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Re: Initial Experience Using Microwave Ablation Therapy for Renal Tumor Treatment: 18-Month Follow-Up
LAPAROSCOPY/NEW TECHNOLOGY
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and overall survival (OS) were analyzed. Results: Overall, 53 patients were identified; 23 had metastatic disease, and of these 21 had received targeted therapy (median age 34 years). Seven patients achieved an objective response. In first line, median PFS was 8.2 months [95% confidence interval (CI) 2.6 –14.7 months] for sunitinib (n ⫽ 11) versus 2 months (95% CI 0.8 –3.3 months) for cytokines (n ⫽ 9) (log-rank P ⫽ 0.003). Results for further treatment (second, third, or fourth line) were as follows: all three patients receiving sunitinib had a partial response (median PFS 11 months). Seven of eight patients receiving sorafenib had stable disease (median PFS 6 months). One patient receiving mTOR inhibitors had a partial response and six patients had stable disease. Median OS was 27 months with a 19 months median follow-up. Conclusion: In Xp11 translocation RCC, targeted therapy achieved objective responses and prolonged PFS similar to those reported for clear-cell RCC. Editorial Comment: Translocations of Xp11.2 involving the TFE3 oncogene resulting in renal cell carcinoma are prevalent among juveniles and young adults diagnosed with renal cancer. Histologically these tumors are distinct in that they frequently carry mixed papillary and clear cell components. By clinical natural history these tumors appear to metastasize frequently to lymph nodes, and in the juvenile population aggressive lymph node dissection is beneficial. In adults with TFE3 translocation tumors an aggressive natural history with poor disease related outcomes is observed. In these 2 reports the authors demonstrate that despite the distinct etiology, biology and natural history of these tumors, responses to systemic tyrosine kinase inhibitors are similar to those observed for conventional type renal cancers. Samir S. Taneja, M.D.
Laparoscopy/New Technology Re: Initial Experience Using Microwave Ablation Therapy for Renal Tumor Treatment: 18-Month Follow-Up S. M. Castle, N. Salas and R. J. Leveillee Division of Endourology, Laparoscopy and Minimally Invasive Surgery, Department of Urology, University of Miami Miller School of Medicine, Miami, Florida Urology 2011; 77: 792–797.
Objectives: To assess efficacy and morbidity of microwave ablation (MWA) for small renal tumors in an initial cohort of patients. MWA is a recently introduced thermal needle ablation treatment modality with theoretical advantages compared with radiofrequency ablation, such as greater intratumoral temperatures, lack of a grounding pad, and superior convection profile. However, experience has been limited in the human kidney. Methods: Ten patients with a single, solid-enhancing renal tumor from June 2008 to November 2008 received laparoscopic or computed tomography-guided percutaneous MWA at a tertiary referral center with ⱖ14 months of follow-up. MWA was performed using the Valleylab Evident, 915-MHz MWA system at 45 W with intraoperative biopsy before ablation, and peripheral fiberoptic thermometry to determine the treatment endpoints. The patients were followed up with contrast-enhanced computed tomography at 1 month, 6 months to 1 year, and annually to monitor for tumor recurrence. Results: The follow-up duration for the 6 male and 4 female patients (mean tumor size 3.65 cm, range 2.0 –5.5; mean age 69.8 years) was 17.9 months. The recurrence rate, defined by persistent enhancement, was 38% (3 of 8). The intraoperative and postoperative complication rate was 20% and 40%, respectively. Conclusions: MWA resulted in poor oncologic outcomes with a significant complication rate at an intermediate level of follow-up. However, MWA has promising theoretical advantages and should not be discarded. Additional studies should be considered to better understand the microwave-tissue interaction and treatment endpoints for different size renal masses before widespread use.
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LAPAROSCOPY/NEW TECHNOLOGY
Editorial Comment: Despite using peripheral thermocouples to monitor tissue temperature at the periphery of the ablation, this early report by these experienced authors suggests that modestly large central tumors (mean 3.65 cm) cannot be confidently treated using microwave ablation. As such, this technology does not seem to improve on the established results with cryoablation and radio frequency ablation of similar renal tumors. Jeffrey A. Cadeddu, M.D.
Laparoscopic High-Intensity Focused Ultrasound for Renal Tumours: A Proof of Concept Study R. W. Ritchie, T. A. Leslie, G. D. Turner, I. S. Roberts, L. D’Urso, D. Collura, A. Demarchi, G. Muto and M. E. Sullivan Department of Urology, Churchill Hospital and Nuffield Department of Surgery, Department of Cellular Pathology and Nuffield Department of Clinical Laboratory Sciences, John Radcliffe Hospital, Oxford, United Kingdom, and Department of Urology, St. Giovanni Bosco Hospital, Turin, Italy BJU Int 2011; 107: 1290 –1296.
Objective: To test and establish clinical proof of concept for a laparoscopic high-intensity focused ultrasound (HIFU) device that facilitates delivery of ultrasound by direct application of a probe to the tumour surface. Patients and Methods: Twelve patients with renal tumours were treated with laparoscopic HIFU using a newly designed probe inserted via an 18-mm laparoscopic port. HIFU treatment was targeted at a pre-defined proportion of the tumour and immediate laparoscopic partial or radical nephrectomy was then performed. Results: No tumour ablation was seen in the first five patients which made modifications in the treatment protocol necessary. After this, definite histological evidence of ablation was seen in the remaining seven patients. The ablated zones were within the targeted area in all patients and no intra-lesional skipping was seen. Subcapsular skipping was seen at the probe–tumour interface in two patients with viable tumour cells seen at microscopy. One patient did not undergo surgical extirpation; subsequent biopsy revealed no viable tumour cells. There were no intraoperative or postoperative complications directly related to HIFU therapy and patients have reached a mean (range) follow-up of 15 (8 –24) months with no evidence of metastatic disease or late complications. Conclusions: Tumour ablation with laparoscopic HIFU is feasible. Homogenous ablation can be achieved with no vital tissue within the targeted zone. The technique is associated with low morbidity and may have a role in the definitive management of small tumours. Editorial Comment: This certainly is an early clinical assessment of laparoscopic application of HIFU to treat small renal tumors. The ideal application, extracorporeal HIFU, has been limited by abdominal wall movement and rib cage interference. Although laparoscopic application would overcome such factors, I am doubtful that this approach will provide any measurable benefit over laparoscopic cryoablation or radio frequency ablation in terms of tumor eradication and treatment time. Laparoscopic HIFU certainly cannot compete with percutaneous ablation. Jeffrey A. Cadeddu, M.D.
Robot-Assisted Laparoendoscopic Single-Site Surgery: Partial Nephrectomy for Renal Malignancy W. K. Han, D. S. Kim, H. G. Jeon, W. Jeong, C. K. Oh, K. H. Choi, E. I. Lorenzo and K. H. Rha Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea Urology 2011; 77: 612– 616.
Objectives: To describe our experience with robot-assisted laparoendoscopic single-site surgery (LESS) to perform partial nephrectomy and evaluate a hybrid homemade port system as an effective
1275
and overall survival (OS) were analyzed. Results: Overall, 53 patients were identified; 23 had metastatic disease, and of these 21 had received targeted therapy (median age 34 years). Seven patients achieved an objective response. In first line, median PFS was 8.2 months [95% confidence interval (CI) 2.6 –14.7 months] for sunitinib (n ⫽ 11) versus 2 months (95% CI 0.8 –3.3 months) for cytokines (n ⫽ 9) (log-rank P ⫽ 0.003). Results for further treatment (second, third, or fourth line) were as follows: all three patients receiving sunitinib had a partial response (median PFS 11 months). Seven of eight patients receiving sorafenib had stable disease (median PFS 6 months). One patient receiving mTOR inhibitors had a partial response and six patients had stable disease. Median OS was 27 months with a 19 months median follow-up. Conclusion: In Xp11 translocation RCC, targeted therapy achieved objective responses and prolonged PFS similar to those reported for clear-cell RCC. Editorial Comment: Translocations of Xp11.2 involving the TFE3 oncogene resulting in renal cell carcinoma are prevalent among juveniles and young adults diagnosed with renal cancer. Histologically these tumors are distinct in that they frequently carry mixed papillary and clear cell components. By clinical natural history these tumors appear to metastasize frequently to lymph nodes, and in the juvenile population aggressive lymph node dissection is beneficial. In adults with TFE3 translocation tumors an aggressive natural history with poor disease related outcomes is observed. In these 2 reports the authors demonstrate that despite the distinct etiology, biology and natural history of these tumors, responses to systemic tyrosine kinase inhibitors are similar to those observed for conventional type renal cancers. Samir S. Taneja, M.D.
Laparoscopy/New Technology Re: Initial Experience Using Microwave Ablation Therapy for Renal Tumor Treatment: 18-Month Follow-Up S. M. Castle, N. Salas and R. J. Leveillee Division of Endourology, Laparoscopy and Minimally Invasive Surgery, Department of Urology, University of Miami Miller School of Medicine, Miami, Florida Urology 2011; 77: 792–797.
Objectives: To assess efficacy and morbidity of microwave ablation (MWA) for small renal tumors in an initial cohort of patients. MWA is a recently introduced thermal needle ablation treatment modality with theoretical advantages compared with radiofrequency ablation, such as greater intratumoral temperatures, lack of a grounding pad, and superior convection profile. However, experience has been limited in the human kidney. Methods: Ten patients with a single, solid-enhancing renal tumor from June 2008 to November 2008 received laparoscopic or computed tomography-guided percutaneous MWA at a tertiary referral center with ⱖ14 months of follow-up. MWA was performed using the Valleylab Evident, 915-MHz MWA system at 45 W with intraoperative biopsy before ablation, and peripheral fiberoptic thermometry to determine the treatment endpoints. The patients were followed up with contrast-enhanced computed tomography at 1 month, 6 months to 1 year, and annually to monitor for tumor recurrence. Results: The follow-up duration for the 6 male and 4 female patients (mean tumor size 3.65 cm, range 2.0 –5.5; mean age 69.8 years) was 17.9 months. The recurrence rate, defined by persistent enhancement, was 38% (3 of 8). The intraoperative and postoperative complication rate was 20% and 40%, respectively. Conclusions: MWA resulted in poor oncologic outcomes with a significant complication rate at an intermediate level of follow-up. However, MWA has promising theoretical advantages and should not be discarded. Additional studies should be considered to better understand the microwave-tissue interaction and treatment endpoints for different size renal masses before widespread use.
1276
LAPAROSCOPY/NEW TECHNOLOGY
Editorial Comment: Despite using peripheral thermocouples to monitor tissue temperature at the periphery of the ablation, this early report by these experienced authors suggests that modestly large central tumors (mean 3.65 cm) cannot be confidently treated using microwave ablation. As such, this technology does not seem to improve on the established results with cryoablation and radio frequency ablation of similar renal tumors. Jeffrey A. Cadeddu, M.D.
Laparoscopic High-Intensity Focused Ultrasound for Renal Tumours: A Proof of Concept Study R. W. Ritchie, T. A. Leslie, G. D. Turner, I. S. Roberts, L. D’Urso, D. Collura, A. Demarchi, G. Muto and M. E. Sullivan Department of Urology, Churchill Hospital and Nuffield Department of Surgery, Department of Cellular Pathology and Nuffield Department of Clinical Laboratory Sciences, John Radcliffe Hospital, Oxford, United Kingdom, and Department of Urology, St. Giovanni Bosco Hospital, Turin, Italy BJU Int 2011; 107: 1290 –1296.
Objective: To test and establish clinical proof of concept for a laparoscopic high-intensity focused ultrasound (HIFU) device that facilitates delivery of ultrasound by direct application of a probe to the tumour surface. Patients and Methods: Twelve patients with renal tumours were treated with laparoscopic HIFU using a newly designed probe inserted via an 18-mm laparoscopic port. HIFU treatment was targeted at a pre-defined proportion of the tumour and immediate laparoscopic partial or radical nephrectomy was then performed. Results: No tumour ablation was seen in the first five patients which made modifications in the treatment protocol necessary. After this, definite histological evidence of ablation was seen in the remaining seven patients. The ablated zones were within the targeted area in all patients and no intra-lesional skipping was seen. Subcapsular skipping was seen at the probe–tumour interface in two patients with viable tumour cells seen at microscopy. One patient did not undergo surgical extirpation; subsequent biopsy revealed no viable tumour cells. There were no intraoperative or postoperative complications directly related to HIFU therapy and patients have reached a mean (range) follow-up of 15 (8 –24) months with no evidence of metastatic disease or late complications. Conclusions: Tumour ablation with laparoscopic HIFU is feasible. Homogenous ablation can be achieved with no vital tissue within the targeted zone. The technique is associated with low morbidity and may have a role in the definitive management of small tumours. Editorial Comment: This certainly is an early clinical assessment of laparoscopic application of HIFU to treat small renal tumors. The ideal application, extracorporeal HIFU, has been limited by abdominal wall movement and rib cage interference. Although laparoscopic application would overcome such factors, I am doubtful that this approach will provide any measurable benefit over laparoscopic cryoablation or radio frequency ablation in terms of tumor eradication and treatment time. Laparoscopic HIFU certainly cannot compete with percutaneous ablation. Jeffrey A. Cadeddu, M.D.
Robot-Assisted Laparoendoscopic Single-Site Surgery: Partial Nephrectomy for Renal Malignancy W. K. Han, D. S. Kim, H. G. Jeon, W. Jeong, C. K. Oh, K. H. Choi, E. I. Lorenzo and K. H. Rha Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea Urology 2011; 77: 612– 616.
Objectives: To describe our experience with robot-assisted laparoendoscopic single-site surgery (LESS) to perform partial nephrectomy and evaluate a hybrid homemade port system as an effective