tumor tissue by targeting the tumor with the guidance of medical imaging technology. The ablation of renal tumors and oligometastases mainly includes radiofrequency ablation and cryoablation. CT and MRI combined with multimodal imaging system can be used to observe lesions that cannot be reached by ultrasound, and CT and MRI-guided techniques can also be applied to ablate metastases in lung, liver, adrenal gland, bone, etc.
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Radiofrequency ablation
The route of radiofrequency ablation is usually divided into percutaneous ablation and transcatheter ablation, with no difference in postoperative complication rates, recurrence rates, or tumor-specific survival rates in patients with stage T1a renal tumors. In patients with stage T1a renal tumors, there was no difference in overall survival and tumor-specific survival between radiofrequency ablation and partial nephrectomy, and the complication rate and transfusion rate of radiofrequency ablation were lower than those of partial nephrectomy.
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Cryoablation
The routes of cryoablation are usually divided into percutaneous ablation and transluminal ablation, with no difference in overall survival, tumor-specific survival, recurrence-free survival, or complication rates between the two. When comparing cryoablation with partial nephrectomy, some studies showed no difference in overall survival, tumor-specific survival, recurrence-free survival, disease-free survival, local recurrence rate and distant metastasis rate, and some studies showed that partial nephrectomy was superior to cryoablation in the above indexes.
Indications for ablation therapy: ① in stage T1a, in advanced age or with comorbidities.
(ii) those with recurrence or unresectable in stage IV, who can be combined with ablation of oligometastases based on systemic therapy; (iii) those who do not accept or tolerate surgery; (iv) those who need to preserve renal units as much as possible; (v) those with renal insufficiency; (vi) those with contraindications to general anesthesia.
Contraindications to ablation therapy: ①uncorrectable coagulation dysfunction; ②severe infection; ③significant reduction in peripheral blood leukocytes and platelets (not an absolute contraindication, such as hypersplenism): leukocytes <3.0×109/L and platelets <50×109/L.
Key points of operation procedure: ① puncture biopsy is required before ablation to provide support for subsequent treatment and follow-up; ② the size, location and number of tumor should be comprehensively and adequately evaluated before treatment; attention should be paid to the relationship between tumor and adjacent organs, and reasonable puncture path and ablation range should be formulated to achieve sufficient safety range while ensuring safety; ③ according to the size and location of tumor, suitable image guidance techniques ( For infiltrating cancer or metastatic cancer foci with unclear boundary and irregular shape, it is recommended to expand the ablation range if the adjacent tissues and structures permit.
Postoperative complications: fever, pain, bleeding, infection, etc., most of them are mild. Most patients can recover completely after symptomatic treatment.
(3)
Other techniques
(3) Other techniques: Other ablative treatments for renal tumors include: microwave ablation, high-intensity focused ultrasound ablation, irreversible electroporation, and high and low temperature combined ablation. The above methods have also been gradually applied in the ablative treatment of renal cell carcinoma.