This report describes renal artery occlusion as a therapeutic alternative to nephrectomy and chemotherapy in treating patients with metastatic renal carcinoma. Using a combination of Gelfoam and the Gianturco stainless steel coil, embolization was performed on 75 patients at the University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute with promising results. Its use is recommended 1) to facilitate surgical removal of large and difficult tumors, 2) to control local symptoms (pain, bleeding, etc), and 3) as part of a planned therapeutic program consisting of infarction, nephrectomy and progestins for patients with minimal to moderate metastatic disease

Johnson, Douglas E.

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Henry Ford Hosp Med Journal Vol 27, No 2, 1979 Percutaneous Transfemoral Renal Artery Occlusion in the Management of Advanced Renal Carcinoma Douglas E. Johnson, MD* This report describes renal artery occlusion as a therapeutic alternative to nephrectomy and chemotherapy in treating patients with metastatic renal carcinoma. Using a combina-tion of Gel foam and the Gianturco stainless steel coil, embolization was performed on 75 patients at the University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute with promising results. Its use is recom-mended 7 jto facilitate surgical removal of large and difficult tumors, 2) to control local symptoms (pain, bleeding, etc), and 3) as part of a planned therapeutic program consisting of infarction, nephrectomy and progestins for patients with minimal to moderate metastatic disease. Because nephrectomy^ and chemotherapy^ have not sig-nificantly improved the prognosis for patients with meta-static renal carcinoma, there has been increased interest in renal artery occlusion as a therapeutic alternative. In the past, arterial embolization has been used for treating ar-teriovenous malformations,^'" aneurysms,^ postbiopsy ar-teriovenous renal fistulas,^ control of gastrointestinal and pelvic bleeding,'''^ and management of bone tumors. Almgard et aP^ were among the first to report promising results in the treatment of massive renal tumors by embolic occlusion of the larger renal vessels, and subsequent re-ports^^"'"' have confirmed their findings. Submitted for publication: February 27, 1979 Accepted for publication: April 27, 1979 * The University of Texas System Cancer Center, M. D.Anderson Hospital and Tumor Institute, Houston, Texas Address reprint requests to Dr. Johnson at The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston, TX 77030 Materials and Methods Although a variety of agents have been used to occlude the renal vessels (autogenous clot and tissue, Gelfoam, metal and plastic spheres, synthetic plastic compound, balloon catheters, and stainless steel coils), the technique developed at the University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute at Houston com-bines Gelfoam"'^ and the Gianturco stainless steel coiP^"''^to occlude both the peripheral arterioles and the main renal artery. Initially, embolization was performed immediately after the diagnostic angiographic evaluation of the sus-pected renal tumor. However, in two patients renal failure developed following renal artery occlusion, and it was believed that the considerable amount of contrast media (350 cc of 76% renographic) used during the combined diagnostic and therapeutic angiographic procedures con-tributed to the failures. Subsequently, the procedures have been performed at least 48 hours apart without any recur-rence of this problem. Results Within several hours after embolization has been per-formed, patients usually experience a "postinfarction" syn-drome consist ing of pain, fever and gastrointestinal complaints (Table 1). Pain is usually localized to the affected 92 Johnson renal area and is directly related to the degree of infarction achieved by the procedure and inversely related to the amount of collateral and parasitic arterial supply to the tumor. Mild to moderate gastrointestinal symptoms of nau-sea, vomiting and paralytic ileus frequently require re-stricted oral intake and intravenous fluids for two or three days. In one patient, a gas-forming infection developed within the necrotic tumor mass and resulted in his death. Since then all patients wfth a positive urine culture, recent urinary tract infection, ora history of renal calculous disease have been placed on prophylactic antibiotics beginning the night before the procedure. TABLE 1 Side Effects of Renal Artery Occlusion Type Percentage Mean Duration (Hours) Pain requiring injectable narcotics 88 57 (range: 24-144) Fever 85 83 (range: 24-264) Nausea and vomiting 78 41 (range: 24-144) Hypertension 5 — Sepsis 2 — To date, 75 patients wfth advanced renal carcinoma have been subjected to renal artery embolization (Table 11). In 14 patients renal artery occlusion was done to facilitate re-moval ofthe renal tumorswithin three days of nephrectomy. We believe that surgery was simplified in these cases because of the collapse of the engorged and fragile tumor vessels and the presence of edema induced by the infarction which tended to make tissue planes more distinct. Opera-tive time and blood loss were also reduced. Although some investigators are now recommending its use in all surgical cases of renal carcinoma, there are inherent risks. These include escape of the embolization material into the sys-temic circulation with occlusion of vessels resulting in arterial insufficiency, gangrene or paraplegia, as well as the morbidity and expense ofthe procedure. Consequently, we suggest that its use should be restricted to those with large and difficult tumors. Perhaps later we wi l l demonstrate that ft also plays a role in reducing local recurrences and subsequent metastases in patients with stage 11 and stage III disease by reducing intraoperative tumor dissemination. TABLE ll 75 61 Total Patient Population With Metastases Infarction / nephrectomy / progestins Infarction / nephrectomy/other Infarction alone Without Metastases 35 3 23 Twenty-three patients wfth metastatic renal carcinoma un-derwent renal artery embolization wfthout subsequent sur-gical removal. All except one patient died of disease one week to nine months laterwfthout evidenceof a response. In the one patient who remained alive with disease, the procedure was performed for relief of local symptoms (pain, hematuria) which abated following the infarction. Based on these limited results, the procedure is not believed to alter survival in patients with metastatic disease if nephrectomy is not subsequently performed. Thirty-five patients with metastatic renal carcinoma have been treated with a combination of selective renal artery embolization, radical nephrectomy within five to seven days and medroxyprogesterone acetate (400 mg IM twice weekly). Twenty-eight patients are currently being evalu-ated. Six have achieved a complete response with disap-pearance of all known metastatic disease for periods ranging from 3 to 13 months, and six have had a partial response (greater than 50% reduction in the maximal diameters of all lesions). In two cases, the disease has stabilized. One patient has had a mixed response: while his pulmonary lesions disappeared, osseous metastases de-veloped during the same period. Discussion The cause for these varied responses is as yet unexplained. Whether or not an altered immune response is associated wfth necrosis remains speculative. Swanson,* working our department, has suggested that the infarction may release a shower of tumor antigens into the c i rcu la t ion wh ich abruptly alters the relative concentrations of tumor antigens and anti-tumor specific antibodies and thereby affects the amount and solubility of circulating immune complexes. These alterations could reduce the effective level of serum-blocking factors by clearing the complexes in the reticulo-endothel ial system and / or reducing the ef f ic iency of the blocking factors so that a net improvement in cell-mediated, tumor-specific immune response would result. Someof our patients who had the combination of infarction and nephrectomy showed an increased reactivity in skin tests to a battery of recall antigens. Also, in a few patients there was a change in the level of circulating immune complexes after infarction but before nephrectomy using an assay which measures binding to radioiodinated Clq. While these limited results suggest that the procedure is altering the cell-mediated immune response, the system is obviously very complex and considerable work needs to be com pleted before we can hope to understand the exact mechanisms. 14 * Personal Communication. 93 Renal Artery Occlusion Conclusion Our early results with renal artery embolization are encour-aging. At the present time, the procedure would appear to be indicated: 1) to facilitate surgical removal of large and difficult tumors; 2) to control local symptoms (pain, bleed-ing, etc); and 3) as part of a planned therapeutic program consisting of infarction, nephrectomy and progestins for patients with minimal to moderate metastatic disease. While it does not offer permanent eradication of disease, the combination program does prolong survival for some pa-tients. Consequently, until effective chemotherapeutic agents become available, its use should be considered. References 1. Johnson DE, Kaesler KE and Samuels ML: Is nephrectomy justified in patients with metastatic renal carcinoma?/ Urol 114:29, 1975. 2. Johnson DE and Samuels ML: Chemotherapy for metastatic renal carcinoma. Cancer Chemotherapy Fundamental Concepts and Recent Advances. Chicago, Year Book Medical Publisher, Inc. 1975, p 493. 3. Luessenhop AJ and Spence WT: Artificial embolization of cerebral arteries; Report of use in a case of arteriovenous malformation. jAMA 172:1153, 1960. 4. Kricheff I, Madayag M and Braunstein P: Transfemoral catheter emolization of cerebral and posterior fossa arteriovenous malforma-tions. Radiology 103:107, 1972. 5. Almgard LE and Fernstrom I: Embolic occlusion of an intrarenal aneurysm: A case report. Br I Urol 45:485, 1973. 6. BooksteinJJ and Goldstein H M : Successful management of postbiopsy arteriovenous fistula with selective arterial embolization. Radiology 109:535, 1973. 7. Prochaska JM, Flye M W and johnsrude IS: Left gastric artery emboliza-t ion for cont ro l of gastric b leed ing : A c o m p l i c a t i o n . Radiology 107:521, 1973. 8. RoschJ, DotterCTand Brown MJ: Selective arterial embolization: New method for control of acute gastrointestinal bleeding. Radiology 102:303, 1972. 9. Ring EJ, Athanasoulis C, Waltman AC, Margolies MN and Baum S: Arteriographic management of hemorrhage following pelvic fracture. Radiology 109:65, 1973. 10. Feldman F, Casarella WJ, Dick HM and Hollander BA: Selective intra-arterial embolization of bone tumors. Am / Roentgenol 123:130, 1975. 11. Almgard LE, Fernstrom I, Haverling M and Ljungovist A: Treatment of renal adenocarcinoma by embolic occlusion ofthe renal circulation. Br I Urol 45:474, 1973. 12. Bracken RB, Johnson DE, Goldstein HM, Wallace S and Ayala AG: Percutaneous transfemoral renal artery occlusion in patients with renal carcinoma: A preliminary report. Urology 6:6, 1975. 13. Bischoff W and Goerttler U: Current aspects of renal vascular embol-ization. Dtsch Med Wochenschr 102:901, 1977. 14. Nakao N, Sugiki K, Inamato K, Sakurai T, Uchida H and Nakamura H: Transcatheter arterial embolization of renal cell carcinoma. / / pn Coll Angiology 17:547, 1977. 15. Goldstein HM, Medellin H, Beydoun MT, Wallace S, Ben-Menachem Y, Bracken RB and Johnson DE: Transcatheter embolization of renal cell carcinoma. Am j Roentgenol 123:557, 1975. 16. Gianturco C, Anderson J and Wallace S: Mechanical devices for arterial occlusion. Am / Roentgenol 124:428, 1975. 17. Habighorst LV, Kreutz W, Klug B, Sparwasser HH and Gobel EA: The Gianturco method of spiral embolization of the renal artery. Fortschr Ceb Roetgenstr Nuklearmed 128:47, 1978. 94 

Percutaneous Transfemoral Renal Artery Occlusion in the Management of Advanced Renal Carcinoma

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Percutaneous Transfemoral Renal Artery Occlusion in the Management of Advanced Renal Carcinoma

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