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Urology gynecology ri renal tumor p taourel

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Urology gynecology ri renal tumor p taourel

  1. 1. Interventional Radiology in the renal tumor : Biopsy and RF P. Taourel (Montpellier)
  2. 2. • Diagnosis • Treatment
  3. 3. Solid Tumors Invasive tumor = Cancer Staging Fat = Angiomyolipoma Characterized by imaging Small tumors : adenocarcinoma ?, oncocytoma? AML without fat Diagnosis difficulties
  4. 4. Be careful with US in angiomyolipoma AML •  Characteristics : –  Hyperechoic ≥ : sinusal fat –  Homogeneous •  Be careful –  Calcification –  Hypoechoic rim •  30% of cancers are hyperechoic •  US can not characterize an angiomyolipoma : CT Cancer
  5. 5. AML diagnosis = fat •  < -20 UH •  Easy AML typique (-60 UH)
  6. 6. •  Tiny content of fat may be challenging AML à faible contingent adipeux
  7. 7. CT identification of the fat •  Thin slice Temps néphrographique •  Adapted ROI •  ≤ - 20 UH •  No IV contrast Sans injection, coupes fines
  8. 8. How to recognize AML without fat •  5 à 15% •  Orientation criteria –  STB –  Multiple AML in a young woman –  US –  Spontaneously hyperdense (= muscle) + hypervascular –  Présence de vaisseaux anévrismaux •  MRI ? •  Biopsy +++ Biopsy : AML)
  9. 9. Solid Tumors Invasive tumor = Cancer Staging Fat = Angiomyolipoma Characterized by imaging Small tumor without fat : adk, aml without fat, oncocytoma Diagnosis difficulties
  10. 10. CT Temps cortical (artériel) •  Fast enhancement (cortical phase) •  Washout •  Scarr hypodense : central + small + starr Temps néphrographique
  11. 11. Small oncocytoma < 4 cm •  Characterization : difficult •  Enhancement : homogeneous •  Scarr : missing (10%) Small homogeneous oncocytoma
  12. 12. •  Solid tumor in multicystic kidney Biopsy= ONCOCYTOMA No iv cortical 35 sec tubular 80 sec
  13. 13. Solid renal tumor without fat on CT ≤ 4 cms must be biopsied •  Only one tumor must be characterized : AML •  Incidence of benign lesion : 20% ( if ≤ 2 cms) •  Biopsy easy to perform
  14. 14. CT value to characterize tumor •  Consecutive study of 99 solid renal tumor without fat •  18 G biopsy with FU •  CT accuracy – B (25%) / M (75%) Millet AJR 2011
  15. 15. CT findings •  Morphologic criteria –  siza –  Ball versus bean –  Segmental inversion –  scarr –  Interface with the parenchyma •  Critères cinétiques –  Enhancement intensity –  Time-course pattern
  16. 16. Metanephric adenoma
  17. 17. Ischemia
  18. 18. ONCOCYTOMA ADK
  19. 19. Wegener Lymphoma
  20. 20. adk oncocytoma
  21. 21. Inverted segment ADK oncocytoma
  22. 22. A weak significant finding of benignancy : progressive enhancement •  •  •  •  Sen = 60% Spe = 73% PPV = 43% (prevalence of benignancy) NPV = 84% – AJR 2011 Millet et al
  23. 23. Tubulo-papillar adk
  24. 24. Biopy of small renal tumor is mandatory •  Benign versus malignant : impact ++++ •  Type of adk : impact ? •  Grade : impact + –  Partial surgery –  Temperature ablation –  Active FU
  25. 25. •  187 solid tumors ≤ 4cms •  145 Malignant •  132 renal cancers, –  61 surgery –  36 RF –  35 FU Millet J Urol 2012
  26. 26. Table 1 Biopsy-surgery correlation for the histologic subtype Biopsy subtype Surgical subtype Clear cell Clear cell Chromophobe Tubulopapillary Unclassified Chromophobe Tubulopapillary Unclassified 55 13 5 1
  27. 27. Table 2 Biopsy-surgery correlation for the Fuhrman grade Biopsy grade Surgical grade G1 G1 G2 G3 G4 G2 G3 7 11 33 2 2 6 G4
  28. 28. To conclude on diagnosis : the biopsy of renal tumor is •  Easy (LD if lesion in upper part of the kidney) •  Accurate •  Useful (25% of benign lesion) •  Mandatory (no CT characteriation) •  Impact on treatment of adk (weak underestimation of the grade)
  29. 29. •  Diagnosis •  Treatment
  30. 30. Radiofrequency of renal tumors •  Why ? (overdiagnosis and overtreatment ?) •  How ? •  What results ? •  When ?
  31. 31. → Ionic agitation → Friction with heat in the tissues → Thermal damage with heating → Nécrosis of coagulation (50 – 100 ° ) →  ≥ 100 ° carbonization with non efficiency of the treatment
  32. 32. Radiographics 2001
  33. 33. What evaluation before ? •  Proof of malignancy (25% : B) •  Size of the lesion : < 3cm, 3-5 cm •  Localization de la lésion : ball vs bean central or not •  Contact = pleura, bowel, ureter
  34. 34. What technique ? •  •  •  •  decubitus Ureteral stent Hydrodissection Displacement of the mass by the electrode
  35. 35. What FU ? •  2 questions : –  Efficiency –  Recurrence •  Sémiologie uniqvoque –  fat stranding –  Rim finding (no significance) •  Enhancement : residu or recurrence –  nodules or croissants (triphasic CT)
  36. 36. M2
  37. 37. What FU ? •  2 questions : –  Efficiency –  Recurrence •  Sémiologie uniqvoque –  fat stranding –  Rim finding (no significance) •  Enhancement : residu or recurrence –  Cortico-medullary phase
  38. 38. M2
  39. 39. M8 FU : 2m, 6m, 1y, then every y
  40. 40. What results : ? •  Efficiency : 80 – 90 % •  Predictive factors : –  exophytic (oven effect) –  < 3 cm
  41. 41. What results ? Excise,ablate or observe : the small renal mass dilemna J Urol 2008
  42. 42. What results : a metaanalaysis age PN Cryoablation RF FU 5037 (77,8 %) 496 (7,7 %) 607 (9,4 %) 331 (5,1 %) size 60 65,7 67,2 68,9 3,40 2,56 2,69 3,04 J Urol 2008
  43. 43. What results : a meta analysis FU (month) Dgc pathol : K LR 2,6 % 4,6 % 11,7 % PN Cryoablation RF 54 18 16 87 % 76 % 88 % FU 33 91 % M 5,6 % 1,2 % 2,3 % 0,9 % J Urol 2008
  44. 44. Ablation of renal tumor : (cryoablation or RF) •  •  •  •  Tm < 4 cm exophytic or parenchymateous Age > 70 ans cobormidity or failure renal factor risk or •  Recurrence after partial nephrectomy or •  VHL syndroma

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