Student: James Cassuto, MS IV

Attendings: Grigory Rozenblit, MDShekher Maddineni, MDSamuel McCabe, MD

Department: Vascular and Interventional Radiology

Chief Complaint & HPI

61 year old female who is 18 years post double pediatric kidney transplantation for end stage renal disease (ESRD) 2o 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

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

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%

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. 2011Cheung et al. Int Urol Nephrol. 2011

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. 2011Cheung et al. Int Urol Nephrol. 2011

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

What percent of RCC’s are diagnosed as incidental findings on radiologic exams?

A: 10%

B: 20%

C: 30%

D: 40%

Diagnostic Workup- Question

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

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

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

Intervention: Microwave Ablation

MWA probe in renal mass (CT) Post-ablation series

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

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 CASELin et al. Urology. 2014

Yu et al. Radiology. 2014

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 CASELin et al. Urology. 2014

Yu et al. Radiology. 2014

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 CASELin et al. Urology. 2014

Yu et al. Radiology. 2014

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 2o to thermal injury

1.5 months post ablation, musculoskeletal and neurological symptoms resolved

2 month follow-up MRI revealed no residual tumor

Clinical Follow Up: Right Femoral Neuropathy

MRI: T1W Demonstrates thickened right femoral nerve (arrow) MRI: T1W SPIR 2 month follow upRA: renal allograft; I: iliacus muscle reveals no residual tumor

RA

I

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 andnephrostomy tube were placed within the treated kidney(image at right)

The nephrostomy tube was removed 2.5 months laterwith subsequent resolution of the complication

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

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):1261-1263.

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 UrolNephrol. 2011;43(3):675-680.

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;187:48-53.

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):357-363.

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):880-887.