Marcin Matuszewski PhD, FEBU Department of Urology, Medical University in Gdansk Poland
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
Histology of SRT 25% benign - non RCC AML, Oncocytoma If RCC then still many low grade ccrcc papilaryrcc chromophobe RCC Volpe A. Cancer 2004
Treatment op6ons Surgery Open Laparoscopic Robot Ablation Watchful waiting Risk
Imaging Ultrasound CT (small tumors??) MRI Patient Age Comorbidities Obesity How to decide? Biopsy
15% - not reliable Positive biopsy OK. Negative biopsy??? Biopsy When??? Before Frozen section During the treatment
Imaging guided tumor abla6on First developed in paliative treatment of liver metastases
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
Imaging guided abla6on Radio Frequency Ablation Cryo Others: Microwave ablation HIFU Laser ablation Elektroporation = IRE (nano- knife) Similar Chemoablation
Results How the energy is generated, dispersed and controled Imaging technique Evaluation of results Tumor selection
+RFA Current of 300 khz Cooled electrode
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 +)
+Cryoalbla6on Several freezing and thawing periods
+Cryoabla6on + Does not depend on electric current distribution + is better visible on USG 89% success rate El Dib R BJU Int 2012 - Larger probe - Does not coagulate vessels
- MicroWave Termoabla6on = MWT Electromagnetic wave 900 Mhz to 2 GHz Recurence rate 38% complication 40% in 18 m f- up Castle SM Urology 2011
- Laser abla6on Neodymium; Yag 1064 mm under MRI Kariniemi J. Acta Radiologica 2010 Laser with photosensitazer Kroeze GC. J Urol 2012
- HIFU Remote Laparoscopic
HIFU Necrosis present only in 8 from 14 treated tumors Problems with respiratory movements Nabi G Indian J Urol 2010
- 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
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
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
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
Other indica6ons for IGTA Antihemorhagic Matuszewski Scan J Urol 2009 Cytoreductive Zagoria Urology 2011 Immunostimulatory??? Matuszewski Urol Onc 2011
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
Perspec6ves for SRT Technology improvement Source of energy Imaging improvement MRI Knife or joystick?
Thank You