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Student:

James Cassuto, MS IV

Attendings:

Grigory Rozenblit, MD
Shekher Maddineni, MD
Samuel 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. 2011


Cheung et al. Int Urol Nephrol. 2011

SORRY, THATS 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. 2011


Cheung 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

Diagnostic Workup- Question


What percent of RCCs are diagnosed as incidental findings on radiologic exams?
A: 10%
B: 20%

C: 30%
D: 40%

CORRECT!
What percent of RCCs 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, THATS INCORRECT


What percent of RCCs 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, THATS 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 CASE
Lin et al. Urology. 2014
Yu et al. Radiology. 2014

SORRY, THATS 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 CASE
Lin 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 CASE
Lin 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

RA

MRI: T1W Demonstrates thickened right femoral nerve (arrow)


RA: renal allograft; I: iliacus muscle

MRI: T1W SPIR 2 month follow up


reveals no residual tumor

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 and


nephrostomy tube were placed within the treated kidney
(image at right)
The nephrostomy tube was removed 2.5 months later
with 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 Urol
Nephrol. 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.