LESS INVASIVE THERAPY OF SMALL RENAL MASSESuroonkoloji10.naklenkongre.com/sunumlar/1111050.pdf ·...

LESS INVASIVE THERAPY OF SMALL RENAL MASSES

MICHAEL MARBERGERPROFESSOR OF UROLOGY

MEDICAL UNIVERSITY OF VIENNA

LESS INVASIVE THERAPY OF SMALL RENAL MASSES

“ENERGY ABLATIVE THERAPY”

MICHAEL MARBERGERPROFESSOR OF UROLOGY

MEDICAL UNIVERSITY OF VIENNA

OPEN PARTIAL NEPHRECTOMY FOR RCC SURVIVAL vs. TU DIAMETER

0 12 24 36 48 60 72 84 96 1080

20

40

60

80

100

120

< 4 cm 310 PATS.> 4 cm 175 PATS.

Months

Ca. specific survival %

HAFEZ, J.UROL. 162:1930, 1999

CASE

COMPLICATIONS

TRANSFUSION

LAPAROSCOPIC PARTIAL NEPHRECTOMY IN 800 PATIENTS

0 - 211

24%

14%

669 - 800

11%

16%

GILL, J. UROL. 183:34, 2010

CASE

COMPLICATIONS

TRANSFUSION

LAPAROSCOPIC PARTIAL NEPHRECTOMY IN 800 PATIENTS

0 - 211

24%

14%

669 - 800

11%

16%

GILL, J. UROL. 183:34, 2010

MORBIDITY SIGNIFICANT !

0

-1

0

1

2

3

THE ALTERNATIVE WITH LOWER MORBIDITY : “ ACTIVE SURVEILLANCE”

JEWETT, EUR UROL 60:39,2011

0 20 40 60 80 100 120 140

151 RENAL MASSES < 4cmMEAN FOLLOW-UP 28 MOS

16% LOCAL PROGRESSION, 1.3% M2

BENIGNRCCØ HISTOLOGY

cm

TWO EXTREMES….

RADICAL SURGERY “DOING NOTHING”

ENERGY ABLATIVE THERAPY : THE OPTION IN BETWEEN

PERCUTANEOUS RFA

+ 28 HE

RFA SONDE

RADIOFREQUENCY ABLATION

WITH PERCUTANEOUS RFA

“. . . ALL 95 RENAL MASSES< 3.7cm SUCCESSFULLY ABLATED”

ZAGORIA, AJR 189:423,2007

WITH PERCUTANEOUS RFA

“. . . ALL 95 RENAL MASSES< 3.7cm SUCCESSFULLY ABLATED”

NO CONTRAST ENCHANCEMENT, 9.8MOS. MED. FOLLOW-UP

ZAGORIA, AJR 189:423,2007

CONTRAST ENHANCEMENT AND 6 MONTHS FOLLOW-UP BIOPSY

NO ENHANCEMENTRFA 24% POSITIVE BxCRYO 0% POSITIVE Bx

WEIGHT CJ., et al. J UROL 179:1277, 2008

CONTRAST ENHANCEMENT AND 6 MONTHS FOLLOW-UP BIOPSY

NO ENHANCEMENTRFA 24% POSITIVE BxCRYO 0% POSITIVE Bx

CENTRAL ENHANCEMENTRFA 29% NEGATIVE BxCRYO 64% NEGATIVE Bx

WEIGHT CJ., et al. J UROL 179:1277, 2008

LAP. RFA PARTIAL NEPHRECTOMY

PATS / KIDNEYS 17MEAN TU. DIAMETER 22mmPERIPHERAL 16/17

HISTOLOGY POSITIVERCC, 32mm Ø, EXOPHYTIC 70%RCC, 40mm Ø, EXOPHYTIC 60%RCC, 24mm Ø, EXOPHYTIC 10%ANGIOMYOLIPOMA, 23mm Ø 40%

24%SKIPPING

KLINGLER, BJU Int 99:998, 2007

LAP. RFA PARTIAL NEPHRECTOMY

PATS / KIDNEYS 17MEAN TU. DIAMETER 22mmPERIPHERAL 16/17

HISTOLOGY POSITIVERCC, 32mm Ø, EXOPHYTIC 70%RCC, 40mm Ø, EXOPHYTIC 60%RCC, 24mm Ø, EXOPHYTIC 10%ANGIOMYOLIPOMA, 23mm Ø 40%

24%SKIPPING

KLINGLER, BJU Int 99:998, 2007

SKIPPING IS AN INHERENT RFA PROBLEM WHICH CAN NOT BE SOLVED BY IMAGING

3 CRYO PROBESCRYO-

ABLATION

PERC. RFA(30 STUDIES, 914 PATS.)

PERC. CRYO(10 STUDIES, 339 PATS.)

LAP CRYO(18 STUDIES, 1088 PATS.)

COMPLI-CATIONS

11%

14%

12%

M. REMZI, EAU 2010

INCOMPL.ABLATION*

16%

12%

4.9%

m F-U(MOS)

18.7

9.4

26

*Bx PROVEN RCC ONLY

METAANALYSIS: ENERGY ABLATION OF SRM




COMPLI-CATIONS

11%

14%

12%

M. REMZI, EAU 2010

INCOMPL.ABLATION*

16%

12%

4.9%

m F-U(MOS)

18.7

9.4

26

*Bx PROVEN RCC , AFTER 1st TX


PERCUTANEOUS PUNCTURE OF A SMALL MOBILE TARGET IS DIFFICULT




COMPLI-CATIONS

11%

14%

12%

M. REMZI, EAU 2010

INCOMPL.ABLATION*

16%

12%

4.9%

m F-U(MOS)

18.7

9.4

26



INCOMPLETE ABLATION RATES

SIGNIFICANTLY HIGHER IN RFA STUDIES THAN IN CRYO STUDIES

SIGNIFICANTLY HIGHER IN PERCUTA-NEOUS THAN LAPAROSCOPIC STUDIES REGARDLESS OF ABLATION TYPE

AUA SRM GUIDELINE PANEL 2009

www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm

RECURRENCE FREE SURVIVAL

SIGNIFICANTLY HIGHER IN LAPAROSCOPIC COMPARED TO PERCUTANEOUS STUDIES

TREND (p=0.092) FOR MORE MAJOR UROLOGICAL COMPLICATION IN PERCUTANEOUS THAN IN LAPROSCOPIC STUDIES

AUA SRM GUIDELINE PANEL, 2009

www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm




COMPLI-CATIONS

11%

14%

12%

M. REMZI, EAU 2010

INCOMPL.ABLATION*

16%

12%

4.9%

m F-U(MOS)

18.7

9.4

26



LAPAROSCOPIC HIFU

DEPT. UROLOGY, UNIVERSITY OF VIENNA

17 JAN 07 Bx: RCC G2

LAPARASCOPIC HIFU - FOLLOW-UP

17 JAN 07 Bx: RCC G2 POST HIFU


17 JAN 07 Bx: RCC G2 POST HIFU


16 MAY 07 12 FEB 08

LESS RELIABLE THAN ( MORE INVASIVE) PARTIAL NEPHRECTOMY

ENERGY ABLATIVE THERAPY


LOW MORBIDITY WITH PERIPHERAL TUMORS < 3cm, PATIENT SELECTION ! !


+ 48HE

MALE, 83YRS 2004 RT.TU. NEPHRECTOMY(PAP. RCC II pT3a)

2.4cm

MALE, 76 YRS

INCIDENTAL

FEMALE, 77YRS

DIABETES MELL.HYPERTENSION , COPD

(CCI 2 ) , INCIDENTAL

RISK FACTORS FOR INCOMPLETEABLATION / COMPLICATIONS WITH

CRYOABLATION OF RENAL TUMORS

144 PATIENTS

PILAR LAGUNA, EUR.UROL., 56:355, 2009

OR p

FEM. GENDER 1.09 0.03

CCI > 2 ,CARD.MBDTY 3.66 0.01

TU. SIZE (cm) 3.07 <0.01*

* > 3.4cm SIGN. PREDICTOR FOR NEGATIVE OUTCOME

RISK FACTORS FOR INCOMPLETEABLATION / COMPLICATIONS WITH

CRYOABLATION OF RENAL TUMORS

144 PATIENTS

PILAR LAGUNA, EUR.UROL., 56:355, 2009

OR p

FEM. GENDER 1.09 0.03

CCI >- 2 ,CARD.MBDTY 3.66 0.01

TU. SIZE (cm) 3.07 <0.01*

< 2 cm

2.1 – 2.9 cm

3.0 – 4.0 cm

TU Ø cm > pT3a

4%

15%

36%

M+

2 %

2 %

8 %

n.

65

103

119

G 3/4

4%

5%

26%

REMZI, J.UROL. 176:896, 2005

SMALL ( T1A ) RCC REMOVED SURGICALLY

> 3 cm SIGNIFICANTLY MORE AGGRESSIVE !



CRYOABLATION MORE RELIABLE THAN RFA, LAP. MORE RELIABLE THAN PERC.




CRYOABLATION MORE RELIABLE THAN RFA, LAP. MORE RELIABLE THAN PERC.

PRECISE FOLLOW-UP WITH CROSS-SECT. IMAGING/ BIOPSY ESSENTIAL


26 MAR 11Bx: RCC G216 MAY 07 12 FEB 08

LAPAROSCOPIC HIFU - FOLLOW - UP

26 MAR 11

LAPAROSCOPIC HIFU - „LATE“ FOLLOW - UP

MANAGING SMALL RENAL MASSES:

MY APPROACH TODAY

SOLID RENAL MASS ≤ 3cmPAT. STATE OF HEALTH

SOLID RENAL MASS ≤ 3cm

GOOD

PARTIAL NEPHRECT.

PAT. STATE OF HEALTH


MODERATEGOOD

PARTIAL NEPHRECT.



MODERATE

BIOPSY

GOOD

PARTIAL NEPHRECT.



MODERATE

BIOPSY

RCC

LAP. CRYO ABLATION

GOOD

PARTIAL NEPHRECT.



MODERATE

BIOPSY

RCC

LAP. CRYO ABLATION

GOOD POOR

BIOPSY

PARTIAL NEPHRECT.



MODERATE

BIOPSY

RCC

LAP. CRYO ABLATION

PERIPHERAL

PERC.CRYO

ACT.SURV.

GOOD POOR

BIOPSY

RCC

PARTIAL NEPHRECT.



MODERATE

BIOPSY

RCC

LAP. CRYO ABLATION

PERIPHERAL CENTRAL

PERC.CRYO

ACT.SURV.

GOOD POOR

BIOPSY

RCC

PARTIAL NEPHRECT.


OPEN PARTIAL

ENERGY ABLATIVE 11%

LAP. PARTIAL

OPEN N´ECTOMY.

LAP. N´ECTOMY.

MANAGEMENT OF RENAL TUMORS(UNIVERSITY OF VIENNA)

1039 KIDNEYS 2002-2010

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