9/8/2014. Cryoablation & RF Ablation for Renal Tumors, Challenges and Pearls for Success. RFA and Cryoablation for Renal Tumors

Transcription

1 9/8/2014 Cryoablation & RF Ablation for Renal Tumors, Challenges and Pearls for Success Debra A. Gervais, MD Division Chief, Abdominal Imaging, Massachusetts General Hospital Associate Professor, Harvard Medical School WCIO RFA and Cryoablation for Renal Tumors Both about % effective for small tumors. Cryoablation more evaluated for larger tumors. Cryo has more bleeding than RF; RF has more urinary strictures Both are rare when cases selection optimized Operator preference often dominates decision making Case 1: Octagenarian with recurrence after RF ablation 1

2 9/8/2014 RF Ablation Retrograde Pyeloperfusion to Chill Ureter Hydrodissection to Protect Colon

3 9/8/2014 Case 2: Octagenarian with recurrence after Cryoablation Upper Mid Lower Recurrence After Cryo 3

4 9/8/2014 Recurrence After Cryo Recurrence After Cryo Colonic Fistula Treated by Nephrectomy 4

5 9/8/2014 Pearls 1) Beware the ureter/upj but do not despair the calyx 2) Use pyeloperfusion to protect ureter/upj cm from ablation zone 1) Optimal distance values unknown 3) Cool D5W for RF; Room Temperature Saline for Cryo a. want fluid that will not conduct electricity for RF 4) Opacify fluid used for hydrodissection; aim for 1 2 cm distance from ablation zone a) Optimal distance values unknown b) There is air in the bowel; and introduced by needles c) There is fluid in the bowel; unopacified bowel wall looks same d) The iceball looks like fluid e) There is not usually white fluid in the body References Gervais DA, Arellano RS, McGovern FJ, McDougal WS, Mueller PR. Radiofrequency ablation of renal cell carcinoma: part 2, Lessons learned with ablation of 100 tumors. AJR Am J Roentgenol Jul;185(1): Wah TM, Koenig P, Irving HC, Gervais DA, Mueller PR. Radiofrequency ablation of a central renal tumor: protection of the collecting system with a retrograde cold dextrose pyeloperfusion technique. J Vasc Interv Radiol Nov;16(11): DeBenedectis CM, Beland MD, Dupuy DE, Mayo-Smith WW. Utility of iodinated contrast medium in hydrodissection fluid when performing renal tumor ablation.j Vasc Interv Radiol May;21(5): I have always found that plans are useless, but planning is indispensable. Dwight D. Eisenhower, on Preparing for Battle 5

6 9/8/2014 Case 2 What went wrong? Case 1 What might have gone wrong? THANK YOU 6

7 9/8/2014 Ablating Renal Cell Carcinoma A Perspective from Private Practice Andrew Hines MD Disclosures None Thank you Jason Swenson MD Eric Wang MD Michael Meuse MD Peter Simon MD Dan Stackhouse MD Dave Sheridan MD Brad Dick MD Audience Private Practice or Private Practice Curious Early to Mid Career Comfortable with RCC ablation and IO in general Active IO practice but looking to expand/improve/brand 1

8 9/8/2014 My Perspective IO academic fellowship 2009 Small private practice four years Recently in large private practice I knew nothing about private practice building Getting the Patient is Hard 60,000 new cases annually Majority diagnosed by our partners Many should be treated with ablation Most will not Goals of Lecture Financial Pro Forma and Due Diligence Defining Market Clinic Patient Ownership Interacting with Peers 2

9 9/8/2014 Why Do RCC Ablation? Personal Satisfaction? Doing the Right Thing for Patients? Financial? Other Motivating factors? Academic advancement Political Leverage in Hospital Due Diligence How Does Group Feel? Define Reimbursement Measure Current Utilization/Mixture of Lab Measure Current Utilization of Clinic Does/Will Hospital Care? Define commitment for phone calls, speaking with family What Else Could you be Doing? Cook Book Pro Forma Take last 10 ablations and talk to billing company Direct Revenue reports signed by you Indirect Revenue reports ordered by you signed by partner Calculated Total time per patient Consult, procedure, writing orders, post-op, follow-up, phone calls Understand revenue needed to pay your salary including overhead Most groups know this number; you should ask. Penalties? Will competing specialties stop referring diagnostic imaging? 3

10 9/8/2014 Non-Financial Pro Forma Interest from Hospital Interest from Referring Physicians Interest for Group Marketing Indirect Benefits are difficult to calculate and less important unless you can quantify Market Analysis How many RCC diagnosed in your area! Current Referral Pattern? Who What Why What are the current motivations? Financial? Ego? Political? Academic? Cookbook Market Analysis Identify CPT diagnoses of RCC in your area Ask Vendor to get information Identify who owns RCC at your hospital Ask Vendor Ask Hospital Cancer Coordinator Ask Surgical Coordinator for partial nephrectomy/nephrectomy Ask Billing Company/PACS to identify RCC Get list of PCPs, Urologists, Oncologists in Outlining areas Low Hanging Fruit Current Referrers for Biopsies 4

11 9/8/2014 Clinic Must Have BUT, Clinics can be Unproductive Clinic might be broom closet and the RN, receptionist, and scheduler might be YOU when you start. Start doing, ask for resources later Prepare Amazing Clinic Notes Add Pictures Always have something in note that referrer didn t know! Find a heart murmur Social History how many cats, who is support structure Patient Ownership Own RCC imaging and call referrers Give talks to PCPs Advertise to patients directly Have Hospital Do a Patient Success Story Those direct referrals are very important because 5

12 9/8/2014 Patient Ownership Get friendly with Urologists REFER patients TO Urologists REFER patients TO Oncologists Talk about referrals from urologists to oncologists Publically applaud a multidisciplinary approach Patient Ownership Get it Right on Game Day Pick Winners to start Pick Appropriate Challenges Don t turn down a case because of adjacent structures Don t turn down a case just because of size Do be careful of central location (high risk, high recurrence) Minimize Pain and Risks Pain Control Separate adjacent structures Call patients calling improves outcome 6

13 9/8/2014 Interacting with Peers Follow-up with patient Patient must Call YOU, not referring Tell Patients to Market for You Upsell Urologists Who Refer to you Run Tumor Conferences IRB and other Hospital Committees Don t be Afraid to Ask Don t be afraid to ask for Referrals Treat Referrers as VIPs and tell them. Asking Shows You are interested in doing the procedure You are committed to doing a good job That They can Ask You for Favors 7

14 9/8/2014 Promote the Team Promote Your Partners Promote Your Practice Promote Those Who Refer Promote Other Colleagues in IR Thank You 8

15 Role of Fusion Imaging in Liver Ablation Matthew Callstrom, MD PhD Mayo Clinic Rochester, Minnesota USA What does US/CT/MRI/PET Fusion Imaging Add? Expansion of ablation cases 1. Targeting tumors with poor CT visualization 2. Out of axial plane probe placement 3. Treating tumors in difficult locations 4. Treatment of multifocal liver disease Improved operator confidence Real-time imaging Improved accuracy of device placement Fiducial Magnetic Field Generator Magnetic Field Sensor

16 Magnetic Field Generator Magnetic sensor CT data 1. Targeting tumors with poor CT visualization Metastatic Leiomyosarcoma Contrast enhanced CT Solitary tumor identified 1. Targeting tumors with poor CT visualization 3 Tumors identified with MRI CT treatment options Treat visible disease Use anatomy as a guide Planning US imaging found additional tumor US treatment options Work to find third tumor Fusion imaging

17 US MR Fusion Real-time US Previous MR 1. Targeting tumors with poor CT visualization Pre Ablation T2 MRI Post Ablation CE CT 2. Out of axial plane probe placement CRC with prior left hepatectomy R lobe Fusion Imaging Identify two masses in right lobe

18 2. Out of axial plane probe placement Fusion imaging benefit Avoid portal vein Avoid IVC 2. Out of axial plane probe placement 2. Out of axial plane probe placement Can t see vessels Can t see tumor Off axial plane Rapid selection of a safe device path 2 probes placed with fusion imaging avoiding vessels RFA electrodes placed with fusion imaging

19 2. Out of axial plane probe placement 3. Treatment of tumors in difficult locations 3. Treatment of tumors in difficult locations 26yo with Met Pseudopapillary Pancreatic CA Old ablation defects 1 of 7 tumors 1 of 7 tumors Fusion allows comparison of gas with target Pre ablation MR Difficult treatment with CT guidance adjacent to heart

20 3. Treatment of tumors in difficult locations Ablation of anterior left lobe tumor 4. Treatment of multifocal liver tumors Metastatic Insulinoma Prior ablation 10 new small tumors Symptomatic 4. Treatment of multifocal liver tumors Metastatic Insulinoma Prior ablation 10 new small tumors Symptomatic Goal: palliate symptoms (>80% tumor destruction)

21 4. Treatment of multifocal liver tumors Time to Tumor Localization and Confidence Level Tumors Identified Time to Localization (seconds) Operator Confidence (1 5 scale) Image Fusion of CT/MRI with US Conclusions Allows US accuracy with CT familiarity Result: all tumors treated Hypoglycemia eliminated US alone US/CT fusion 49/60 (82%) 55/60 (92%) 74 (53-103) 20 (8-33) 3.9 ( ) 4.5 ( ) p = p = 0.03 McBride et al. Society of Interventional Radiology 2012 Allows treatment of complex patients Tumors that are not visible with CT Difficult locations for CT Difficult angles for CT Multifocal small liver tumors Improves Tumor Identification and Confidence Improves Technical Ablation Outcomes

22 9/2/2014 Ablation of Hepatic Malignancies: Tips and Tricks Alain T. Drooz, MD, FSVM Division of Vascular and Interventional Radiology Inova Fairfax Hospital Falls Church, VA Fairfax Radiological Consultants Disclosures Covidien Consultant, inactive Percunav Consultant SIRTEX Proctor Topics Candidates for Thermal Ablation Guidance and Followup Which Energy Source to Use Treating Safely in Challenging Locations When Ablation isn t Enough 1

23 9/2/2014 Ablation vs. Regional Therapy Solitary Esophageal Met 2 mos. Post microwave Ablation Guidance and Followup Ablation Followup: Metastatic Disease Good Margins Customize Imaging Modality Imaging f/u for mets*: 4-6 weeks 3 mos Q 4 mos Train your Imagers! 2

24 9/2/2014 Ablation for Debulking Metastatic Carcinoid 70 y/o male with carcinoid syndrome Sx: diarrhea, cough, flushing, pruritis Lab: chromogranin A 14,360 Imaging: massive liver disease, splenic and pulmonary lesions Rx: 90Y 12/08 TACE 6/10 (30%shunt) CT pre and post-ablation Sup. Inf. 3

25 9/2/2014 Choosing the Right Ablative Technology 81 y/o female with two CRC hepatic metastases One month post RFA 4

26 9/2/2014 Microwave Ablation Followup 2 Months post MWA 6 months post MWA When Heat May Hurt. 5

27 9/2/2014 Consider Cryoablation Superficial Lesions Superficial HCC 59 y/o AA male, HCV. CP A, ECOG 0 6

28 9/2/2014 7

29 9/2/2014 CRC mets adjacent to adrenal gland Combined Regional and Local Rx 6.5 cm HCC: TACE + RFA 7 year followup New lesion ablated at year 5 Patient remains diseasefree at 12 y Case Presentation 60 y/o A/A male presents with abd pain Colonoscopy/CT: Stage IV sigmoid CRC with >5 synchronous liver mets CEA59.9 KRAS mutant 8

30 9/2/2014 Case FOLFOX/Bevacizumab-PR March 2011: progressive disease; CEA incr 6.6 FOLFIRI/Bevacizumab and referral to IO clinic Radioembolization with SIRSPHERES & MW Ablation 15 Month Followup 9

31 9/2/2014 Combined Intraoperative Procedures Intraoperative RFA & Metastatectomy 71 y/o male, ECOG 0, presents one year post resection/systemic therapy for CRC 10