A Challenging Case of Renal Cancer Treated With RFA
By Ken Thomson, MD
I work in a tertiary referral university hospital of about 450 acute beds in Melbourne, Australia. We treat everything except children under 15 and liver transplants: everything else, from toenails to motor vehicle trauma and heart-lung transplants. Some days are diamonds and others stones.
Take a day last month. A patient aged 70 years came in for left renal tumor ablation. His medical history included weight of 330 lbs, post cardiac transplant and subsequent right partial nephrectomy for RCC in 2007, chronic congestive cardiac failure, diabetes, and a new biopsy-proven carcinoma 2 cm in diameter in the left kidney. Creatinine was 221 mMols/L.
He has trouble lying flat and has sleep apnea requiring a CPAP unit. Will he need a monitored bed?
He was not a good candidate for a local anesthetic. He had been fasting 12 hours but took his usual dose of insulin. His blood sugar was 2.9 – at least that was easy to fix.
After some discussion with the anesthetist and an abortive attempt to find the tumor with ultrasound, we elected to do the procedure with a general anesthetic, prone, and with 60 mL of nonionic contrast. More Lasix is added to his daily cocktail of 45 medications.
We struggled with positioning in the CT gantry because he could not raise his arms over his head and with his arms at his sides it was a tight fit. Many concerns came to mind. What is his realistic life expectancy: will a renal carcinoma kill him before his cardiac complications do? Will I push him over the edge to dialysis? How will we manage any postoperative pain with his sleep apnea? Do I use my beloved irreversible electroporation device, which I know won’t hurt, or do I assume that a small ablation will be easily hidden? Because the tumor is nearly invisible should I use one of our positioning robots?
I think, what would Lassie the dog do? Since “going home” isn’t really possible for me, I decided quick was better and did a 2 cm radiofrequency ablation (RFA) freehand. So that we could do a check scan after needle placement I had to push the electrode in further than I needed to access the tumor and then withdraw it afterwards. Halfway through the 6-minute burn I thought, “What does it look like? Has the electrode slipped?" The image I obtained with the CT during RF activation was totally degraded. I didn’t know that happened as I had never used CT for that. Hoping I hadn’t damaged the CT unit we finished and in view of the renal function decided to do a follow-up CT in 3 months.
We have a huge range of devices, machines, and tricks to treat tumors and for most of us it is enormously satisfying. Unfortunately I think sometimes we need to take a step back and think about what we are doing. I wonder how long we can thrash our health dollar the way we do now. When we have totally bankrupted our systems will the clinicians who follow in our footsteps treat us kindly? What will I say in 3 months at the case review meeting should there be a recurrence or another tumor?
In the end, at 6 PM when the patient has passed clear urine, is awake, and is very grateful for the treatment he has had,all of these negative thoughts disappear in an instant.
Bring on the next one.
