Zusammenfassung
Nierentumoren und insbesondere das Nierenzellkarzinom - werden aufgrund moderner Untersuchungsverfahren wie Mehrzeilen-CT und Hochfeld-MRT zunehmend häufiger diagnostiziert. Auch wenn Tumore unter 4 cm Größe sehr selten metastasieren, gelten grundsätzlich alle tumorsuspekten Veränderungen als behandlungspflichtig. Traditionelle Behandlungsverfahren sind die radikale Nephrektomie oder parenchymschonende Operationstechniken, die zunehmend auch laparoskopisch durchgeführt werden. Für Patienten, bei denen diese Techniken kontraindiziert sind oder die eine Operation generell ablehnen, können moderne Thermoablationstechniken eine hilfreiche Therapiealternative sein. Hierzu zählen die hyperthermen (Radiofrequenzablation, LITT und Mikrowellentherapie) sowie die hypothermen Techniken (Kryotherapie). Die Kryotherapie ist das älteste Thermoablationsverfahren und kann sowohl perkutan als auch laparoskopisch erfolgen. Da tiefe Temperaturen keinen hämostyptischen Effekt haben, müssen zusätzliche Maßnahmen zur Blutstillung ergriffen werden. Eine interessante Technik ist die perkutane MR-gesteuerte Kryoablation von Nierentumoren, für die allerdings nur geringe Erfahrungen vorliegen. Die Radiofrequenzablation (RFA) wird von allen Verfahren am häufigsten durchgeführt. Moderne Sondentypen ermöglichen Läsionsgrößen zwischen 2 und 5 cm. Aufgrund der Möglichkeit der Punktionstraktablation gilt das Verfahren als sicher und komplikationsarm. Wenngleich randomisierte Vergleichsstudien zu operativen Verfahren noch fehlen, sind die bisherigen Erfahrungen vielversprechend und lasssen die RFA gegenüber den anderen Thermoablationsverfahren vorteilhaft erscheinen. Für beide Verfahren, Kryo- und RF-Ablation, betragen die klinischen Erfolgsraten über 90 %. Während die laserinduzierte Thermotherapie (LITT) in der Behandlung von Lebertumoren einen festen Stellenwert hat, liegen bei der Niere nur geringe Erfahrungen vor. Für Läsionen über 2 cm im Durchmesser sind Kühlkatheter zur Leistungsmaximierung erforderlich. Zur Temperaturüberwachung bietet sich die MR-Thermometrie an. Die Mikrowellentherapie (MW) ist durch kleine Läsionsdurchmesser gekennzeichnet und wird klinisch nur als Koagulationshilfe bei chirurgischen Teilresektionen verwendet. Der fokussierte Ultraschall (FUS) ist als einzige Methode nichtinvasiv, befindet sich aber noch im Experimentalstadium.
Abstract
Due to modern examination techniques such as multidetector computed tomography and high-field magnetic resonance imaging, the detection rate of renal neoplasms is continually increasing. Even though tumors exceeding 4 cm in diameter rarely metastasize, all renal lesions that are possible neoplasms should be treated. Traditional treatment techniques include radical nephrectomy or nephron-sparing resection, which are increasingly performed laparoscopically. Modern thermal ablation techniques such as hyperthermal techniques like radiofrequency ablation RFA, laser induced thermal ablation LITT, focused ultrasound FUS and microwave therapy MW, as well as hypothermal techniques (cryotherapy) may be a useful treatment option for patients who are unfit for or refuse surgical resection. Cryotherapy is the oldest and best known thermal ablation technique and can be performed laparoscopically or percutaneously. Since subzero temperatures have no antistyptic effect, additional maneuvers must be performed to control bleeding. Percutaneous cryotherapy of renal tumors is a new and interesting method, but experience with it is still limited. Radiofrequency ablation is the most frequently used method. Modern probe design allows volumes between 2 and 5 cm in diameter to be ablated. Due to hyperthermal tract ablation, the procedure is deemed to be safe and has a low complication rate. Although there are no randomized comparative studies to open resection, the preliminary results for renal RFA are promising and show RFA to be superior to other thermal ablation techniques. Clinical success rates are over 90 % for both, cryo- and radiofrequency ablation. Whereas laser induced thermal therapy is established in hepatic ablation, experience is minimal with respect to renal application. For lesions of more than 2 cm in diameter, additional cooling catheters are required. MR thermometry offers temperature control during ablation. Microwave ablation is characterized by small ablation volumes and plays a role as a coagulation tool during resection. Focused ultrasound is the only non-invasive method, but it is still experimental.
Key words
Thermal ablation - renal cell cancer - radiofrequency ablation - RFA - LITT - MW - cryotherapy
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Prof. Dr. med. Josef Tacke
Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Klinikum Passau
Innstr. 76
94032 Passau
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