Kidney Cancer     Minimally invasive treatment options Procedures performed by interventional radiologists are being increasingly used in the care of patients with cancer. These specially trained physicians use X-rays, ultrasound or other imaging techniques to guide needle small tubes called catheters and miniature tools directly to the site of the disease. Interventional Radiology procedures for patients with cancer include new approaches for treatment, relieving pain and diagnosing cancer without surgical biopsy.
Kidney cancer is the eighth most common cancer in men and the tenth in women. The most common type of kidney cancer is renal cell carcinoma that forms in the lining of the renal tubules in the kidney that filter the blood and produce urine. Approximately 85 percent of kidney tumours are renal cell carcinomas. When kidney cancer spreads outside the organ, it can often be found in nearby lymph nodes, lungs, bones or liver, as well as the other kidney.
Surgical removal of tumours confined to the kidney offers the best chance for a cure. Unfortunately, some patients may not tolerate surgery due to underlying medical conditions. In this group of patients, minimally invasive image-guided therapies performed by interventional radiologists offer a less invasive option. These treatments also offer valuable benefits to those patients with advanced or metastatic renal cell carcinoma. Chemotherapy drugs and radiation are generally ineffective at curing kidney cancer.
More than 30,000 Europeans each year are diagnosed with kidney cancer-many of them don't have symptoms. Typically, those with kidney cancer are past the age of 40 and twice as often are men.
Other risk factors include:
• Smoking
• Obesity
• High blood pressure
• Long-term dialysis
• Von Hippel-Lindau syndrome
The incidence of kidney cancer is on the rise. Fortunately, the availability of modern imaging technology has led to more frequent detection of small, asymptomatic tumours that otherwise would be undetected. Often, small tumours do not cause symptoms and are discovered on CTs, MRIs or ultrasounds that are performed for some other reason, such as standard imaging studies (CT or ultrasound) performed during many emergency room visits. These small tumours are often the best candidates for nonsurgical treatment options. Common symptoms may include: • Blood in the urine
• Side pain that does not go away • A lump or mass in the side of the abdomen • Weight loss • Fever • Feeling very tired In addition to a basic physical exam, urine test and blood tests, several other techniques can be used to diagnose kidney cancer. CT scan, MRI or ultrasound can be performed to see inside the body and identify a tumour. An image-guided needle biopsy can be done to remove tissue samples and look for cancer cells. At the time of diagnosis, 25 to 30 percent of patients have metastases. In a biopsy, a sample of tissue from the tumour or other abnormality is obtained and examined by a pathologist. By examining the biopsy sample, pathologists and other experts also can determine what kind of cancer is present and whether it is likely to be fast or slow growing. This information is important in deciding the best type of treatment. Open surgery is sometimes performed to obtain a tissue sample for biopsy. But in most cases, tissue samples can be obtained without open surgery with Interventional Radiology techniques.
Needle biopsy, also called image-guided biopsy, is usually performed using a moving X-ray technique (fluoroscopy) computed tomography (CT), ultrasound or magnetic resonance (MR) to guide the procedure. In many cases, needle biopsies are performed with the aid of equipment that creates a computer-generated image and allows radiologists to see an area inside the body from various angles. This "stereotactic" equipment helps them pinpoint the exact location of the abnormal tissue.
Needle biopsy is typically an outpatient procedure with very infrequent complications; less than 1 percent of patients develop bleeding or infection. In about 90 percent of patients, needle biopsy provides enough tissue for the pathologist to determine the cause of the abnormality.
Advantages of needle biopsy include:
• With image guidance, the abnormality can be biopsied while important nearby structures such as blood vessels and vital organs can be seen and avoided.
• The patient is spared the pain, scarring and complications associated with open surgery. • Recovery times are usually shorter and patients can more quickly resume normal activities.
In this technique, a special needle is used that enables the radiologist to obtain a larger biopsy sample. The technique offers the following advantages: • It is less painful and requires less recovery time than open surgical biopsy
• It avoids the scarring and disfigurement that may result from open surgery A similar technique called fine needle aspiration can be used to withdraw cells from a suspected cancer. It also can diagnose fluids that have collected in the body. Sometimes, these fluid collections also may be drained through a catheter, such as when pockets of infection are diagnosed.
Many Interventional Radiology procedures for the diagnosis and treatment of cancer can be performed on an outpatient basis or during a short hospital stay. In many cases, the procedures:
• offer new cancer treatment options
• are less painful and debilitating for patients
• result in quicker recoveries
• have fewer side effects and complications.
As vascular experts, interventional radiologists are uniquely skilled in using the vascular system to deliver targeted treatments via catheter throughout the body. In treating cancer patients, interventional radiologists can attack the cancer tumour from inside the body without medicating or affecting other parts of the body. For kidney cancer, interventional radiologists use thermal ablation, as well as some laser therapy, to kill the cancer cells. Although the devices used are FDA approved, research to evaluate the long-term effects of these treatments is still ongoing. For inoperable kidney tumours, radiofrequency ablation (RFA) offers a nonsurgical, localized treatment that kills the tumour cells with heat, while sparing the healthy kidney tissue. This treatment is much easier on the patient and is more effective than systemic therapy. Radiofrequency energy can be given without affecting the patient's overall health and most people can resume their usual activities in a few days. In this procedure, the interventional radiologist guides a small needle through the skin into the tumour. From the tip of the needle, radiofrequency energy is transmitted into the tumour, where it produces heat and kills the tumour cells. The dead tumour tissue shrinks and slowly turns into a scar.
Additional facts on Radiofrequency Ablation
• Is most effective when the kidney cancer is small in size (5cm or less)
• May be performed under conscious sedation or general anesthesia
• Is well tolerated-most patients can resume their normal routines the next day and may feel tired only for a few days
• Can be repeated if necessary
• May be combined with other treatment options
Efficacy
If the tumour is small, RFA can shrink and likely kill the tumour. Although early results are encouraging, long-term follow-up is necessary to determine the precise role of RFA in treating small kidney cancers. Current ongoing studies will determine long-term survival.
Because it is a local treatment that does not harm healthy tissue, the treatment can be repeated as often as needed. It is a very safe procedure, with low complication rates, and it has become more widely available over the last couple of years. The FDA has approved RFA for use in soft tissue tumors, of which renal cell carcinoma is one.
Risks of Radiofrequency Ablation The risks of RFA are similar to a biopsy, namely localized bleeding and some pain. Bleeding that requires action is uncommon partly because the heating from the radiofrequency energy cauterizes the tissue and minimizes the risk of hemorrhage. Heating of the tumour may cause heating of an adjacent structure, which can lead to some healthy tissue damage. This can be avoided by carefully reviewing the size and location of the tumour before the procedure. Tumours adjacent to structures such as bowel may not be candidates for RFA or may require special procedures (injection of fluid) to create safe distances between the tumour being treated and the adjacent bowel.
Cryoablation is similar to RFA in that the energy is delivered directly into the tumour by a probe that is inserted through the skin. But rather than killing the tumour with heat, cryoablation uses an extremely cold gas to freeze it. This technique has been used for many years by urologists in the operating room, but in the last few years, the needles have become small enough to be used by interventional radiologists through a small incision in the skin without the need for an operation. The "ice ball" that is created around the needle grows in size and destroys the frozen tumour cells.
Preliminary reports have suggested that RFA and cryoablation are equally effective for treatment of small renal tumours. At this time, the choice of therapy depends on the availability of technology and local expertise.
Advanced renal cell carcinoma tumours are often quite large and invade adjacent structures and veins. They may even extend through the veins into one of the heart chambers. Some patients with advanced tumours may not be surgical candidates. Arterial embolisation is an invaluable treatment option for such patients.
During embolisation, an interventional radiologist inserts a small tube (catheter) into an artery in the groin and directs it to the renal artery that supplies blood to the kidney and the tumour. The doctor injects small solid particles or special liquid agents into the artery to block the flow of blood into the kidney. The blockage prevents the tumour from getting oxygen and other substances it needs to grow, causing it to shrink.
In some patients, arterial embolisation may shrink the tumour substantially, rendering the patient a suitable surgical candidate. In others, arterial embolisation effectively eliminates tumour-related symptoms and improves patients' quality of life.
Biological therapy and immunotherapy Biological therapy is a systemic therapy that uses substances injected into the bloodstream to reach and affect cells all over the body. Biological therapy utilizes the body's natural ability, such as using the immune system, to fight cancer.2 Recent advances in immunotherapy have made a significant improvement in survival of patients with inoperable renal cancer. Chemotherapy Treatments for Cancer Complications
Treating pain
Controlling bleeding Treating organ obstruction and infection
One common side effect of cancer or cancer treatments is the development of blood clots, or emboli, that can be
life-threatening if they travel to the brain, lungs or heart. There are two Interventional Radiology procedures that can reduce the risks posed by blood clots:
Intra-arterial thrombolysis
In this technique, the interventional radiologist guides a catheter through the blood vessels and to the site of a blood clot. Clot-busting drugs are infused through the catheter to break up the clot.
Filter placement
This technique is most often used when a blood clot is detected in the blood vessels of the leg (a condition called deep vein thrombosis). The interventional radiologist guides a small filter into the blood vessel that receives blood from the lower body (the vena cava) and carries it to the heart. If the blood clot dislodges from the vein in the leg, the filter will trap it before it can reach the heart.
Interventional Radiology is playing a role in developing new techniques that may improve cancer treatment in the future, including the use of magnetic particles to draw cancer-killing agents into tumours; and the delivery of genetic material, called gene therapy, to fight or prevent cancers. These techniques are still investigational, but they offer new hope in the war against cancer.
Interventional radiologists are currently investigating a new technique in which magnets are used to pull chemotherapy drugs into tumours. Microscopic magnetic particles are attached to the cancer-killing drugs and infused through a catheter into the blood vessel that feeds the tumour. A rare earth magnet is positioned over the patient’s body directly above the site of the tumour. The magnet pulls the drug-carrying particles out of the blood vessel so that they lodge in the tumour. Although the technique is still experimental, early research is promising. Physicians are hopeful that it will bolster the effects of chemotherapy while avoiding some of the drugs’ side effects, such as hair loss and nausea. In recent years, scientists have gained a new understanding about genes the basic biological units of heredity—and the role they play in disease. This knowledge has set the stage for medical science to alter patients’ genetic material to fight or prevent cancer. Although the science of gene therapy is still in the early, experimental stages, researchers are hoping that in the future the therapy can be used to: - alter the cells of a patient’s natural immune system with cancer-fighting genes and returning them to the body, where they could more forcefully attack the cancer;
Bibliography
edited by Prof. A.Hatzidakis May 2005 |
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