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Renal cryoablation: a new treatment in need of careful clinical investigation

Nature Clinical Practice Oncology volume 3, pages 286–287 (2006)Cite this article

Historically, patients with small renal masses escaped clinical detection. Over the last 10 years, however, because of the widespread use of abdominal imaging, a distinct population of small renal cortical tumors (RCTs; median size 4.0 cm [T1]), has emerged, now comprising 70% of the renal tumors that are incidentally detected.1 RCTs are members of a family of renal cortical neoplasms, each of which has distinct pathological features, cytogenetic defects, and metastatic potentials.2 Twenty percent of patients undergoing operation for a suspicious renal mass have a benign lesion (including angiomyolipomas and oncocytomas).3 The conventional clear-cell tumor type accounts for 65% of the RCTs detected and for 90% of the metastatic tumors. The remainder of the RCTs (35%) are the indolent papillary or chromophobe carcinomas with limited metastatic potential, or oncocytomas with no metastatic potential. Contemporary radiological imaging modalities such as CT cannot distinguish benign from malignant tumors, and needle biopsy methods are only 60–70% accurate.4 Small renal tumors followed expectantly can remain stable for years or enlarge at a slow rate (0.49 cm3/year), and metastasis is rare for those less than 4 cm in size.5 Major US medical centers now perform partial nephrectomy whenever possible (>60% of nephrectomies for RCTs ≤7 cm), with results indicating local tumor control and survival rates (>90%) equivalent to those of radical nephrectomy, with maximum preservation of long-term renal function. Patients who have undergone partial nephrectomy remain under lifetime surveillance because they have a 5% chance of ipsilateral and a 5% chance of contralateral tumor recurrence.6,7

Small renal masses have recently been treated by cryoablation (freezing to at least −19.4 °C using liquid nitrogen or argon). Subsequent MRI or CT scans are used to evaluate the ablation, with diminution of the tumor in the cryolesion and lack of contrast enhancement considered a favorable result, and increase of the tumor in the cryolesion or interval growth considered signs of inadequate treatment. A percutaneous biopsy, a standard resection, or retreatment with cryoablation can then occur. The mechanism leading to tumor destruction is uncertain and may be a combination of direct cytotoxicity and damage to vascular elements leading to ischemic necrosis. Experimental models have demonstrated that tissue temperatures are warmer from a few millimeters from the ice ball edge, and nonlethal tissue damage might occur in this region. For this reason, surgeons extend the ice ball edge slightly beyond the tumor margins.

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  1. Attending Surgeon in the Department of Urology, Memorial Sloan–Kettering Cancer Center, New York, NY, USA

    Paul Russo

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  1. Paul Russo
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Correspondence to Paul Russo.

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Russo, P. Renal cryoablation: a new treatment in need of careful clinical investigation. Nat Rev Clin Oncol 3, 286–287 (2006). https://doi.org/10.1038/ncponc0507

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