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Was kann/soll bei Nierentumoren wann behandelt werden

What can/should be treated in kidney tumors and when

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Zusammenfassung

Klinisches/methodisches Problem

Bei der Behandlung des lokalisierten Nierenzellkarzinoms stellt das fehlende Randomisieren in den kontrollierten Studien zur Thermoablation eine wesentliche Limitation dar. Letztgenanntes führt zu wesentlichen Studienverzerrungen und es bleibt letztendlich unklar, ob das verbesserte Gesamtüberleben zugunsten der partiellen Nephrektomie tatsächlich auf die Behandlungsmethode selbst zurückzuführen ist.

Radiologische Standardverfahren

Für T1a (≤4 cm)-Nierenzellkarzinome ohne Lymphknoten- und Fernmetastasen sind exzellente technische und klinische Ergebnisse nach bildgeführter Radiofrequenz- und Kryoablation beschrieben.

Methodische Innovationen

Niedrige Majorkomplikationsraten, die Erhaltung der Nierenfunktion sowie die dreidimensionale Bestätigung negativer Ablationsränder (A0-Ablation) sind die Vorteile der CT-gesteuerten Thermoablation.

Leistungsfähigkeit

Entsprechend kontrollierten (nichtrandomisierten) klinischer Studien zum T1a Nierenzellkarzinom sind die krebsspezifischen Überlebensraten zwischen ablativen und chirurgischen Techniken vergleichbar.

Bewertung

Es ist höchste Zeit für prospektive randomisierte kontrollierte Studien, um den tatsächlichen Stellenwert der perkutanen Thermoablation und der partiellen Nephrektomie bei der Behandlung des T1a-Nierenzellkarzinoms zu bestimmen.

Empfehlung für die Praxis

Neben dem lokalisierten Nierenzellkarzinom eignen sich Angiomyolipome und Onkozytome für die Thermoablation. Die transarterielle Embolisation erweitert das radiologische Spektrum bei der Behandlung von Nierentumoren, entweder als ergänzende Embolisation (z. B. vor Thermoablation von T1a- und T1b-Nierenzellkarzinomen), als prophylaktische Embolisation (z. B. Angiomyolipome >6 cm), als präoperative Embolisation (z. B. vor laparoskopischer partieller Nephrektomie) oder als palliative Embolisation (z. B. bei inoperablen Patienten mit symptomatischer Makrohämaturie bei Nierenzellkarzinom).

Abstract

Clinical/methodical issue

In the treatment of localized renal cell carcinoma, the lack of randomization in controlled trials on thermal ablation is a major limitation. The latter leads to significant study bias and it ultimately remains unclear whether the improved overall survival in favor of partial nephrectomy can actually be attributed to the treatment method.

Standard radiological methods

For T1a (≤4 cm) renal cell carcinoma without lymph node and distant metastases, excellent technical and clinical results have been described after imaging-guided radiofrequency ablation and cryoablation.

Methodical innovations

Low major complication rates, preservation of renal function and three-dimensional confirmation of negative ablation margins (A0 ablation) are the advantages of computed tomography (CT)-guided thermal ablation.

Performance

According to the results of controlled (non-randomized) trials on T1a renal cell cancer, the cancer-specific survival rates are comparable between ablative and surgical techniques.

Achievements

It is high time for prospective randomized controlled trials to define the actual value of percutaneous thermal ablation and partial nephrectomy in the treatment of T1a renal cell carcinoma.

Practical recommendations

Apart from localized renal cell carcinoma, angiomyolipoma and oncocytoma can be treated by thermal ablation. Transarterial embolization extends the radiological spectrum for the treatment of renal tumors, either as complementary embolization (e. g. before thermal ablation of T1a and T1b renal cell carcinoma), prophylactic embolization (e. g. angiomyolipoma >6 cm), preoperative embolization (e. g. before laparoscopic partial nephrectomy) or palliative embolization (e. g. in patients with symptomatic macrohematuria due to renal cell carcinoma)

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Authors and Affiliations

  1. Klinik für Diagnostische und Interventionelle Radiologie, Radiologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    C. M. Sommer & H. U. Kauczor

  2. Klinik für Diagnostische und Interventionelle Radiologie, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Deutschland

    C. M. Sommer & G. M. Richter

  3. Abteilung Neuroradiologie, Radiologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    D. F. Vollherbst

  4. Klinik für Radiologie, minimal-invasive Therapien und Nuklearmedizin, SLK-Kliniken Heilbronn GmbH, Heilbronn, Deutschland

    P. L. Pereira

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C.M. Sommer, D.F. Vollherbst, G.M. Richter, H.U. Kauczor und P.L. Pereira geben an, dass kein Interessenkonflikt besteht.

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Sommer, C.M., Vollherbst, D.F., Richter, G.M. et al. Was kann/soll bei Nierentumoren wann behandelt werden. Radiologe 57, 80–89 (2017). https://doi.org/10.1007/s00117-016-0202-y

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