Interventional Treatments for Renal Cell Carcinoma: An Interview With David J. Breen, MRCP, FRCR

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IO360: What is your experience treating renal cell carcinoma, and what is new in the realm of interventional oncology for renal cell carcinoma?

Breen: My unit and my team have been treating renal cell carcinoma for a long time. I’m not going to suggest for a moment that image-guided ablation is the answer to all renal disease. Some patients need a resection. However, for small-volume disease (up to 5 cm in diameter) I think we are rapidly moving to a phase where oncologic outcomes are in equipoise between diligent careful ablation and surgery. In my own practice, ablation usually means cryoablation rather than radiofrequency or microwave ablation. But the paradigm is shifting, and it’s almost unique in the field of interventional oncology that you see equipoise of oncologic outcomes between surgery and ablation for lesions smaller than 5 cm. 

There is also reduced morbidity, cost, and bed stay for these interventional procedures, so considering those additional benefits, we are forced to wonder whether diligent image-guided renal tumor cryoablation should become the standard of care. I think we are headed rapidly in that direction. Our outcomes are similar to what the Mayo Clinic reports, and we are currently looking at some of our own data on more than 450 consecutive renal tumor cryoablations. Our recurrence ranges from about 2% to 3%, and remember that’s not in randomized patients. This is in patients who have been declined for surgery, patients with comorbidities like diabetes or a previous contralateral nephrectomy. So we have equipoise in a tough patient group and therefore I believe we are moving toward renal cryoablation as a standard of care.

IO360: Any other clinical pearls for renal interventional oncology that you’ve stumbled upon recently? 

Breen: I’m convinced about the value of what we are doing. The only reason there’s reticence about the therapy is because it crosses professional boundaries. It is performed primarily by interventional radiologists, but I think it’s coming as a standard of care. 

Also, I don’t think we’ll see a randomized study. We’ve already been there. We have just closed another study of ablation versus surveillance, but even that couldn’t recruit. It was a health technology assessment funded by the British government, and it had to close due to nonrecruitment. Simply put, we have a solid low-morbidity procedure. 

We tend not to treat very old and frail patients. However, there are many patients who are in their early to mid 70s who would rather not undergo a partial nephrectomy, which is not insubstantial, robotic, laparoscopic, or otherwise, and is technically difficult. And with ablation we have a game changer. It is just going to take a few years to convince everyone. 

IO360: Did you start with microwave and radiofrequency ablation in the kidney and then moved to cryoablation and because you saw better results?

Breen: I originally did animal work in ablation in 1994 in Vancouver so I’ve been doing this a long while. We were doing porcine work. All of my early work was with radiofrequency ablation, through the early 2000s, and then I converted our renal practice to cryoablation in about 2008. Really, I think it’s important for us to put our foot down as interventional radiologists and say, no, the right tool for this is cryoablation in the kidney. Similarly, we have a big microwave ablation practice in the liver. Then, at least in our case we use microwave in the lung. We have not used radiofrequency ablation now for about 5 to 6 years in my department. Barring some niche applications, I think the use of radiofrequency ablation is increasingly water under the bridge. 

IO360: Do you think others would disagree?

Breen: I think that there will be a mixture of opinions. I personally believe a fully equipped, large department dealing with a sizeable patient volume should have cryo- and microwave devices. I also think irreversible electroporation (IRE) is an interesting product. We are beginning an IRE program for difficult liver tumors and locally advanced pancreatic cancer, but that is a niche patient population. 

There is enormous uptake still to occur in patients who have focal retroperitoneal or body wall disease and are undergoing multiple radiotherapy cycles simply because radiotherapy and oncology colleagues aren’t aware of other options. We in the interventional oncology community talk at great lengths about this, but those in other specialties are still largely unaware. For as much talk as we hear about it, stereotactic body radiation therapy also remains niche. 

IO360: How do you think interventional radiologists can better educate colleagues in other disciplines?

Breen: That’s a tough one. We are very good at talking amongst ourselves. The interventional radiology community gets it, as we are seeing with the ascendancy of interventional oncology. The only way forward will be for interventional radiologists, and interventional oncologists in particular, to start submitting their abstracts and their formal data to big meetings and getting around the big table. That means ASCO, the European Association of Urology, and hepato-pancreato biliary surgical groups for example, and making the case for image-guided ablation. That will require due diligence. If I were a surgeon, I would be looking at some of the radiofrequency data outcomes that are still being published today. Some of these publications show a persistent failing in the liver with 20% to 30% worse progression-free survival in as little an interval as 2 years consistently, for even small and relatively conservative colorectal metastasis and HCC. We’ve got to do the job better in house and then take our good data to the big settings, the bigger oncology venues and meetings.

Suggested citation: Ford J. Interventional treatments for renal cell carcinoma: an interview with David J. Breen, MRCP, FRCR. Intervent Oncol 360. 2016;4(4):E72-E74.

Dr. Breen reports no related disclosures.