Percutaneous Renal Ablation

AJ Gunn, MD, University of Alabama at Birmingham, discusses percutaneous renal ablation. Dr Gunn explains where percutaneous renal ablation fits in the treatment paradigm for patients and how to best collaborate with colleagues for this treatment. He also gives an overview on the changes to the NCCN guidelines that pertain to percutaneous renal ablation.

Transcript:

My name is AJ Gunn, I'm an interventional radiologist and associate professor at the University of Alabama at Birmingham and I'm here at the CIO annual meeting and have several talks here about percutaneous renal ablation which is a passion of mine.

One of the talks is about some of the top clinical and technical pearls for providers as they perform percutaneous renal ablations. First of all, we're going to be talking about taking clinical care of your patients, evaluating them in your clinic. We're going to talk about some risk assessment scores that we can do, and then performing the procedure and following your patients after the procedure to provide good clinical care. We're going to talk about some technical tips about how we align our ablation probes to make sure that we miss any critical structures like the colon or the ureter. We're going to talk about some of the data that's out there about difficult tumors including central tumors, larger tumors, and anterior tumors. And then lastly we're going to talk about some of the changes that have come forward over the last year with the NCCN guidelines and how and how those have affected patients that are eligible for subcutaneous renal ablation, including patients that have larger tumors, including microwave ablation in the guidelines instead of just cryoablation, and radiofrequency ablation.

People, if they attend the sessions, are going to get a lot out of it. They're going to learn about clinical care, they're going to learn about difficult tumors, and they're going to learn some data that they can take back to their multidisciplinary tumor boards to treat their patients better.

How does renal ablation compare to other treatments for patients in this population?

I would say the main comparator for percutaneous renal ablation is surgical resection, so either total nephrectomy or partial nephrectomy. Of course, if the patient is eligible for a partial nephrectomy where they only remove part of the kidney, that's preferred, but that's not always the case. What we know from the data that's out there, and these are some of the things that we'll talk about, percutaneous renal ablation is cheaper. It keeps patients out of the hospital compared to surgery. It has less effect on renal function, and it has fewer complications. And its clinical outcomes are essentially equal.

I think for anybody who has a small renal tumor, percutaneous ablation is probably a superior treatment, compared to partial nephrectomy, based on all of these other kinds of things. So, I think learning about it and being able to maximize the opportunities to treat patients, and then when you do have those referrals for percutaneous renal ablation, to be able to do it safely and follow those patients afterwards will be very important for people to learn.

How important is multidisciplinary collaboration for this treatment?

Certainly, I take responsibility for my patients. We have a very robust ambulatory clinic where we evaluate all the patients prior to the procedure, and we talk about things, like whether we're going to use general anesthesia or moderate sedation and we obviously perform the procedure and then we follow up with our patients after they've been referred to us. That said, when I'm discussing this with my referring physicians, I always kind of couch myself as an extension of their practice. This isn't taking patients away from them necessarily, as much as providing them a treatment that the patients might not otherwise be able to have.

For example, these patients might have a tumor in a location where they don't think they can do a partial nephrectomy. These patients might not want to undergo a full surgery or might not be able to undergo a full surgery due to their medical comorbidities. And so, when working with referring physicians, I think one of the keys is taking responsibility for the patients and not dumping the work back on them. And then number two, just kind positioning yourself as an extension of their practice rather than a competing practice, which has really been a key for us.

What were the changes to the NCCN guidelines that pertain to percutaneous renal ablation?

I think the 3 big changes that occurred in 2023 and continued into 2024 are, number one, they removed some language that kind of said that the limit for percutaneous ablation would be 3 cm. and they moved it to 4 cm, to include all patients that have T1A tumors. Prior versions of the NCCN guidelines didn't have microwave ablation as a treatment alternative. It was just radiofrequency or cryoablation. And so sometimes that was causing problems with payors who may not want to reimburse for microwave ablation. So, we got that added into the guidelines. And then lastly, for patients with larger tumors greater than 4 cm in size, previously only observation or really surgery were listed as an alternative. We actually got percutaneous ablation listed as an alternative in select patients. Now the outcomes aren't as good as they are for smaller tumors. That said, it wasn't even mentioned in the guidelines before. So, it bred this idea that percutaneous ablation for renal tumors was contraindicated, maybe above a certain size. And I think this is just saying, well, it's not as good as it is for smaller tumors, that said, you can still do it in select patients.

Why do IRs need to be aware of this and other treatment procedures?

Just everything in the oncology space, which is why I think this meeting is so important, because everything in the oncology space changes so rapidly. Thinking about the oncology space as part of a multidisciplinary team rather than, this is what interventional radiology does and this is what radiation oncology does and this is what surgery does. And then really rather than understanding it from a procedure standpoint, but understanding it from a patient care standpoint, from a disease process standpoint, where can we combine therapies? Where might the data for an alternative therapy be better than what it is in interventional radiology? And so that's why I think coming to these kinds of events is really important for people to be able to stay up to date to all the things that are changing pretty rapidly in all areas.