PMC8532053_01
Contrast-enhanced CT scan in coronal reconstruction revealed a 4.5 x 3.5 x 7.0-cm renal AML located in the left kidney, with signs of recent blood component and cellular resentment.
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F1
CA 199, CA 153, CA 724, cytokeratin 19 [CK 19], carcinoembryonic antigen [CEA], and alpha-fetoprotein [AFP]) were within normal range. Contrast-enhanced CT scan revealed a 4.5x3.5x7.0-cm oval mass with heterogeneous density in based scan (CT value: 17-40 HU), located in the left kidney (Figure 1).
Abdominal MRI demonstrated the presence of an expansive capsulated heterogeneous mass, with inhomogeneous low-to-high signal intensity on (A) T2-weighted images; (B) partial high-signal intensity on in-phase image; and (C) on opposed phase image due to blood content partly and foci of internal fat. (D-F) Subtracted images confirmed an enhancing component in mid-internal portion of mass.
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F2
In the excretory phase, presence of compressive effects was confirmed, with shift of both upper/middle calyceal groups and renal pelvis (Figure 2).
(A) Digital subtraction angiography (DSA) showing a multi-lobulated aneurysm arising from one of the segmental branches of the left renal artery, which was the source of bleeding for this AML. (B-D) DSA obtained post-embolization with coil demonstrating occlusion of the aneurysm.
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F3
We used a liquid embolic agent, N-butyl cyanoacrylate-methacryloxy sulfolane (NBCA-MS; Glubran 2 ; GEM Srl, Viareggio, Italy) with Lipiodol  (Guerbet, Aulnay-Sous-Bois, France) to make the glue radiopaque and modulate the delay of polymerization (Figure 3).
Two-year MRI control: (A, C) T1-weighted contrast-enhanced images, and (B, D) subtracted images demonstrated a reduced size of AML with only a small residual portion vascularized and without damage to healthy renal parenchyma.
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F4
The size of the left renal AML was indicated by MRI to be reduced (Figure 4), with only a small residual portion vascularized and without damage to the healthy renal parenchyma.
PMC8532053_02
Contrast-enhanced CT scan revealed a 3.0x2.7-cm oval mass in the upper pole of the right kidney with (A) heterogeneous density in based scan due to (B-D) sporadic fat foci and a progressive enhancement observed in the major part of the tumor.
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F5
For appearance of macroscopic hematuria, a contrast-enhanced CT scan was performed revealing a 3.0x2.7-cm oval mass with heterogeneous density in based scan located in the upper pole of the right kidney (Figure 5).
CT scans in (A) axial and (B) coronal reconstruction during the procedure established the intralesional positioning of five cryoprobes and the dissection with air obtained to separate the bowel from the ablation zone. (C, D) CT scans at the end of the procedure depicted perirenal hematoma without active bleeding.
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F6
A total of five cryoprobes (BTG, Boston Scientific) of 17 G were placed into the target area, with assistance of combined CT and augmented infrared navigation system (SIRIO, MASMEC, Italy) (Figure 6) to cover the complete lesion and to spare as much normal parenchyma as possible.
Contrast-enhanced CT scan after 6 months demonstrated complete necrosis area without residual viable tissue.
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F7
All symptoms disappeared after 1 month of cryoablation; the CT control after 6 months demonstrated complete necrosis area without residual viable tissue (Figure 7).