James Cassuto, MS IV. Shekher Maddineni, MD Samuel McCabe, MD Vascular and Interventional Radiology

Transcription

1 Student: Attendings: Department: James Cassuto, MS IV Grigory Rozenblit, MD Shekher Maddineni, MD Samuel McCabe, MD Vascular and Interventional Radiology

2 Chief Complaint & HPI 61 year old female who is 18 years post double pediatric kidney transplantation for end stage renal disease (ESRD) 2 o to glomerulonpehritis who presents with a lesion identified on routine surveillance ultrasound Ultrasound revealed 2.2 x 1.5 x 1.9 cm hypoechoic lesion of RLQ renal allograft, with low level of internal echoes

3 Relevant History Past Medical History Glomerulonephritis, ESRD, Post-transplant lymphoproliferative disorder (2002), Renal cell carcinoma (RCC:T1a, Nx, Mx) right native kidney (2009) Past Surgical History Double cadaveric pediatric kidney transplantation (1994), radical nephrectomy of right native kidney for RCC (2009, 15 years post transplant) Review of Systems Feeling well, no weight change, no pain, (-) fever/chills

4 Relevant History - Question Development of RCC in native kidneys post transplant has been reported to be as high as what percent? A: 3% B: 5% C: 7% D: 9%

5 CORRECT! Development of RCC in native kidneys post transplant has been reported to be as high as what percent? A: 3% B: 5% C: 7% D: 9% RETURN TO CASE Vesgo et al. Transplant Proc Cheung et al. Int Urol Nephrol. 2011

6 SORRY, THAT S INCORRECT Development of RCC in native kidneys post transplant has been reported to be as high as what percent? A: 3% B: 5% C: 7% D: 9% RETURN TO CASE Vesgo et al. Transplant Proc Cheung et al. Int Urol Nephrol. 2011

7 Diagnostic Workup MRI revealed a 1.9 x 2.2 x 2.6 cm mild homogeneous enhancing lesion, suspicious for RCC CT guided biopsy confirmed papillary RCC, grade 2/4 Follow-up MRI at 9 months showed lesion grew to 2.1 x 2.5 x 3.1 cm Arterial enhanced MRI shows RCC in RLQ transplanted kidney

8 Diagnostic Workup- Question What percent of RCC s are diagnosed as incidental findings on radiologic exams? A: 10% B: 20% C: 30% D: 40%

9 CORRECT! What percent of RCC s are diagnosed as incidental findings on radiologic exams? A: 10% B: 20% C: 30% D: 40% RETURN TO CASE Palsdottir et al. J Urol. 2012

10 SORRY, THAT S INCORRECT What percent of RCC s are diagnosed as incidental findings on radiologic exams? A: 10% B: 20% C: 30% D: 40% RETURN TO CASE Palsdottir et al. J Urol. 2012

11 Intervention Considerable discussions with urology regarding the most appropriate treatment concluded that partial or radical nephrectomy would dramatically limit renal function, given the size of the remaining kidney(s). This would place the patient at high risk for requiring dialysis. Thus, it was recommended that renal sparing thermal ablation techniques be used to treat the cancer. Microwave Ablation (MWA) CT image guidance was used to place a 17 gauge 15 cm Certus MWA probe into the malignant lesion (NeuWave Medical, Madison, WI) MWA targeted 4 locations. 140 W for 10 minutes Tract ablation was performed as the probe was withdrawn Follow-up CT images revealed no evidence of hematoma surrounding the transplanted kidney

12 Intervention: Microwave Ablation MWA probe in renal mass (CT) Post-ablation series

13 Intervention - Question Which of the following is a major complication of thermal ablation? A: Bowel injury B: Track seeding C: Collecting system injury D: Parasthesia E: A, B, and C F: All of the above

14 SORRY, THAT S INCOMPLETE Which of the following is a major complication of thermal ablation? A: Bowel injury B: Track seeding C: Collecting system injury D: Parasthesia E: A, B, and C F: All of the above RETURN TO CASE Lin et al. Urology Yu et al. Radiology. 2014

15 SORRY, THAT S INCORRECT Which of the following is a major complication of thermal ablation? A: Bowel injury B: Track seeding C: Collecting system injury D: Parasthesia E: A, B, and C F: All of the above RETURN TO CASE Lin et al. Urology Yu et al. Radiology. 2014

16 CORRECT! Which of the following is a major complication of thermal ablation? A: Bowel injury B: Track seeding C: Collecting system injury D: Parasthesia E: A, B, and C F: All of the above RETURN TO CASE Lin et al. Urology Yu et al. Radiology. 2014

17 Clinical Follow Up: Right Femoral Neuropathy 12h post MWA, patient complained of dull right flank pain which progressed to right lower extremity weakness and parasthesias by morning MRI of the pelvis and lumbo-sacral spine revealed edema and fat stranding within the plane between the right iliacus and psoas muscles, a thickened right femoral nerve with loss of fasicular architecture, without evidence of disc herniation, spinal stenosis, or neural foramen narrowing Diagnosis: Right femoral neuropathy 2 o to thermal injury 1.5 months post ablation, musculoskeletal and neurological symptoms resolved 2 month follow-up MRI revealed no residual tumor

18 Clinical Follow Up: Right Femoral Neuropathy RA I MRI: T1W Demonstrates thickened right femoral nerve (arrow) RA: renal allograft; I: iliacus muscle MRI: T1W SPIR 2 month follow up reveals no residual tumor

19 Clinical Follow Up: Renal-Cutaneous Fistula 3 months post ablation, the patient developed a renal-cutaneous fistula with urine draining from the ablation probe site Under fluoroscopic guidance a ureteral stent and nephrostomy tube were placed within the treated kidney (image at right) The nephrostomy tube was removed 2.5 months later with subsequent resolution of the complication

20 Summary & Teaching Points This is the first case, to our knowledge, detailing the treatment of RCC within a transplanted kidney using MWA Our experience underscores the value of MWA as a renal sparing technique in difficult to treat RCC Assessment of anatomic real-estate is essential in thermal ablation procedures, as was seen in this case were the transplant kidneys overlay the iliacus muscle and femoral nerve Complications of MWA include: ureteral obstruction, collecting system injury, bowel injury, track seeding, pain at ablation site, paresthesia, hematuria, hematoma, and neuropathy

21 References & Further Reading Vegso G, Toronyi E, Hajdu M, et al. Renal cell carcinoma of the native kidney: a frequent tumor after kidney transplantation with favorable prognosis in case of early diagnosis. Transplant Proc. 2011;43(4): Cheung CY, Lam MF, Lee KC, et al. Renal cell carcinoma of native kidney in Chinese renal transplant recipients: a report of 12 cases and a review of the literature. Int Urol Nephrol. 2011;43(3): Palsdottir HB, Hardarson S, Petursdottir V, et al. Incidental detection of renal cell carcinoma is an independent prognostic marker: results of a long-term, whole population study. J Urol. 2012;187: Lin Y, Liang P, Yu XL, et al. Percutaneous microwave ablation of renal cell carcinoma is safe in patients with a solitary kidney. Urology. 2014;83(2): Yu J, Liang P, Yu XL, et al. US-guided percutaneous microwave ablation versus open radical nephrectomy for small renal cell carcinoma: intermediate-term results. Radioloy. 2014;270(3):