Embolotherapy in the management of renal cell carcinoma

Renal cell carcinoma (RCC) is an uncommon tumor, accounting for only 3% of all adult malignancies (1), yet of all urological malignancies, it is the most lethal (2). Diagnosis and treatment of RCC have changed dramatically since the 1950s, when the disease was usually diagnosed at an advanced stage on the basis of clinical symptoms of palpable mass, flank pain and hematuria (3). In recent years, routine use of cross-sectional abdominal imaging has resulted in earlier diagnosis (4, 5). Radical nephrectomy, once believed to be the standard for treatment of RCC, is now used only to treat large tumors that are locally advanced or metastatic at diagnosis. Today, the treatment of choice for smaller tumors (<4 cm in diameter) is partial nephrectomy (6). Energy-ablative techniques such as cryoablation and radiofrequency ablation (RFA) are promising, minimally invasive treatment options for smaller tumors in patients who may not be suitable surgical candidates (7–9). Embolotherapy has been used as an adjunctive therapy in the management of RCC since the 1970s, although its role has evolved over the years (Table 34.1). At one time, it was thought that preoperative embolization of RCC would result in an immunologic response – that is, a form of autovaccination; therefore, some investigators advocated routine use of preoperative embolization (10). The initial enthusiasm for this practice was dampened by a lack of scientific evidence that embolization of RCC did, in fact, induce a significant immunologic response, and the practice was abandoned.