Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3899_Библиотеки_им_академика_М_И_Перельмана.pdf
Series Preface
For decades, practitioners have used classic textbooks
of several thousand pages to study interventional
radiology. We, however, identifi ed a great need for
small, subject-focused, and clinically oriented guides
to help practitioners and trainees master key skills on
the job. We envisioned portable, printed books that
could easily be carried to the clinic, procedure suite,
and inpatient ward, as well as new technologies
that would enable access on any phone, tablet, or
computer.
This Practical Guides in Interventional Radiology
Series will be extremely valuable for residents, fel-
lows, practicing physicians, and midlevel practi-
tioners who are currently involved in or look forward
to specializing in areas within the interventional
radiology spectrum. Book chapters systematically
coverindications,contraindications,patientselection
and preprocedure workup, procedural technique,
postprocedure management and follow-up, side
effects and complications, clinical data and outcomes,
and key references.
Interventional oncology (IO) has been an area of
tremendousgrowthandinterest over thelast20years
—considered by some to be its own subspecialty. I am
very pleased to see that both classic IO and the latest
advances and procedures are so well represented in
our Interventional Oncology volume.
Our editors, Suvranu Ganguli, MD, of Massachu-
setts General Hospital, Harvard Medical School, and
Ripal Gandhi, MD, of Miami Cardiac and Vascular
Institute, did a wonderful job working with a stellar
group of authors and thought leaders in the field.
We hope that readers find our Practical Guides in
Interventional Radiology Series to be a new and
improved way to master procedures and clinical care
skills in a focused and time-efficient manner.
Salomão Faintuch, MD, MSc
Series Editor–Practical Guides in
Interventional Radiology
Assistant Professor of Radiology
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Harvard Medical School
Clinical Director of Interventional Radiology
ix
Preface
Interventional oncology is an exciting, fast-growing,
and rapidly changing area within our specialty of
interventional radiology. Interventional oncology
uses image-guided techniques to diagnose and treat
localized cancers in targeted and minimally invasive
ways.The specialtyof interventional oncology had its
origins in the development of specifi c treatments for
hepatocellular carcinoma, including transarterial
chemoembolization and percutaneous alcohol injec-
tion, well before the term interventionaloncology had
ever been recognized. Interventional oncology has
expanded far beyond its scattered origins, with the
mature specialty now comprising a variety of new
treatment technologies and incorporating the full
clinical care of the oncology patient before, during,
and after treatment. Supported by ever-increasing
clinical expertise and clinicaltrialdata,interventional
oncology is cementing its place as one of the four
pillars of comprehensive, multidisciplinary cancer
care—medical oncology, radiation oncology, surgical
oncology, and interventional oncology.
Given the rapidly advancing fi eld, we envisioned
this textbook on interventional oncology to be suc-
cinct, clinically focused, and image-rich. We wanted
to create a concise resource on interventional oncol-
ogy that could be used by trainees as well as seasoned
interventional radiologists starting or expanding an
interventional oncology practice. Each chapter is laid
out with a similar format, including indications,
contraindications, patient selection, preprocedure
workup, technique (including equipment), postpro-
cedure management and follow-up evaluation, side
effects and complications, clinical data and out-
comes, pearls, and references. The layout makes for
high-yield preparation before seeing the oncology
patient in clinical consultation before any proposed
intervention, as well as knowing what to expect and
look for in terms of patient management after the
procedure.
We compiled a fabulous and experienced group of
authors for the chapters of this book—international
leaders and experts in the area. We hope that you find
this book a valuable addition and resource for your
interventional oncology practice.
Ripal T. Gandhi, MD
Suvranu Ganguli, MD
x
Contributors
Fereidoun Abtin, MD
Associate Professor
UCLA Department of Radiological Sciences
David Geffen School of Medicine
Los Angeles, California
Muneeb Ahmed, MD
Chief
Division of Vascular and Interventional Radiology
Beth Israel Deaconess Medical Center
Assistant Professor of Radiology
Harvard Medical School
Boston, Massachusetts
Shawn Ahmed, MD, PhD
Clinical Fellow
Vascular and Interventional Radiology
Massachusetts General Hospital
Boston, Massachusetts
Karen Brown, MD
Professor of Radiology
Weill-Cornell Medical College
Cornell University
Attending Physician
Interventional Radiology
MH Member
Memorial Sloan Kettering Cancer Center
New York, New York
Matthew Brown, MD
Resident
Department of Radiology
University of Colorado School of Medicine
Anschutz Medical Campus
Aurora, Colorado
Matthew R. Callstrom, MD, PhD
Professor of Radiology
Mayo Clinic College of Medicine
Rochester, Minnesota
Arash Eftekhari, MD, FRCPC
Department of Radiology
University of British Columbia
Department of Radiology
Vancouver General Hospital
Vancouver, British Columbia
Canada
Salomão Faintuch, MD, MSc—SERIES EDITOR
Assistant Professor of Radiology
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Harvard Medical School
Clinical Director of Interventional Radiology
Ripal T. Gandhi, MD, FSVM—EDITOR
Attending Physician
Vascular and Interventional Radiology
Miami Cardiac and Vascular Institute
Associate Clinical Professor
Herbert Wertheim College of Medicine at Florida
International University
Assistant Clinical Professor
University of South Florida School of Medicine
Miami, Florida
Suvranu Ganguli, MD—EDITOR
Associate Chief of Interventional Radiology
Co-Director,CenterforImage-Guided Cancer Therapy
Massachusetts General Hospital
Assistant Professor of Radiology
Harvard Medical School
Boston, Massachusetts
Scott Genshaft, MD
Assistant Professor
Radiology
UCLA Department of Radiological Sciences
David Geffen School of Medicine
Los Angeles, California
Debra A. Gervais, MD
Division Chief
Abdominal Imaging
Department of Radiology
Massachusetts General Hospital
Boston, Massachusetts
Rajan K. Gupta, MD
Assistant Professor
Department of Radiology
University of Colorado School of Medicine
Anschutz Medical Campus
Aurora, Colorado
xi
Antonio Gutierrez, MD
Assistant Professor, Radiology
UCLA Department of Radiological Sciences
David Geffen School of Medicine
Los Angeles, California
Steven L. Hsu, MD, MBA
Assistant Professor
Radiology
University of Texas Southwestern Medical Center
Dallas, Texas
Sanjeeva P. Kalva, MD, FSIR
Chief
Interventional Radiology
Associate Professor of Radiology
University of Texas Southwestern Medical Center
Dallas, Texas
Darren Klass, MD, PhD
Clinical Assistant Professor
University of British Columbia
Division of Interventional Radiology
Vancouver General Hospital
Vancouver, British Columbia
Canada
Matthew J. Kogut, MD
Assistant Professor
Interventional Radiology
University of Washington
Seattle, Washington
A. Nicholas Kurup, MD
Assistant Professor of Radiology
Mayo Clinic College of Medicine
Rochester, Minnesota
Edward Wolfgang Lee, MD, PhD
Assistant Professor
Interventional Radiology
UCLA Department of Radiological Sciences
David Geffen School of Medicine
Los Angeles, California
Riccardo Lencioni, MD, FSIR, EBIR
Professor and Director
Division of Diagnostic Imaging and Intervention
Pisa University Hospital and School of Medicine
Pisa, Italy
David Liu, MD, FRCPC, FSIR
Clinical Associate Professor
Department of Radiology
University of British Columbia
Vancouver Imaging LLC
Vancouver, British Columbia
Canada
Charles McGraw, MD, MBA
Fellow
Miami Cardiac and Vascular Institute
Miami, Florida
Prasoon P. Mohan, MD, MRCS (Eng.)
Clinical Instructor
Vascular and Interventional Radiology
University of Miami/Miller School of Medicine
Miami, Florida
Govindarajan Narayanan, MD
Chief
Vascular and Interventional Radiology
Associate Professor of Clinical Radiology
Program Director
Vascular Interventional Radiology Fellowship
University of Miami
Miller School of Medicine
Miramar, Florida
Rahmi Oklu, MD, PhD
Assistant Professor of Radiology
Harvard Medical School
Interventional Radiologist
Massachusetts General Hospital
Boston, Massachusetts
Siddharth A. Padia, MD
Associate Professor
Interventional Radiology
University of Washington
Seattle, Washington
Elena N. Petre, MD
Senior Research Scientist
Department of Radiology
Memorial Sloan Kettering Cancer Center
Section of Interventional Radiology
New York, New York
Contributors
xii
Charles E. Ray Jr., MD, PhD
Professor
Department of Radiology
University of Illinois at Chicago
Chairman of Radiology
University of Illinois Medical Center
Chicago, Illinois
Paul J. Rochon, MD
Assistant Professor, Radiology
University of Colorado School of Medicine
Anschutz Medical Campus
Aurora, Colorado
Constantinos Sofocleous, MD, PhD, FSIR, FCIRSE
Professor of Radiology
Weill-Cornell Medical College
Cornell University
Attending Physician, Interventional Radiology
MH Member
Memorial Sloan Kettering Cancer Center
New York, New York
Robert Suh, MD
Professor, Clinical Radiology
Director, Diagnostic Radiology Training Program
Director, Thoracic Interventional Services
University of California, Los Angeles
UCLA Department of Radiological Sciences
David Geffen School of Medicine
Ronald Reagan UCLA Medical Center
Los Angeles, California
Avnesh S. Thakor, BA, MA, MSc, MD, PhD, MB, BChir,
FHEA, FRCR(IR)
Assistant Professor
Division of Interventional Radiology, Department of
Radiology
Lucile Packard Children’s Hospital and Stanford
University Medical Center
Stanford, California
Raul N. Uppot, MD
Assistant Professor
Harvard Medical School
Director, Abdominal Imaging Fellowship
Associate Director, Harvard Medical School Core
Radiology Clerkship
Boston, Massachusetts
Aradhana M. Venkatesan, MD
Associate Professor, Term Tenure Track
Section of Abdominal Imaging
Department of Diagnostic Radiology
MD Anderson Cancer Center
Houston, Texas
Bradford J. Wood, MD
Chief
Interventional Radiology
Director
Center for Interventional Oncology, Radiology and
Imaging Sciences
NIH Clinical Center and National Cancer Institute
National Institutes of Health
Bethesda, Maryland
Omar Zurkiya, MD, PhD
Instructor
Division of Interventional Radiology
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts
Contributors
xiii
Chapter 1
Percutaneous Ablation of Renal
Cell Carcinoma
1.1 Introduction 2
1.2 Indications 3
1.3 Contraindications 4
1.4 Patient Selection and
Preprocedure Workup
4
1.5 Technique 5
1.6 Imaging Guidance 6
1.7 Patient Positioning 8
1.8 Postprocedure
Management and
Follow-up Evaluation
8
1.9 Side Effects and
Complications
9
1.10 Clinical Data and
Outcomes
9
1 Percutaneous Ablation of Renal Cell Carcinoma
Shawn Ahmed, Raul N. Uppot, and Debra A. Gervais
1.1 Introduction
Renal cell carcinoma (RCC) accounts for approxi-
mately 4% of all adult malignancies, with more
than 65,000 estimated new cases projected in the
United States in 2015, resulting in nearly 14,000
deaths during the same period of time.
1
The dis-
ease is more common in men than in women.
1
Risk factors include hypertension, smoking, obe-
sity, and hemodialysis in patients with end-stage
renal disease. Patients with certain genetic syn-
dromes, such as von Hippel–Lindau (VHL) disease,
have a high incidence of multiple and recurrent
tumors. The classic presentation is the triad of
flank pain, hematuria, and palpable abdominal
mass. Other symptoms include loss of appetite,
weight loss, anemia, and fatigue. Four dominant
RCC subtypes have been identified, with the clear
cell variety representing about 75% of cases.
2
Renal malignancies are staged using the TNM
staging system (▶ Table 1.1).
3
Approximately one-
fifth of patients present with advanced disease
and have associated poor 5-year survival.
1
The
increased use of cross-sectional imaging, however,
Table 1.1 TNM classification of renal cell carcinoma
Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Tumor ≤ 7 cm in greatest dimension, limited to the kidney
T1a Tumor≤ 4cm in greatest dimension, limited to the kidney
T1b Tumor >4cm but ≤ 7 cm in greatest dimension, limited to the kidney
T2 Tumor > 7 cm in greatest dimension, limited to the kidney
T2a Tumor>7 cm but ≤ 10 cm in greatest dimension
T2b Tumor >10cm, limited to the kidney
T3 Tumor extends into major veins or perinephric tissues but not into the ipsilateral adrenal
gland and not beyond Gerota’s fascia
T3a Tumor grossly extends into the renal vein or its segmental (muscle-containing) branches,
or tumor invades perirenal and/or renal sinus fat but not beyond Gerota’s fascia
T3b Tumor grossly extends into the vena cava below the diaphragm
T3c Tumor grossly extends into the vena cava above the diaphragm or invades the wall of the
vena cava
T4 Tumor invades beyond Gerota’s fascia (including contiguous extension into the ipsilateral
adrenal gland)
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis to regional lymph node(s)
Distant metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
Percutaneous Ablation of Renal Cell Carcinoma
2
has led to earlier detection. Currently, more than
half of all renal masses are discovered inciden-
tally,
4
with as many as 80% of patients presenting
with localized, low-stage disease.
1
Early detection
of small, organ-confined tumors has led to the
development of nephron-sparing treatment
options. Partial nephrectomy has shown compara-
ble long-term survival when compared to radical
nephrectomy in the treatment of organ-confined,
stage I and II tumors,
5,6,7
and has thus become the
treatment of choice for these patients. Image-
guided percutaneous ablation is also fast becoming
an accepted treatment option for select patients
with small tumors.
8,9,10,11,12,13,14,15,16,17,18,19
These
methods offer a number of advantages over sur-
gery. First, percutaneous ablation has been shown
to be associated with fewer complications and fast-
er recovery compared to surgery.
8
The procedures
can also be repeated when not completely suc-
cessful or in syndromic patients with recurrent
tumors. Importantly, there is some evidence to
suggest that renal function in patients with soli-
tary kidneys is better preserved following ablation
as compared to par tial nephrectomy.
20
Finally, per-
cutaneous ablation may be the only local treat-
ment option in patients who are poor surgical
candidates.
Several percutaneous ablative methods have
been described, including radiofrequency ablation
(RFA), cryoablation, microwave ablation, and high-
intensity, focused ultrasound ablation. The largest
experience to date has been with RFA and cryoa-
blation, with hundreds of cases reported in the lit-
erature.
8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,
29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,
53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68
There are com-
paratively limited data on the effectiveness of per-
cutaneous microwave ablation and high-intensity
focused ultrasound.
16,69,70,71,72,73,74,75,76
Several
investigators have reported the short-term and
mid-term effectiveness of both RFA and cryoabla-
tion of small renal masses with favorable results.
8,9,
10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,29,30,31,32,33,34,
35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,
59,60,62,63,65,66,67,77,78
Long-term survival data (> 5
years) following RCC ablation is sparse; however,
early studie s have shown promise.
13,28,61,64,77
To
date, there is no compelling evidence to suggest
superiority of one ablative method over another. A
recent meta-analysis comparing RFA and cryoabla-
tion demonstrated similar clinical efficacy and
complication rates.
79
As such, the choice between
RFA or cryoablation is often driven by physician
preference and local practice patterns.
1.2 Indications
Surgical resection remains the standard of care for
RCC treatment given the lack of robust, long-term
survival and disease-free survival data with percu-
taneous ablation procedures. Percutaneous abla-
tion is thus limited to patients who are not ideal
surgical candidates. Formal indications for the use
of percutaneous ablation in the treatment of RCC
have yet to be validated with prospective scientific
studies.
33
Percutaneous ablation therapies are,
however, considered appropriate for use in elderly
patients, in patients with comorbid conditions that
preclude surgery, in individuals with a solitary
kidney or renal insufficiency, and in patients with
multiple or recurrent tumors as with VHL disease.
Additionally, ablation is usually performed in
patients with a > 1-year life expectancy, because a
small RCC is unlikely to cause clinically significant
morbidity before 1 year.
14
In addition to the patient-specific criteria already
listed, there are tumor-specific criteria, such as
lesion size and location, that are also important in
determining the feasibility of percutaneous inter-
vention. Multiple studies have shown decreased
effectiveness of RFA with increasing tumor size.
14,
15,16,17,19,20,21,23,34,35,36,37,53,55
Zagoria et al
17
reported
a technical success rate with RFA ablation of
100% in tumors < 3 cm as compared to 69%
with tumors > 3 cm. In a retrospective study of
100 tumors treated with R FA, Gervais et al
14,15
found that tumor size was an independent predic-
tor of RFA success. Ninety-two percent of tumors
< 3 cm were successfully ablated in a single session,
whereas 44% of tumors measuring 3 to 5 cm
required more than one ablative session for com-
plete eradication. Tumors>5cm invariably requir-
ed more than one session.
Tumor location is also important in determining
the success of an ablative procedure. Gervais et al
showed that a noncentral location is an independ-
ent predictor of complete tumor necrosis.
14,15
This
is believed to be due in part to insulation of the
exophytic tumor by surrounding perirenal fat
allowing generation of higher ablative tempera-
tures. Poor treatment outcomes with centrally
located tumors in turn may be the result of a “heat
sink” effect of blood flow in hilar vessels causing
perfusion-mediated tumor cooling.
80
A retrospec-
tive study of 115 renal tumors treated with cryoa-
blation reported similar results with regard to
tumor size and position.
39
In the study, Atwell et al
reported technical success in 112 of 115 tumors
(97%). The three technical failures occurred in
Percutaneous Ablation of Renal Cell Carcinoma
3
central tumors, two of which were > 4 cm. Other
considerations include the proximity of central
tumors to the collecting system, ureter, and central
renal vasculature, which increases the risk of com-
plication, including significant hemorrhage and
ureteral injury. On the other hand, injury to adja-
cent organs or bowel is a concern with some exo-
phytic masses.
1.3 Contraindications
Absolute contraindications to percutaneous renal
ablation include uncorrected coagulopathy and
acute illness.
33
Serious comorbidities (e.g., conges-
tive heart failure, pulmonary hypertension, cardiac
arrhythmias) can be considered a relative contra-
indication necessitating assessment on a case by
case basis. High-risk patients may benefit from
close monitoring by anesthesiology personnel.
Patients with large tumors, as already discussed,
may be better served by surgical resection. By the
same token, local tumor spread beyond Gerota’s
fascia or distant metastatic spread may preclude
curative intent. Ablation may still be indicated
with advanced disease, with the purpose of
debulking or for palliation to control pain or
hematuria.
81
1.4 Patient Selection and
Preprocedure Workup
All potential ablation patients are evaluated in the
interventional radiology clinic in the weeks or
months leading up to the procedure. The clinic vis-
it is an opportunity for the physician to develop a
rapport with the patient as well as the patient’s
family. The proposed procedure, including the
risks, benefits, and alternatives, is discussed in
detail with the patient. A detailed medical history
is obtained and a full physical exam performed.
Additionally, every patient should undergo con-
trast-enhanced computed tomography (CT) or
magnetic resonance imaging (MRI) for tumor stag-
ing, and appropriate laboratory tests should be
ordered.
1.4.1 Laboratory Studies
Appropriate blood tests include a complete blood
count (CBC), coagulation studies, and renal func-
tion tests. Anticoagulants and antiplatelet agents
are discontinued far enough in advance of the pro-
cedure for coagulation parameters and function to
return to normal.
32
Given the elective nature of
the procedure and the hypervascularity of RCCs, it
is reasonable to postpone the procedure in the set-
ting of markedly abnormal laboratory findings,
such as an international normalized ratio (INR) >
1.5 or a platelet count< 50 × 103/μL. If necessary,
fresh frozen plasma and platelets can be adminis-
tered prior to or during the procedure.
Patients being considered for percutaneous ab-
lation often have abnormal renal function. It is
important to assess renal function prior to the pro-
cedure with a serum creatinine and estimated glo-
merular filtration rate (GFR) because this will help
to guide the procedural approach and imaging fol-
low-up. Iodinated contrast may be used during CT-
guided ablation to define the tumor margins
before applicator placement or during the proce-
dure to assess whether the tumor has been suc-
cessfully ablated. In the case of cryoablation,
contrast is not used as frequently because the ice
ball is well seen with both unenhanced CT and
MRI.
9,11,12,41,42,43,44,45,46,47,48,49,50,51,82
1.4.2 Preprocedure Biopsy
There is some controversy regarding the need for a
biopsy prior to percutaneous ablation. However,
given that a substantial fraction of small, solid
masses are benign,
83
it seems prudent to obtain a
tissue diagnosis in most cases. This not only has
the advantage of decreasing unnecessary treat-
ment in patients with benign neoplasms, such as
angiomyolipoma or oncocytoma, it also allows
tumor subtyping and grading in the case of malig-
nancy, information that can be used to tailor future
treatment and surveillance.
84
The timing of the
biopsy is also somewhat controversial; some advo-
cate tissue sampling prior to ablation,
85
whereas
others favor performing both procedures on the
same day.
86
In most circumstances, it seems rea-
sonable to obtain a biopsy in advance of the abla-
tion because this provides the pathologist more
time to analyze the specimen with special staining,
and, in the case of a benign diagnosis, it obviates
the need for an additional clinic visit and further
workup.
87
On the other hand, if the probability of
renal cancer is extremely high, as in the case of a
suspicious mass in a patient with VHL disease,
same-day biopsy may be a reasonable approach .
1.4.3 Prophylactic Antibiotics
Periprocedural administration of prophylactic
antibiotics is another topic of debate.
32
Some
Percutaneous Ablation of Renal Cell Carcinoma
4