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. 2017 Feb;7(1):8-23.
doi: 10.21037/qims.2017.01.02.

Selective arterial embolization of symptomatic and asymptomatic renal angiomyolipomas: a retrospective study of safety, outcomes and tumor size reduction

Florian Bardin  1 , Olivier Chevallier  1 , Aurélie Bertaut  2 , Emmanuel Delorme  3 , Morgan Moulin  4 , Pierre Pottecher  1 , Lucy Di Marco  1 , Sophie Gehin  1 , Eric Mourey  4 , Luc Cormier  4 , Christiane Mousson  5 , Marco Midulla  1 , Romaric Loffroy  6
Affiliations

Selective arterial embolization of symptomatic and asymptomatic renal angiomyolipomas: a retrospective study of safety, outcomes and tumor size reduction

Florian Bardin et al. Quant Imaging Med Surg. 2017 Feb.

Abstract

Background: Angiomyolipoma (AML) is the most common renal benign tumor. Treatment should be considered for symptomatic patients or for those at risk for complications, especially retroperitoneal bleeding which is correlated to tumor size, grade of the angiogenic component and to the presence of tuberous sclerosis complex (TSC). This study reports our single-center experience with the use of selective arterial embolization (SAE) in the management of symptomatic and asymptomatic renal AMLs.

Methods: In this retrospective mono-centric study, all demographic and imaging data, medical records, angiographic features, outpatient charts and follow-up visits of patients who underwent prophylactic or emergency SAE for AMLs between January 2005 and July 2016 were reviewed. Tumor size and treatment outcomes were assessed at baseline and after the procedure during follow-up. Computed tomography (CT), magnetic resonance imaging (MRI) or ultrasonography was used to evaluate AML shrinkage. Renal function was measured pre- and post-procedure.

Results: Twenty-three patients (18 females, 5 males; median age, 45 years; range, 19-85 years) who underwent SAE either to treat bleeding AML (n=6) or as a prophylactic treatment (n=17) were included. Overall, 34 AMLs were embolized. TSC status was confirmed for 6 patients. Immediate technical success rate was 96% and 4 patients benefitted from an additional procedure. Major complications occurred in 3 patients and minor post-embolization syndrome (PES) in 14 patients. The mean AML size reduction rate was 26.2% after a mean follow-up was 20.5 months (range, 0.5-56 months), and only non-TSC status was significantly associated with better shrinkage of tumor (P=0.022). Intralesional aneurysms were significantly more frequent in patients with hemorrhagic presentation (P=0.008). There was no change in mean creatinine level after SAE.

Conclusions: SAE is a safe and effective technique to manage renal AMLs as a preventive treatment as well as in emergency setting, with significant reduction in tumor size during follow-up. A multidisciplinary approach remains fundamental, especially for TSC patients. In addition to size, the presence of intralesional aneurysms should be considered in any prophylactic treatment decision.

Keywords: Renal tumor; angiomyolipoma (AML); arterial embolization; bleeding patient; outcomes; therapeutic response.

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Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Flow chart of the study cohort. AML, angiomyolipoma; SAE, selective arterial embolization.
Figure 2
Figure 2
A 63-year-old woman with TSC, hospitalized for left acute flank pain, hematuria and deglobulisation. Unenhanced CT scan revealed three right AMLs and left perirenal hematoma whose origin was a giant left AML, with almost no recognizable renal tissue (A,B). Embolization to stop bleeding was performed urgently. Selective injection of four branches of the left renal artery showed diffuse perirenal hypervascularization with neovascularization and small vascular malformations (example of left lower branch presented) (C,D). Angiogram after selective embolization with microspheres (Embozene® 400 µm) showed good devascularization of the lower contingent. The persistent hypervascular contingents were treated in a second time (E,F). The three right AMLs were also treated in the same time with glue and microcoils. Four years after, CT-scan follow-up showed a total decreased in size of 11% of the three right AMLs with consistent viable renal parenchyma and no decrease of renal function. An average shrinkage of 17% of the left AML was also noted, without persistent perirenal collection (G-I). AML, angiomyolipoma; TSC, tuberous sclerosis complex; CT, computed tomography.
Figure 3
Figure 3
A 45-year-old woman with two small incidentally discovered angiomyolipomas in the right kidney. Biopsy of the first one in the medial pole confirmed an epithelioid variant without macroscopic fat component as shown in density histogram of unenhanced CT scan after tumors segmentation (A,B) and the second one in the lower pole had predominant angiomyomatous content with less than 5% of fat (C-E). An endovascular approach was decided. Right renal angiogram demonstrates middle and inferior pole AMLs (F). After selective embolization of the first AML with Onyx® (G,H) and the second one with a mixture of Glubran 2® and lipiodol (1:6) (I), post-procedure angiogram showed total devascularization of both tumors (J). Contrast-enhanced CT scan 8 months after embolization showed total atrophy of lower pole AML (K,L). Maximum diameter of epithelioid middle pole AML decreased by 21% and additional percutaneous thermal ablation with microwaves was decided because of its uncertain evolution. AML, angiomyolipoma; CT, computed tomography.
Figure 4
Figure 4
A 77-year-old woman hospitalized for right acute flank pain, hematuria and deglobulisation. Unenhanced CT scan revealed right perirenal hematoma caused by a giant right lower pole AML (A). Post-treatment maximum intensity projection (MIP) (B) and volume rendering (VR) (C) images of arterial phase CT scan revealed several clusters of aneurysms on the periphery of the mass. Embolization to stop bleeding was performed urgently. Selective injection of a lower branch of the right renal artery showed hypervascularization of AML with neovascularization and aneurysms (D). After selective embolization of AML with a mixture of 1:7 glue and lipiodol (E,F), post-procedure angiogram showed total exclusion of AML with good preservation of viable renal parenchyma (G). AML, angiomyolipoma; CT, computed tomography.
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