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Introduction | Renal Ablation
Introduction | Renal Ablation
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Renal Cell Carcinoma: Facts & Therapeutic Options | Renal Ablation
Renal Cell Carcinoma: Facts & Therapeutic Options | Renal Ablation
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Patient Selection Using TNM Staging & R.E.N.A.L Nephrometry | Renal Ablation
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Case: Radiofrequency Ablation in RCC | Renal Ablation
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Case: Cryoablation in Renal Cyst | Renal Ablation
Case: Cryoablation in Renal Cyst | Renal Ablation
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Case: Cryoablation in Endophytic RCC | Renal Ablation
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Case: Cryoablation in RCC | Renal Ablation
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Case: Microwave Ablation in RCC | Renal Ablation
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Case: IRE in RCC with Comorbidities | Renal Ablation
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Technical Outcomes of Percutaneous Ablation | Renal Ablation
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Oncological Outcomes of Percutaneous Ablation | Renal Ablation
Oncological Outcomes of Percutaneous Ablation | Renal Ablation
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2018ablationAVIRcellchapterclinicalepidemiologyfull videoguysinterventionalpercutaneousrenaltechtunneled

- Thank you Dr. Osland. So, our next speaker is Dr. Gunn. Dr. Gunn received his medical degree from the University of South Dakota, he then completed his residency at Massachusetts General Hospital where we got to know him as just an incredible person,

hard worker, and a driven person to improve clinical care. He then moved on to John Hopkins to do his interventional radiology fellowship and since has established himself pretty well in terms of spearheading a clinic and being a big driving force in terms of

IVC filter management, uterine artery embolization. Anybody who's on Twitter, you'll see how active Dr. Gunn is and the impact that he's making with the media to spread the word about the great things that we do in IR. Today he's gonna to talk to us, which gets just a little bit still keeping in the same vein as cancer therapy

but now we're gonna move a little bit into RCC, so renal cell carcinoma. So with that, I'm going to ask Dr. Gunn to come up and share his expertise with us. Thank you. (audience clapping) - [Dr. Gunn] Good morning.

Thanks Rob, I appreciate it and to Chris and to Stephanie for inviting me here. I'm really honored to talk to you guys for a little bit about the part of my practice that is a big part of my practice and especially because I always tell my trainees

that it was a tech that taught me how to put in a PICC line. It was a tech that taught me how to put in a port. It was a tech that taught me how to put in a tunneled central line. So I really appreciate what you guys are doing. I'm happy to be here and talk to you guys today.

So I've just got three objectives. First, I want to review the epidemiology of renal cell carcinoma, the treatment options that we have for patients, and how we select patients for percutaneous ablation and interventional radiology.

I'm gonna show you guys five or six cases that are gonna kind of highlight the technical aspects of percutaneous ablation and then finally, I'm just gonna show a couple slides about the clinical outcomes after percutaneous ablation.

So, renal cell carcinoma,

It's gonna count for about 15,000 patient deaths this year. It's about 4% of all new cancer diagnoses and the incidence of renal cell carcinoma's actually increased in the United States. And why is it increasing? It's increasing because we're scanning patients more often

with ultrasound, with CT, with MRI and we're finding more and more of these incidentally detected renal masses. Like this patient here who's a 65-year-old guy. He comes in for right lower quadrant pain. He gets scanned, and then all of a sudden

you find a two and a half centimeter exophytic RCC which you can see on the screen. And so the good news for these patients is that these incidentally found masses are of lower grade. They have longer survivals, and patients do better than the symptomatic masses

but once we find them, what are we gonna do for these patients? Well, one of the options one of the options is just a surveillance, right? Renal cell carcinoma's an extraordinarily indolent tumor. It has a doubling time of about 500 to 600 days.

What I tell my patients at this clinic is we're talking about three to five millimeters a year. So you're coming across somebody who's maybe an 85-year-old patient and it's a one and a half or two centimeter tumor, maybe we're gonna watch this for six months or a year

and kind of see where it goes from there and that's a totally reasonable option. There's a whole group of therapies that people are gonna classify as nephron-sparing interventions. And what they mean by nephron-sparing interventions

is they're not taking out the whole kidney. And the reason I have lap or open partial nephrectomy in gold there is because that's considered the gold standard therapy for patients with RCC. There's laparoscopic ablation which surgeons can do and then there's percutaneous ablation

which is an interventional radiology therapy. And then, of course, patients can always go to radical nephrectomy, but you can see they lose a lot more or their kidney. You lose a piece of the ureter, and then they cut the artery.

They cut the vein, so it's a lot more morbid, which is why people opt for nephron-sparing interventions whenever possible.

So how do we choose patients? Well, we do best in interventional radiology when we know it's a T1a tumor.

And what that means, it's confined to the kidney, but it's less than four centimeters in size. But anybody who does enough renal interventions, renal ablations, are gonna tell you that we see plenty of patients who are not good surgical candidates because of heart failure, anti-coagulation issues,

oxygen issues, and so we see a lot of patients that are T1b tumors between four and seven centimeters. I went back and looked at UAB's data for something that we're writing up and we have plenty of tumors that are eight, nine centimeters in size as well. So these indications are expanding,

especially as we get an older, sicker patient population who are unable to undergo a traditional surgery. And then on top of that, just in JVAR, last month or two months ago there was a report of about 30 patients that they had done when there's actually renal vein involvement,

so we're kind of creeping more and more into RCC. So this is one way to look at it. It's the R.E.N.A.L. nephrometry score. It includes the radius of the tumor, whether it's exophytic, where it's popping out, or endophytic, whether it's within the kidney.

The nearness to the collecting system and also whether it's anterior in the kidney or posterior to the kidney. Now I would never go to one of my patients in clinic and say, well your R.E.N.A.L. nephrometry score is nine so I'm not gonna do it, but what I tell my trainees

is that the nephrometry score is a good way for you to kind of visualize and think about whether this is going to be a difficult ablation or a straight-forward ablation. So I think it's important. We'll see some examples as we go through here.

So, like I said, I'm gonna show you a couple of cases

that are going to discuss the technical aspects of ablation, and the oldest and probably most studied technology is radiofrequency ablation. This is a case that Deb Gervais and I did back when I was a resident.

So, a 56-year-old man, two centimeter RCC. You can see it there, and I hope you can... Does this point? There's a pen on here that points, perfect. So what you're gonna see here is, when I think about ablation, what I like to do

is think about, OK, if I was gonna use a scissor where would I want to cut that kidney to get that tumor off? And that's one of my ablation probes is always gonna go across that location if I can. So, what you can see here is this two and a half centimeter RCC.

This is the RF ablation probe, acting almost like a scissor, because what I'm gonna get, is I'm gonna get margin on this side of the kidney, and then I'm gonna devascularize the tumor on this side of the kidney so I know I'm gonna get good kill, okay?

Now RF ablations uses electricity. It goes through the patient and it causes the water mole-- I don't want to get too much into this because Dr. Akhmed's gonna talk about this but, and it causes the water molecules to vibrate and that vibration of the water molecules causes heat

and that heat kills the tumor. This is immediately post-ablation. You see some air bubbles. We see that all the time. We see a little bit of blood. I tell my patients, you're gonna bleed a little bit.

How much we don't know until we do the case, and then there's some hyper-density along here and that's the coagulative necrosis and so it's not blood, it's actually the dense tissue after you burn it. And this is that same patient six months out.

You can see that there isn't any enhancement here and so we know this patient has had a nice response. I don't do a lot of RF for renal tumors anymore because you have to put a grounding pad on the patient. It can cause skin burns. It's a little slower and on top of that

it's a little more, thermal technologies, I think, are a little more uncomfortable than the freezing technologies. And you're gonna see some cases of that.

So... I do primarily cryoablation,

and what I mean by cryoablation is that we freeze the tumor, And so this is a very typical case. This is a 45-year-old gentleman who had an incidentally found complex right renal cyst that we see here. Had a little bit of calcification in it.

They watched it, but it grew over a year and so they referred the patient over for percutaneous ablation. And again, you can see what we're doing is we're coming across. This is almost acting like a scissor.

I'm cutting across here. I'm getting a margin on this side, and I'm devascularizing that tumor. So I'm thinking about that every time. On top of that, every time I'm doing ablation, especially with cryoablation, what I'm thinking is,

I wanna point my probe to the area of danger, the area that I'm most worried about. And it's a little counter-intuitive, but what happens is when you freeze, you freeze out this way, and you freeze out this way, but you only freeze about five millimeters out from the tip.

So I know I can control my ablation zone out from the tip better than I can control it on perpendicular to my probe. And so you'll see that on another case. I'm always pointing to the area of danger. And this is another reason I like cryo, because it is a little slower,

but it's a lot more comfortable for patients, I think, And you can see. What I really like about cryo is I can see this ice ball being formed and so I know how close it's getting to the renal hilum. I know how close it's getting to critical structures

and that makes me feel very comfortable. I know I'm getting a good margin when I'm using cryoablation.

So this is another patient, 52-year-old male, anterior, endophytic RCC. We're talking about R.E.N.A.L. nephrometry score

again, seeing this patient in clinic you're thinking okay, well it's endophytic, not ideal. It's anterior, not ideal. It's small, so... But this patient's never going to go to the OR, right? So it's either we watch this, or I'm gonna do something.

And if you can hallucinate over here, this is the ureter, and so that's really what's... It's here and then it's also up here. And so that's the thing that I do not want to freeze. That's the point of danger that I don't want to freeze at all.

And so when I'm planning my ablation what do I want to do is I come across and I point toward that area of danger because I can control my ablation zone there. So I hope that kind of makes sense. And then I'm thinking about creating a margin here,

And then I know I'm going to devascularize out here. So this is immediately, this is during our ablation. You can see here's the low-density area. This is my ablation zone. It's safely away from my ureter. Again, one reason I like cryo,

I know exactly where I am all the time. I don't have to guess like I have to do with the thermal technologies. And this is the patient six months later, no enhancement on CT follow up, so we know we've had a good result, okay?

And we follow those patients out for about five years.

54-year-old man, lymphoma. Again, incidentally noted to have RCC. And so what's dangerous about here is it's you know, it's anterior, but it's exophytic. It's not very large, but there's colon

draping all across the kidney here. So that's what makes me nervous. I never say to the patient, wow I'm really nervous about your case, but I'm thinking about this when I'm seeing him in clinic. The other thing that you don't really know

is once you put the patient prone, or once you put them on their side, you're not ever really sure what this is gonna look like. So when the patient goes prone, I'm still not happy with how much... So, instead of cutting across like a scissor,

what did I do? I decided to point toward the danger, which is the colon, so I'm pointing towards that danger, but I still don't love how close my ablation probes are to the colon across here. And so one adjunctive maneuver that we can do

is I insert a 22 gauge needle into the space between the colon and the kidney and I put fluid there and so that's hydrodissection. Some people use air. I like to use fluid in this situation because it's gravity-dependent.

If, for example, I wanted to dissect up here, I might put in air, because then it's gonna go to the top of the patient. So once my probes are in place, then I do hydrodissection, and now I feel really comfortable

that my ablation zone is going to be far away from my colon so I feel really good about that, right? And so we freeze, and this is six months post ablation. You can see no enhancement, fiber fatty change around the kidney, the guy's gonna have a great result, okay?

So, microwave ablation again is a thermal technology. This is from one of my partners, because I don't do a lot of microwave ablation, but it's similar to RF in that it burns the tumor. You don't have to have grounding pads like you do with radiofrequency ablation,

because it does it inside the probe itself. It's quick. It is a little more painful than cryoablation, but the speed about it is really one of the things that makes it nice. This is a two and a half centimeter right RCC.

You can see that it's exophytic, and you just kind of come in with the probe and then you burn. This is immediately post ablation. There's that hyper dense area, that coagulative necrosis that we also saw with the RF ablation,

and then this is two years post ablation. The nodule's getting smaller and you see that kind of fiber fatty change around there. So this patient's had a nice result, okay?

So what are we gonna do with this guy, right? So this guy is never--this is his RCC.

This guy's never gonna go to the OR because he has sever portal hypertension, CHF, COPD, all these other things. He's got colon, he's got small bowel, and he has this huge dilated IVC. I can't hydrodissect this,

like which area of danger am I gonna point to? And so this is a really great application for irreversible electroporation, or IRE. And so this is what I use as a secondary, some people call it nano knife. I use it as a secondary ablative technology

because what's good about it is it's a little cumbersome because you have to be very exact with your probe placements but what it does is it sends electrical pulses between these two probes and then between this probe and that probe

and then between that probe and that probe But it doesn't burn, it doesn't burn anyway, but it doesn't kill tumors outside of the probes. It only kills tumors inside the probe And so, in this kind of a patient

where I'm worried about the IBC, I'm worried about the small bowel, I'm worried about the colon, that's kind of where I'm going to use the IRE I don't think anyone's really using this as its primary ablative technology.

but for areas that we're concerned about or edges that we might not have gotten the first time it's a great option for here. And this is six weeks post ablation. No enhancement. He's doing great. Okay?

So just a couple slides about

the clinical outcomes after ablation. Number one, we are about 95 to 100% technically successful when the tumor's less than four centimeters. We are almost exactly, we have oncological outcomes almost exactly like surgery. And so we do really, really well.

As we've seen, larger and endophytic tumors have lower success rates, but complications are anywhere between four and 10% depending what you read. Bleeding, you know you're worried about that a lot It's a highly vascular organ.

You're poking it multiple times, and then you're either freezing it or you're cooking it, so you're always worried about bleeding. Infection, renal impairment, damage to the collecting system, and damage to adjacent organs,

and I show this case because this is really the one bad outcome I've had of the close to 100 now of these that I've done This is a 52-year-old lady complex right renal cyst that you can see, I mean it's this nodule everybody's worried about.

Here, when you look at her MRI, I'm not really worried about anything. It's large, but it's exophytic. I think, you know, we're gonna have a nice result here, But when we turn her on her belly the colon became a lot closer to the kidney

and so we proceeded with hydrodissection. I felt like we had a good hydrodissection margin And you can see that nice ice ball that was one of three probes that we put in and she did great. We sent her home and about three weeks later she comes in

and she has this huge abcess So I clearly, at some point during that procedure we nicked her colon or froze her colon. Now, fortunately, we put in a percutaneous drain She got a ureteral stent. She was gonna go to the OR but we watched her

she did fine They ended up scoping her at some point and saw no damage to the colon and her kidney healed and so she did great but this is one of the things that you're really, really worried about,

damaging the collecting system, or damaging the colon. The patients can have bad outcomes even though hers wasn't terrible but they can have bad outcomes.

So, oncologic outcomes, there's not really any good randomized

you know Sarah was talking about those randomized control trials, level one evidence comparing partial nephrectomy to percutaneous ablation, right? But when you look at retrospective reviews, this is radiofrequency ablation

versus partial nephrectomy in T1a tumors. They found no difference in overall survival, cancer-specific survival, disease-free survival, or local recurrence in five years. And then another study looked this is a large SEER database review

and that's 578 patients doing RF and 4,402 patients getting partial nephrectomy they found no difference in overall survivor or cancer-specific survival So this is what I'm always telling my patients compared to surgery, we are oncologically equivalent

when your tumor's less than four centimeters. And I say this, looking forward to comparative effectiveness data, so we're gonna look at cost and complications, and I say this because I know there's a tumor brewing, or not a tumor brewing, there's a paper brewing

that's gonna look at that. And so I really think in five to 10 years, it's gonna be T1a tumors is going to be percutaneous ablations's gonna be the standard of care. It's not going to be partial nephrectomy We just have to get there. I think we're getting there.

So, in summary, RCC is increasingly being diagnosed as an incidental finding. Percutaneous ablation is safe, it's minimally-invasive approach to RCC and the oncologic outcomes are nearly identical to surgery for lesions less than four centimeters.

And, with that, I'd be happy to take any questions if you have them. And these are two good papers if you guys are excited to read them. So, thank you (audience clapping)

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