Seventy-year-old female patient presented to the ER with a complaint of abdominal pain for 2 days associated with nausea and vomiting.
Hypertension, Diabetes, dyslipidemia and obesity. She underwent a cardiac pacemaker implantation 3 years before.
Tenderness mainly at the right lower abdomen, Murphy sign positive.
Abdominal ultrasound showed gallbladder calculi and signs of acute cholecystitis with poor visualization of the pancreas. Abdominal CT scan revealed a hypervascular solid lesion of 16mm in left renal lower pole. (Figure 1)
Figure 1. Abdominal CT scan, axial, coronal and sagital cutts, arterial phase, arrows show hypervascular solid lesion of 16 mm in the lower pole of left kidney.
Radiologic diagnosis: Renal cell carcinoma
Colecystectomy was performed and patient was referred to the Urology clinic afterweards. Since patient was elderly and presented multiple comorbidities, minimally invasive therapy was the choice of treatment - focal therapy with cryoablation of renal lesion. Due to the proximity of renal lesion to the collecting system, a double J stent was placed before cryoabaltion. Cryo was performed under general anesthesia with patient in ventral position under CT scan monitoring. Initially, lesion was biopsied with a tru cutt needle under US guidance and 3 fragments were extracted. Pathology confirmed conventional clear cell carcinoma as the diagnosis (Fuhrman 1-2) and eosinophilic cells (Fuhrman 2-3). (Figure 2)
Figure 2. Renal biopsy pathology. Red arrow shows eosinophilic carcinoma and, black points clear cell carcinoma.
Next, cryoablation needle was inserted into the center of lesion under CT guidance (Figure 3). Cryotherapy is then initiated which generates intracellular icing resulting in vasuclar stasis and cellular ischemia. Iceball formation must be seen in CT (Figure 4).
Figure 3. O posicionamento da agulha de crioablação é realizado por fino ajuste tomográfico em diveros cortes. As setas demonstram a posição adequada e central da mesma na lesão tumoral.
Figura 4. Cryotherapy effect is also confirmed by CT imaging. Arrows point to the iceball which promotes vascular ischemia.
Procedure was uneventful and had a 2 hour duration. Patient was discharged home in the day after.
This case is a good example of a proper indication for renal ablation.
It is a fairly small renal lesion (T1a), with no contcat with excretory system in a patient who is a poor candidate for nephrectomy and with a restricted life expectancy considering her comorbidities and age. Although ablation is associated with higher risk of local recurrence, when compared to surgical removal it yields similar metastasis free survival. Watchful waiting with timely treatment of disease progression may also be an option in selected cases.
1- Protocolos em Uro-Oncologia Baseada em Evidência da PUC-Campinas 2015.
2- NCCN Clinical Practice Kidney Cancer Guideline (http://www.nccn.org/).
Leonardo Oliveira Reis MD, MSc, PhD
Urology professor PUC-Campinas
Postdoctoral Fellow da Johns Hopkins University