Ablative treatment modalities for kidney tumours. Ankara, 6th November 2009

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1 Ablative treatment modalities for kidney tumours Ankara, 6th November 2009

2 Vasa Central Hospital, Finland Peter Nylund

3 Nephronsparing cryoablation of kidneycancer Vasa Central Hospital Finland Preliminary five years experiance

4 Renal Cryosurgery From open transabdominal renal cryosurgery over percutaneus renal cryosurgery to laparoscopic renal cryosurgery and retroperitoneal renal cryosurgery

5 Result: All single tumour patients tumour free several years later on MRI Advantage: Less expensive Comfortable for the patient Small tumors 2 3 cm Cryoablation of kidney cancer December Sepember -09 If just one solitary kidney left Absolute need of haemodialysis in case of radical nephrectomy In one patient 5 multiple tumours in the same kidney Nephronsparing cryoablation with 6 cryoneedles 17G, 2 thermosensors, 2 cycles -70ºC

6 Patient 1 78 years old male Aortal valve insufficiency Post myocardial infarction CABG 1993 Microhematuria in fall 2002 Kidney US: lower pole right kidney tumour 3.7x 4,5 cm, 1 month before 2,4 x 2,7 cm Referred by GP

7 Preop MRI

8 Renal insufficiency Krea 176 Kidney MRI: renal tumour (carcinoma) in the right lower pole Preop Thorax-rtg: no metastases OPEN CRYOABLATION Open needlebiopsy-pad GI renal cell cancer Open nephronspearing cryoablation 2 times 5 min freezing to -40 and -70 C

9 Postop Preop Krea 184 (181202) Postop Krea 233 (221202) Preop Hb 131 (181202) Postop Hb 92 (201202) EPO IE s.c. + Spartocine 1x2 No transfusion Delivery Hb 103 (261202)

10 MRI 1 year 3 months later

11 Follow up Urol pkl (3 month) Krea 221, Hb 127 No dialysis Kidney US : 1,9 cm cystic process in the right lower pole Kidney MRI : no tumour left, just fibrosis Kidney US : same cystic process Kidney MRI : no tumour Kidney US : same cystic process Kidney US : no tumor, Krea 208 Kidney US : still no tumour, Krea 223 Kidney US : still no tumour, Krea 123

12 Patient 2 79 years old female (Jehova witness) Arterial hypertension Back pain Rising Krea from 95 to 174 Abdominal US: bilateral renal cysts Kidney MRI: 4,5 cm cyst in right kidney 3 cm tumour in the medioposterior part of the right kidney. Left kidney hydronefrotic with duplexsystem and parenchymal reduction

13 Preop MRI

14 Good renal function only in the right affected kidney OPEN CRYOABLATION Open nephronspearing cryoablation with 6 ultrathin 17 G cryoneedles 10 min 2 cycles -40 C Pull back 1 cm 10 min 2 cycles -41 C

15 Postop Postop Krea 122 no dialysis needed Postop Hb 82 EPO IE s.c. + Spartocine 1x2 No transfusion needed

16 MRI 1 year later

17 Follow up Kidney US : no solid tumour left Kidney function normal : Krea 89 Kidney CT scan : no tumour Kidney US : no tumour Kidney US : no tumour Kidney MRI : still no tumour Kidney US : still no tumour, Krea 106

18 MRI 4 years later

19 First 2 patients with kidney cryoablation Still free from tumour 8 years later Still kidney function not impaired

20 Patient 3 51 years old male leftside transabdominal radical nephrectomy PAD: 5 cm renal cancer Right kidney US : hyperdensitive focus 15 mm Kidney : 3 focus in the lower pole, one focus in the middle and one in the upper pole multiple tumours single kidney

21 Preop: Multiple tumours

22 Single kidney cancer OPEN CRYOABLATION Open needle biopsy: PAD: clarocellular renal adenoca open nephronspearing cryoablation with ultrathin 17 G cryoneedles 5 up to 2 cm tumours are freezed down to -70 C each

23 MRI 6 months later

24 Follow up Preop Krea 96 (050603) Postop Krea 295 (080603) Krea 110 (250803) 2 months later No dialysis needed Kidney MRI : rest after cryoresection Kidney MRI :no contrast concentration in resection area Patient uptaking sports activities: Vasaloppet in spring 2004 Kidney MRI and : same status

25 Multiple tumor recidives MRI 20th september 2005

26 Postop: MRI

27 Second open transabdominal multiple cryoablation on right kidney 17th November 2005 Preop Krea 108 Postop Krea 360 Controlled Krea 214 2nd January 2006 MRI : no tumour Still no dialysis

28 Nephrectomy l.dx Kidney MRI : 3 new right renal tumours, of which one close to hilus Radical right nephrectomy PAD pt3n0g2 renal adenocarcinoma Thoraxrtg : small suspect findings in both lungs Cerebral CT : 3 cerebral metastasis Rx and Sutent in our oncologic unit

29 Percutaneus ultrasound guided cryoablation of renal cell carcinoma 85 years old male Severe aorta valve stenosis with dyspnea Debuted with hematuria und right flan pain elevated Krea >200 US right kidney hydronepfrotic, lower pole 3 cm tumour double pigtail to the right side Krea down to 176 US needle biopsy PAD: clarocellular renal adenocarcinoma GI

30 Lower pole tumour in the right kidney

31 Inoperable due to cardiac disease New option needed: Nephronspearing in local anesthesia Percutaneus cryoneedle ablation of right lowerpole tumour in ultrasound control 22nd March 2005

32 Collaboration between urologist and radiologist

33 Ultrasound guided needle insertion

34 Template guided

35 Freezing shadow on ultrasound

36 Follow up MRI at one year 14th February 2006

37 MRI : no tumour

38 Follow up Pig-tail withdrawel Cystoscopi OK No more haematuria MRI : Tumour shrinking MRI : No tumour US : No evident tumour Krea 136, Still alive MRI 2008, no tumour

39 Laparoscopic cryoablation of kidney tumour 14th March 2006

40 2 cm tumour in right kidney, 70 year old male, Krea 127

41 Laparoscopic exploration of the right renal tumour

42 Percutaneus needle insertion after laparoscopic exploration

43 Freezing first needle for fixation of the tumor

44 Transabdominal intraoperative US Mandatory to find and define endophytic tumours. Guiding needles placement in all tumours, exophytic as endophytic.

45 6 cryoneedles 2 cm deep and 2 termosensors in place

46 Freezing down to -70 degrees Celcius 10 minutes

47 Thawing before a second cycle of freezing

48 Second cycle of freezing

49 Follow up CT scanning : no more tumour CT scannig : no tumour US : no tumour

50 Futher experience By now 5 lapaoscopic renal cryoablations Successfull results Iceseed or Icerods Termosensor in the middle of the tumour and 0,5 cm outside the tumour

51 Retroperitoneal approch 3 patients with a small kidney tumour on the back side of the kidney A minimal lumbotomy was made to get direct approach to the tumor Cryo needles inserted percutaneusly under open vision PresIce controlled freezing

52 78 year old male Nephrectomy of the left kidney 2001 due to renal cancer US and CT 3 cm tumour on the backside of the right kidney Krea 131 before cryoablation Krea 217 half a year later

53 Retroperitoneal Cryoablation

54 Postop follow up: MRI : no tumour left MRI : no tumour

55 64 year old female US due to abdominal discomfort 2006 Preop CT ,5 cm tumour in the right kidney Cryoablation PresIce Tacozil for control of bleeding PAD: oncocytom MRI : no tumour US : no tumour

56 72 year old female Backpain fall 2006 Preop CT ,5 cm tumour in the right kidney Cryoablation PresIce Tacozil for control of bleeding PAD: Adenoca G1 MRI : no tumour

57 Next step Retroperitonel lapascopic approach as in Heilbronn, Germany

58 Laparoscopic approach standard Transabdominal laparoscopy for cryoablation of tumours on the anterior side of the kidney Retroperitoneal laparoscopy for cryoablation of tumours on the posterior side of the kidney If robotic surgery availabel it can be used equally

59 Conclusion 1 All nephronspearing cryoablation is a safe option of kidneycancer treatment in patients with small tumors < 4 cm and risk of renal failure No dialysis needed cheep Good quality of life

60 Conclusion 2 Nowadays cryoablation of small kidneytumors < 4 cm cm is used on regular bases as a nephronsparing method Percutaneus, laparoscopic or open surgery routes can be used equally, depending on the site of the tumor and the possible approach

61 Marberger,EAU Milan 08 Pooled 5 years followup data showes cryoablation of small kidney tumors as superior to RF. Cryo patients 98% disease free RF patients 80% disease free

62 Cryoablation of small renal tumours produces recurrences rates approaching, and morbidity rates significantly less, than those of LPN. Kyle J. Weld and Jaime Landman 2005 BJU International / 96,

63 5 years results of laparoscopic renal cryoablation seem to be sustained over time. Robert J. Stein and Jihad H. Kaouk 2007 BJU International / 99,

64 Jean de la Rosette, Amsterdam 2008 Cryablation can safely be offered to all patients with small kidney tumors

65 Cryoablation of renal tumours should be limited to lesions not greater than 4 cm D. Brooke Johnson et al The Journal of Urology /04/ /0 Vol. 172, , September 2004

66 Pegasus The winning ice sculpture on the marketplace in Vaasa The international ice sculpture competition 2004

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68 Welcome to Vaasa