BlueCross and BlueShield of Montana Medical Policy/Codes
Radiofrequency Ablation (RFA) and Cryoablation of Renal Cell Carcinoma (RCC)
Chapter: Surgery: Procedures
Current Effective Date: November 26, 2013
Original Effective Date: November 26, 2013
Publish Date: November 26, 2013
Description

Radiofrequency ablation (RFA) and cryoablation are two minimally invasive methods for treatment of localized renal cell carcinoma (RCC).  These ablative techniques cause cell death by coagulative necrosis.  The goal is to ablate the same amount of diseased renal tissue that would be removed if conventional surgical excision of the tumor were performed.  Both methods are being actively investigated as a treatment option for selected patients. 

Radiofrequency Ablation

In RFA, a probe is inserted into the center of a tumor and the non-insulated electrodes, which are shaped like prongs, are projected into the tumor, using image guidance; heat is then generated locally by a high-frequency, alternating current that flows from the electrodes.  The local heat treats the tissue adjacent to the probe, resulting in a 3 cm to 5.5 cm sphere of dead tissue.  The cells killed by RFA are not removed but are gradually replaced by fibrosis and scar tissue.  If there is local recurrence, it occurs at the edge and, in some cases, may be retreated.  The procedure may be performed safely on an outpatient basis with local anesthetic and conscious sedation, although more complex cases may require general anesthesia and overnight observation. 

RFA is being evaluated to treat various tumors, including inoperable tumors, or to treat patients ineligible for surgery due to age, presence of comorbidities, or poor general health.  Goals of RFA may include: 1) controlling local tumor growth and preventing recurrence; 2) palliating symptoms; or 3) extending survival duration for patients with certain tumors.  The effective volume of RFA depends on the frequency and duration of applied current, local tissue characteristics, and probe configuration (e.g., single vs. multiple tips).  RFA can be performed as an open surgical procedure, laparoscopically, or percutaneously with ultrasound (US) or computed tomography (CT) guidance. 

Potential complications associated with RFA include those caused by heat damage to normal tissue adjacent to the tumor, structural damage along the probe track, or secondary tumors if cells seed during probe removal.

RFA is being investigated as an alternative to surgery for operable tumors.  Well-established local or systemic treatment alternatives are available for each of these malignancies.  The hypothesized advantages of RFA for these cancers include improved local control as well as those common to any minimally invasive procedure (e.g., preserving normal organ tissue, decreasing morbidity, decreasing length of hospitalization).

Radical nephrectomy remains the principal treatment of RCC, however partial nephrectomy or nephron-sparing surgery has been shown to be as effective as radical nephrectomy, with comparable long term recurrence-free survival rates, in a select group of patients.  Alternative therapy such as RFA is of interest in patients with small renal tumors when preservation of renal function is necessary (e.g., in patients with marginal renal function, a solitary kidney, bilateral tumors), and in patients with comorbidities that would render them unfit for surgery.  Another consideration would be in patients at high risk of developing additional renal cancers (as in von Hippel-Lindau disease).

Cryoablation

In cryoablation, a cryoprobe is inserted into the kidney tumor and the targeted diseased renal tissue is rapidly frozen in place (in situ) with a surrounding margin of healthy renal tissue.  The freezing process causes those cells to rupture and die.  The devitalized tissue is then allowed to slough off over time, with new tissue forming in its place.  The basic process of cryosurgery includes rapid freezing, slow thawing, and repetition of the freeze-thaw cycle.

Localized RCC is treated by radical nephrectomy or nephron-sparing surgery.  Prognosis drops precipitously if the tumor extends outside the kidney capsule, since chemotherapy is relatively ineffective against metastatic RCC.  Cryoablation is felt to be appropriate in cases where the patient is a poor surgical candidate, or has multiple comorbid illnesses, a solitary kidney, renal insufficiency, and/or unresectable tumors.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Radiofrequency ablation (RFA) or cryoablation of renal cell carcinoma (open, percutaneous or laparoscopic) may be considered medically necessary only when determined to be indicated by the treating physician for:

  • palliative treatment of medically or surgically inoperable tumor(s); or
  • patients for whom preservation of kidney function is necessary (i.e., the patient has one kidney or renal insufficiency defined by a glomerular filtration rate [GFR] of less than 60 mL/min per m2) and standard surgical approach (i.e., resection of renal tissue) is likely to substantially worsen kidney function; or
  • patients who have failed, or are a poor candidate for, standard treatment such as surgical intervention, radiation, chemotherapy, or opioids.

For all situations that do not meet the above criteria, radiofrequency ablation (RFA) or cryoablation of renal cell carcinoma (open, percutaneous or laparoscopic) is considered experimental, investigational and unproven.

Rationale

Radiofrequency Ablation

The outcomes of radiofrequency ablation (RFA) procedures in more than 550 patients with a total of nearly 700 lesions have been described in 21 uncontrolled studies.  The characteristics of the patients and RFA procedures varied widely within and across the studies in terms of tumor type (e.g., exophytic, parenchymal, central, with or without history of von Hipple-Lindau disease), tumor size (from less than 1 cm to over 8 cm), length of follow-up (from less than one month to 48 months), imaging modality used for guidance, and reason for using RFA.  Overall, 88%–100% of procedures were considered successful shortly after one or two ablations (i.e., no signs of residual tumor by histologic analysis after excision or by post-RFA radiologic imaging).  Significant but nonfatal complications were reported in 8%–13% of patients in seven studies, including perinephric hematomas, hemorrhage, and ureteral strictures.

In general, available data were inadequate or lacked appropriate statistical analyses to estimate duration of survival or quality of life.  Follow-up duration in most studies was insufficient to determine recurrence rates after RFA from viable tumor cells remaining in situ at ablation sites.  A particular concern with the available data is that patient selection criteria and rationale for using RFA were not well described or did not provide a compelling argument to use the technique in lieu of potentially curative surgical resection or extirpation.  In total, the available evidence was insufficient to permit conclusions on net health outcomes of RFA for renal cancers.

Additional information is available in recent review articles.

2010 Update

Stern and colleagues retrospectively compared patients with stage T1a renal tumors, confirmed by pathology to be renal cell carcinoma (RCC), treated with either partial nephrectomy (n=34) or RFA (n=34).  The mean follow-up for the partial nephrectomy group was 47 months (range: 24–93) and for the RFA group 30 months (range: 18–42).  Three-year recurrence-free survival rate was 95.2% for partial nephrectomy and 91.4% for RFA (p=0.58).  There were no disease-specific deaths in either group.  In this small study, intermediate outcomes for patients with T1a RCCs were similar whether treated with partial nephrectomy or RFA.

A review article summarizes the literature from the last five years, which includes 713 patients who underwent RFA of 866 renal tumors with an average follow-up of 12.6 months.  The average tumor-free survival rate was 85.4%.  The author notes that across different study reports there are significant variations in the practice of RFA for kidney tumors—including the types of devices used, imaging modality and performance experience—making it difficult to compare results across studies.  Additionally, the article points out that the longest average follow-up of published studies of RFA and kidney tumors is 28 months, and that long-term follow-up data are necessary to validate the use of this technique.

Kunkle and Uzzo conducted a comparative meta-analysis evaluating cryoablation and RFA as primary treatment for small renal masses.  Forty-seven case series representing 1375 renal tumors were analyzed.  Of 600 lesions treated with cryoablation, 494 were biopsied before treatment vs. 482 of 775 treated with RFA.  The incidence of RCC with known pathology was 71.7% in the cryoablation group and 90% in the RFA group.  The mean duration of follow-up after RFA was 15.8 months.  Local tumor progression was reported in 31 of 600 lesions after cryoablation and in 100 of 775 lesions after RFA, a difference that was significant (p<0.0001).  Progression to metastatic disease was described in 6 of 600 lesions after cryoablation vs. 19 of 775 after RFA (p=0.06).  The authors caution that minimally invasive ablation generally has been performed selectively on older patients with smaller tumors, possibly resulting in selection bias; series of ablated lesions tend to have shorter post-treatment follow-up compared with tumors managed by surgical excision or active surveillance; and treatment efficacy may be overestimated in series that include tumors with unknown pathology.

In summary, based on the scientific data (large numbers of patients treated with follow-up) and the clinical guidelines discussed below, RFA of small renal cancers may be considered medically necessary in those patients who are not surgical candidates due to comorbid conditions or who have baseline renal insufficiency such that standard surgical procedures would impair their kidney function.

The  National Comprehensive Cancer Network (NCCN) 2010 Guidelines have added the statement that ”emerging energy ablative techniques (e.g., cryosurgery or RFA) are currently considered an option by some experts for selected small tumors although a rigorous comparison with surgical resection (i.e., total or partial nephrectomy by open or laparoscopic techniques) has not been done.”

In the National Cancer Institute Clinical Trials Database (PDQ®), one ongoing Phase II/III trial is identified that compares surgery and RFA for the treatment of renal tumors (NCT00221728).  The study design is open label and randomized with expected enrollment of 180 patients from nine centers.  Patients are eligible if they have a kidney tumor smaller than 4 cm, confined to the kidney (T1a).  Principal outcome is five-year efficacy measured as no residual tumor and no recurrence at the site of treatment.  The estimated study completion date is April 2011.

National Institute for Clinical Excellence (NICE) issued a Guidance in 2004 in which they indicate that “limited evidence suggests that percutaneous radiofrequency ablation (RFA) of renal cancer brings about reduction of tumour bulk and that the procedure is adequately safe.  However, the evidence of its effect on symptom control and survival is not yet adequate to support the use of this procedure without special arrangements for consent and for audit or research” and that ”the procedure should normally be limited to patients who are unsuitable for surgery”.

2012 Update

In 2010, Salas and colleagues reviewed 17 studies identified from literature published between 2003 and 2009.  The authors found RFA has proven to demonstrate oncologic outcomes that are almost equivalent to surgical resection when treating renal tumors with a mean size less than 4.0 cm.  Renal function also declines minimally and is significantly lower than surgical resection.  Van Poppel et al. also conducted a review of the literature published between 2004 and May 2011.  In this review, the authors concluded RFA is a reasonable treatment option for most low-grade renal tumors less than 4 cm in patients who are not candidates for surgical resection or active surveillance.  The authors noted the need for long-term prospective studies to compare ablative techniques for renal ablation, such as RFA versus cryoablation.

Based on the scientific data (large numbers of patients treated with follow-up), RFA of small (i.e., 4 cm or less) renal cancers may be considered medically necessary in those patients who are not surgical candidates due to comorbid conditions or who have baseline renal insufficiency such that standard surgical procedures would impair their kidney function.  In addition, updated 2012 NCCN guidelines indicate RFA is a thermal ablation option for the treatment of kidney cancer in select patients such as elderly patients and others with competing health risks.

Cryoablation

In a 2010 Cochrane review, Nabi and colleagues review the evidence on the management of localized RCC.  No randomized trials comparing cryoablation to open radical or partial nephrectomy were identified.  One nonrandomized study compared laparoscopic partial nephrectomy with laparoscopic cryoablation using a matched paired-analysis (O’Malley et al.) and three retrospective studies.  The review notes percutaneous cryoablation can successfully destroy small RCC and may be considered a treatment option in patients with serious comorbidities that pose surgical risks.  The review concluded that high quality, randomized controlled trials (RCTs) are required in the management of localized RCC and that one area of emphasis should be the role of renal surgery compared to minimally invasive techniques for small tumors (<4 cm).

Long et al. reported on a 2011 systematic review comparing percutaneous cryoablation to surgical cryoablation of small renal masses.  A total of 42 studies treating small renal masses (pooled total of 1,447 lesions) were reviewed including 28 articles on surgical cryoablation and 14 articles on percutaneous cryoablation.  The authors concluded percutaneous and surgical cryoablation for small renal masses have similar, acceptable short-term oncologic outcomes, and each technique is relatively equivalent.  Long-term data are needed to ultimately compare ablation techniques to the gold standard of partial or radical nephrectomy.

Kunkle and Uzzo conducted a comparative meta-analysis evaluating cryoablation and RFA as primary treatment for small renal masses.  Forty-seven case series representing 1,375 renal tumors were analyzed.  Of 600 lesions treated with cryoablation, 494 were biopsied before treatment versus 482 of 775 treated with RFA.  The incidence of RCC with known pathology was 72% in the cryoablation group and 90% in the RFA group.  The mean duration of follow-up after cryoablation was 22.5 months.  Most studies used contrast enhanced imaging to determine treatment effect.  Local tumor progression was reported in 31 of 600 (5%) lesions after cryoablation and in 100 of 775 (13%) lesions after RFA.  Progression to metastatic disease was described in 6 of 600 (1%) lesions after cryoablation versus 19 of 775 (2.5%) after RFA.  The authors caution that minimally invasive ablation generally has been performed selectively on older patients with smaller tumors, possibly resulting in selection bias; series of ablated lesions tend to have shorter post-treatment follow-up compared with tumors managed by surgical excision or active surveillance; and treatment efficacy may be overestimated in series that include tumors with unknown pathology.

A number of studies reported intermediate term outcomes for cryoablation with RCC.  Weld and colleagues reported on three-year follow-up of 36 renal tumors (22 were malignant) treated with laparoscopic cryoablation.  In this series, the three-year cancer-specific survival rate was 100%, and no patient developed metastatic disease.  The authors concluded that these intermediate-term data seemed equivalent to results obtained with extirpative therapy.  Hegarty and co-workers reported results on 164 laparoscopic cryoablations and 82 percutaneous RFAs for localized renal tumors.  Mean tumor size was 2.5 cm.  Cancer-specific survival following cryotherapy was 98% at a median follow-up of three years and 100% for RFA at just one year median follow-up.  The authors noted that cryoablation and RFA are developmental nephron-sparing options and that early results are encouraging in terms of early oncologic control, preservation of renal function, and low complication rates.  Studies are also reporting results with small numbers of patients comparing laparoscopic cryoablation with laparoscopic partial nephrectomy for treatment of renal masses (O’Malley et al.).

Matin and Ahrar reviewed studies of cryoablation and RFA with at least 12-month follow-up and found that recently published three- and five-year outcomes show 93–98% cancer-specific survival in small cohorts.  They caution that, while studies suggest satisfactory outcomes, given the limitations of imaging and the indolent nature of the tumors, stringent selection criteria and rigorous follow-up is required.

Strom and colleagues reported on a retrospective comparison of 145 patients who underwent laparoscopic (n=84) or percutaneous (n=61) cryoablation of small renal masses at five academic medical centers in the United States.  These patients were offered cryoablation because they were considered to be at higher risk for complications from partial nephrectomy or were not surgical candidates due to comorbidities.  Mean tumor size was 2.7 cm in the laparoscopic group versus 2.5 cm in the percutaneous group.  Patients were followed for a longer period of time in the laparoscopic group (mean of 42.3 + 21.2 months) compared to the percutaneous group (31.0 + 15.9 months [P=0.008]).  Complications in both treatment groups were similar and did not occur with any significant difference in frequency.  At a mean intermediate follow-up of 37.6 months, local tumor recurrence was significantly more frequent in the percutaneous group at 16.4% (10/61) compared to 5.9% (5/84) in the laparoscopic group.  However, disease-free survival and overall survival were not significantly different at last follow-up in the laparoscopic group compared to the percutaneous group (91.7% and 89.3% vs. 93.7% and 88.9%, respectively).

In a prospective, single institution study, Rodriguez et al. reported on 113 patients consecutively treated with percutaneous cryoablation for 117 renal lesions.  The average size of renal lesions in the study was 2.7 + 2.4 cm (83 or 71% were RCC).  Patients were selected for cryoablation over surgery when tumors were equal to or less than 4 cm and percutaneously approachable or if the patient could not tolerate surgery when tumors were greater than 4–7 cm.  Technical success was reported to be 100% with 93% of patients having no complications or only mild complications.  At a median follow-up of two years with 59 patients, efficacy was 98.3% and 92.3% at three years with 13 patients.  Metastatic disease did not occur in any of the patients during the follow-up period, and cancer specific survival was 100%.

Nguyen et al. evaluated options for salvage of ipsilateral tumor recurrence after previous ablation.  Recurrence rates at their center were 13 of 175 (7%) after cryoablation and 26 of 104 (25%) after RFA.  Extensive perinephric scarring was encountered in all salvage operations following cryoablation, and the authors conclude that cryoablation in particular can lead to extensive perinephric fibrosis, which can complicate attempts at salvage.

An online search of ClinicalTrials.gov in February 2012 found no randomized controlled trials.  NCT01117779, Tracking Renal Tumors After Cryoablation Evaluation (TRACE) Registry is an observational, open-label, single-arm, multi-center registry of subjects who have undergone renal lesion cryoablation per their physician's standard of care.  This registry is currently accepting participants.  Subjects will be observed for five years from the date of their cryoablation procedure.  Several other trials are currently accepting participants.

The 2009 guidelines from the American Urological Association on stage one renal masses indicate percutaneous or laparoscopic cryoablation “is an available treatment option for the patient at high surgical risk who wants active treatment and accepts the need for long-term radiographic surveillance after treatment.  The guidelines also indicate cryoablation “should be discussed as a less-invasive treatment option” in healthy patients with a renal mass equal to or less than 4.0 cm and clinical stage T1a.  Patients should be informed that “local tumor recurrence is more likely than with surgical excision, measures of success are not well defined, and surgical salvage may be difficult.”  These recommendations are based on review of the data and “appreciable” majority consensus.

The National Comprehensive Cancer Network (NCCN) practice guidelines for kidney cancer state that based on lower level evidence and uniform NCCN consensus, cryosurgery “can be considered for patients with clinical stage T1 renal lesions who are not surgical candidates.  Biopsy of small lesions may be considered to obtain or confirm a diagnosis of malignancy and guide surveillance, cryosurgery … [and] ablation strategies.”  The NCCN guidelines also note “rigorous comparison with surgical resection (i.e., total or partial nephrectomy by open or laparoscopic techniques) has not been done and [t]hermal ablative techniques are associated with a higher local recurrence rate than conventional surgery.”

Summary

The literature on the use of cryosurgical ablation of RCC tumors consists primarily of reports of single-center case series; however, evidence is accumulating that cryoablation provides short-term tumor control and perhaps survival benefit for carefully selected patients with small RCCs, including for palliative treatment of inoperable tumor(s); cases where preservation of kidney function is critical; or patients who have failed, or are a poor candidate for, standard treatment such as surgical intervention, radiation, chemotherapy, or opioids.

Coding

Disclaimer for coding information on Medical Policies           

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

55.32, 55.33, 55.34, 55.35, 55.39, 189.0, 189.1, 189.8, 189.9, 198.0

ICD-10 Codes

C64.1, C64.2, C64.9, C68.8, C68.9, C79.00, C79.01, C79.02

Procedural Codes: 50250, 50541, 50542, 50592, 50593, 76940, 77013
References

Radiofrequency Ablation

  1. Pavlovich, C.P., Walther, M.M., et al.  Percutaneous radiofrequency ablation of small renal tumors: initial results.  Journal of Urology (2002 January) 167(1):10-16.
  2. Rendon, R.A., Kachura, J.R., et al.  The uncertainty of radio frequency treatment of renal cell carcinoma: findings at immediate and delayed nephrectomy.  Journal of Urology (2002 April) 167(4): 1587-92.
  3. Farrell, M.A., Charboneau, W.J., et al.  Image-guided radiofrequency ablation of solid renal tumors.  American Journal of Roentgenology (2003) 180(6):1509-13.
  4. Gervais, D.A., McGovern, F.J., et al.  Renal cell carcinoma: clinical experience and technical success with radio-frequency ablation of 42 tumors. Radiology (2003) 226(2):417-24.
  5. Mayo-Smith, W.W., Dupuy, D.E., et al.  Imaging-guided percutaneous radiofrequency ablation of solid renal masses: techniques and outcomes of 38 treatment sessions in 32 consecutive patients.  American Journal of Roentgenology (2003) 180(6):1503-8.
  6. Su, L.M., Jarrett, T.W., et al.  Percutaneous computed tomography-guided radiofrequency ablation of renal masses in high surgical risk patients: preliminary results.  Urology (2003) 61(4 supplement 1):26-33.
  7. Hwang, J.J., Walther, M.M., et al.  Radio frequency ablation of small renal tumors: intermediate results.  Journal of Urology (2004) 171(5):1814-8.
  8. Lewin, J.S., Nour, S.G., et al.  Phase II clinical trial of interactive MR imaging-guided interstitial radiofrequency thermal ablation of primary kidney tumors: initial experience.  Radiology (2004) 232(3):835-45.
  9. Matsumoto, E.D., Watumull, L., et al.  The radiographic evolution of radio frequency ablated renal tumors.  Journal of Urology (2004) 172(1):45-8.
  10. Veltri, A., De Fazio, G., et al.  Percutaneous US-guided RF thermal ablation for malignant renal tumors: preliminary results in 13 patients.  European Radiology (2004) 14(12):2303-10.
  11. Zagoria, R.J., Hawkins, A.D., et al.  Percutaneous CT-guided radiofrequency ablation of renal neoplasms: factors influencing success.  American Journal of Roentgenology (2004) 183(1):201-7.
  12. Gervais, D.A., McGovern, F.J, et al.  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.  American Journal of Roentgenology (2005 July 6) 185:64-71.
  13. Ahrar, K., Matin, S., et al.  Percutaneous radiofrequency ablation of renal tumors: technique, complications, and outcomes.  Journal of Vascular Interventional Radiology (2005) 16(5):679-88
  14. Boss, A., Clasen, S., et al.  Magnetic resonance-guided percutaneous radiofrequency ablation of renal cell carcinomas: a pilot clinical study.  Investigative Radiology (2005) 40(9):583-90.
  15. Chiou, Y.Y., Hwang, J.I., et al.  Percutaneous radiofrequency ablation of renal cell carcinoma.  Journal of the Chinese Medical Association (2005) 68(5):221-5.
  16. Mahnken, A.H., Rohde, D., et al.  Percutaneous radiofrequency ablation of renal cell carcinoma: preliminary results. Acta Radiologica (2005) 46(2):208-14.
  17. Matsumoto, E.D., Johnson, D.B., et al.  Short-term efficacy of temperature-based radiofrequency ablation of small renal tumors. Urology (2005) 65(5):877-81.
  18. McDougal, W.S., Gervais, D.A., et al.  Long-term followup of patients with renal cell carcinoma treated with radio frequency ablation with curative intent.  Journal of Urology (2005) 174(1):61-3.
  19. Merkle, E.M., Nour, S.G., et al.  MR imaging follow-up after percutaneous radiofrequency ablation of renal cell carcinoma: findings in 18 patients during first 6 months.  Radiology (2005) 235(3):1065-71.
  20. Varkarakis, I.M., Allaf, M.E., et al.  Percutaneous radio frequency ablation of renal masses: results at a 2-year mean followup.  Journal of Urology (2005) 174(2):456-60.
  21. Weizer, A.Z., Raj, G.V., et al.  Complications after percutaneous radiofrequency ablation of renal tumors.  Urology (2005) 66(6):1176-80.
  22. Rosenthal DI. Radiofrequency treatment. Orthop Clin North Am 2006; 37(3):475-84, viii.
  23. Stern JM, Svatek R, Park S et al. Intermediate comparison of partial nephrectomy and radiofrequency ablation for clinical T1a renal tumors. BJU Int 2007; 100(2):287-90.
  24. Aron M, Gill IS. Minimally invasive nephron-sparing surgery (MINSS) for renal tumours. Part II: probe ablative therapy. Eur Urol 2007; 51(2):348-57.
  25. Mouraviev V, Joniau S, Van Poppel H et al. Current status of minimally invasive ablative techniques in the treatment of small renal tumours. Eur Urol 2007; 51(2):328-36.
  26. Kunkle DA, Uzzo RG. Cryoablation or radiofrequency ablation of the small renal mass. Cancer 2008; 113(10):2671-80.
  27. Abdellaoui A, Watkinson AF. Radiofrequency ablation of renal tumors. Future Oncol 2008; 4(1):103-11.
  28. Salas N, Ramanathan R, Dummett S et al. Results of radiofrequency kidney tumor ablation: renal function preservation and oncologic efficacy. World J Urol 2010; 28(5):583-91.
  29. Van Poppel H, Becker F, Cadeddu JA et al. Treatment of localised renal cell carcinoma. Eur Urol 2011; 60(4):662-72.
  30. Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors.  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2012 October) Surgery 7.01.95.
  31. Kidney Cancer. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. V.2.2012; Available online at http://www.nccn.org (Last accessed February 2012).
  32. National Institute for Clinical Excellence (NICE). Percutaneous radiofrequency ablation of renal cancer. (2004 September) Available online at http://www.nice.org.uk (Accessed February 2012).

Cryoablation

  1. Gill, I.S., Novick, A.C., et al.  Laparoscopic renal cryoablation: initial clinical series. Urology (1998) 52(4):543-51.
  2. Gill, I.S., Novick, A.C., et al.  Laparoscopic renal cryoablation in 32 patients. Urology (2000) 56(5):748-53.
  3. Rukstalis, D.B., Khorsandi, M., et al.  Clinical experience with open renal cryoablation. Urology (2001) 57(1):34-9.
  4. Nadler, R.B., Kim, S.C., et al.  Laparoscopic renal cyrosurgery: the Northwestern experience.  Journal Urology (2003) 170(4 pt 1):1121-5.
  5. Shingleton, W.B., and P.E. Sewell.  Cryoablation of renal tumours in patients with solitary kidneys.  British Journal of Urology International (2003) 92(3):237-9.
  6. Hegarty NJ, Gill IS, Desai MM et al. Probe-ablative nephron-sparing surgery: cryoablation versus radiofrequency ablation. Urology 2006; 68(1 suppl):7-13.
  7. Weld KJ, Figenshau RS, Venkatesh R et al. Laparoscopic cryoablation for small renal masses: three-year follow-up. Urology 2007; 69(3):448-51.
  8. O’Malley RL, Berger AD, Kanofsky JA et al. A matched-cohort comparison of laparoscopic cryoablation and laparoscopic partial nephrectomy for treating renal masses. BJU Int 2007; 99(2):395-8.
  9. Kunkle DA, Uzzo RG. Cryoablation or radiofrequency ablation of the small renal mass: a meta-analysis. Cancer 2008; 113(10):2671-80.
  10. Matin SR, Ahrar K. Nephron-sparing probe ablative therapy : long-term outcomes. Curr Opin Urol 2008; 18(2):150-6.
  11. Finley DS, Beck S, Box G et al. Percutaneous and laparoscopic ablation of small renal masses. J Urol 2008; 180(2):492-8.
  12. Nguyen CT, Lane BR, Kaouk JH et al. Surgical salvage of renal cell carcinoma recurrence after thermal ablative therapy. J Urol 2008; 180(1):104-9.
  13. Casalino DD, Francis IR, Arellano RS et al. Expert Panel on Urologic Imaging. ACR Appropriateness Criteria® follow-up of renal cell carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. 6 p. [62 references]. Available at http://guidelines.gov/ (accessed 2012 February).
  14. American Urological Association Education and Research, Inc. Guideline for management of the clinical stage 1 renal mass. Linthicum (MD): American Urological Association Education and Research, Inc.; 2009. 81 p. [182 references]. Available at http://guidelines.gov/ (accessed 2012 February).
  15. Nabi G, Cleves A, Shelley M. Surgical management of localised renal cell carcinoma. Cochrane Database Syst Rev 2010; (3):CD006579.
  16. Long CJ, Kutikov A, Canter DJ et al. Percutaneous vs surgical cryoablation of the small renal mass: is efficacy compromised? BJU Int 2011; 107(9):1376-80.
  17. Strom KH, Derweesh I, Stroup SP et al. Second prize: recurrence rates after percutaneous and laparoscopic renal cryoablation of small renal masses: does the approach make a difference? J Endourol 2011; 25(3):371-5.
  18. Rodriguez R, Cizman Z, Hong K. Prospective analysis of the safety and efficacy of percutaneous cryoablation for pT1NxMx biopsy-proven renal cell carcinoma. Cardiovasc Intervent Radiol 2011; 34(3):573-8.
  19. Cryosurgical Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors.  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2011 July) Surgery 7.01.92.
  20. National Comprehensive Cancer Network® (NCCN). NCCN Clinical Practice Guidelines in Oncology. Kidney Cancer (V.2.2012). Available at:  www.nccn.org (accessed 2012 February).
History
November 2013  New 2013 BCBSMT medical policy.  Previously part of the "Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors" policy.  Removed the restriction that tumors must be less than 4 centimeters in size.  Added the following indication in the medically necessary statement: palliative treatment of medically or surgically inoperable tumor(s).
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Radiofrequency Ablation (RFA) and Cryoablation of Renal Cell Carcinoma (RCC)