Transcript Targeted Cryoablation of the Prostate where we were where

Management of the Incidental
Renal Mass
Lee N. Hammontree, M.D.
Urology Centers of Alabama
Birmingham, Alabama
Key Considerations

What are the indications for active
surveillance
 What is the risk of progression
 When will it metastasize (Natural History)
 What is the risk of observation
 What is the optimal F/U regimen?
Indications for active
surveillance
Absolute – Not surgical candidates due to
severe comormidities
 Relative – Chronic stable comorbidities
 Elective

– Pt wishes for period of observation due to small
size of renal mass
Observation
110 Patients > 75 years of age (Median 81 years old)
Size Variable
Mean tumor growth – 0.28 CC/YR
43% no tumor growth at 29 months
Four patients progressed
RX’D
31% Died…..None from Renal Cell Cancer
Novick JU 2008, 180:505
Malignancy Risk

2770 sporatic unilateral nonmetastatic solid
renal tumors
 1970-2000
 Reviewed by single pathologist
 Correlation to size
Frank, et al 2003
Histologic Subtypes for benign
and RCC tumors
Number of tumors (%)
Benign

Oncocytoma
 Angiomyolipoma
 Papillary Adenoma
 Not otherwise specified
 Metanephric adenoma

274
 67
 16
 14
 5
(72.9)
(17.8)
(4.3)
(3.7)
(1.3)
There were 376 benign (12.8%) and
2,559 (87.2%) malignant tumors.
Proportion of benign to RCC
tumors based on size
Tumor size (cm)
 0.0- less than 1.0
 1.0- less than 2.0
 2.0- less than 3.0
 3.0- less than 4.0
 4.0- less than 5.0
 5.0- less than 6.0
 6.0- less than 7.0
 7.0 or greater
No. Benign (%)
 37 (46.3)
 38 (22.4)
 75 (22.0)
 71 (19.9)
 37 (9.9)
 40 (13.0)
 11 (4.5)
 67 (6.3)
Bigger tumor = More likely malignant
No. RCC (%)
43 (53.8)
132 (77.7)
266 (78.8)
285 (80.1)
336 (90.1)
267 (87.0)
232 (95.5)
998 (93.7)
Role of Percutaneous Bx?

Indications
– Suspected metastasis
– Suspected lymphoma
– Suspected abscess

Cons
– Seeding tract?
– unreliability
Percutaneous biopsy?

Sampling error is major problem
– Non diagnostic specimens ~ 20%
– Predictors of non diagnostic specimen
 Tumor size (<3cm 37%)
 Number and size of cores
 Experience of cytopathologist
 Presence of cystic components
– Oncocytomas (30% may actually be RCC)
Percutaneous biopsy?

Issue of tract seeding
– Only 1 reported case: Shenoy et al, 1991

Biopsy is of limited value in determining
malignancy risk
Risk of Tumor Growth

Growth rate of RCC vs Benign is unknown
 9 single institution studies
– 234 lesion meta-analysis
– Mean size at presentation = 2.6cm (1.73-4.08)
– Mean follow-up = 34 months
– Mean growth rate = 0.28cm/year (0.09-0.86)
Chawla, JU Feb 2006
Risk of Tumor Growth

No difference in growth rate based on size
of initial presentation
 No difference in growth rates between
oncocytoma and RCC
 No growth = benign
Chawla, JU Feb 2006
Risk of Metastasis

Chawla Meta-analysis of Observational
studies:
– 3/286 had mets in avg. 34mo follow up
 2/3 were tumors > 8cm, other not reported
 One had slow growth (0.2cm/yr) other rapid
(1.3cm/yr)

Bell’s autopsy-based data (1938-1950)
– 3/62 tumors < 3cm metastasized (~5%)
– 70/106 tumors >3cm metastasized
Risk of Metastasis

Duffey et al, JU 2004
– 181 patients with VHL
– 108 patients with tumors < 3cm followed until
tumor reached 3cm (then treatment)
– 73 patients with tumors >3cm
definitive Rx
Risk of Metastasis

Duffey 2004
– Of the 108 < 3cm
 Mean F/U 58.1 months
 71 (66%) went on to surgery due to growth
 No metastasis within the follow up period
– Of the 73 > 3cm
 Mean follow up 72.9 months
 20 (27.4) developed mets
Risk of Observation / Delayed
Intervention

Development of Symptoms
– Poorly reported in observational series
– Chawla: 5 reported cases of gross hematuria

Metastasis
– Chawla: 3/286 cases (were large tumors)
– No published cases of incidental small masses
that have progressed to mets during observation

(Rendon & Jewett, Uro Onc 24:62, 2006)
Surveillance Regimen

Same imaging modality (CT or MRI)
 Consistency in location of measurement
 Best to review films yourself
 Imaging q 3-6 months x 2 years then yearly
if stable
Small Renal Mass
Do we need to remove the entire kidney?
▪
Cancer specific survival
Should we remove the entire kidney?
▪
Long term renal function
Renal Cell Cancer
Incidence - 2007
51,190 Cases
pT1a (<4cm) = 48-66%
5 year survival is 95%
Radical nephrectomy vs. Partial
nephrectomy
Cancer specific survival:
MSK Series
252 patients < 4 cm
189 Radical
79 Partial
95% CA Specific Survival (40 mos.)
Radical = Partial
JU 2000, 163:730
Indications for Partial
Nephrectomy



Bilateral Tumors
Solitary Kidney
Contralateral kidney at risk
– Heriditary RCC
– Medical renal disease
– Stones
– Chronic pyelonephritis
– VUR
– Diabetes Melletis


Exophytic mass <4cm with normal contralateral
Expanding indications….
Survival: Radical vs Partial
327 Patients < 65 years old
10 year survival (OVERALL)
Radical Nephrectomy 82%
Partial Nephrectomy 93%
CKD (not on dialysis)
Anemia, Osteoporosis, CV
Mortality
Mayo Clinic JU 2008, 179:468
Development of Chronic Renal Disease
Lancet Oncology. 2006, 7:735 MSK
662 PTS 1989 – 2005
RX: RN 81% PN 19%
3 year risk of CKD (III) GFR < 60 CC/MIN
65% Radical
20% Partial
Pre-Op GFR > 60 CC
New onset GFR < 45 CC
RN 43% PN 7%
26% had Pre-Op GFR < 60 CC/MIN
Difference from Renal Donors
Nephrectomy (Tumor)
GFR 69 CC/MIN Average age…58
Donor Nephrectomy
GFR 92 – 103 CC/MIN Average age…50
Small Renal Mass
Options for Renal Preservation
1. Observation
2. Partial Nephrectomy (Open, Lap, Haln, and Robotic)
3. Cryo Ablation (Open, Lap, and Percutaneous)
4. Radiofrequency Ablation (RFA) (Open, Lap,
Percutaneous)
Small Renal Mass – RX Options
Meta – Analysis 1980 – 2006
RX Modality
Number Studies
Number Tumor
PN
50
5037 (78%)
Cryo
19
496 (8%)
RFA
21
607 (9%)
Surveillance
10
331 (5%)
UZZO JU 2008, 179:1227
Pathology
Renal Cell Cancer
79.7%
Benign
12.2%
Unknown
8.1%
Local Recurrence
RN
3.7% 226/6140
PN
2.6% (132/5037)
Cryo
4.6% (23/496)
RFA
11.7% (71/607)
Progress to Mets
RX Options
Number
F/U (Months)
PN
281/5037 5.6%
54
Cryo
6/496
1.2%
18
RFA
14/607
2.3
16
Observation
3/331
0.9%
33
Renal Cryoablation Patient
Selection

Candidate for laparoscopic or open partial
Nephrectomy
 Exophytic Mass < or =4 cm
 Solitary kidney
 Multiple lesions
 Renal failure
 Comorbidity putting renal function at risk
Laparoscopic Cryoablation:
Ultrasound Monitoring

Survey of the kidney and assessment of
tumor size
 Ultrasound visualization across the kidney
is essential to monitor the full extent of the
iceball
 Monitor in real-time to confirm total
coverage of lesion + margin
Freeze Test Each Probe
To ensure each
CryoProbe will
function properly
they must be tested
in a basin of sterile
water or saline
before placement in
patient
Laparoscopic Renal
Cryoablation
Intraoperative Real Time Ultrasound

Dedicated articulating laparoscopic transducer
 Place transducer crystal on kidney surface opposite lesion
 Survey treatment progress through normal renal tissue
Ice Ball Formation
Edge of Ice Ball
Acoustic Shadow
August 2006
March 2007
September 2007
September 2008
Comparison of Partial Nephrectomy
and Cryoablation
References:
For Partial Nephrectomy:
All studies quoted in Campbell’s Urology Table 75-15:
“Results of nephron Sparing surgery for renal cell carcinoma”
Study Sizes: 10 – 485 patients, Mean follow-up: 24 – 75 months
For Cryoablation:
Series
Reference
No. Pts.
Mean F/u (mo)
Hegarty
Urology 2006
161
36
Davol
Urology 2006
72
64
Journal of Urology 2006
59
24.5
2006 AUA
60
72
Journal of Urology 2005
56
43
Lawatsch
Hegarty
Gill
Cryo vs. Partial Nephrectomy: Cancer Specific Survival
100
Percent
80
60
40
20
0
Partial Nephrectomy
Cryoablation
1. Andrew C. Novick and Steven C. Campbell. Renal Tumors. In: Campbell’s Urology 8th Edition 2. Nicholas J. Hegarty, et al. 2006 Jul;68(1 Suppl):7-13. 3.
Patrick E. Davol, et al. Urology. 2006 Jul;68(1 Suppl):2-6. 4. Lawatsch EJ, et al. J Urol. 2006 Apr;175(4):1225-9. 5. Nicholas J Hegarty, et al. Presented at the
2006 Annual Meeting of the American Urological Association, May 20-25, 2006, Atlanta Georgia 6. Gill IS, et al. J Urol. 2005 Jun;173(6):1903-7.
Cryo vs. Partial Nephrectomy: Local Recurrence Rate
10
Percent
8
6
4
2
0
Partial Nephrectomy
Cryoablation
1. Andrew C. Novick and Steven C. Campbell. Renal Tumors. In: Campbell’s Urology 8th Edition 2. Nicholas J. Hegarty, et al. 2006 Jul;68(1 Suppl):7-13. 3.
Patrick E. Davol, et al. Urology. 2006 Jul;68(1 Suppl):2-6. 4. Lawatsch EJ, et al. J Urol. 2006 Apr;175(4):1225-9. 5. Nicholas J Hegarty, et al. Presented at the
2006 Annual Meeting of the American Urological Association, May 20-25, 2006, Atlanta Georgia 6. Gill IS, et al. J Urol. 2005 Jun;173(6):1903-7.
Risks of metastasis

99 studies representing 6,471 lesions were analyzed.
No statistical differences were detected in the
incidence of metastatic progression regardless
of whether lesions were excised, ablated or
observed.
Excise, Ablate or Observe: The Small Renal Mass Dilemma—A Meta-Analysis and Review
Kunkle, et all JU, 2008
Cryoablation series, UCA

Single surgeon (LH)
 208 cases since July 2006-November 2010
 1 local recurrence (0.5%) (4cm +)
– Treated with repeat cryoablation 2 years later

All were laparoscopic (45% extraperitoneal
approach)
 4 patients with metastatic disease (1.9%)
 T1a tumors
FireFly™ Fluorescence
Imaging for the da Vinci® Si
In service Guide


BILITRANSLOCASE (BTL) IS IMMUNOLOCALISED IN
PROXIMAL AND DISTAL RENAL TUBULES AND ABSENT
IN RENAL CORTICAL TUMORS ACCURATELY
CORRESPONDING TO INTRAOPERATIVE NEAR
INFRARED FLUORESCENCE (NIRF) EXPRESSION OF
RENAL CORTICAL TUMORS USING INTRAVENOUS
INDOCYANINE GREEN (ICG)
Dragan J Golijanin*, Jonah Marshall, Allison Cardin, Eric A Singer,
Ronald W Wood, Jay E Reeder, Guan Wu, Jorge L Yao, Sabina
Passamonti, Edward M Messing. Rochester, NY, and Trieste, Italy.
JU May, 2008
ICG

Conclusion: This is the first study to show
that ICG and bilotranslocase are uniformly
present in normal parenchyma and benign
tumors but differentially downregulated in
renal cortical tumors. ……… this may
explain the non or hypo fluorescence of
renal cortical tumors observed
intraoperatively with near infrared imaging.