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
Phone: ++ 49/8 51/53 00 23 66
Fax: ++ 49/8 51/53 00 2202
Email: josef.tacke@klinikum-passau.de
