The Role of Arterial Embolization in Renal Cell Carcinoma

Abstract

Twenty-five years ago arterial embolization was introduced to facilitate the surgical excision of the carcinomatous kidney or to palliate symptoms, such as haemorrhage from non-resectable tumours. The role of this technique in the therapeutic armamentarium has been a source of debate in the literature. We reviewed all the available literature. A total of 389 papers were evaluated. Fifty-one publications and 3225 case histories met explicit entry criteria for inclusion. Until now no prospective randomized study of this approach to the management of renal carcinoma has been published. In the majority of studies the patients are grouped together irrespective of indication, i.e. pre-operative or palliative. Few articles are prospective or contain clear information regarding tumour stage, indication and adequate follow-up. Although we are not able to distinguish with certainty the effect of embolization on the course of the disease, it seems that complete pre-operative renal artery embolization facilitates the excision of large vein-invading tumours. The optimal delay between embolization and operation is probably one day. The embolization material of choice is ethanol. Palliative embolization in non-operable tumours with serious haemorrhage seems to have been successful in most cases. The scientific basis for the implementation of renal artery embolization in renal cell carcinoma is weak. We believe that either controlled trials or parallel prospective cohort studies should be undertaken to compare treatment of selected locally advanced renal carcinomas with and without embolization.

Reply to R Loffroy's letter to the Editor re: M May et al. Pre-operative renal arterial embolisation does not provide survival benefit in patients with radical nephrectomy for renal cell carcinoma. Br J Radiol 2009;82:724–31.

“…It remains speculative as to why our results in respect of the blood transfusion requirements are not in concordance with other studies describing a reduction of the post-operative transfusion rate in patients with PRAE [3][4][5]. However, in the present study we compared a historical group of patients (PRAE between 1992 and 1997) with current patients (nephrectomy alone between 1992 and 2006), dealing with indications for administering blood transfusions in both groups.…”

“…However, references relating to this point were reported and discussed in our paper [3][4][5]. It is reasonable to use pre-operative embolisation of the tumour-harbouring kidney to decrease/avoid extensive blood loss during surgery and/or to facilitate surgery with huge renal tumours when the renal vessels are difficult to reach [3][4][5].…”

Renal artery embolisation prior to radical nephrectomy for renal cell carcinoma: when, how and why?

“…Although we are not able to distinguish with certainty the effect of embolisation on the course of the disease, observation data from many urologists testify that many patients are helped by angioinfarction. According to the literature, complete PRAE is now recognised as a technique that facilitates nephrectomy in selected patients; in particular, intraoperative blood loss and the duration of surgery are reduced, thus decreasing blood transfusion requirements [2,3]. The benefits of pre-operative infarction include notably decreased tumour vascularity.…”

“…First, surgery was delayed for 2-3 days in most patients (range 1-12 days). We now know that the optimal delay between embolisation and operation is probably less than 1 day [2]. Thus, the distress caused by the post-infarction syndrome can be reduced.…”

Arterial embolization using poly‐N‐acetyl glucosamine gel in a rat kidney model

“…Materials investigated have included blood clots, acetocellulose gauze, cyanocrylates, ethanol, and polyvinyl alcohol (Khayata et al, 1994;Matsumaru et al, 1997). Although these materials are effective for specific endovascular embolizations, many of them have certain shortcomings, such as postembolization pain and elevated temperature, difficulty of injection (highviscosity materials such as ethibloc), venous passage, unwanted embolization of normal tissue (lipiodol emulsion), recanalization (particle form agents such as gelstin sponges or fibrillar collagen), or material toxic effects (tissue toxic agents such as ethanol) (Kauffmann et al, 1981;Khayata et al, 1994;Ono et al, 1995;Matsumaru et al, 1997;Kalman and Varenhorst, 1999). There are also several recently studied materials, including thermosensitive polymer gels (An et al, 2000), alginate gels (Kishi et al, 1995;Becker et al, 2001;Kang et al, 2002), and chitosan microspheres Tabara et al, 1993;Khayata et al, 1994;Wang et al, 1995;Denkbas et al, 1999).…”