Marcin Matuszewski PhD, FEBU Department of Urology, Medical University in Gdansk Poland

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1 Marcin Matuszewski PhD, FEBU Department of Urology, Medical University in Gdansk Poland

2 Epidemiology General increase in the incidence of small renal tumors SRT(<4cm) Increase in this SMT in old or otherwise ill patients Hollingworth JM. J Natl Can Ins 2006

3 Histology of SRT 25% benign - non RCC AML, Oncocytoma If RCC then still many low grade ccrcc papilaryrcc chromophobe RCC Volpe A. Cancer 2004

4 Treatment op6ons Surgery Open Laparoscopic Robot Ablation Watchful waiting Risk

5 Imaging Ultrasound CT (small tumors??) MRI Patient Age Comorbidities Obesity How to decide? Biopsy

6 15% - not reliable Positive biopsy OK. Negative biopsy??? Biopsy When??? Before Frozen section During the treatment

7 Imaging guided tumor abla6on First developed in paliative treatment of liver metastases

8 Indica6ons for RCC Ablation of SRT is to be a radical treatment Biopsy is necessary for patient s qualification SRT (RCC) in single kidney SRT (RCC) in renal insuficiency SRT (RCC) in patients with limited life expectancy

9 Imaging guided abla6on Radio Frequency Ablation Cryo Others: Microwave ablation HIFU Laser ablation Elektroporation = IRE (nanoknife) Similar Chemoablation

10 Results How the energy is generated, dispersed and controled Imaging technique Evaluation of results Tumor selection

11 +RFA Current of 300 khz Cooled electrode

12 Cheap + almost ambulatory + can be repeated + coagulation of vessels +RFA - depends on current flow disturbancies (skipping effect) (cooling effect) - heat may destroy adjacent organs - not easily seen on USG or MRI (CT +)

13 +Cryoalbla6on Several freezing and thawing periods

14 +Cryoabla6on + Does not depend on electric current distribution + is better visible on USG 89% success rate El Dib R BJU Int Larger probe - Does not coagulate vessels

15 - MicroWave Termoabla6on = MWT Electromagnetic wave 900 Mhz to 2 GHz Recurence rate 38% complication 40% in 18 m f- up Castle SM Urology 2011

16 - Laser abla6on Neodymium; Yag 1064 mm under MRI Kariniemi J. Acta Radiologica 2010 Laser with photosensitazer Kroeze GC. J Urol 2012

17 - HIFU Remote Laparoscopic

18 HIFU Necrosis present only in 8 from 14 treated tumors Problems with respiratory movements Nabi G Indian J Urol 2010

19 - Irreversible Electropora6on = IRE Non- thermal cell destruction (spares kolagen fibres) Very much dependent on electric current flow May influence cardiac function Pech M Card Int Radiol 2011

20 NanoKnife is already comercially available? Nefrectomy done 4 weeks after revealed: necrosis zone in the treated area disturbed histoarchitecture residual cancer cells within the necrosis zone in 1 of 3 cases Wendler Cardiovasc Interv Radiol 2015

21 Imaging guided (precision) USG guided 65.2% 1st 84.8 % 2nd Matuszewski 2011 CT guided 5y f- up = 89% Zagoria RJ Urology 2011 Open guided 5y f- up = 95% Trace CR Cancer 2010 Lap guided 5y f- up = 97.8% Ji C Urology 2011

22 Follow- up No enhancement on CT?? No growth (long follow- up needed)?? Biopsy No CT enhancement 24% RCC on biopsy Weight CJ. J Urol 2006

23 Other indica6ons for IGTA Antihemorhagic Matuszewski Scan J Urol 2009 Cytoreductive Zagoria Urology 2011 Immunostimulatory??? Matuszewski Urol Onc 2011

24 Tumor selec6on All small renal tumors = NO ( not yet) Small < 3.5 cmsrt Lower pole SRT Egzophytic SRT Away from the hillum Ablation compete with easy partial nephrectomy

25 Perspec6ves for SRT Technology improvement Source of energy Imaging improvement MRI Knife or joystick?

26 Thank You

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