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Interventional Radiology in the
renal tumor :
Biopsy and RF
P. Taourel (Montpellier)
• Diagnosis
• Treatment
Solid Tumors

Invasive tumor
=
Cancer
Staging

Fat
=
Angiomyolipoma
Characterized by imaging

Small tumors : adenocarcinoma ?,
oncocytoma? AML without fat

Diagnosis difficulties
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
AML diagnosis = fat

•  < -20 UH
•  Easy
AML typique (-60 UH)
•  Tiny content of fat may be challenging

AML à faible contingent adipeux
CT identification of the fat
•  Thin slice

Temps
néphrographique

•  Adapted ROI
•  ≤ - 20 UH
•  No IV contrast

Sans injection,
coupes fines
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)
Solid Tumors

Invasive tumor
=
Cancer
Staging

Fat
=
Angiomyolipoma
Characterized by imaging

Small tumor without fat : adk, aml
without fat, oncocytoma
Diagnosis difficulties
CT
Temps cortical (artériel)

•  Fast enhancement
(cortical phase)
•  Washout
•  Scarr hypodense :
central + small + starr

Temps néphrographique
Small oncocytoma < 4 cm
•  Characterization : difficult
•  Enhancement :
homogeneous
•  Scarr : missing (10%)

Small homogeneous oncocytoma
•  Solid tumor in multicystic
kidney
Biopsy= ONCOCYTOMA

No iv

cortical 35 sec

tubular 80 sec
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
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
CT findings
•  Morphologic criteria
–  siza
–  Ball versus bean
–  Segmental inversion
–  scarr
–  Interface with the parenchyma

•  Critères cinétiques
–  Enhancement intensity
–  Time-course pattern
Metanephric
adenoma
Ischemia
ONCOCYTOMA

ADK
Wegener

Lymphoma
adk

oncocytoma
Inverted segment ADK

oncocytoma
A weak significant finding of
benignancy : progressive enhancement
• 
• 
• 
• 

Sen = 60%
Spe = 73%
PPV = 43% (prevalence of benignancy)
NPV = 84%

– AJR 2011 Millet et al
Tubulo-papillar adk
Biopy of small renal tumor is
mandatory
•  Benign versus malignant : impact ++++
•  Type of adk : impact ?
•  Grade : impact +
–  Partial surgery
–  Temperature ablation
–  Active FU
•  187 solid tumors ≤ 4cms
•  145 Malignant
•  132 renal cancers,
–  61 surgery
–  36 RF
–  35 FU

Millet J Urol 2012
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
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
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)
•  Diagnosis

•  Treatment
Radiofrequency of renal tumors
•  Why ? (overdiagnosis and
overtreatment ?)
•  How ?
•  What results ?
•  When ?
→ 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
Radiographics
2001
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
What technique ?
• 
• 
• 
• 

decubitus
Ureteral stent
Hydrodissection
Displacement of the mass by the electrode
What FU ?
•  2 questions :
–  Efficiency
–  Recurrence

•  Sémiologie uniqvoque
–  fat stranding
–  Rim finding (no significance)

•  Enhancement : residu or recurrence
–  nodules or croissants (triphasic CT)
M2
What FU ?
•  2 questions :
–  Efficiency
–  Recurrence

•  Sémiologie uniqvoque
–  fat stranding
–  Rim finding (no significance)

•  Enhancement : residu or recurrence
–  Cortico-medullary phase
M2
M8

FU : 2m, 6m, 1y, then every y
What results : ?
•  Efficiency : 80 – 90 %
•  Predictive factors :
–  exophytic (oven effect)
–  < 3 cm
What results ?
Excise,ablate or observe :
the small renal mass dilemna
J Urol 2008
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
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
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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Urology gynecology ri renal tumor p taourel

  • 1. Interventional Radiology in the renal tumor : Biopsy and RF P. Taourel (Montpellier)
  • 3. Solid Tumors Invasive tumor = Cancer Staging Fat = Angiomyolipoma Characterized by imaging Small tumors : adenocarcinoma ?, oncocytoma? AML without fat Diagnosis difficulties
  • 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. AML diagnosis = fat •  < -20 UH •  Easy AML typique (-60 UH)
  • 6. •  Tiny content of fat may be challenging AML à faible contingent adipeux
  • 7. CT identification of the fat •  Thin slice Temps néphrographique •  Adapted ROI •  ≤ - 20 UH •  No IV contrast Sans injection, coupes fines
  • 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. Solid Tumors Invasive tumor = Cancer Staging Fat = Angiomyolipoma Characterized by imaging Small tumor without fat : adk, aml without fat, oncocytoma Diagnosis difficulties
  • 10. CT Temps cortical (artériel) •  Fast enhancement (cortical phase) •  Washout •  Scarr hypodense : central + small + starr Temps néphrographique
  • 11. Small oncocytoma < 4 cm •  Characterization : difficult •  Enhancement : homogeneous •  Scarr : missing (10%) Small homogeneous oncocytoma
  • 12. •  Solid tumor in multicystic kidney Biopsy= ONCOCYTOMA No iv cortical 35 sec tubular 80 sec
  • 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. 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. CT findings •  Morphologic criteria –  siza –  Ball versus bean –  Segmental inversion –  scarr –  Interface with the parenchyma •  Critères cinétiques –  Enhancement intensity –  Time-course pattern
  • 22.
  • 23.
  • 24. A weak significant finding of benignancy : progressive enhancement •  •  •  •  Sen = 60% Spe = 73% PPV = 43% (prevalence of benignancy) NPV = 84% – AJR 2011 Millet et al
  • 26. Biopy of small renal tumor is mandatory •  Benign versus malignant : impact ++++ •  Type of adk : impact ? •  Grade : impact + –  Partial surgery –  Temperature ablation –  Active FU
  • 27. •  187 solid tumors ≤ 4cms •  145 Malignant •  132 renal cancers, –  61 surgery –  36 RF –  35 FU Millet J Urol 2012
  • 28. 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
  • 29. 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
  • 30. 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)
  • 32. Radiofrequency of renal tumors •  Why ? (overdiagnosis and overtreatment ?) •  How ? •  What results ? •  When ?
  • 33.
  • 34. → 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
  • 35.
  • 37.
  • 38. 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
  • 39.
  • 40.
  • 41. What technique ? •  •  •  •  decubitus Ureteral stent Hydrodissection Displacement of the mass by the electrode
  • 42.
  • 43.
  • 44.
  • 45. What FU ? •  2 questions : –  Efficiency –  Recurrence •  Sémiologie uniqvoque –  fat stranding –  Rim finding (no significance) •  Enhancement : residu or recurrence –  nodules or croissants (triphasic CT)
  • 46.
  • 47.
  • 48.
  • 49.
  • 50.
  • 51.
  • 52.
  • 53. M2
  • 54. What FU ? •  2 questions : –  Efficiency –  Recurrence •  Sémiologie uniqvoque –  fat stranding –  Rim finding (no significance) •  Enhancement : residu or recurrence –  Cortico-medullary phase
  • 55.
  • 56. M2
  • 57.
  • 58. M8 FU : 2m, 6m, 1y, then every y
  • 59. What results : ? •  Efficiency : 80 – 90 % •  Predictive factors : –  exophytic (oven effect) –  < 3 cm
  • 60.
  • 61.
  • 62.
  • 63.
  • 64. What results ? Excise,ablate or observe : the small renal mass dilemna J Urol 2008
  • 65. 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
  • 66. 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
  • 67. 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