Freeze, Fry or Cut Jennifer A. Linehan, MD Associate Professor Urologic Oncology John Wayne Cancer Institute 2/9/2018
Disclosures Consultant for UroGen Pharma.
REDEFINING WHAT SURGEONS SEE Bay Area-based healthtech startup Beautiful, detailed 3D models created from existing CTs and MRIs Viewed from surgeon s own smartphone and, optionally, through basic VR headset Full cloud-based software service (hospital radiology uninvolved in model creation) FDA-cleared for both preoperative planning and intraoperative display; HIPAA compliant
Evolution Discuss the treatment of SRM Discuss Cryotherapy, RFA, Microwave ablation techniques Discuss oncologic outcomes compared to partial nephrectomy
GOALS of Treatment Margins Oncologic outcomes Conserve Renal Function Patient Quality of Life
Case Presentation 77 y.o. female, Solitary R kidney, -left radical nephrectomy in 2000 -right lap partial nephrectomy for AML in 2006 Returns in 8/2016 3.5 cm renal mass - Nephrotomy score 7x Renal biopsy positive for RCC No meds no comorbidities Creatinine 0.87
Case Presentation
Case Presentation KIDNEY, RIGHT, ROBOTIC PARTIAL NEPHRECTOMY: - CLEAR CELL RENAL CELL CARCINOMA, FUHRMAN GRADE 3, WITH PROMINENT TUMOR NECROSIS; SIZE = 3.0 CM - TUMOR LIMITED TO KIDNEY - SURGICAL MARGINS: TUMOR PRESENT AT RENAL PARENCHYMAL MARGIN (SEE PART C FOR ADDITIONAL RENAL PARENCHYMAL MARGIN STATUS) PERINEPHRIC FAT/RENAL CAPSULAR MARGIN NEGATIVE FOR TUMOR (SEE PART A FOR ADDITIONAL PERINEPHRIC FAT MARGIN STATUS) - FOCUS SUSPICIOUS FOR LYMPHOVASCULAR INVASION - PATHOLOGIC STAGING: pt1a
Case Presentation
Lap Cryo 1/23/18 Case Presentation
Case Presentation CT Guided Cyro 5/5/18 NO TUMOR!!!! 12/2018
INCIDENCE 63,000 new diagnosis of kidney cancer annually 10th most common cancer; 3rd most common GU malignancy 14,000 deaths annually Approximately 70% of renal masses are incidental ct1a = 42% ct1b = 25%
RCC incidence vs mortality Increase in the incidence of RCC but no change in mortality suggesting overdiagnosis and overtreatment
Tumor Characteristics
AUA Guidelines
AUA Guidelines Partial Nephrectomy (PN) and Nephron-Sparing Approaches Principles Related to PN
AUA Guidelines
AUA Guidelines Thermal Ablation Statements 24-27 Physicians should consider thermal ablation (TA) as an alternate approach for the management of ct1a renal masses <3 cm in size. Counseling about TA should include information regarding an increased likelihood of tumor persistence or local recurrence after primary thermal ablation relative to surgical extirpation, which may be addressed with repeat ablation if further intervention is elected For patients who elect TA, a percutaneous technique is preferred. Both RFA and cryoablation are options. RMB should be performed prior to ablation
EAU Guidelines
Active Surveillance Presentation for AUA Plenary Session, Steven Campbell. Renal Mass and Localized Renal Cancer: AUA Guideline Published 2017
Ablative Therapies Cryoablation Radiofrequency Ablation Microwave Ablation HIFU LITT Laser Interstitial Thermal Therapy Centrifugal: energy dissipates towards the periphery from an applicator inserted into the center of the tumor target Centripetal: convergence of energy from the periphery towards the center of the tumor IRE- Irreversible Electroporation O. Seror. CIR, Diagnostic and Interventional Imaging Volume 96, Issue 6, June 2015,
HIFU acoustic wave is propagated through tissue, a portion of its energy is absorbed and converted into heat ultrasound waves are focused with an appropriately shaped transducer the temperature at the focal point can exceed the threshold for cell death, while adjacent tissue is spared. HIFU Kidney Ablation, Chopra et al, Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017 JU
IRE Irreversible Electroporation high-voltage electrical pulses of microsecond duration are applied to induce irreversible permeabilization of the cell membrane, presumably through nanoscale defects in the lipid bilayer, leading to apoptosis non thermal can be used in dangerous places Irreversible Electroporation of Renal Cell Carcinoma: A First-in-Man Phase I Clinical Study 6 patients One case of supraventricular extrasystole was encountered feasible and safe technique by which to treat patients with kidney tumors Pech et al CardioVascular and Interventional Radiology February 2011, Volume 34, Issue 1, pp 132 138
LITT Laser Interstitial Thermal Therapy specialized laser fibers to deliver energy into tissue laser light that is converted to heat, achieving tissue necrosis (Nd:YAG) lasers and diode lasers investigational Sartori et al. (2018). Ultrasound-guided percutaneous laser ablation is safe and effective in the treatment of small renal tumors in patients at increased bleeding risk. International Journal of Hyperthermia. 35. 1-7. 10.1080/02656736.2018.1468038.
Microwave Ablation microwave energy operate in the 900-MHz to 2.45-GHz range of the electromagnetic spectrum and create rapid water ion oscillation in the tissue and frictional heat degree of tissue penetration and heat related to the water content of tissue achieving treatment temperatures (>60 C) faster than RFA No tissue charring and desiccation as experienced with RFA more efficient treatment times and may make MWA less susceptible to the heat sink phenomenon,
Microwave Ablation Microwave ablation versus partial nephrectomy for small renal tumors: intermediateterm results. 102 patients 2 year follow up RANDOMIZED 54 had either open (19) or lap (35)PN 48 had lap(28) or open (20) MA Kaplan Meier estimates of overall local recurrence free survival at 3 years 91.3% for microwave ablation 96.0% for PN feasible and safe technique by which to treat patients with kidney tumors, Guan, et al, J Surg Oncol. 2012 Sep
Microwave Ablation Percutaneous microwave ablation of renal cancers under CT guidance: safety and efficacy with a 2-year follow-up 62 patients, 84 tumors, RCC mean diameter: 25.6 mm included 4 patients, the treatment was stopped due to gas dissection 3 months, six residual tumors were observed (8%) 6 months, two recurrences and one residual tumor (3.8%) 12 months, local control of the disease was achieved in 94% of cases 2 cases of distal metastasis were observed after 12 and 24 months complication rate was 4.8% including one grade III complication and two grade II 2 years, the cumulative disease-free survival rate and overall survival were 95% and 97%, respectively., Chana et all, Clinical Radiology September 2017,
Comparison All Modalities: Rate of Local Recurrence http://www.ilovemykidney.org/partial-nephrectomy-vs-cryo-ablation.html
Percutaneous Ablation Complications Krokidis et al, CIRSE Guidelines on Percutaneous Ablation of Small Renal Cell Carcinoma. Cardiovasc Intervent Radiol. Dec 2016
Outcomes RFA RCC Nonsurgical Focal Therapy for Renal Tumors Chad R. Tracy MD and Jeffrey A. Cadeddu MD Campbell-Walsh Urology, 62
Outcomes Cryoablation RCC Nonsurgical Focal Therapy for Renal Tumors Chad R. Tracy MD and Jeffrey A. Cadeddu MD Campbell-Walsh Urology, 62
LPN better oncological outcomes and significantly lower risk for local recurrences (OR = 13.03; 95% CI, 4.20-40.39; P <.001) and for distant metastasis (OR = 9.05; 95% CI, 2.31-35.51; P =.002) On the other side, LCA was associated with significantly shorter operative time, less blood loss, lower risk of conversion, and fewer overall complications. Faba et al, Urology, 2016-04-01, Volume 90, Pages 9-15, Copyright 2016 Elsevier Inc.
Is Cryotherapy a Genuine Rival to Robotic-assisted Partial Nephrectomy in the Management of Suspected Renal Malignancy? A Systematic Review and Meta-analysis Bhavan Prasad Rai, Patrick Jones, Campbell Tait, Ramachandran Amitharaj, Raj Gowda, Aftab Bhatti, Jim Adshead and Bhaskar Somani Urology, 2018-08-01, Volume 118, Pages 6-11 There was a statistically significant difference for recurrence rates between the 2 techniques, favoring the RAPN cohort There was trend toward better preservation of renal function with the CA cohort
ct1a, N0M0 1424 T1c 1057 underwent PN 180 underwent RFA 187 underwent cryoablation local recurrence-free survival same and metastases-free survival significantly better after PN (p = 0.005) and cryoablation (p = 0.021) when compared with RFA 379 ct1b 326 patients underwent PN 53 patients were managed with cryoablation 8 RFA patients were excluded local recurrence-free survival (p = 0.81) and metastases-free survival (p = 0.45) were similar between PN and cryoablation ct1a and ct1b groups, PN patients were significantly younger, with lower Charlson scores and had superior overall survival (p < 0.001 for all)
CA for ct1b renal tumors had a higher rate of local cancer recurrence than patients treated with PN.
Urology August 15, 2018 Cryotherapy vs Robotic-Assisted Partial Nephrectomy for the Management of Suspected Renal Malignancy The objective of this meta-analysis was to compare oncologic, functional, and safety outcomes between robotic partial nephrectomy (RPN) and cryoablation for renal tumors Over 1000 patients were identified in four studies comparing RPN with cryoablation. Local recurrence rates were 12% compared with 0%, favoring RPN. Complication rates (and high-grade complications) were equivalent between the modalities. Renal function reporting was heterogenous in the trials; Based on these data, the authors suggest that partial nephrectomy remains the procedure of choice in patients requiring nephron-sparing treatment for renal tumors
Renal Cryoablation Versus Robot-Assisted Partial Nephrectomy: Washington University Long-Term Experience 267 patients who underwent laparoscopic or percutaneous cryoablation perioperative complication rate was 8.6% in the cryoablation group vs 9.4% in the RAPN 6% lower than preoperative egfr in the cryoablation group and 13% lower in the RAPN 5-year Kaplan-Meier disease-free survival (DFS), cancer-specific survival (CSS), and overall survival was 83.1%, 96.4%, and 77.1% cryoablation cohort vs 100%, 100%, and 91.7% in the RAPN group Conclusions: While RAPN offers improved DFS, for those willing to undergo close postoperative monitoring and accept the potential need for re-treatment of recurrent disease, cryoablation offers excellent long-term CSS. Tanagho, Bhayani, Kim, and Figenshau Journal of Endourology Vol. 27, No. 12Laparoscopy and Robotic Surgery
Comparison All Modalities: Rate of Local Recurrence http://www.ilovemykidney.org/partial-nephrectomy-vs-cryo-ablation.html
Just because you can QOL example
Bottom Line After analysis of over 32 articles and chapters Preop biopsy reduce unnecessary partial by 20% 11-14% local cancer recurrence after Cryo Outcomes decline for ablation for tumors >3cm For ablation, tumor cannot be too large, cystic, hilar, anterior, endophytic, abutting bowel, ureter pancreas or spleen 2-4% local cancer recurrence after PN Limited role for lap cryo PN still gold standard for both margins and recurrence PN and Cryo have similar CFS More metastasis seen with RFA AUANEWS, Sept 2018, Jamie Landman and Craig Rogers
Wise Advice Counsel your patients wisely ultimately you have to make some compromise between margins, oncologic outcomes and renal function if you choose ablative therapy Create a renal mass team of both urologist, medical oncologist and interventional radiologist to discuss complex situations
Thank you! Clayton Lau Tim Wilson All the faculty and staff who gave up time to join us today
Ablative Techniques Kyungmouk Steve Lee, Bradley B. Pua, Alternative to surgery in early stage NSCLC interventional radiologic approaches. TLCR Vol 2, No 5 (October 2013)
Excise, Ablate or Observe: The Small Renal Mass Dilemma A Meta- Analysis and Review The Journal of Urology Volume 179, Issue 4, April 2008, Pages 1227-1234 David A.Kunkle Brian L.Egleston Robert G.Uzzo Overestimation of treatment