Imaging Followup

There is no consensus as to the frequency and timing of imaging after ablation. At UW CSC, the follow-up protocol is an immediate postprocedure CT, followed by a CT at 1, 3, 6, and 12 months. If there is no evidence of recurrence at 12 months, follow-up is decreased to every six months. Contrast-enhanced CT or MRI is generally utilized for follow-up imaging. The tissues surrounding the ablated tumor often show concentric, symmetric enhancement in the first six months after an ablation (26). This is likely related to inflammation associated with the tissue necrosis. Irregular, nodular enhancement around the periphery of the ablated area, or any enhancement within the ablated tumor itself are concerning, as is any increase in the size of the ablated tumor (Fig. 9). With most tumors, local recurrence usually occurs within one year. However, because of the slow growth rate of small RCC (5), recurrences may take longer to manifest. The length of time necessary for the follow-up of a RCC ablation is yet to be determined.

Figure 9 Identification of local recurrence on follow-up imaging. (A) A posteriorly located right RCC (arrow) underwent percutaneous cryoablation. Immediate post-ablation imaging (not shown) identified no residual enhancement, but was complicated by adjacent hemorrhage. (B) Follow-up CT three months later showed a large portion of the tumor was necrotic and had no residual enhancement. (C) However, along the inferior aspect of the tumor, there was brisk nodular enhancement, indicating local recurrence. A second ablation was performed and there has been no further evidence of recurrence. Abbreviations: RCC, renal cell carcinoma; CT, computed tomography.

Figure 9 Identification of local recurrence on follow-up imaging. (A) A posteriorly located right RCC (arrow) underwent percutaneous cryoablation. Immediate post-ablation imaging (not shown) identified no residual enhancement, but was complicated by adjacent hemorrhage. (B) Follow-up CT three months later showed a large portion of the tumor was necrotic and had no residual enhancement. (C) However, along the inferior aspect of the tumor, there was brisk nodular enhancement, indicating local recurrence. A second ablation was performed and there has been no further evidence of recurrence. Abbreviations: RCC, renal cell carcinoma; CT, computed tomography.

Tumors that have imaging findings consistent with RCC are not usually biopsied prior to definitive treatment because there is evidence to suggest that imaging is as good as, or better than percutaneous biopsy for diagnosing RCC (94,95), and there is also a small risk of tumor seeding during the biopsy. However, with smaller renal tumors, the imaging findings are often not as clear cut and because there is no tissue sample available after an ablation procedure, some investigators biopsy renal tumors prior to an ablation. The results of this biopsy are often used to guide the intensity of follow-up imaging, but rarely have an impact on the decision to perform an ablation.

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