DR. PINTO: Can we have all the speakers come up to the panel? I know we got a late start due to the inclement conditions, but I'm sure we have a few questions from the audience before we move on to our next session.
PARTICIPANT: I have a question for Howard. I wonder if we can borrow a page from the bladder cancer book. We have learned that Periot, Mitomycin or other drugs diminish implant after TURBT. You pointed out the risks and worry about tumor in the distal ureter especially. I wonder if for the nephroureterectomy, whether laparoscopic or open, would a day before treatment of Mitomycin be sensible? We always worry about the opening of the bladder however we do it, and whether we are going to spill. Have you done that?
DR. WINFIELD: We actually haven't done that, but I think that is an excellent idea. I talked to Mike O'Donnell, who handles a lot of our bladder cancer, and we are hoping to proceed in that direction.
PARTICIPANT: My question is an extension of the previous question. In those people that you elect to treat endoscopically, what role if any is there in rendering a ureter incompetent, putting the stent, and as a result of that incompetency giving topical chemotherapy that flushes up to the kidney?
We know there is a high recurrent rate. That is a given. So is there any role for rendering a ureter incompetent and then giving intravesical chemotherapy once you prove your refluxes?
DR. JARRETT: Two reasons. One is, absolutely right, it is a better way to deliver this system. Also, if you render it incompetent and size the ureter orifice, you can do an outpatient ureteroscopy in your office without any anesthesia.
The problem is, the numbers are so low. There are no studies that they can say it has definitively shown an improvement. Anecdotally, I have had patients who have had multifocal disease that had long term improvement following therapy, but there is no study that can document that.
PARTICIPANT: I have two questions regarding RFA. First of all, you had some complications in the hilum. I presume this is all dry technique, not wet. If you used wet, would that decrease that complication rate?
Secondly, you didn't give us any data on repeat RFA. Is the tissue impedance a problem for doing second-time treatments? I thought there was some data supporting that.
DR. WALTHER: The first part about the wet electrode, we have avoided that because of the difficulty in predicting the extravasation of the saline. I think if you treat a tumor in the hilum, it is going to want to flow along the renal pelvis, and you will end up treating that area. We just haven't done that.
I'm sorry, what was the second question?
PARTICIPANT: About repeat treatments for enhancement under Hounsfield inadequate --
DR. WALTHER: You probably could. Because I want to get the pathologic data, we haven't done that. Even though everybody wants us to at my institution, I have avoided that to try to get the pathologic data. I think it is reasonable to do, but we just haven't done it yet.
PARTICIPANT: I have a comment and then a question about the renal cells. The interesting thing about the NIH series is, presumably these are renal cells, but many of these small renal masses, as we know from the partial nephrectomy data, are actually not renal cell carcinomas.
The other thing that is coming out is that we are starting to see stratification of these small masses by location. I think, Dr. Walther, you gave us clear indications of what locations are best for what.
When we did an immediate surgery or delayed surgery, we found a high rate of viable tumor after radio frequency, which we call thermal therapy. The word ablation concerns me, because clearly some of them aren't ablated. But we found residual tumor. Now, we may not have been doing it as well as some have suggested, but the follow up is concerning to me, when you think of how slow growing these tumors are. You don't see complete disappearance of the mass. You may well be leaving residual tumor cells there.
One of the problems seems to be the high perfusion of the kidney and the heat sink effect. Maybe that is the reason that some of them don't completely disappear.
Could you comment on the potential risks or benefits of renal artery occlusion at the time of either cryo or heating to improve the efficacy of the therapy?
DR. WALTHER: I think I have a couple of comments. One is, I guess I have a little knee-jerk defensiveness about not doing biopsies. I think when we see lesions that take up contrast in these patients with VHL and things like the other hereditary syndromes that I won't mention by name this early in the morning, when we operate on the cancer.
So I can't prove it to you, but I'm convinced that we are not operating on angiomyolipomas. Unlike the data in the radiology literature for the people you are talking about, the Bosniak classification comes to mind; he is good enough to publish his actual data in some of his publications. If you get your calculator out and do a statistical calculation on the growth rates of the ones he has biopsies on and the ones he doesn't, the ones he doesn't have biopsies on don't hardly grow, and you wonder if those are the angiomyolipomas.
So I think in our patients, they are a little bit different from that.
Renal artery occlusion – I haven't done that much with it. Jonathan Coleman, who has joined us on the staff here, has done some work with that, and was seeing larger ablated lesions with occlusion. You might talk to him after this, because he has done that work, and I'm not on top of it. We have not done it, though.
DR. KAOUK: Just a small comment, Dr. Jarrett. We have a small series of RFA done. We have done about 27 cases, and we always start as in the cryo, by taking a biopsy. We had about 80 percent of the pre-RFA biopsies that were renal cell, and the tumors are about two centimeter on average.
DR. MARTIN: I'm on a team from M.D. Anderson. This was a very nice panel, thank you.
I just wanted to make some comments regarding Howard's presentation. We recently presented the data from Cleveland Clinic on 60 patients that underwent laparoscopic nephroureterectomy. What I thought was very interesting in that data that hasn't really been highlighted, there was a 27 percent rate of multi-focality in these upper tract tumors. Independent of that, there was a similar rate of patients with carcinoma in situ in the upper tract. That is not going to be evident radiographically, nor may it be evident ureteroscopically.
I think that when it becomes important is in terms of the bladder cuff management. When we looked at our endoscopic GIA control of the bladder cuff versus the Cleveland Clinic technique, there was about a 25 percent rate of local recurrence. This is local perivesical recurrence associated with the Endo GIA technique.
What that is exactly related to is unclear. It may be patient selection bias, because this is a retrospective study. But I think that does throw some caution in regards to that technique. The Cleveland Clinic technique on the other hand had about one recurrence and about a three percent local perivesical recurrence rate.
So I just wanted to mention that. That is data that we recently presented, it hasn't been published, but I think it is very important to make note of that.
The other thing I wanted to stress was Howard's point about the pluck technique, which is a bit of a misnomer. It is transurethral resection of the ureteral orifice. If you do a detailed literature review, that has the highest number of -- that is the one procedure that is associated with the largest amounts of local perivesical recurrences, and also port tract occurrence. So it is a disease to be respected.
I think more detailed data with regard to the different techniques of distal cuff management is going to be important to have.
DR. JARRETT: Two comments on that. Lou and I, we have done quite a few of these.
As far as the GIA thing, I have eight years into it now dug out a couple of cuffs that weren't taking as well as I thought they were. That was not a lot of fun. One patient required a cystectomy. So my personal bias is that I don't -- I'm not doing that; I'm back to the original open cuff.
As far as the ND gill technique, one comment on that. A lot of the cases, the patients have had previous ureteroscopies, multiple ureteroscopies, and that doesn't work real well if that ureter has been manipulated, because like any stented ureter, it is scarred in. So once again, I have swung all the way around, and I personally am back to just doing the case laparoscopically, get the ureter as far as I can, and doing the standard open cuff the way I would with an open one.
DR. WALTHER: I have one comment also on the pluck thing. It was invented in the '50s and '60s to try to avoid that huge incision, to try to get back towards a regular little flank incision. They did not occlude the ureter, and they had a lot of retroperitoneal seeding. So if you occluded the ureter, you might have a better result.
But having said that, I agree with Tom. You are going to make an incision anyway; why don't you just pull the kidney up, do your bladder open cuff, and go home an hour earlier and spend less money on instruments? It just seems easier.
DR. PINTO: The important thing to remember is that when you are sparing the patient's morbidity, is that flank incision. You are sparing them taking out that 11th or 12th rib or taking out flank. Giving you a small midline is not much of a morbidity. That is what you are sparing.
We have time for just a few more questions.
PARTICIPANT: Could you comment on the handling of C stick lesions, complex cystic masses in the kidney that have enhancing elements, probably malignant, with RFA or cryo?
DR. KAOUK: For the RFA and cryo, if it is cystic we don't choose this technique. We don't puncture the cyst and try to do the cryo, for the obvious reason of spilling cells. We then focus more on partial nephrectomy if it is possible.
DR. WALTHER: I'm not sure who you would use it in. Certainly if the patient wants treatment and you think there is an indication, it would be reasonable.
I have been purposely trying to avoid these people, because I don't think they are representative of solid malignancies as a whole. That is what we are trying to evaluate the treatment for.
A second comment along that same line is that in the VHL patients, I take the turned-around view that I don't want to operate on them to cure them of cancer, because I know they all have cancer at the end of every one of my operations. There is stuff just everywhere in those kidneys microscopically. I want to remove tumors -- I want to reset the clock and remove tumors that are going to metastasize. But this is just sort of an editorial comment against treatment of cystic lesions, and that is why.
DR. PINTO: Last question.
PARTICIPANT: It is kind of confusing from a clinician's perspective to sort out which of these various options for small renal tumors is the one that I should be using as an individual. I just wonder if the panelists have given any thought to whether we have reached the point with these technologies where we should plan a comparative trial, a registry.
How are we going to figure out which is the one that we should be offering patients? Or are we stuck with the, to a man with a hammer everything is a nail phenomenon that we basically have now, that you do whatever you have available in your institution?
DR. WALTHER: I think RFA is definitely the best. We can fight up here on the stage to prove it.
I think cryo is good. I think as far as non-interventional things, that is in my mind the gold standard. I think RFA is evolving. We are just getting devices that are powered enough to treat. Then once we have some more data, then you can decide how many patients you are going to have to treat to have the power to tell the differences.
These little selected cases from Cleveland Clinic, they are virtually all dead. We are seeing -- knock on wood -- fairly good response rates. So I think that is a good idea. I think it is a little bit down the road for planning the actual study yet, though.
DR. KAOUK: Whichever way you choose, these are all evolving techniques, and one should be very careful, meticulously following them up.
So far, we do more cryos than RFA, because we have more extensive experience in it, and we know the limitations more than we know what is happening with the RFA. That is why if we elect to do an ablative procedure, we go for the cryo, unless the patient is a high risk for anesthesia and with a lot of comorbidities. Maybe then we will do a percutaneous RFA, although this is also limited by the access. So you can only get the posterior and posterior lateral.
DR. PINTO: That is an important question. I think we should wrap up the session, following that question with what I mentioned at the beginning. As image guided technology is here to stay and progressing, technology is heavily involved in that.
So what I want to do is, everybody who is involved with cryo and RFA here, what your thoughts are on the opportunities to perform these procedures without us involved. Any thoughts, Mac?
DR. WALTHER: I think we are seeing this with lithotripsy and percutaneous nephrostomies. It is sort of a battle. When we get involved and we are treating the patients, then we can do these cases, too.
I think there is a selection bias. We sit down with our colleagues who -- Brad Wood is just unbelievably good. He can put the needle in so it is centered in a 3D fashion, which really requires some time to do. He is an interventional specialist guy, and he is good at it. We can pick up the skills, but it does require some extra work.
What we do have a little bit that he doesn't have is, we know a little bit more about the natural history of the tumors, and ones you might not want to treat and ones you might want to treat. They tend to be less selective about who they are treating.
But I think we do have a lot to learn from them. Certainly we can do these, I think, but I have been fortunate to have an interaction with a nice guy, and I hope it continues to work. But these are skills that anybody can learn, I think.
DR. PINTO: Is that the feeling of everybody else here, the same situation? Thank you very much.
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