Cryoablation vs RFA
Cryoablation vs RFA
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>> What about a head to head cryoablation versus RFA? There actually there aren't too many studies that look at this. There's a couple that came out a few years ago. The data was a little more heterogeneous at that time.

We weren't getting all biopsy confirmed RCCs, the follow up and definitions for recurrence were a little bit mixed. But basically the results were that both were effective techniques for renal mass is less than three centimeters. The pool clinical efficacy was quite high really no statistical different there. Okay so, just quickly an

very interesting. So I'm gonna start with heat based ablation techniques, temperature and time effects on tissue, this is probably familiar to most of you but we know that instantaneous cell death typically occurs around 60

degrees if you hold lower temperatures for a longer periods of time you can also achieve irreversible cell damage and cell death. I'm gonna start with radiofrequency ablation basically you're turning the patient into a circuit they've got grounding pads. This is

a technique that uses thermal diffusion, conductive heat transfer, the generator is producing frequencies in the 300 to 500 Kilohertz range is the RF range. This is a frictional heating technique so you've got denaturation, desiccation, coagulative necrosis and as you're doing so the impedance

of the probe can rise and that's an important factor in RF. So RF ablation probes come in many different shapes and sizes, there are the time probes, there are the straight probes, they are some to have cool tip type devices. In terms of the advantages let's just jump right in well we know we've been using RF for a long

time in the kidney, we have the longest term user experience in RF it's a relatively fast technique, faster than cryo and not as fast as microwave, one of the benefits is the relatively small applicators. And some of these newer applicators that I talked about

with a cooling with the timed electrodes, they can address some of the transfer impedance issues but they are not perfect. Some of the disadvantages that I would say, one you've got grounding pads, there is a potential for burns doesn't happen very often but it does, it's really unfortunate. I think one of the key things with any of the heat based techniques is the uncertainty

about the ablation margins, you are returning on your device you are looking at the charts you are expecting a certain type of ablation zone, but you don't have as much to intra procedurally monitor with your imaging technique, whether it be CT or ultrasound and that's really important when you are worried about collateral damage.

I talked about the tissue impedance that can limit the energy delivery with RF you get the desiccation you get the trying, your impedance goes up and some of the devices are impedance based can shut off so you have to play these games to keep your energy delivery up. So

conductive heat transfer that's the mechanism your local environment is very important to how well you can transfer heat into that so perfusion, heat sinks, poorly conductive tissues. These are all the things you have to be aware of when you're performing RF ablation.

So just briefly on outcomes, there are a couple of studies from a few years ago, these were all T1a masses. I completely 100% agree with doctor Clark, we need to be biopsing these lesions,

we need to be confirming that they're are RCC's before we're ablating, these were all biopsy proven RCC's and five and ten year recurrence free survival, were very high 96 and 93%. You often get the question when you're seeing a patient in clinic. What happens if it comes back? What are my options?

Well you can re-ablate and that's important to talk to the patient about, and this particular study they re-ablated 24 patients that the residual disease successfully, so secondary efficacy is something that we often see reported. What about oncologic control?

This is a nice paper that came out from Dr.Oman's group, they looked at, and this sort of intermediate two year follow up and a 100 RCC's and basically they showed really excellent control at two years. They did show what predicts primary efficacy is location,

the size, proximity to the collecting system, lower RENAL nephrometry scores and the number of ablation zones, so when you're picking your optimal patients these are some of the things you wanna think about.

What about RF verses partial nephrectomy, there some comparative studies. This one's a few years ago but they had more than five year follow up and I think duration of follow up is a really important factor in these studies. They were greater comorbidities in the RF group. They had comparable longer term oncologic outcomes.

Overall survival was a little bit less during that period of time, again probably related to the comorbidities.

So our second case, 65-year old female, HBV, cirrhosis, minimally elevated AFP. Previous ablation. No, sorry. This is just inside a large nodule that was growing, and there is a I think a 1 cm-ish

hypervascular nodule within the larger lower attenuation area. And it's seen best I think on the coronal image down on the left there, the little hypervascular dot. So enlarging low attenuation lesion in segment VI, it's a 1.1 cm hypervascular nodule. So it's the classic nodule within the nodule. It does have washout. So, how would you guys approach?

[BLANK_AUDIO] I go back? >> So how long was this follow up in this patient? >> I think we, I can't remember exactly- >> Okay. >> But I know it is new. This nodule, the hypervascular nodule is new.

>> And it's been enlarging? >> Well, from nothing to now a hypervascular with washout. So I think that pushes us into the larynx 5. >> Right. Without going through the entire series, first things first we wanna make sure that it's not a vascular issue from the previous ablation. >> No. >> Once we've cleared that,

and this is a 1.1 cm nodule in this particular patient, and if it's enlarging on the second follow up. One of the options would be to re-ablate, and do a biopsy frozen at the same time with the coaxial system, and if it is positive or not, we just go ahead and ablate it and do a track ablation out of that time. That's one option.

>> You mentioned this was ablated before. >> It's not a previous ablation- >> It's not. It's not, yeah. Because you mentioned and then you say no. So number one, the whole thing is an HCC, it's not just the one 1.1. It's all HCC. If not all HCC, it's almost HCC, meaning it's such a high grade dysplasia that you really need to take care of the whole

thing. Because this is nodule in nodule is typical, and I think so the mass is clearly like 4cm here or so, right? So what I think, so that being said, just to clarify because you've mentioned the ablation that's why Raj was, yeah I think looking at that answer, that would be like what has been left behind. So this could be a combo case I think, in

the right- >> You would the whole thing? >> In the right way, which means to do ablation first. >> [LAUGH] >> Followed by injection of, followed by transcriptive

therapy. This is the like a kind of alternate protocol that we developed. Actually I understand that if you do TACE in the first place, you have a nice picture to target the ablation. But as I said before, especially if you use different modalities, an ultrasound or whatever, you don't really need that. And particularly for this patient that is not prominently upper

vascular, doing the ablation in the first place will create the hyperemia and the upper vascularity that would then potentially facilitate the effect of the combo therapy. So that can be an option. I think that the whole lesion should be treated as an HCC, so the goal should be to ablate the whole thing.

>> So let me now get our approach, which is of course exactly the opposite. But that's okay, there is a reason for it. It's not that we are just doing that to disagree with the Italian approach. >> It's the Miami approach. Before I- >> That's fine. >> Before I moved there.

>> Before you were there? >> Yes, before I was there. >> These Miami people, they're very south. But- >> If I can tell you that Raj told me, his percentage of local recurrence with the combo, with microwave followed by the duct TACE. Guess how much?

>> 8%. >> 0. >> [LAUGH] >> Anyway so, I have a question for you. It looks to me, first of all before I say why we do it differently and how, it looks to me that the right liver and especially the posterior sector is small.

It looks like there is left hypertrophy. Is the portal vein patent? >> Yes. >> Or is it invaded? >> No, it's patent. >> Because it looks to me that, that right liver is a little small, which is a picture you see if there is invasion of the portal vein. >> No. This is a classic patient here who's Asian, who has a left lobe caudate hypertrophy splenomegaly related to HBV and

cirrhosis. >> Okay, so Riccardo and Raj like to do the ablation first, and then they use the hyperemia to give their TACE or drug-eluting beads. And that makes sense because they use chemotherapy in those beads and in the TACE, and they think the chemotherapy works. So in our approach, we don't think that chemotherapy adds anything

to the mix. We believe that it's only bland embolization enough to treat this tumor. And as a matter of fact again, we just published a JCO paper in January, showing that there is no difference between drug-eluting beads and there was no difference, Riccardo. >> There was a difference that was not significant. >> Well, okay, fine. So we don't believe there is a significant difference

between, in small particles versus small particles with doxorubicin. And therefore we think that de-vascularizing the tumor before will actually allow us to get a better ablation zone with better tumor kill, less viable tumor left behind. >> But that's not endovascular/g. >> No, I understand. I understand. I'm just saying the rationale on why we do it differently. In this

particular case, I'm not sure how big it is. If it is over 6 or 7, you may just do embolization, I don't know. But if it's 4, we'll definitely do to a kill or 5 definitely. And just to reiterate on this. I think from our institution and others it has been proven, at least in matched patients with resection, that segmentectomy is not better, but combination of intra-arterial

therapy with ablation. And I believe it was up to 7 cm at least from our cohort, and I think if I'm not mistaken, you may correct me if I'm wrong, I think it's up to 8 cm from other series. Which you can argue the 8 cm that you can do combined treatment, but at least the data so far, and again they're not randomized trials, but they at least match. And it seems that the only difference in mortality

or in survival of the patients was the occluded state at least in our series, or the Child cirrhosis level in others. So it was really the level of disease, the only factor that affected outcomes. >> And I just want to just clarify because we're all like kidding a bit. I've nothing against a combo in which you do your TACE first and

then the ablation. You probably can also do the other way round. And this particular case because it's not prominent hypervascular I would really, let's say go a little bit more aligning toward the other way for that reason. >> Okay. >> Fred,

do you wanna? >> I didn't want to convert this into a TACE, bland versus loaded discussion, since we are an ablation panel. But to Riccardo's point, the only thing we haven't done so far is publish that data and it is gonna come out, and I hope it's not dismissed the way you just dismissed it at a 0% low.

>> [LAUGH] >> So, >> 0% is almost like perfection. >> [LAUGH] Yeah.

So now that everybody else has given you their opinion, let me just tell you how it is here. >> [LAUGH] >> You notice how our panel, nobody has strong opinions about anything. We're a bunch of low toasts/g up here. So our philosophy is a little bit

different than Riccardo's and Raj's, and may be a little closer to Costi's, but still there's some differences. So first of all, when we think about combination therapies, virtually any combination of anything is probably better than monotherapy alone for larger and mid-sized tumors. So I think that's the first thing. We tend to treat with conventional

TACE. We do it 2 weeks or so before we do the ablation, and there's two reasons why we do that. Number one is that there was a interesting animal study by Nahum/g Goldberg a number of years ago, looking at the order of embolization and ablation. And it turns out if you do the embolization first, you tend to get

larger ablation zones, than the other way around. Now that was in normal animals and this is in tumors, and so that's a little bit, you know how it applies, I don't know. So that's number one. Number two is that if you use conventional TACE with ethiodol, the background liver clears, mostly the ethiodol, after a couple of weeks. And so

when you do your ablation, it's really easy to see where your margins are. And you can see the tumor, you can see the margins and you know exactly what you got. So those are the main reasons why we do that. We tend to use chemoembolization. It's just been the standard, not planned, but that's been our considered way for a long time.

>> So, entirely different for us. We follow these extremely closely, so we don't go after, I think it's potentially a different patient population. We don't treat the part that's not hypervascular, it's that part what's stable. So we don't feel like that part's the part to treat, so we wouldn't. But we would follow that up, and we would treat the part that we, and the Europeans or the Asians or Canadians in the audience, we

do use Definity or other ultrasound contrast agents. So we use that to approach this lesion and within that, the top images are the pre and the bottom images are the post. And the beauty of that is we can continue to give as many doses as you need. You place the needle in, and we use just a standard ablation. Needle goes in, and we do a standard ablation using the standard protocols.

And that's our post-ablation images afterwards, and we will continue to follow. >> Great. >> Yep, that's good. >> Okay, thanks Steve. You're gonna have to click through the images. >> Okay. >> With this image you show the rationale for the combo later because what was not hypervascular is now surrounded by an unseen ring,

and you would be able to deliver some beads and chemotherapy. Of course, we don't know in this case that you really had an excellent ablation, but not margin. So if you want the margin in a lesion that is really above a certain size, it's gonna be difficult to get it with a single modality. That's something that I think we need to acknowledge as a practical limitation because

theoretically you can do multiple overlapping, but in reality I don't believe that this is really very common.

So this particular case, maybe we'll have a couple of questions for discussion. We saw the mCRC case that Costi showed. Again, here is another patient similar history, but 3.5 cm hypodense

lesion. PET positive, and you can see the close proximity of this lesion next to the hepatic veins. Costi, comments? >> Well, the number one question is whether it's invading the vein, and that would make it extremely challenging. Other than that, you can treat it with thermal ablation I think. >> With that proximity to the vein, the hepatic vein? I'll show you

more images, but it's almost like in the crux of the hepatic veins. Would that be of concern to you? >> Yeah, it's a concern of course. First of all, it's a concern whether it's invading already. Number two, it's a concern about heat sink. Like Alban suggested before, you can consider putting a balloon, or you can consider being extra aggressive and extending your zone

medially to that vein, which is not easy. But certainly it's a concern, there's no question about it. >> Any other comments? [BLANK_AUDIO] So again, this is why we do what we do in Miami, and all three points that Costi made are extremely valid when you go with a thermal

ablation. I was in a panel once with Teddy DeBare/g, where a similar patient, where they had to put a balloon in the hepatic vein before they performed this ablation. So this particular patient was treated with four probes with IRE from using CT fluoro, and we bracketed the tumor both cranially and caudally. And this is the follow up of the patient in 24 hours post. You

can see where the lesion is and the vessels, and the proximity of it is again, was one of the reasons we did not opt for the thermal ablative technique. And the PET scan of the patient two months shows no evidence of local disease. And looking further out into the follow up of the patient at eight months, the vasculature is preserved and you don't see any evidence of local. The patient

had a follow up PET also in this particular lesion. We continued to stay PET negative. So this is another potential advantage where we use IRE. When we have lesions which are in close proximity to vasculature, we don't have to, we have not, for over 600 treatments now we've not performed separation maneuvers and so far. We also published our results when we looked at the

effect of IRE on vasculature in over 100 patients in CVAR. About 7 patients showed changes in their vessels and all of them interestingly were the portal vein, of which one was of clinical significance.

do you have any question? Anybody?

>> [INAUDIBLE] >> What do you mean? I'm not sure I understand the question. How do you do creating a pneumothorax without actually puncturing the lung? There is a special needle. It's called the- >> Yeah.

>> Safe-T-Centesis needle. I don't know, you have an example of that to show? >> No, I'm sorry I didn't prepare it but- >> Yeah, the Safe-T-Centesis is the least traumatic that you can achieve. It doesn't mean that

it works all the time but it tells you when you reach the pleura. >> [INAUDIBLE] >> Yeah well actually you know it's a blunt tip that tells you. [CROSSTALK]>> Veress needle used for a- >> It's a modification of the

Veress needle. >> Yes. >> It's the Safe-T-Centesis, you're right, but it becomes blunt before it forms the actual loop. If you see the end of it, it has a little trocar, but

when it reaches the pleura it tells you with a little red marker on the handle that it reached the pleura and it becomes blunt. So at that point you have to inject something to separate, to create a space and then advance. >> As soon as you are in pleura you have negative pressure and the little bead is moving so you know that you are in the pleura.

If not, the last thing of the case I have presented, you can use also the sheba/g but you may injure the vessel or pleura. It's very risky. >> Just to- >> Question. >> Yes, go ahead. >> [INAUDIBLE]

[INAUDIBLE] >> With cryo, the stick node is sufficient. The problem in that when you go to thaw, if you do an active thawing, you may lose your retraction so you have to take care of that. >> So with microwave there is one of the vendors that actually has

a small Cryo-Cycle that is called the Tichlog/g that it does exactly the same thing like the Cryostick. The other microwave devices are less likely to do that but they all have some char but is less reliable obviously than the one that has the cryostick or cryoablation for that matter. In terms of how much pressure,

I think you have to kind of get a feel for it with your hands and watching on probably CT fluoroscopy real time where you're going and how much space you need to do this. >> It isn't working any time. Sometimes you have some adherences and it's

very difficult to withdraw the nodule but generally it works. >> So we need to wrap it up I think.

Okay in terms of renal cryoablation just very quickly, irreversible cell damage typically occurs around minus 20. The cryoprobe is a closed gas expansion systems.

Probably heard of the Joule-Thompson effect. Rapid expansion of the gas you get a change in temperature, most gases under the Joule-Thompson effect induce cooling, helium actually warms up, and again

the iceball is growing by thermal diffusion, different from the microwave. In terms of mechanisms of cell death you get intracellular ice formation, extracellular ice formation, disruption of intra and extracellular membranes.

osmotic shifts and dehydration. Just to plug for Dr. Enduran and Dr. Clark wrote an incredible paper on the mechanisms of cryoablation. If you ever want to look into the details, very, very nice paper. I think probably one of the most important things to know about

cryoablation is the edge of the ice ball, that is not your ablation zone. That is not your lethal ice edge. You have to remember it's minus 20 or less, and so you need to be

aware that that's several millimeters inside the outer margin of the ablation of the ice ball that you can see on CT. You put in multiple simultaneous probes you can get kind of this confluence. You can make really big ice balls. You can also kinda sculpt or shape your ice ball depending on the

size and location and sort of configuration of your lesion. You can change the amount of gas that's delivered to the system. So in terms of renal cryo what are the advantages? I think the most important thing, the biggest differentiator is the ability to see the ice ball on MR, on CT, on ultrasound,

you can see it very well in any of these modalities. You can modify the growth rate, the size, the shape of the ice ball. You can sort of sculpt it as I mentioned. And for that reason you can perform ablations near ureter, bowel, other structures so you obviously wanna be very careful,

if you can use this in combination with hydrodissection or in displacement techniques, and do this very safely. Other advantages, there's actually quite a bit of clinical experience now. Longer term outcomes data has come out.

It's well tolerated under conscious sedation as we discussed. It's a non electrical technique, no grounding pads. It tends to maintain the renal architecture, something that is less likely to induce a urine leak and collecting system injury is uncommon

there was a nice paper out of Duke that showed extending ice ball into the renal sinus. And it's very unlikely to cause collecting system injuries. What are the disadvantages? Well, the longer ablation time. You can take up to half an hour to once you start,

you get your probes in place, you start the ablation it will be thirty minutes before you're done with that. There has been a higher association with bleeding and hemorrhage associated with cryoablation. Larger

applicator size is really the surface area of the probe is really important, the size of the ice ball that you can create, many of you who have used these systems know that the process can be substantially bigger, you get smaller ablations per applicator so in most cases we are using multiple applicators for renal ablation.

Then there's the logistics you gotta bring out the helium tanks, the argon tanks, and that's a little more difficult compared to some of the other techniques. So what are the outcomes renal cryoablation, here's a study by Christos Georgiades. And he looked at 134 biopsy proven RCCs, they had excellent overall

fiber survival over 97% cancer specific five year survival 100% and none of their patients develop metastasis during the follow up period and had low rate of CTCA radio complications. They had one transfusion requiring hemorrhage. So overall, they determined that CT-guided percutaneous cryoablation highly efficacious, very favorable safety profile.

How does it do versus partial nephrectomy, this is a great study by doctor Thompson. Came out a couple of years ago, they were comparing partial nephrectomy, radio frequency ablation and cryoablation. This is from the Mayo Clinic Renal Tumor Registry which is an unbelievable registry it's contributed so much to our literature.

Retrospective review over ten years of data and basically they found that their recurrence free survival for partial nephrectomy was the same as ablation that statement groups the RF and cryo patients. Overall survival's superior after partial nephrectomy but again with the current AUA guidelines we're getting the patients

with more comorbidities so that's also not unexpected selection by us there. Other papers that have come out using cryoablation after partial nephrectomy, again this question you get from patients if you're discussing risk benefits and alternatives to the different options.

What happens if it comes back? Whether it's after partial nephrectomy or after ablation you can perform cryo, this is a nice study look at that after it's lateral partial nephrectomy. It's feasible low rate of major complications and they were able to demonstrate that preserves renal function,

very important. A lot of patients are obviously concerned about that.

Okay something you may never have heard of photodynamic therapy. What is that?

It's another non thermal ablation technique. Basically it has been used in dermatologic applications in the past. You're intravenously injecting a photo sensitizer, it travels throughout your body. It doesn't necessarily concentrate in the tumor as it says here

but it collects in the tumor. Then you activate that photo sensitizer with a light fiber and the ideas that the tumor's life will be destroyed. And so, there've been a number of agents over the years the original agents, you couldn't go out in the sunlight for a period of time afterwards because basically you'd activate it.

The newer agents don't have that problem so there's some vascular targeted photodynamic therapy agents otherwise known as VTP, basically it's generating reactive oxygen species and you get cell death it's kinda like a ischemia reperfusion injury. This was a study that we recently did at Memorial. One of the names of these

sensitizers is WST11 and basically we're putting in fibers. This is all in pigs. Illuminating after the infusion of the sensitizer. We did 68 ablations, looked at CT histopathology from four hours to seven days, and we were able to find really well demarcated zones

of nonthermal necrosis, they weren't that large just per fiber so you have to put in multiple fibers. That's one of the issues with this technique but multiple fibers you can get this confluent necrosis. So 2016 we've made a lot of progress and I think there's still some significant knowledge gaps in the field of renal ablation.

We still don't have definitive parameters for radiographic success. We don't have good comparative effectiveness studies relative to active surveillance which is certainly something we should be talking about in the right patient population. We need some patient reported outcomes data. This is becoming more and more important,

we need some cost effectiveness

irreversible electroporation IRE, we're applying a short duration high voltage pulses, you have to have multiple electrodes, in order to do this and basically you are irreversibly damaging the cell membrane. That's predominantly a non thermal technique although there's some evidence,

there is some thermal effect there and there are multiple parameters that affect the outcomes and length of pulses. The number of pulses, the spacing, the current that's applied, the voltage so it's a fairly complex algorithm that goes into this.

There's a lot of modelling software that's typically built some of these machines. What are the theoretical advantages is where you can treat near blood vessels without that heat sink effect. It's got a cellular killing mechanism basically maintains the extracellular matrix so if you're close to vital structures this may be a technique

that you wanna consider. The problems are that it does take quite a bit of experience and training on skill in order to use this, get the probes place just right there's a lot of planning software as I mentioned, typically requires paralysis to do this.

Not a lot of outcomes data. At least in the kidney there's some animal data that's quite promising. There is an ongoing prospective human study that will be interesting to see what that shows in a few years.

I'll go very quickly just to show some images and frankly I'm in the first case, the HCC. In a compensated cirrhosis, the patient who received prior TACE and RFA.

And you see this is like the story of these patients who will develop new tumors over time. So one issue is to do a good job the first time you see and you diagnose the tumor, but another issue is to really be very careful and meticulous in the follow up. Because literally 100% of the patients will have new tumors in the next three to five years. So in this particular

case, you can see that this is one of the tumors and this is the other one of the tumors. And because of the location of this tumor, again in the hepatic vascular, according to the approach that Raj has already described, we opted for IRE. And you can see the

four-needle configuration as here for the lesion next to the cava, and the three-needle were used for this lesion here. And this is actually the outcome, this is the prior RFA combo case. This is the lesion next to the cava, and you can see that it looks like we got a decent margin in both instances. So that's one of the case. I

Last one, my case again. This is a biopsy-proven HCC. This was again, January of 2011. Extremely close to the gall bladder. Again, it would be interesting

to hear the comments of the panel on what ablative modality they would use, if at all they would choose this for ablation. >> One quick comment about veins. We've been studying this a little bit at our place, and it turns out that the hepatic veins and hepatic artery are pretty hard to shut down with almost any thermal ablative modality. So would we have a tumor in those locations, we just

go really hard at it. More probes, longer times, bigger ablations, that kind of stuff, to try to overcome the heat sink effect. The portal vein, especially in cirrhotics we're a little more worried about and especially because the bile duct runs with the portal vein. So we're a little more careful there. With the gall bladder, we've started to become a little bit more

carefree about it, I have to say. We were very cautious for a number of years, we used to kind of hydrodissect the gallbladder away from these ablation zones. We go at it now, and there's been some fairly decent studies in the RF literature that shows that patients will sometimes get a non-infective cholecystitis-type picture for a week or two afterwards if you really burn the wall of the gallbladder.

But they don't perforate, they don't just like fall apart and spill bile into the abdomen, but there's no question it can hurt afterwards for a couple of weeks. >> So this patient was treated with five needles, we used IRE

because of the proximity to the gall bladder. And this was an attorney, who actually went against medical advice the next morning to work, and, [LAUGH] He left at 10 in the morning. And so this is the 1-month follow up with no evidence of collateral injury to the gallbladder, and the lesion was non-enhancing. And due to the lack of time, I'm gonna

move fast. His six-month follow up and 15-month follow up, again with no evidence of local recurrence. The patient went on to have a successful transplant. So I'm gonna stop here, and hand it over to Riccardo. You have a case? >> For that,

In summary producing is...relation of...a real soccer sonoma has promising

...outcomes but up to fifteen, fifteen months of clinical and forty six months of imaging follow-up the declined india far was minimum and the mobility related to the operation procedure itself ...low your numbers can be avoided by using a tangential approach and avoiding direct puncture of the collecting system and,...of...include that as a single center study using one ...system and we longer follow-up.

Thank you I can take any questions...may... Yes, one question I have some a little bit confused as to what the term complexity means and how you ...yes so they really don't know from a tree score it's a standardized standardize of what it takes ...consideration is the size of the tumor the end of it like...it component

...units to the collecting system and then if it how close to the middle of the kidney it is so each one is given a number and then for the six is considered low seventy nine is moderate in above that is highly complex? So, we're using any treasury rover cooling of the questions...from ...interfering tumors were not. One thing I was curious about...wouldn't matter whether it tumor was a great for y which

can contemplate something like that. And, it displaying ...better question for fred but what I understand is that to myself as more complex if you miss just a little bit of it it's more likely to recur versus we've seen that if you actually don't have a complete margin with less complex tumors for some reason those tumors don't recur even if you don't the entire thing?

Here are patient characteristics now that we had a fairly morbid population as well as a high...the tumors are also fairly complex with fifty

...being moderate to highly complex and you can see here that the decline india far was insignificant. Technical success. Was a hundred-percent and cancer specific survival...also ...hundred-percent with no evidence of medicine attic recurrence...any of our patients today. We experienced eleven early complications according to the

craving general system which are within the first thirty days ...procedure three the three involved were directly related to the procedure majority of...the main the bad complications where due to patients core abilities, for example, this patient had a stroke seven days after the procedure but he had past history of stroke and number four shows my according on...twenty three days ...procedure in a patient with severe coronary artery disease.

We did have six-year ...that were detected incidentally I'm followup more than thirty days plus procedure three which were associated with critical atrophy. Here you can see that all technique that we use the probes... Too deep into the collecting system and actually penetrated into the...sinus. You can see here.

The...the ...extends from the real sinus through the cortex into the pairing of space and this allows for the...to leak through in accumulate. And, twenty four months follow-up imaging ...the situated sequence you can see the enormous running the kidney...in the ...the prince you can see this completely the vascular...tumor...the year...is surrounding it.

Here's another example with the probes pointed toward the...here...not penetrating the sinus. So, although we don't like to do this anymore this is nap associated with your ...additionally if you coming from a tangential approach in the brain extends into the collecting system this also was not associated with your enormous. However, to avoid that we now use... here we come from the side and since we implemented this

...twenty fourteen we have no...enormous today. So, showing that data when the...pointed...collecting system? And, physics humor's six of the patients...whereas when we use the tangential approach zero percent of the patience of our tournaments with the same tumor complexity. Here's our follow-up we have nineteen months nineteen months of clinical follow-up with sixteen months of imaging follow-up we had one local team

regression and this was in a patient ...a needle biopsy was permitted to he was ...follow-up and came back we sell local recurrence so he went ...radical...me an x plants histology was graded as affirming great for which is an aggressive tumor that we normally do not like to a plate so due to the needle biopsy sample we probably it probably was

a it was affirming great for to begin with and this is a two-minute initially went to a plated so that accounts for the local recurrence most likely. Primary patients pass away due to conditions not related to the relation itself, for example, one patient died of an mri another gi ...another of subsets. Giving us...cancer specifics, specifics survival of a hundred-percent.

You can see are certified patient follow-up we have thirty six patients with less than one year of ...follow-up...with thirty, thirty six month of imaging follow-up sorry excuse me thirty six patients with one or two years of imaging follow-up twenty with two to three and six patients with greater than three are continuing to follow up all these patients are...our follower term.

[BLANK_AUDIO] So this is the Advanced Liver Ablation program. We're going to talk mostly about technical approaches to liver tumors, but we'll also cover different types of tumors, and different types of technology as well. Again feel free to ask any questions as we're going through the discussions, and as I noted this is a very, very august panel

that we have today. Our first presenter is going to be Dr. Stephen Ho. He's a clinical professor at the University of British Columbia, right down the street. In fact, he was working this morning. He's the head of the Section of Interventional Radiology, and he's the leader of one of the busiest IO practices in North America. It's

an extremely busy practice due to the large Asian population here in Vancouver. He's also one of the founders of the Vancouver General Hospital Liver Treatment Group, which is incredibly busy and very accomplished, as you could tell from many of the presentations that were here this week. I asked Steve to tell us something about himself that most people don't know, and it turns out that he's

called Poppa Ho by his trainees. >> [LAUGH] >> He claims because he's so young. [LAUGH] And interestingly enough, he writes all of his notes in a green fountain pen just like the head of MI6. So it's Ho, Stephen Ho.

[LAUGH] I'll be the next presenter. I'm a professor of radiology, biomedical engineering, urology at the University of Wisconsin. I've been working ablation for many years. I'm one of the founders of NeuWave Medical. And one of the things you may not know about me is I'm a huge Michigan football fan, and I grew up with

the Harbaugh brothers in Ann Arbor, Michigan. Don't ask my opinion, by the way. My co-moderator today is Raj Narayanan, who everybody knows, there's no need for an introduction here. He is a professor of radiology at the University

of Miami, and the chief of vascular and interventional radiology in Miami. He's a true world authority in interventional oncology, and he has likely the world's greatest experience in IRE, both in the liver and the pancreas, and he'll show you some things today. He has a great meeting down in Miami every year named Synergy,

if you've never been. And when I asked him to say something about himself that people don't know, he only said, due to a recent WikiLeaks release, everybody already knows everything about him. >> [LAUGH] >> www.drraj.com. >> [LAUGH]

>> Our next presenter will be Riccardo Lencioni, he also needs no introduction. He's a professor of radiology now at the University of Miami, lately at the University of Pisa. He's the director of Interventional Oncology Research at Miami, and is truly one of the founders. I wanna call him one of the fathers of interventional oncology, but he's too young for that. As you can see, he looks like a male model

up here. And so when I asked him something about himself that most people don't know, it turns out that he has a past life as a professional soccer, I mean football referee. >> [LAUGH] >> We were speculating male model based on the picture, but that didn't fly. Our last faculty member is Dr. Costi Sofocleous, who we all

know as well. He's from Sloan Kettering, he's a professor of radiology at Cornell. And is an extraordinary interventional oncologist, who does all kinds of crazy stuff that most people wouldn't do. He's well published, and is the foremost authority on treatment response. He uses PET/CT to treat liver tumors and all kinds of other crazy technologies that we've only heard of in our dreams, I think. Right,

Costi? When I asked him something about himself that most people don't know, he says, I'm great looking and modest. >> [LAUGH] >> And I said, tell us something we don't know! >> [LAUGH] >> So he said, he can kick some a.. on the tennis court.

[LAUGH]

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