








































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Renal cell carcinoma, stereotactic ablative 
radiotherapy, thermal ablation, microwave 
ablation, stereotactic ablative radiotherapy, 
SABR, radiofrequency ablation, RFA

None declared. Received on August 1, 2022 
Accepted on August 27, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(6):437–449

DOI: 10.48083/UEML5802

2022 WUOF/SIU International Consultation on 
Urological Diseases: Ablative Therapies for Localized 
Primary Renal Cell Carcinoma

Muhammad Ali, 1,2 Vanessa Acosta Ruiz,3 Sarah P. Psutka,4 David Liu,5,6,7 Shankar Siva,1,2

1 Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia 2 Sir Peter MacCallum Department of Oncology, University of Melbourne, 
Melbourne, Australia 3 Department of Surgical Sciences, Radiology, Uppsala, Sweden 4 Department of Urology, University of Washington, Seattle Cancer Care Alliance, 
Washington, United States 5 Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, Canada 6 School of Biomedical Engineering, 
Faculty of Applied Sciences, University of British Columbia, Vancouver, Canada 7 Department of Interventional Radiology, Miller School of Medicine, University of Miami, 
Miami, United States

Abstract

Surgery with either partial or radical nephrectomy remains the standard of care for localized primary renal cell 
carcinoma (RCC). However, most RCCs are detected in an older age group, and some may have multiple comorbidities 
that preclude surgery. Thermal ablation (TA) with radiofrequency ablation (RFA), cryoablation (CA), or microwave 
ablation (MWA) is considered an alternative to extirpative surgical procedures for select patients with small renal 
tumors. There is more than 90% post-ablation local control in carefully selected patients with reported complication 
rates of less than 10%. Most thermal ablation require only a single procedure. More recently, stereotactic ablative 
body radiotherapy (SABR) has emerged as an attractive noninvasive treatment modality for elderly patients with 
comorbidities and localized RCC. It has shown more than 90% local control rates for both small and relatively larger 
tumors (> 4 cm). Modest post-SABR renal function decline has been observed. Despite most patients presenting with 
mild or moderate chronic kidney disease there is less than a 5% chance of progression to end-stage renal disease. This 
article aims to summarize the key evidence and ablative treatment’s optimal patient selection, efficacy, and toxicity.

Introduction 

Surgery is the standard of care for primary localized renal cell carcinoma (RCC); however, many patients in this 
population have comorbidities that render them at high risk for complications from both anesthesia and surgery. 
Moreover, partial (PN) or radical nephrectomy (RN) is associated with a potential risk for long-term impairment 
of renal function and chronic kidney disease (CKD)[1–3]. In patients where surgery is contraindicated, active 
surveillance (AS) is commonly used, particularly in patients with multiple comorbidities, tumor size of less than 2 cm, 
and tumor growth kinetics of less than 5 mm/year[4].

For patients with small renal masses (SRMs) who are not considered good candidates for surgery or have declined 
surgery and are not candidate for AS, thermal ablation (TA) has been endorsed by multiple international guidelines 
as a safe and effective alternative[5,6]. More recently, stereotactic ablative radiotherapy (SABR), a form of hypofrac-
tionated radiation, has emerged as an alternative noninvasive treatment option for patients who are not suitable for 
surgery. The European Society of Medical Oncology (ESMO) guidelines have endorsed SABR as a treatment option for 
patients considered unsuitable or who have declined other treatment options[6]. The 2022 National Comprehensive 
Cancer Network (NCCN) version 1.0 Kidney Cancer guidelines state, “SABR may be considered for medically inop-
erable patients with stage I kidney cancer (category 2B) [and patients] with stage II/III kidney cancer (category 3)”[7].

437SIUJ.ORG SIUJ  •  Volume 3, Number 6  •  November 2022

2022 WUOF/SIU INTERNATIONAL CONSULTATION ON UROLOGICAL DISEASES

mailto:muhammad.ali%40petermac.org?subject=
http://SIUJ.org


The aim of this article is to review the role of abla-
tive therapies (TA/SABR) for localized primary kidney 
cancer. It will also report and summarize each modali-
ty’s optimal patient selection, efficacy, and toxicity.

Thermal Ablation 
TA refers to the local application of thermal energy to 
a tumor[8]. When TA is applied to a renal tumor, the 
thermal energy is delivered directly into the tumor 
via an antenna or probe inserted through an image-
guided percutaneous approach or surgically via an 
open or laparoscopic approach. Renal tumors can be 
ablated via application of extreme heat (radiofrequency 
[RFA], microwave [MWA]) or cooling ablation (CA); 
the advantages and disadvantages of each system are 
summarized in Table 1.

Small (T1) localized renal tumors are well suited for 
ablation because of their rounded shape and relative 
isolation from temperature-sensitive structures in the 
retroperitoneum[9]. Given the in situ nature of the treat-
ment, evaluation of treatment efficacy relies on contin-
ued surveillance via computed tomography (CT) or 
magnetic resonance imaging (MRI).

Indications and Patient Selection 
Historically, TA has been reserved for patients who 

are considered poor surgical candidates due to renal 
insufficiency or a high burden of comorbid conditions. 
International guidelines now support consideration of  
TA in treating patients with a renal tumor of < 3 cm as 
a primary treatment[10–12]. TA is also considered an 
effective treatment for patients with a solitary kidney, 
renal insufficiency, multiple tumors, or hereditary 
tumors.

Ablation is the treatment of choice in patients with 
compromised renal function where dialysis and/or 
nephrectomy are not desired[10,12]. Percutaneous TA 
has the advantage of avoiding the temporary vascu-
lar clamping, which is required during PN[13,14]. 
Also, the sphere-shaped ablation zone can be adjusted 
to minimize unnecessary damage to the normal renal 
parenchyma.

An appropriate patient selection for TA can gener-
ate oncologic outcomes comparable to those of neph-
ron-sparing surgery, with the added benefit of better 
preservation of renal function[15–18].

Technical Considerations
The effect of ablative therapies varies across tumors. 
Tumor size is one of the most important factors; 
RFA and MWA have excellent outcomes for masses 
of < 3 cm. Masses measuring 3 to 4 cm or larger may 
need repeated treatment or multiple probes[19–22]. 
Microwave ablation should theoretically be able to treat 
larger tumors efficiently given the physics behind the 

Abbreviations 
AS active surveillance 
CA cooling ablation 
CKD chronic kidney disease 
CSS cancer-specific survival 
CT computed tomography 
IROCK International Radiosurgery Oncology Consortium for 
Kidney
MRI magnetic resonance imaging 
MWA microwave ablation 
PN partial nephrectomy 
RCC renal cell carcinoma 
RFA radiofrequency ablation 
RN radical nephrectomy 
SABR stereotactic ablative radiotherapy
SMRs small renal masses 
TA thermal ablation

TABLE 1. 

Advantages and disadvantages between ablative 
technologies 

Advantages Disadvantages

RFA

• Most used system, more 
studies are available

• Short treatment time 
(12–30 min ablation time)

• Treatment of maximum 
3 cm tumors

• More affected by heat 
sink effect

• RF current may be 
redirected to high 
electrolyte content  
of urine

MWA

• Achieves larger ablation 
zones than RFA

• Quicker than RFA (5–8 
min ablation time)

• Less affected by heat 
sink effect

• Newer system; needs 
further validation but 
principles of thermal 
coagulation same as 
RFA

• More painful than RFA

CA

• Can treat larger tumors 
(> 4 cm)

• Can treat central tumors
• Real-time monitoring 

of ice ball (however not 
reflective of the zone of 
cell death)

• Requires several probes; 
increased risk for post-
procedural hemorrhage

• Argon (and possibly 
helium) canister required

• Time-consuming 
(30–40 min ablation 
time)

CA: cooling ablation; MWA: microwave ablation;  
RFA: radiofrequency ablation.

438 SIUJ  •  Volume 3, Number 6  •  November 2022 SIUJ.ORG

2022 WUOF/SIU INTERNATIONAL CONSULTATION ON UROLOGICAL DISEASES

http://SIUJ.org


larger active heating zone. Although T1b tumors have 
been treated with secondary efficacy rates of up to 95%, 
current reports are limited by small samples (the largest 
series included 56 patients)[23–25]. High-output centers 
have reported good tumor control with single-session 
treatment for larger tumors using CA[26,27]. However, 
the upper size limit at which complete ablation can be 
expected remains to be defined. Moreover, larger tumors 
also have an increased risk for hemorrhage with TA 
modalities.

Centrally located tumors are at increased risk for 
treatment failure as proximity to the larger hilar vessels 
washes out the extreme temperature gradients generated 
during ablation procedures, which is necessary for cell 
death[19,28]. CA appears to provide better oncologic 
outcomes for centrally located tumors than RFA[29,30]. 
RFA for central tumors is associated with low rate of 
complications but with severe sequelae, such as uret-
eropelvic junction obstruction, urinoma, and proximal 

ureteral stricture[31,32]. The early reports of CA appear 
to show that CA safe, with fewer complications than 
those reported with RFA[30,33].

The insulative properties of the surrounding retro-
peritoneal fat and the greater distance to large hilar 
vessels render exophytic tumors easier to ablate in a 
single session[19,20]. Endophytic tumors are surrounded 
by renal parenchyma, through which temperature gradi-
ents may dissipate more rapidly, resulting in increased 
risk for treatment failure[34,35].

Hydrodissection via saline instillation and intentional 
patient positioning can increase the distance between 
adjacent structures and the tumor target[34] (Figure 1). 
Retrograde pyeloperfusion can be similarly used to 
protect the ureter and ureteropelvic junction from 
thermal injury, with resultant risk for perforation, urine 
leak, and/or subsequent stricture[34]. Renal tumor 
scoring systems can aid preprocedural planning and 
tumor selection[36,37].

A 43-year-old woman with prior history of von Hippel-Lindau syndrome and polycystic kidneys was treated for a 2.6-cm exophytic 
tumor in the lower pole of the left kidney. On the day of the procedure, the tumor (arrow) is seen in contact with the psoas muscle 
when the patient is examined in the prone position (A). Two MWA probes are inserted in the tumor (blue arrows) and through a 
spinal needle (yellow arrow) (B), carbon dioxide (c, arrow) is insufflated, and the tumor is displaced from the psoas muscle (C, D).

FIGURE 1. 

Example of a patient requiring tissue displacement prior to ablation 

A B

C D

439SIUJ.ORG SIUJ  •  Volume 3, Number 6  •  November 2022

Ablative Therapies for Localized Primary Renal Cell Carcinoma

http://SIUJ.org


To summarize, a small (< 3 cm) exophytic tumor, with a 
minimum of 1 cm distance from the adjacent anatomic 
structures represents ideal morphologic characteristics 
for tumor ablation.

Preprocedural Planning 
Before TA, patient evaluation should include relevant 
comorbidities, risk factors for RCC, familial history 
of hereditary RCC syndromes, and blood workup 
including coagulative profile and renal function[38]. The 
American Urological Association/ Society of Urologic 
Oncology (AUA/SUO) guidelines recommend renal 
mass biopsy prior to TA to characterize the tumor 
histolog y, subsequently informing posttreatment 
surveillance[10].

Percutaneous ablation can be performed under either 
general anesthesia or conscious sedation. Image-guided 
percutaneous techniques are preferred over laparoscopic 
approaches due to a lower risk for associated compli-
cations, shorter hospitalization and operative times, 
reduced morbidity, reduced opioid analgesic require-
ment, and faster recovery time[15,16,39–41].

Preprocedural imaging aims to evaluate the feasibil-
ity of ablation, access site, the number of probes needed, 
the tumor’s location relative to other structures, and the 
need for any ancillary procedures[42,43]. CT is most 
commonly the modality of choice for both procedural 
planning and probe placement at the time of treatment. 
MRI can be used but is more expensive and techni-
cally demanding. Ultrasound alone allows for direct 

monitoring during probe placement; however, it may be 
limited in its ability to visualize adjacent structures, and 
thus is commonly used in combination with CT[43,44].

Peri- and Post-Procedural Complications 
TA is considered a safe procedure with very few 
complications (7.4%) compared to surgery (11%)[15]. The 
incidence of significant complications after TA is lower 
than following surgery (2.3% vs. 5%)[15,45].

Complications during ablation of renal tumors 
include the following:

1. Post-ablation syndrome: A transient and self-limiting 
constellation of symptoms experienced following 
TA characterized by fever, nausea, vomiting, and 
malaise. Larger volumes of necrosis may prolong 
symptoms. Fewer than 10% of patients experience 
the full spectrum of symptoms, while 60% report 
flu-like symptoms within the first 10 days following 
ablation[46].

2. Bleeding: Most commonly, TA-associated bleeding 
is minor (6%), while massive hemorrhage requiring 
transfusion is extremely rare (< 1% of cases)
[19,43,47]. Some tumors may require pretreatment 
embolization, most often in the context of highly 
complex tumors[43,47,48].

3. Hematuria: This is a rare side effect of TA (0.5–1%) 
that generally spontaneously resolves within 12 to 
24 hours of treatment[43]. If hematuria persists, 
thermal damage to the pelvicalyceal system should 

TABLE 2. 

Long-term cohort studies of percutaneous thermal ablation of T1 renal tumors 

Author, year of 
publication

Study 
type 

Tumor sizea  
(cm)

No. 
patients

Median 
follow-up 

(years)
LC (%) CSS DFS

Andrews et al. 
(2019)[17]

R

T1 367 
Median 

RFA 1.9 cm 
CA 2.8 cm

367
RFA 7.5 
CA 6.3

RFA 95.9% 
CA 95.9%

RFA 96% 
CA 100%

NR

Psutka et al. 
(2012)[18]

R
T1a 143 
T1b 42 

Median 3 cm
185

6.43 T1a 96.1% 
T1b 91.9%

NR
T1a 91.5% 
T1b 74.5%

Georgiades et al. 
(2014)[48]

P
T1a 115 
T1b 19 

Median 2.8 cm
134 5 97% 100% NR

Yu et al. 
(2021)[88]

R
T1a 275 
T1b 48 

Mean 2.9 cm
323 5.1

T1a 98.1% 
T1b 88.7%

T1a 95.9 % 
T1b 91.4%

T1a 85.2%  
T1b 69.1%

amedian or mean. 
CA: cooling ablation; CSS: cancer-specific survival; DFS: disease-free survival; LC: local control; NR: not reported; P: prospective;  
R: retrospective; RFA: radiofrequency ablation.

440 SIUJ  •  Volume 3, Number 6  •  November 2022 SIUJ.ORG

2022 WUOF/SIU INTERNATIONAL CONSULTATION ON UROLOGICAL DISEASES

http://SIUJ.org


be suspected. In the case of hydronephrosis due to 
clot obstruction, placement of a ureteric stent and/or 
manual irrigation of the bladder may be necessary.

4. Ureteric/Collecting System Injury: This complication 
is associated with treatment of central tumors. 
Although rare (1%–3% of cases[43]), injury can 
result in ureteric strictures, urine leak, urinoma, 
or formation of a urinary fistula[40,43,47], which 
may present in a delayed fashion (weeks to months 
following treatment).

5. Neuropraxia: Nerve injury (1%–3%) can occur 
following ablation of tumors close to the psoas 
muscle, or intercostal or lumbar nerves[43]. One 
study found that nerve injury resolved in 90% of 
affected patients within 6 months of treatment[47].

Other rare complications include bowel perforation[43], 
infection[43,49], pneumothorax, skin burn or freeze 
at the site of entry, and tumor seeding along the entry 
site[9,41,47].

Evidence Synthesis 
Local Tumor Control 
Current literature suggests that careful patient and 
tumor selection can result in the successful ablation of 
nearly all renal tumors, with low recurrence rates over 
short and intermediate follow-up. To date, however, TA 
has not been compared against surgery in a randomized 
controlled trial. The available (retrospective) data 
is limited by selection bias, institutional practices, 
and local expertise, impacting generalizability of TA 
across centers, providers, and patients. The sum of the 
comparative efficacy data suggests comparable oncologic 
and safety outcomes between TA and radical or partial 
nephrectomy for T1a disease[50]. The largest-cohort 
studies of the long-term oncologic results following 
ablation are reported in Table 2.

Comparative Studies 
In a retrospective review of 1424 RCC patients (367 
treated with RFA or CA; 1055 with PN), there was no 
difference in the clinical outcome of T1a disease, with 
5-year CSS of 96%, 100%, and 99% for RFA, CA, and PN, 
respectively. However, a higher death rate from RCC was 
observed for CA compared to PN in this subset. For 376 
cT1b patients, 5-year CSS was lower for CA compared to 
PN (91% vs. 98%, respectively). Despite the limitations 
associated with the retrospective analysis design and 
risk of selection bias, the authors concluded that any 
clinically significant difference between ablation and 
PN of cT1a tumors was unlikely but encouraged further 
research regarding the oncologic efficacy of CA for cT1b 
tumors[17].

In a systematic review and meta-analysis of 107 
studies, Pierorazio et al. compared the effectiveness of 

AS, TA, and RN or PN for T1 tumors. They reported 
an increased incidence of local recurrence following a 
single ablation session but no difference when secondary 
ablations were considered. TA was associated with less 
perioperative morbidity and complications compared to 
PN. There was no difference in the CSS across the differ-
ent management options[50]. Katsanos et al. reported 
similar findings as well[15].

Selection bias is likely to contribute to some of these 
findings; for example, surgery is often favored for 
healthier patients and ablation for patients with a high 
burden of comorbidity or limited projected life expec-
tancy. However, current data suggests that TA can be 
considered a practical alternate approach to surgery 
in small T1a tumors, and sometimes for larger tumors 
in patients unsuitable for or at higher risk from partial 
nephrectomy.

Several groups report a significantly lower cost for 
ablation (up to a third) than for surgery[51–53]. These 
cost-savings are the short procedure time, outpatient 
nature, limited ancillary perioperative costs, and lower 
complication rate[51,52]. Theoretically, when consider-
ing the occasional need for retreatment post-TA, TA may 
contribute to additional expense due to further treat-
ments. Some data support that radiofrequency ablation 
is still less expensive than nephron-sparing surgery[54]. 
However, the authors concluded that future studies are 
necessary before using the analysis for policy-level deci-
sion-making. Furthermore, the analysis was limited to 
short-term cost-effectiveness.

Stereotactic Ablative Radiotherapy (SABR) 
Preclinical studies on mouse models with implanted 
human RCC cell lines and in vitro cell culture indicate 
that the entrenched dogma of radioresistance of RCC 
may not be relevant in the era of high doses per fraction, 
which can be safely delivered with the advent of 
SABR[55,56]. These reports were reinforced by excellent 
local control (LC) rates using SABR in patients with 
extracranial metastatic RCC[57]. Since then, multiple 
retrospectives and prospective phase 1 and 3 studies 
have demonstrated the feasibility, safety, and efficacy of 
SABR[58–73]. The results of selected published studies 
are summarized in Table 3.

Patient Selection for SABR 
Current published studies have evaluated the safety and 
efficacy of SABR in patients with localized RCC who 
are inoperable, those who refuse surgery, and those 
with baseline CKD and high risk for renal replacement 
therapy with PN or RN. SABR has the advantage of 
being a noninvasive treatment that does not require 
anesthesia or sedation. Therefore, it may be a more 
suitable option for older and/or more frail patients, 

441SIUJ.ORG SIUJ  •  Volume 3, Number 6  •  November 2022

Ablative Therapies for Localized Primary Renal Cell Carcinoma

http://SIUJ.org


TABLE 3. 

Summary of selective Studies evaluating SABR for the treatment of primary renal cell carcinoma 

Author, year of 
publication

Study type 
Tumor sizea 

 (cm)
No. patients

Dose (Gy)/
fraction

LC (%)
Median  

follow-up (mo)

Grelier et al. 
(2021)[71]

R 4.0 23 35/5–7 96 22

Grubb et al. 
(2021)[68]

P 3.7 11
48/3 
54/3 
60/3

90 34.3

Tetar et al.(2020)
[69]

R 5.6 36 40/5 95.2 16.4

Siva et al. 
( 2020)[70]

R 4.9 95 — 97.1 32.4

Correa et al. 
(2019)[80]

MA 4.6 372 — 97.2 28

Siva et al. 
(2017)[61] 

P 4.8 33
26/1 
42/3

100 24

Chang et al. 
(2016)[59] 

R 4.0 16 30–40/6 100 19

Sun et al. 
(2016)[66]

R 3.9 40 21–48/3 92.7 NA

Ponsky et al. 
(2015)[65]

P
57.9 

(median tumor 
volume)

19 24–48/4

No evidence of 
local progression 
in 15 evaluable 

patients

14

Staehler et 
al.(2015)[62]

P — 40 25/1 96 28

amedian or mean. 
cm: centimeter; Gy: gray; LC: local control; MA: meta-analyses; mo: months; NA: not available; P: prospective; R: retrospective.

442 SIUJ  •  Volume 3, Number 6  •  November 2022 SIUJ.ORG

2022 WUOF/SIU INTERNATIONAL CONSULTATION ON UROLOGICAL DISEASES

http://SIUJ.org


TABLE 4. 

Suggested SABR dose constraints. Adapted from IROCK Consensus Statement,  
Siva S et al. Future Oncol. 2016;12(5):637-645[78] 

Organ at risk 1 fraction 3 fractions 5 fractions 

Spinal cord
< 1 mL to 8 Gy 
< 0.03 mL to 12 Gy

< 0.03 mL to 18 Gy 
Max 22.2 Gy

< 0.5 mL to 23 Gy 
< 0.03 mL to 27.5 Gy

Small bowel 

< 20 mL to 14 Gy 
Full circumference 
< 12.5 Gy 
PRV, D0.03 mL < 26 Gy

< 10 mL to 11.4 Gy 
< 1 mL to 24 Gy 
PRV, D0.03 mL < 30 Gy

< 5 mL to 20 Gy 
Max 30 Gy

Stomach
< 10 mL to 11 Gy 
< 5 mL to 22.5 Gy

< 10 mL to 16.5 Gy 
5 mL to < 22.5 Gy 
Max 30 Gy

< 5 mL to 18 Gy 
Max 30 Gy

Large bowel  PRV, D1.5 mL< 26 Gy
PRV, D1.5 mL < 42 Gy 
20 mL to < 24 Gy

Max 38 Gy 
< 20 mL to 25 Gy

Chest wall N/A < 700 mL to 30 Gy < 70 mL to 37 Gy

Skin Max 24 Gy < 10 mL to 30 Gy
< 10 mL to 15 Gy 
< 0.03 mL to 30 Gy

Liver N/A
< 700 mL to 15 Gy 
V17 < 66%

< 700 mL to 15 Gy

Heart 15 mL to < 16 Gy Max 27.9 Gy
< 15 mL to 32 Gy 
Max 38 Gy

Contralateral kidney ALARA
ALARA 
V10 < 33%

ALARA

Ipsilateral kidney 
ALARA: minimize 
volume receiving > 50% isodose

ALARA: minimize 
volume receiving > 50% isodose

ALARA: minimize 
volume receiving > 50% isodose

ALARA: amount of radiation dose is as low as reasonably achievable; IROCK: International Radiosurgery Oncology Consortium for Kidney;  
N/A: not applicable; PRV: planning organ at risk volume.

443SIUJ.ORG SIUJ  •  Volume 3, Number 6  •  November 2022

Ablative Therapies for Localized Primary Renal Cell Carcinoma

http://SIUJ.org


those requiring ongoing anticoagulation, or those with 
multiple competing comorbidities that would place 
them at unacceptably high risk from anesthesia, surgery, 
or TA. Furthermore, SABR has the added advantage of 
having minimal impact on quality of life, which reverted 
to baseline at subsequent follow-up in a study in older 
and frail patients[74].

The treatment options are limited for patients with 
tumors measuring ≥4 cm in maximal diameter, who  
are not surgical candidates. TA is not suitable for patients 
with T1b RCC due to the increased risk for local recur-
rence and complications[5,6]. In this subset of patients 
with T1b disease, SABR has shown excellent outcomes 
and can be an attractive approach[69,70].

Treatment of RCC in a patient with a solitary kidney 
is a challenging clinical scenario. PN, if feasible, remains 
the standard of care for renal masses in patients with 
a solitary kidney. However, ablative treatments are a 
good alternative for patients where PN is not possible 
due to tumor location or size. In challenging scenar-
ios with RCC in a single kidney where other neph-
ron-sparing approaches (PN, TA) are not technically or 
medically feasible, SABR has shown excellent tumor-re-
lated outcomes while avoiding the lifelong need for 
dialysis[58,75].

Technical Consideration 
Different treatment units are used to deliver SABR 
to primary RCC[61,62,65,69,73]. Irrespective of the 
treatment system used, respiratory motion management 
is essential for treatment planning and delivery, due to 
the motion of kidneys with respiration[76]. The most 
commonly used technique in linear accelerator-based 
treatment is the internal target volume (ITV) concept, 
where a thin-cut 4-dimensional CT (4D-CT) is obtained 
during simulation. Respiratory gating or tumor tracking 
using implanted fiducial markers may be used to allow 
for a reduction in ITV, and this is usually incorporated 
into the delivery of SABR using CyberKnife. A typical 

linear accelerator-based SABR plan is shown in Figure 2.

Target volumes for SABR are defined as per the 
International Commission on Radiation Units and 
Measurements report (ICRU) 91[77], which has been 
suggested previously by the International Radiosurgery 
Oncology Consortium for Kidney (IROCK) consen-
sus statement as well[78]. Similarly, the IROCK group 
recommended organs at risk (OARs) with accept-
able dose constraints, adapted and summarized in 
Table  4[78]. The IROCK consensus statement recom-
mended 25–26 Gy, 35–45 Gy, and 40–50 Gy in 1, 3, and  
5 fractions, respectively[78].

Clinical Evidence for SABR in Localized 
Primary RCC 
Multiple prospective and retrospective studies have 
reported encouraging results with SABR in patients 
with localized RCC. In the largest reported prospective 
case-control study, Staehler et al. treated 40 patients with 
renal masses who were anticipated to require dialysis 
if they underwent nephrectomy with a single fraction 
of 25 Gy[62]. After a median follow-up of 28 months, 
the authors reported an LC of 96%, with a minimal 
decline in renal function. In a prospective phase 1 trial 
(FASTRACK) of 33 patients with a median tumor size of 
4.8 cm (range, 2.1–7.9), freedom from local progression, 
distant progression, and overall survival (OS) at 2 years 
were 100%, 89%, and 92%, respectively[61]. Treatment-
related grade 1–2 toxicities (flank pain, fatigue, nausea, 
vomiting, diarrhea) occurred in 26 of 33 patients (78%), 
and grade 3 fatigue occurred in only one patient. While 
early results of prospective studies are promising, 
these studies have some inherent limitations: (1) the 
small number of patients treated, (2) the lack of long-
term follow-up, and (3) the varying dose fractionation 
schemes.

In a pooled analysis involving 223 patients with a 
mean tumor size of 4.4 cm, the IROCK group reported 
LC, cancer-specific survival (CSS), and progression-free 

FIGURE 2. 

Axial (left), coronal (middle), and sagittal sections (right) showing highly conformal radiation dose distribution  
with a typical SABR plan 

444 SIUJ  •  Volume 3, Number 6  •  November 2022 SIUJ.ORG

2022 WUOF/SIU INTERNATIONAL CONSULTATION ON UROLOGICAL DISEASES

http://SIUJ.org


survival (PFS) rates of 97.8%, 91.9%, and 65.4% at 4 
years[79]. In another series of 95 patients with cT1b 
(> 4 cm tumor size) localized RCC treated with SABR, 
Siva et al. (2020) reported CSS, OS, and PFS rates of 
96.1%, 83.7%, and 81.0% at 2 years and 91.4%, 69.2%, 
and 64.9% at 4 years, respectively[70]. At 4 years, local, 
distant, and any failure rates were 2.9%, 11.1%, and 
12.1%, respectively. A systematic review and meta-anal-
yses published in 2019 involving 372 patients with local-
ized RCC (median size, 4.6 cm) involving 26 studies (11 
of which were prospective) reported that the random 
effect estimates for LC were 97.2% with SABR[80]. The 
grade 1, 2, and 3–4 toxicity rates were 37.5%, 8.8%, and 
1.5% (95% CI, 0–4.3%), respectively.

Prospective studies have used a range of dose frac-
tionation regimens. The prospective dose-escalation 
studies evaluated doses ranging from 21 to 60 Gy in 3 
fractions[68,81,82] and 24 to 48 Gy in 4 fractions[65]. 
They showed dose escalation to 60 Gy in 3 and 48 Gy in 
4 fractions without dose-limiting toxicity. The ongoing 
phase 2 study TROG 15.03 (FASTRACK II) evaluates 26 
Gy in 1 fraction for tumors of ≤ 4 cm and 42 Gy in 3  
fractions for tumors of > 4 cm in size[83].

Response Evaluation 
Currently, the interpretation of post-SABR response 
and identification of characteristics that coincide 
with treatment response or recurrence remain a key 
challenge. LC post-SABR is currently measured using 
the Response Evaluation Criteria in Solid Tumors 
(RECIST) by either CT or MRI. Currently, lack of 
growth and subsequent slow regression in size is thought 
to represent a successful response to treatment. Given 
that small RCCs are associated with slow growth 
kinetics, radiographic responses following SABR are also 
attenuated. In a study of 40 patients, Sun et al. reported 
an average regression of 0.37 cm in the maximum 
dimension of RCC per year[66]. Unlike TA, where 
the absence of contrast enhancement post-procedure 
assesses the response, there are no significant changes 
in contrast enhancement after SABR[66]. Early results 
of functional MRI (fMRI) have shown some promise in 
detecting early response to SABR[84]; however, further 
exploration is warranted to validate the role of fMRI in 
characterizing the efficacy of SABR.

Routine post-SABR biopsy should be considered 
experimental. In a recent prospective study involving 
11 patients with dose escalation to 60 Gy in 3 fractions, 
5 of 5 posttreatment biopsies in the expansion cohort 
were positive by hematoxylin and eosin staining[68]. 
However, there was no radiological progression in subse-
quent follow-up. Moreover, staining of Ki-67, a nuclear 
protein associated with cell proliferation, was negative in 

the post-biopsy samples, confirming that cell viability on 
microscopy does not necessarily indicate ongoing active 
cell proliferation.

Renal Function Post-SABR 
Given that many patients with RCC are at risk for long-
term CKD following treatment, concerns exist regarding 
the impact of SABR on renal function. The published 
literature demonstrates a mild to moderate decrease in 
baseline renal function following SABR. In the IROCK 
pooled analysis of 223 patients (mean tumor size,  
4.4 cm) treated with renal SABR, the average glomerular 
filtration rate (GFR) decreased by ~5.5 mL/minute after 
SABR, with 6 patients requiring dialysis[79]. Similarly, 
a systematic review and meta-analyses involving 372 
patients showed a post-SABR GFR change of -7.7mL/
min from baseline[80]. Though the renal function 
decline is subclinical in published studies, patients 
with CKD 4–5 at baseline undergoing SABR should be 
counseled regarding ESRD risk following treatment and 
the potential need for renal replacement therapy[59].

Future Perspectives 
One ongoing, prospective, randomized pilot trial 
(NCT03811665) compares SABR with RFA to manage 
SR Ms. However, there are a lways cha llenges in 
completing large, randomized trials comparing different 
interventional modalities. One way to counteract these 
difficulties can be to conduct comparative studies using 
existing datasets and establish prospective registries. 
Considering encouraging results with a combination 
of SABR and MWA in patients with larger (> 5 cm) 
RCCs[85], an ongoing prospective clinical trial is 
exploring the safety and efficacy of this combination in 
patients with RCCs of > 4 cm (NCT02782715). 

Evidence supports that SABR and TA also have 
potent immunomodulatory effects[86,87]. It will be 
interesting to combine ablative treatments, SABR or TA, 
with immunotherapies to optimize immune response to 
improve long-term outcomes. One trial (NCT05024318) 
assesses SABR with or without pembrolizumab in 
patients with T1B-T3, N0 or N1, 0 or low-volume M1 
RCC before nephrectomy.

Take-Home Messages 
• Patients with a newly diagnosed, localized renal mass 

should undergo a detailed assessment, including hist-
ory focusing on comorbidity burden, physical exam-
ination, renal function assessment, and appropriate 
comprehensive tumor staging imaging. In patients 
considering TA or SABR, renal mass biopsy is recom-
mended to characterize the histology of the tumor.

445SIUJ.ORG SIUJ  •  Volume 3, Number 6  •  November 2022

Ablative Therapies for Localized Primary Renal Cell Carcinoma

http://SIUJ.org


• Each case should be discussed in a multidisciplinary 
team meeting consisting of a urologist, interventional 
radiologist, and radiation oncologist, including a 
central imaging review.

• Ablative treatments, including TA or SABR, can 
be considered in patients at high risk for adverse 
outcomes following surgery who decline surgery and 
in whom AS is not optimal. Local expertise should be 
considered for decision-making.

• SRMs less than 4 cm (ideally < 3 cm), predominantly 
exophytic and distant to the renal hilum, should be 
considered for TA preferentially to SABR.

• Tumors measuring more than 4 cm (ideally > 3 cm), 
predominantly endophytic and centrally located, 
could be considered preferentially for SABR over TA.

• Ongoing imaging at regular specified intervals is 
essential to monitor the treatment outcome.

Acknowledgments 
Muhammad Ali is a PhD candidate who is supported 
through an Australian Government Research Training 
Program (RTP) scholarship. Shankar Siva is funded by 
the Cancer Council Victoria Colebatch fellowship.

References 

1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer 
J Clin.2013;63(1):11-30.

2. Demirjian S, Lane BR, Derweesh IH, Takagi T, Fergany A, Campbell SC. 
Chronic kidney disease due to surgical removal of nephrons: relative 
rates of progression and survival. J Urol.2014;192(4):1057-1062.

3. Kim SP, Thompson RH, Boorjian SA, Weight CJ, Han LC, Murad MH, et 
al. Comparative effectiveness for survival and renal function of partial 
and radical nephrectomy for localized renal tumors: a systematic 
review and meta-analysis. J Urol.2012;188(1):51-57.

4. Campbell SC, Uzzo RG, Karam JA, Chang SS, Clark PE, Souter L. 
Renal mass and localized renal cancer: evaluation, management, and 
follow-up: AUA Guideline: Part II. J Urol.2021;206(2):209-218.

5. European Assocation of Urology (EAU) guidelines on Renal Cell 
Cacrcinoma. Available at: https://uroweb.org/guideline/renal-cell-
carcinoma/#7. Accessed August 20, 2022.

6. Escudier B, Porta C, Schmidinger M, Rioux-Leclercq N, Bex A, Khoo 
V, et al. Renal cell carcinoma: ESMO Clinical Practice Guidelines for 
diagnosis, treatment and follow-up†. Ann Oncol.2019;30(5):706-720.

7. National Comprehensive Cancer Network. Kidney Cancer (Version 
2.2022). Available at: ht tps://w w w.nccn.org /professionals/
physician_gls/pdf/kidney.pdf. Accessed August 20, 2022.

8. Ahmed M, Solbiati L, Brace CL, Breen DJ, Callstrom MR, Charboneau 
JW, et al. Image-guided tumor ablation: standardization of 
terminology and reporting criteria--a 10-year update. J Vasc Interv 
Radiol.2014;25(11):1691-1705.e4.

9. Breen DJ, Railton NJ. Minimally invasive treatment of small renal 
tumors: trends in renal cancer diagnosis and management. Cardiovasc 
Intervent Radiol.2010;33(5):896-908.

10. Campbell S, Uzzo RG, Allaf ME, Bass EB, Cadeddu JA, Chang 
A, et al. Renal mass and localized renal cancer: AUA Guideline.  
J Urol.2017;198(3):520-529.

11. Finelli A, Ismaila N, Bro B, Durack J, Eggener S, Evans A, et al. 
Management of small renal masses: American Society of Clinical 
Oncology Clinical Practice Guideline. J Clin Oncol.2017;35(6):668-680.

12. Ljungberg B, Albiges L, Abu-Ghanem Y, Bensalah K, Dabestani S, 
Fernández-Pello S, et al. European Association of Urology Guidelines 
on Renal Cell Carcinoma: the 2019 update. Eur Urol.2019;75(5):799-810.

13. Ginzburg S, Uzzo R, Walton J, Miller C, Kurz D, Li T, et al. Residual 
parenchymal volume, not warm ischemia time, predicts ultimate renal 
functional outcomes in patients undergoing partial nephrectomy. 
Urology.2015;86(2):300-305.

14. Song C, Bang JK, Park HK, Ahn H. Factors influencing renal function 
reduction after partial nephrectomy. J Urol.2009;181(1):48-53; 
discussion -4.

15. Katsanos K, Mailli L, Krokidis M, McGrath A, Sabharwal T, Adam 
A. Systematic review and meta-analysis of thermal ablation versus 
surgical nephrectomy for small renal tumours. Cardiovasc Intervent 
Radiol.2014;37(2):427-437.

16. Acosta Ruiz V, Batelsson S, Onkamo E, Wernroth L, Nilsson T, Lonnemark 
M, et al. Split renal function after treatment of small renal masses: 
comparison between radiofrequency ablation and laparoscopic partial 
nephrectomy. Acta Radiol.2020:284185120956281.

17. Andrews JR, Atwell T, Schmit G, Lohse CM, Kurup AN, Weisbrod A, et al. 
Oncologic outcomes following partial nephrectomy and percutaneous 
ablation for cT1 renal masses. Eur Urol.2019;76(2):244-251.

18. Psutka SP, Feldman AS, McDougal WS, McGovern FJ, Mueller P, 
Gervais DA. Long-term oncologic outcomes after radiofrequency 
ablation for T1 renal cell carcinoma. Eur Urol.2013;63(3):486-492.

19. Gervais DA, McGovern FJ, Arellano RS, McDougal WS, Mueller PR. 
Radiofrequency ablation of renal cell carcinoma: part 1, Indications, 
results, and role in patient management over a 6-year period and 
ablation of 100 tumors. AJR Am J Roentgenol.2005;185(1):64-71.

446 SIUJ  •  Volume 3, Number 6  •  November 2022 SIUJ.ORG

2022 WUOF/SIU INTERNATIONAL CONSULTATION ON UROLOGICAL DISEASES

http://SIUJ.org


20. Wah TM, Irving HC, Gregory W, Cartledge J, Joyce AD, Selby PJ. 
Radiofrequency ablation (RFA) of renal cell carcinoma (RCC): 
experience in 200 tumours. BJU Int.2014;113(3):416-428.

21. Aar ts BM, Prevoo W, Meier M A J, Bex A, Beets-Tan RGH, 
Klompenhouwer EG, et al. Percutaneous microwave ablation of 
histologically proven T1 renal cell carcinoma. Cardiovasc Intervent 
Radiol.2020;43(7):1025-1033.

22. Zagoria RJ, Traver MA, Werle DM, Perini M, Hayasaka S, Clark PE. 
Oncologic efficacy of CT-guided percutaneous radiofrequency ablation 
of renal cell carcinomas. AJR Am J Roentgenol.2007;189(2):429-436.

23. Yu J, Wang H, Cheng ZG, Liu FY, Li QY, He GZ, et al. A multicenter 
10-year oncologic outcome of ultrasound-guided percutaneous 
microwave ablation of clinical T1 renal cell carcinoma: will it stand 
the test of time? Eur Radiol.2022;32(1):89-100.

24. Atwell TD, Vlaminck JJ, Boorjian SA, Kurup AN, Callstrom MR, 
Weisbrod AJ, et al. Percutaneous cryoablation of stage T1b renal cell 
carcinoma: technique considerations, safety, and local tumor control. 
J Vasc Interv Radiol.2015;26(6):792-799.

25. Chen Y, Wu X, Zhou J, Zhang J, Huang J, Huang Y, et al. Thermal 
ablation assisted laparoscopic partial nephrectomy for clinical T1b 
renal tumors. Minim Invasive Ther Allied Technol.2022;31(2):179-184.

26. Atwell TD, Farrell MA, Leibovich BC, Callstrom MR, Chow GK, Blute 
ML, et al. Percutaneous renal cryoablation: experience treating 115 
tumors. J Urol.2008;179(6):2136-2140; discussion 40-1.

27. Breen DJ, Bryant TJ, Abbas A, Shepherd B, McGill N, Anderson JA, et 
al. Percutaneous cryoablation of renal tumours: outcomes from 171 
tumours in 147 patients. BJU Int.2013;112(6):758-765.

28. Acosta Ruiz V, Lonnemark M, Brekkan E, Dahlman P, Wernroth L, 
Magnusson A. Predictive factors for complete renal tumor ablation 
using RFA. Acta Radiol.2016;57(7):886-893.

29. Hinshaw JL , Lubner MG, Ziemlewic z TJ, Fred T. L ee J, 
Brace CL . Percutaneous tumor ablation tools: microwave, 
radiofrequency, or cryoablation–what should you use and why? 
RadioGraphics.2014;34(5):1344-1362.

30. Rosenberg MD, Kim CY, Tsivian M, Suberlak MN, Sopko DR, 
Polascik TJ, et al. Percutaneous cr yoablation of renal lesions 
with radiographic ice ball involvement of the renal sinus: analysis 
of hemorrhagic and collecting system complications. AJR Am J 
Roentgenol.2011;196(4):935-939.

31. Johnson DB, Saboorian MH, Duchene DA, Ogan K, Cadeddu JA. 
Nephrectomy after radiofrequency ablation-induced ureteropelvic 
junction obstruction: potential complication and long-term assessment 
of ablation adequacy. Urology.2003;62(2):351-352.

32. Johnson DB, Solomon SB, Su LM, Matsumoto ED, Kavoussi LR, 
Nakada SY, et al. Defining the complications of cryoablation and radio 
frequency ablation of small renal tumors: a multi-institutional review. 
J Urol.2004;172(3):874-877.

33. Warlick CA, Lima GC, Allaf ME, Varkarakis I, Permpongkosol S, 
Schaeffer EM, et al. Clinical sequelae of radiographic iceball 
involvement of collecting system during computed tomography-guided 
percutaneous renal tumor cryoablation. Urology.2006;67(5):918-922.

34. Schmit GD, Kurup AN, Weisbrod AJ, Thompson RH, Boorjian SA, Wass 
CT, et al. ABLATE: a renal ablation planning algorithm. AJR Am J 
Roentgenol.2014;202(4):894-903.

35. Tsivian M, Lyne JC, Mayes JM, Mouraviev V, Kimura M, Polascik TJ. 
Tumor size and endophytic growth pattern affect recurrence rates 
after laparoscopic renal cryoablation. Urology.2010;75(2):307-310.

36. Kutikov A , Uz zo RG. T he R.E.N. A .L. nephrometr y score: a 
comprehensive standardized system for quantitating renal tumor 
size, location and depth. J Urol.2009;182(3):844-853.

37. Gahan JC, Richter MD, Seideman CA, Trimmer C, Chan D, Weaver 
M, et al. The Performance of a modified RENAL nephrometr y 
score in predicting renal mass radiofrequency ablation success. 
Urology.2015;85(1):125-129.

38. Higgins LJ, Hong K. Renal Ablation Techniques: State of the Art. AJR 
Am J Roentgenol.2015;205(4):735-741.

39. Finley DS, Beck S, Box G, Chu W, Deane L, Vajgr t DJ, et al. 
Percutaneous and laparoscopic cryoablation of small renal masses.  
J Urol.2008;180(2):492-498; discussion 8.

40. Hui GC, Tuncali K, Tatli S, Morrison PR, Silverman SG. Comparison 
of percutaneous and surgical approaches to renal tumor ablation: 
metaanalysis of effectiveness and complication rates. J Vasc Interv 
Radiol.2008;19(9):1311-1320.

41. Acosta Ruiz V, Ladjevardi S, Brekkan E, Haggman M, Lonnemark M, 
Wernroth L, et al. Periprocedural outcome after laparoscopic partial 
nephrectomy versus radiofrequency ablation for T1 renal tumors: a 
modified R.E.N.A.L nephrometry score adjusted comparison. Acta 
Radiol.2019;60(2):260-268.

42. Ahmed M, Solbiati L, Brace CL, Breen DJ, Callstrom MR, Charboneau 
JW, et al. Image-guided tumor ablation: standardization of 
terminology and reporting criteria-a 10-year update. J Vasc Interv 
Radiol.2014;25(11):1691-1705 e4.

43. Krokidis ME, Orsi F, Katsanos K, Helmberger T, Adam A. CIRSE 
guidelines on percutaneous ablation of small renal cell carcinoma. 
Cardiovasc Intervent Radiol.2017;40(2):177-191.

44. Andersson M, Hashimi F, Lyrdal D, Lundstam S, Hellstrom M. Improved 
outcome with combined US/CT guidance as compared to US guidance 
in percutaneous radiofrequency ablation of small renal masses. Acta 
Radiol.2015;56(12):1519-1526.

45. Dai Y, Covarrubias D, Uppot R, Arellano RS. Image-guided 
percutaneous radiofrequency ablation of central renal cell 
carcinoma: assessment of clinical efficacy and safety in 31 tumors.  
J Vasc Interv Radiol.2017;28(12):1643-1650.

447SIUJ.ORG SIUJ  •  Volume 3, Number 6  •  November 2022

Ablative Therapies for Localized Primary Renal Cell Carcinoma

http://SIUJ.org


46. Zhong J, Bambrook J, Bhambra B, Smith J, Cartledge J, Ralph C, 
et al. Incidence of post-ablation syndrome following image-guided 
percutaneous cryoablation of renal cell carcinoma: a prospective 
study. Cardiovasc Intervent Radiol.2018;41(2):270-276.

47. Atwell TD, Carter RE, Schmit GD, Carr CM, Boorjian SA, Curry TB, et 
al. Complications following 573 percutaneous renal radiofrequency 
and cryoablation procedures. J Vasc Interv Radiol.2012;23(1):48-54.

48. Georgiades CS, Rodriguez R. Efficacy and safety of percutaneous 
cr yoablation for stage 1A /B renal cell carcinoma: results of a 
prospective, single-arm, 5-year study. Cardiovasc Intervent Radiol. 
2014;37(6):1494-1499.

49. Crawford D, vanSonnenberg E, Kang P. Infectious outcomes from renal 
tumor ablation: prophylactic antibiotics or not? Cardiovasc Intervent 
Radiol.2018;41(10):1573-1578.

50. Pierorazio PM, Johnson MH, Patel HD, Sozio SM, Sharma R, Iyoha 
E, et al. Management of renal masses and localized renal cancer: 
systematic review and meta-analysis. J Urol.2016;196(4):989-999.

51. Castle SM, Gorbatiy V, Avallone MA, Eldefrawy A, Caulton DE, 
Leveillee RJ. Cost comparison of nephron-sparing treatments for cT1a 
renal masses. Urologic Oncology: Seminars and Original Investigations. 
2013;31(7):1327-1332.

52. Larcher A, Sun M, Dell’Oglio P, Trudeau V, Boehm K, Schiffmann J, 
et al. Mortality, morbidity and healthcare expenditures after local 
tumour ablation or partial nephrectomy for T1A kidney cancer. Eur J 
Surg Oncol.2017;43(4):815-822.

53. Wang Y, Chen Y W, Leow JJ, Levy AC, Chang SL, Gelpi FH. Cost-
effectiveness of management options for small renal mass: a 
systematic review. Am J Clin Oncol.2016;39(5):484-490.

54. Pandharipande PV, Gervais DA, Mueller PR, Hur C, Gazelle GS. 
Radiofrequency ablation versus nephron-sparing surger y for 
small unilateral renal cell carcinoma: cost-effectiveness analysis. 
Radiology.2008;248(1):169-178.

55. Ning S, Trisler K, Wessels BW, Knox SJ. Radiobiologic studies of 
radioimmunotherapy and external beam radiotherapy in vitro and in 
vivo in human renal cell carcinoma xenografts. Cancer. 1997;80(12 
Suppl):2519-2528.

56. Walsh L, Stanfield JL, Cho LC, Chang CH, Forster K, Kabbani W, 
et al. Efficacy of ablative high-dose-per-fraction radiation for 
implanted human renal cell cancer in a nude mouse model. Eur 
Urol.2006;50(4):795-800; discussion

57. Kothari G, Foroudi F, Gill S, Corcoran NM, Siva S. Outcomes of 
stereotactic radiotherapy for cranial and extracranial metastatic renal 
cell carcinoma: a systematic review. Acta Oncol.2015;54(2):148-157.

58. Svedman C, Karlsson K, Rutkowska E, Sandström P, Blomgren H, Lax 
I, et al. Stereotactic body radiotherapy of primary and metastatic 
renal lesions for patients with only one functioning kidney. Acta 
Oncol.2008;47(8):1578-1583.

59. Chang JH, Cheung P, Erler D, Sonier M, Korol R, Chu W. Stereotactic 
ablative body radiotherapy for primar y renal cell carcinoma in 
non-surgical candidates: initial clinical experience. Clin Oncol (R Coll 
Radiol).2016;28(9):e109-114.

60. Lo CH, Huang W Y, Chao HL, Lin KT, Jen YM. Novel application of 
stereotactic ablative radiotherapy using CyberKnife® for early-stage 
renal cell carcinoma in patients with pre-existing chronic kidney 
disease: Initial clinical experiences. Oncol Lett.2014;8(1):355-360.

61. Siva S, Pham D, Kron T, Bressel M, Lam J, Tan TH, et al. Stereotactic 
ablative body radiotherapy for inoperable primary kidney cancer: a 
prospective clinical trial. BJU Int.2017;120(5):623-630.

62. Staehler M, Bader M, Schlenker B, Casuscelli J, Karl A, Roosen A, 
et al. Single fraction radiosurgery for the treatment of renal tumors.  
J Urol.2015;193(3):771-775.

63. Svedman C, Sandström P, Pisa P, Blomgren H, Lax I, Kälkner KM, 
et al. A prospective phase II trial of using extracranial stereotactic 
radiotherapy in primary and metastatic renal cell carcinoma. Acta 
Oncol.2006;45(7):870-875.

64. Pham D, Thompson A, Kron T, Foroudi F, Kolsky MS, Devereux T, et al. 
Stereotactic ablative body radiation therapy for primary kidney cancer: 
a 3-dimensional conformal technique associated with low rates of 
early toxicity. Int J Radiat Oncol Biol Phys.2014;90(5):1061-1068.

65. Ponsky L, Lo SS, Zhang Y, Schluchter M, Liu Y, Patel R, et al. Phase I 
dose-escalation study of stereotactic body radiotherapy (SBRT) for 
poor surgical candidates with localized renal cell carcinoma. Radiother 
Oncol.2015;117(1):183-187.

66. Sun MR, Brook A, Powell MF, Kaliannan K, Wagner A A, Kaplan 
ID, et al. Effect of Stereotactic Body Radiotherapy on the Growth 
Kinetics and Enhancement Pattern of Primary Renal Tumors. AJR Am 
J Roentgenol.2016;206(3):544-553.

67. Kaidar-Person O, Price A, Schreiber E, Zagar TM, Chen RC. Stereotactic 
body radiotherapy for large primar y renal cell carcinoma. Clin 
Genitourin Cancer.2017;15(5):e851-e854.

68. Grubb WR, Ponsky L, Lo SS, Kharouta M, Traughber B, Sandstrom K, 
et al. Final results of a dose escalation protocol of stereotactic body 
radiotherapy for poor surgical candidates with localized renal cell 
carcinoma. Radiother Oncol.2021;155:138-143.

69. Tetar SU, Bohoudi O, Senan S, Palacios MA, Oei SS, Wel AMV, et al. 
The role of daily adaptive stereotactic mr-guided radiotherapy for renal 
cell cancer. Cancers (Basel).2020;12(10).

70. Siva S, Correa RJM, Warner A, Staehler M, Ellis RJ, Ponsky L, 
et al. Stereotactic ablative radiotherapy for ≥t1b primary renal 
cell carcinoma: a repor t from the International Radiosurger y 
Oncology Consortium for Kidney (IROCK). Int J Radiat Oncol Biol 
Phys.2020;108(4):941-949.

448 SIUJ  •  Volume 3, Number 6  •  November 2022 SIUJ.ORG

2022 WUOF/SIU INTERNATIONAL CONSULTATION ON UROLOGICAL DISEASES

http://SIUJ.org


71. Grelier L, Baboudjian M, Gondran-Tellier B, Couderc AL, McManus 
R, Deville JL, et al. Stereotactic Body radiotherapy for frail patients 
with primary renal cell carcinoma: preliminary results after 4 years of 
experience. Cancers (Basel).2021;13(13).

72. Senger C, Conti A, Kluge A, Pasemann D, Kufeld M, Acker G, et al. 
Robotic stereotactic ablative radiotherapy for renal cell carcinoma in 
patients with impaired renal function. BMC Urol.2019;19(1):96.

73. Nomiya T, Tsuji H, Hirasawa N, Kato H, Kamada T, Mizoe J, et al. 
Carbon ion radiation therapy for primary renal cell carcinoma: initial 
clinical experience. Int J Radiat Oncol Biol Phys.2008;72(3):828-833.

74. Swaminath A, Cheung P, Glicksman RM, Donovan EK, Niglas M, 
Vesprini D, et al. Patient-reported quality of life following stereotactic 
body radiation therapy for primary kidney cancer - results from a 
prospective cohort study. Clin Oncol (R Coll Radiol).2021;33(7):468-475.

75. Correa RJM, Louie AV, Staehler M, Warner A, Gandhidasan S, Ponsky 
L, et al. Stereotactic radiotherapy as a treatment option for renal 
tumors in the solitary kidney: a multicenter analysis from the IROCK. 
J Urol.2019;201(6):1097-1104.

76. Siva S, Pham D, Gill S, Bressel M, Dang K, Devereux T, et al. An analysis 
of respiratory induced kidney motion on four-dimensional computed 
tomography and its implications for stereotactic kidney radiotherapy. 
Radiat Oncol.2013;8:248.

77. Wilke L, Andratschke N, Blanck O, Brunner TB, Combs SE, Grosu 
AL, et al. ICRU report 91 on prescribing, recording, and reporting of 
stereotactic treatments with small photon beams : statement from 
the DEGRO/DGMP working group stereotactic radiotherapy and 
radiosurgery. Strahlenther Onkol.2019;195(3):193-198.

78. Siva S, Ellis RJ, Ponsky L, Teh BS, Mahadevan A, Muacevic A, et al. 
Consensus statement from the International Radiosurgery Oncology 
Consortium for Kidney for primary renal cell carcinoma. Future 
Oncol.2016;12(5):637-645.

79. Siva S, Louie AV, Warner A, Muacevic A, Gandhidasan S, Ponsky L, et 
al. Pooled analysis of stereotactic ablative radiotherapy for primary 
renal cell carcinoma: a report from the International Radiosurgery 
Oncology Consortium for Kidney (IROCK). Cancer.2018;124(5):934-942.

80. Correa RJM, Louie AV, Zaorsky NG, Lehrer EJ, Ellis R, Ponsky L, et al. 
The emerging role of stereotactic ablative radiotherapy for primary 
renal cell carcinoma: a systematic review and meta-analysis. Eur Urol 
Focus.2019;5(6):958-969.

81. Kaplan I, Redrosa I, Martin C, Collins C, Wagner A. Results of a phase 
I dose escalation study of stereotactic radiosurgery for primary renal 
tumors. Int J Radiat Oncol Biol Phys.2010;78(3):S191.

82. McBride S, Wagner A, Kaplan I. A phase 1 dose-escalation study of 
robotic radiosurgery in inoperable primary renal cell carcinoma. Int J 
Radiat Oncol Biol Phys.2013;87(2):S84.

83. Siva S, Chesson B, Bressel M, Pryor D, Higgs B, Reynolds HM, et 
al. TROG 15.03 phase II clinical trial of Focal Ablative STereotactic 
Radiosurger y for Cancers of the Kidney-FASTR ACK II. BMC 
cancer.2018;18(1):1-10.

84. Reynolds HM, Parameswaran BK, Finnegan ME, Roettger D, Lau E, 
Kron T, et al. Diffusion weighted and dynamic contrast enhanced MRI 
as an imaging biomarker for stereotactic ablative body radiotherapy 
(SABR) of primary renal cell carcinoma. PLoS One.2018;13(8):e0202387.

85. Blitzer GC, Wojcieszynski A, Abel EJ, Best S, Lee FT, Jr., Hinshaw JL, et 
al. Combining stereotactic body radiotherapy and microwave ablation 
appears safe and feasible for renal cell carcinoma in an early series. 
Clin Genitourin Cancer.2021;19(5):e313-e318.

86. Chow J, Hoffend NC, Abrams SI, Schwaab T, Singh AK, Muhitch 
JB. Radiation induces dynamic changes to the T cell repertoire 
in renal cell carcinoma patients. Proc Natl Acad Sci U S A. 
2020;117(38):23721-23729.

87. Chu KF, Dupuy DE. Thermal ablation of tumours: biological mechanisms 
and advances in therapy. Nat Rev Cancer.2014;14(3):199-208.

88. Yu J, Wang H, Cheng ZG, Liu FY, Li QY, He GZ, et al. A multicenter 
10-year oncologic outcome of ultrasound-guided percutaneous 
microwave ablation of clinical T1 renal cell carcinoma: will it stand 
the test of time? Eur Radiol.2021.

449SIUJ.ORG SIUJ  •  Volume 3, Number 6  •  November 2022

Ablative Therapies for Localized Primary Renal Cell Carcinoma

http://SIUJ.org

