Is renal cryoablation becoming an effective alternative to partial nephrectomy? J GARNON 1, G TSOUMAKIDOU 1, H LANG 2, A GANGI 1 1 department of interventional radiology 2 department of urology University Hospital of Strasbourg
woman 60 y.o 8 mm RCC no CI to surgery => man 55 y.o 20 mm RCC no CI to surgery =>
1.Diagnostic 2.R0 resection 3.No complication 4.No recurrence
ANATOMOPATHOLOGY malignant benign RCC other Overall accuracy: > 90% (one biopsy) 99% (rebiopsy) type Fuhrman grading RCC subtype: identification in 93% accuracy > 90% Fuhrmann grade: accuracy variable difference = 1 grade
CT-scan
CT-scan
MRI
MRI
hydrodissection carbodissection
Ultrasound +/- CT ++ MRI +++
Ultrasound +/- CT ++ MRI +++
No histological analysis after cryo => imaging (MRI+++) COMPLICATIONS? COMPLETE ABLATION? RECURRENT DISEASE? treatment 24h 1 month 1 year death 1. lack of enhancement 2. halo sign 3. retraction of the scar M3 M6 M12
Percutaneous cryoablation of solitary sporadic renal cell carcinomas. Schmit et al. BJU int. 2012 Technical success = 99% Percutaneous cryoablation of renal masses >or=3 cm: efficacy and safety in treatment of 108 patients. Schmit et al. J Endourol. 2010 Technical success = 97% Percutaneous renal cryoablation: prospective experience treating 120 consecutive tumors. Buy et al. AJR 2013 Technical success = 94% Percutaneous cryoablation of renal tumours: outcomes from 171 tumours in 147 patients. Breen et al. BJU int. 2013 Technical success = 92%
less complications after cryo than PN main complication: bleeding Percutaneous cryoablation of solitary sporadic renal cell carcinomas. Schmit et al. BJU int. 2012 complication rate (T1a) = 4% complication rate (T1b) = 15% Percutaneous renal cryoablation: prospective experience treating 120 consecutive tumors. Buy et al. AJR 2013 complication rate = 4% more frequent for T1b Percutaneous cryoablation of renal tumours: outcomes from 171 tumours in 147 patients. Breen et al. BJU int. 2013 complication rate = 4,6% more frequent for T1b
percutaneous injection of thrombin
selective embolisation
coagulation with the cryoprobes
49 y.o man No CI to surgery 1,8cm RCC A. Percutaneous cryoablation is not technically feasible => PN B. Percutaneous cryoablation is feasible but more risky than surgery in this case (pyelo-ureteral junction) => PN C. Percutaneous cryoablation can be proposed to the patient as an alternative to PN => PN or cryo D. Percutaneous cryoablation = active surveillance in this case
134 RCC Mean size: 2,8cm 86% T1a RCC 5 years overall survival: 97,8% 5 years cancer specific survival: 100% Efficacy:
PN vs percutaneous ablation 1424 patients (1057 PN, 367 ablation) 3-years local recurrence free survival: - PN: 98% - Cryo: 98% - RFA: 98% Overall survival:
Problem: few studies with long follow-up Laparoscopic renal cryoablation versus laparoscopic partial nephrectomy for the treatment of small renal masses: a systematic review and meta-analysis of comparative studies. Tang et al. J Laparoendosc Adv Surg Tech A. 2014 Systematic review and meta-analysis of perioperative and oncologic outcomes of laparoscopic cryoablation versus laparoscopic partial nephrectomy for the treatment of small renal tumors. Klatte et al. J Urol. 2014 PN > LCA laparoscopic = percutaneous?
Percutaneous Cryoablation of Stage T1b Renal Cell Carcinoma: Technique Considerations, Safety, and Local Tumor Control. Atwell et al. JVIR 2015 Technical failure = 1/46 complication rate = 15,6% 348 PN / 48 percutaneous ablation 3 years local recurrence free survival: - PN: 96% (229 patients) - Cryo: 97% (13 patients)
Percutaneous renal cryoablation: prospective experience treating 120 consecutive tumors. Buy et al. AJR 2013 worse outcome with T1b tumors (more recurrences and more complications) 30% of incomplete treatments and local recurrences
is renal cryoablation an effective alternative to partial nephrectomy? T1a Almost all tumors may be ablated with a percutaneous approach Oncological results seem almost as good as those obtained with PN BUT Few studies with large cohorts of patients and long follow-up Renal cryoablation versus robot-assisted partial nephrectomy: Washington University longterm experience. Tanagho et al. J Endourol 2013 «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»
is renal cryoablation an effective alternative to partial nephrectomy? T1b High rate of complications High rate of incomplete ablations/recurrent disease => cryoablation only for non surgical candidates
Team work