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2 The Story ofBreast andProstate Cancer: Parallels andCommon Controversies
21

Conclusions

Thanks to large, well-designed randomized clini­cal trials and an understanding of the underlying biology of the tumor progression, the standard of care for BCa has shifted over the past 50years from RM to multidisciplinary therapy, including focal surgical resection and systematic therapy. To date, most newly diagnosed BCa are treated with this multidisciplinary approach to achieve excellent long-term oncologic outcomes while maintaining a good quality of life. The side effects of radical therapies, the biomolecular sim­ilarity to BCa, and the low tumor aggressiveness are leading the urologic scientic community to adopt FTs for PCa. However, the future of PCa FT will depend on the results of long-term onco­logic outcomes and the results of randomized tri­als comparing its efcacy with that of conventional therapies. We should learn from the work of the breast colleagues that a better under­standing of the disease biology will lead to effec­tive combinations of local and systemic therapies for PCa, and this will be the key to preventing, detecting, and treating the recurrence in FT. A comprehensive, biological- based, and multi­modal approach to PCa management will help to improve PFS and patient quality of life.

References

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30. Gill IS, Azzouzi AR, Emberton M, Coleman JA, Coeytaux E, Scherz A, etal. Randomized trial of par­tial gland ablation with vascular targeted photother­apy versus active surveillance for low risk prostate cancer: extended Followup and analyses of effective­ness. J Urol. 2018;200(4):786–93.
31. Ehdaie B, Tempany CM, Holland F, Sjoberg DD, Kibel AS, Trinh QD, etal. MRI-guided focused ultra­sound focal therapy for patients with intermediate­risk prostate cancer: a phase 2b, multicentre study. Lancet Oncol. 2022;23(7):910–8.
32. Labbate CV, Klotz L, Morrow M, Cooperberg M, Esserman L, Eggener SE.Focal therapy for prostate cancer: evolutionary parallels to breast cancer treat­ment. J Urol. 2023 Jan;209(1):49–57.
33. Welch HG, Gorski DH, Albertsen PC.Trends in met­astatic breast and prostate cancer—lessons in cancer dynamics. N Engl J Med. 2015;373(18):1685–7.
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38. Anderson BB, Oberlin DT, Razmaria AA, Choy B, Zagaja GP, Shalhav AL, Meeks JJ, Yang XJ, Paner GP, Eggener SE. Extraprostatic extension is extremely rare for contemporary Gleason score 6 prostate can­cer. Eur Urol. 2017;72(3):455–60.
39. Ross AE, Hurley PJ, Tran PT, Rowe SP, Benzon B, Neal TO, Chapman C, Harb R, Milman Y, Trock BJ, Drake CG. A pilot trial of pembrolizumab plus prostatic cryotherapy for men with newly diagnosed oligometastatic hormone-sensitive prostate cancer. Prostate Cancer Prostatic Dis. 2020;23(1):184–93.
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2 The Story ofBreast andProstate Cancer: Parallels andCommon Controversies
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45. Houssami N, Turner R, Macaskill P, Turnbull LW, McCready DR, Tuttle TM, Vapiwala N, Solin LJ.An individual person data meta-analysis of preoperative magnetic resonance imaging and breast cancer recur­rence. J Clin Oncol. 2014;32(5):392–401.
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Focal Ablative Therapy forLocalized Kidney Cancer
MohannadA.Awad, YuzhiWang, CraigG.Rogers, PilarLaguna, andJereyA.Cadeddu
3

Introduction

Kidney cancer is the sixth and ninth most com­mon cancer in the United States for men and women, respectively. It accounts for approxi­mately 81,800 new cases and 14,980 deaths per year [1]. The incidence of kidney cancer has been rising due to the increasing use of cross-sectional imaging. Along with that, there has been a down­staging of newly detected kidney masses with more than 70% being small and organ-conned. As a result, there has been a paradigm shift in the management of kidney cancer over the last two decades, with an emphasis on minimally invasive
M. A. Awad Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
Department of Surgery, King Abdulaziz University, Rabigh, Saudi Arabia e-mail: mohannad.awad@utsouthwestern.edu
Y. Wang · C. G. Rogers Vattikuti Urology Institute, Henry Ford Health, Detroit, MI, USA e-mail: Crogers2@hfhs.org
P. Laguna Department of Urology, Medipol University, Istanbul, Turkey
J. A. Cadeddu (*) Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA e-mail: Jeffrey.cadeddu@utsouthwestern.edu
treatment with nephron preservation and lower morbidity while maintaining cancer-specic sur­vival (CSS) [2].
Historically, the standard treatment for renal cell carcinoma (RCC), including small renal masses (SRM), was radical nephrectomy. However, partial nephrectomy (PN) has gradu­ally emerged as a viable alternative option for SRM, given that it provides comparable onco­logical outcomes (>95% CSS) with radical nephrectomy and is associated with improved renal function preservation, superior cardiac out­comes, and similar overall survival [3, 4]. As a result of the excellent outcomes of PN, it is con­sidered the gold standard for SRM by most uro­logical guidelines including the American Urological Association (AUA) [5]. Nevertheless, irrespective of the surgical approach (open, lapa­roscopic, robotic), PN is underused due to the higher technical demands and comparative risks with the procedure [6]. Therefore, to broaden minimally invasive management options for SRM, energy-based focal or thermal ablation (TA) systems, including cryoablation (CA) and radiofrequency ablation (RFA) were introduced in the 1990s.
Focal ablative therapies for SRM offer several advantages compared with surgery. First, these procedures are less technically demanding com­pared to open, laparoscopic, or robotic PN. Consequently, these procedures are associ­ated with shorter recovery and fewer complica-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 T. J. Polascik et al. (eds.), Imaging and Focal Therapy of Early Prostate Cancer,
https://doi.org/10.1007/978-3-031-66754-1_3
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tions [4, 7]. Second, ablation therapies have minimal impact on post-ablation renal function. This impact was found to be similar or better when compared to PN [8]. Considering these advantages, these minimally invasive therapies are well indicated for patients with SRM who are poor surgical candidates or at risk for renal insuf­ciency. However, given the excellent long-term published results with the growing experience, these indications have been expanded to include healthy patients with SRM [9]. As a result, European and American urological associations both include focal ablative therapy as a viable alternative therapeutic option to surgery for SRM <3cm [5, 10].
Role, Indications, andContraindications
Studies suggest that around 20% of solid renal tumors are benign at the time of surgery with most small RCCs being low-grade histology [11,
12]. Given the knowledge that some of the SRMs
are benign or indolent, there recently has been greater utility of active surveillance (AS) and non-surgical therapies. While PN is still a neph­ron-sparing surgery for small tumors, TA has a role in patients who are poor surgical candidates due to age and multiple comorbidities, are at risk for renal insufciency, or have solitary, bilateral, and hereditary renal tumors. The current 2021 AUA and the 2023 National Comprehensive Cancer Network (NCCN) guidelines state that TA is an alternative treatment for cT1RMs<3cm. Although there are multiple modalities of TA, only CA and RFA are recommended by the AUA. Patients undergoing TA should be coun­seled on the small risk of tumor persistence and
the possibility of salvage treatment to achieve an outcome similar to conventional surgery [5,
1315]. Absolute contraindications include
uncorrected coagulopathy and acute illness. Relative contraindications include several tumor characteristics that predict a lower chance of suc­cess with TA.Larger renal masses are less favor­able for TA due to a higher likelihood of residual tumors after treatment. Anterior and hilar tumors are more likely to be in proximity to the bowel and vessels, making these tumors more difcult to access [16].

Renal Mass Biopsy

Renal mass biopsy (RMB) has emerged as a diagnostic tool to characterize renal masses (RMs) and guide treatment decision-making for physicians and patients. In the setting of focal therapy, the AUA, EAU, and NCCN guidelines all state that RMB should be performed prior to or at the time of TA to provide pathological diag­nosis and guidance [5, 10, 13, 14].
RMB has been controversial in the past, with criticisms regarding diagnostic accuracy, patient safety, and tumor seeding along the biopsy tract. Early biopsies had a high nondiagnostic rate of 31% [17]. However, recent literature indicates that RMB is a safe and relatively accurate proce­dure with a diagnostic rate of around 90%. Through a systematic review, Patel and col- leagues found that 19% of the biopsies had benign pathology and 14% were undiagnostic. However, repeat RMB led to the diagnosis in 80% of patients with an initial undiagnostic biopsy. Overall, the reported sensitivity, specic­ity, PPV, and NPV were 98%, 96%, 99%, and 69%, respectively. Reported complications were
3 Focal Ablative Therapy forLocalized Kidney Cancer
27
rare, but included hematoma, pain at the biopsy site, gross hematuria, pneumothorax, and hemor­rhage [18]. Another meta-analysis done by Marconi etal. showed a median diagnostic rate of 92%. There was good agreement between tumor histology from RMB and surgical pathol­ogy with a median concordance rate of 90%. There was a fair agreement between tumor grade from RMB and surgical pathology, with a median concordance rate of 87% for the 4-tiered Fuhrman grading system. The sensitivity and specicity for core needle biopsy were 99% for both, respec­tively [19]. Jeon and colleagues found an initial and overall diagnostic rate of 89% and 91% for RMBs at two large tertiary centers.
Tumor seeding is a rare occurrence. From 2013 to 2019 worldwide, there have been 12 cases of seeding associated with core needle biopsy, calculated to be approximately 1 case per 3000 patients. Papillary histology, the use of a needle larger than 20 g, and the absence of a coaxial sheath were associated with tumor seed­ing [20]. The incidence of seeding remains low and should not discourage the use of RMB.

Approach

TA therapies have traditionally been adminis­tered through the open, laparoscopic, and percu­taneous routes. However, open and laparoscopic techniques have been rendered obsolete in cur­rent practice [21, 22]. Percutaneous TA can be performed under conscious sedation with local anesthesia and general anesthesia as an outpa­tient or a short-stay procedure. Ablations can be guided using ultrasound, magnetic resonance (MRI), and most commonly computed tomogra­phy (CT) imaging [16]. Patient positioning and
direction of approach highly depend on the loca­tion and size of the tumor. It is also important to consider the proximity of the SRM to nearby ana­tomical structures such as the bowel, renal ves­sels, ureter, ilioinguinal and genitofemoral nerves, and psoas muscle. Therefore, potential TA-induced complications include bowel injury, ureteropelvic junction obstruction, and neuro­muscular injury. Prior to the use of bowel dis­placement techniques, TA was contraindicated in patients with bowel within 1–3cm of the target lesion.
Hydrodissection is now the most common bowel displacement technique used to protect the bowel and other surrounding structures dur­ing TA.Specically, it can be utilized for ante­rior lesions to displace the colon for RMs located in the posterior lower poles or adjacent to the small bowel. It can also reduce the heat sink effect by increasing the distance of vessels from the tumor ablation site. Hydrodissection is done through ultrasound, CT, or MRI-guided instillation of uid into tissue between the kid­ney and surrounding structure. Typically, the site is infused with 135–150cc of sterile water, normal (0.9%) saline, 5% dextrose in water, or
0.5% lidocaine, which allows for up to 2.5cm of extra bowel separation (Figs.3.1a, b, c). There is caution associated with the use of saline with radiofrequency ablation due to its high electrical conductivity. Failure to separate organs can be a result of uid spillage or difculty instilling uid secondary to abdominal adhesions. In such cases, needle repositioning or other bowel sepa­ration techniques can be utilized. These tech­niques include gas insufation, balloon interposition, and electrode torquing [2326]. TA can proceed when there is sufcient bowel separation.
28
M. A. Awad et al.
a
b
c
Fig. 3.1 (a) A complex right renal mass (red arrow) with adjacent bowel (green arrow). (b) The placement of the RFA probes in the renal tumor and the spinal needle in the small space between the tumor and the bowel. Hydrodissection is then done with saline prior to ablation. Of note, the RFA probe is placed and the umbrella tines
Principles ofAblation
Cryoablation
Background andMechanism ofAction
Although the theory of cryotherapy has existed for millennia, the modern cryoprobe was rst developed in 1963 with pressurized liquid nitro­gen [27]. In 1995, Uchida and colleagues rst described the use of CA for renal cell carcinoma [28]. Currently, standard cryoprobes use argon gas to generate a cooling effect based on the Joule–Thomson principle, which states that low temperatures occur with the rapid expansion of
deployed rst, followed by the spinal needle placement. Then, hydrodissection is performed followed by removing the spinal needle prior to ablation. (c) Post-ablation image of the mass and the hydrodissection plane that was made between the mass and the bowel
high-pressured gas. As argon gas ows through the cryoprobe, it expands and can generate tem­peratures as low as 185.7°C within the target tissue, inducing iceball formation around the tar­get tissue [29, 30].
There are multiple mechanisms that explain cell death during the freezing and thawing pro­cess of CA. Freezing temperatures cause direct cellular injury through physical damage to cell membranes and organelles. This is due to changes in lipid properties with extreme shifts in tempera­tures, increasing uidity and permeability across membranes. Freezing intracellular and extracel­lular liquids also change solute concentrations.
3 Focal Ablative Therapy forLocalized Kidney Cancer
29
Intracellularly, the cell experiences dehydration from freezing, resulting in high solute concentra­tions and further protein denaturation. Extracellular freezing similarly results in the depletion of free water, which contributes to the osmotic gradient to enhance cell dehydration. The opposite extreme occurs with thawing. As the ice melts, solute concentrations quickly decrease, leading to a rapid ow of uid into cells. This causes cellular edema and subsequent membrane rupture. Vascular injury mechanisms are described through multiple aspects. Freezing leads to stasis in affected vessels, causing isch­emia and necrosis in the associated region. Physical distension in vessels can result in tears in the endothelial wall. On the other hand, thaw­ing introduces reperfusion injury to the affected area. Both freezing and thawing can cause plate­let aggregation, coagulation, and thrombosis. Lastly, immunological mechanisms have not been fully characterized but are thought to play a role in cell death after CA.The immune system becomes sensitized to the target tissue, thus destroying any surviving cells in the area [3133]. Overall, cell death occurs from apoptosis and necrosis from the multiple mechanisms stated above. Over several months, inammatory cells in the necrotic tissue slowly create a brous col­lagen scar [34].
Treatment Temperature
The temperature within the iceball is not consis­tent, with the coldest temperatures adjacent to the probe and the warmest temperatures at the edge of the ball. Previous studies show that temperatures below 20 °C are lethal for normal renal paren­chyma. However, many authors theorize that malignant cells, in general, are more cryo-resis­tant due to their brous nature and may require lower temperatures for cellular death [29]. Therefore, it is recommended to achieve tempera­tures around 40 °C during freezing cycles to ensure lethality [30, 32, 34, 35]. Tissue near the edge of the iceball can range from 0 to 20°C, which does not ensure lethality (Fig.3.2) [34].
Necrosis Zone
Indeterminate Zone
Viable Zone
Fig. 3.2 Iceball ablation zones: The central/necrosis zone is characterized by uniform ablation and temperatures <40°C.Surrounding the central zone is the indeterminate zone, which has areas of cell death intermixed with viable cells and temperatures between 40 and −20 °C. The outermost zone is comprised of mostly viable cells with little to no necrosis and temperatures >20°C
Freeze-Thaw Cycles andDuration ofTreatment
Multiple freeze-thaw cycles can promote more desirable results by affecting a larger area. Current CA practices conduct two freeze-thaw cycles with a freeze duration of 8–10 minutes [30, 32, 34, 35]. Passive thawing allows the ice­ball to melt naturally after the freezing cycle, which can be time consuming. Active thawing uses helium gas to create a warming effect, again through the Joule–Thomson principle, which expedites the process [36]. There is no current data to suggest the superiority of either thawing method. The heat sink effect can also raise the temperature of nearby vessels [32]. Lethal tem­peratures in the iceball are present until 3 mm from the margin [29]. To ensure no surviving tumor cells, the visualized edge of the iceball should be at least 5–6mm beyond the edge of the target lesion. Size and shape of the iceball can be altered by different probes. Thinner probes result in a smaller ablation zone, while thicker and mul­tiple probes result in larger ablation zones [32,
33]. In the case of multiple probes, each probe
should be positioned around 1cm from the lesion edge and 2cm from other probes [29].
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Radiofrequency Ablation
Background andMechanism ofAction
RFA uses radiofrequency energy to heat tissue to the point of causing cellular death. In 1981, d’Arsonval described the ability of radiofre­quency waves to heat live tissue [37]. Initially, the technology was not clearly understood, and the energy was not effectively controlled till Cushing and Bovie developed the electrocautery knife. They described the ability to cauterize or cut tissue using electrocautery energy, leading the way to the development of the modern-day electrocautery probe. The electrocautery probe desiccates tissue at the point of contact when the alternating current passes through the patient and eventually dissipates in a remotely placed grounding pad on the patient [38].
In 1990, two individual groups of researchers published the development of probes for percuta­neous ablation. These probes consisted of a layer of insulation down to an exposed metal tip. This allows for the needle to be passed percutaneously to the deeper target tissue. Adjusting the length of the exposed, uninsulated portion of the needle, allows for the control of the amount of tissue being destructed along the central axis of the lesion [39, 40]. RFA uses monopolar alternating electric current which is delivered at a frequency of 450–1200kHz directly into the target tissue, causing vibration of ions with tissue, resulting in molecular friction and heat production. The increase in temperature within the target tissue results in cell membrane disintegration and cel­lular protein denaturation [41, 42].
Variation inRadiofrequency Ablation Equipment
There are two main types of monitoring systems while performing RFA: temperature based and impedance based. These systems are essential to ensure effective treatment and patient safety. Temperature-based systems measure the temper­ature at the electrode tip, while impedance- based systems measure tissue impendence at the tissue probe interface. Temperature-based systems pro­vide accurate measurements of the temperature at the electrode tip but do not measure the tempera-
ture of the surrounding parenchyma. On the other hand, impendence- based systems offer real-time feedback on tissue changes during the procedure and provide insights into the overall tissue response. There is currently no clear evidence supporting superiority of either monitoring sys­tem. The choice of either system depends on vari­ous factors, including the clinical situation, tissue type, and the preference of the clinician.
The initial RFA probes were designed as sin­gle-electrode monopolar probes controlled by changing the exposed uninsulated tip. These probes were limited in their ability to treat tumors larger than 2cm, requiring additional or overlapping treatment regions [43]. To address this issue, LeVeen (1997) introduced an insulated monopolar probe that featured 12 deployable tines functioning as radiofrequency antennas. These tines are deployed in an umbrella shape, allowing for a wider current dispersion and the creation of a spherical lesion (Boston Scientic, MA). When high impedance occurs at one prong, the current is redirected to other areas of lower impedance [44]. Another monopolar probe sys­tem is the starburst-shaped RITA device ® (AngioDynamics, Queensbury, NY). It uses embedded thermistors in ve of its nine tines to modulate energy based on the average tempera­ture of the electrodes. A different monopolar impedance-based system by Covidien (Boulder, CO) uses a single 17-gauge (cool tip) electrode cooled internally with saline to prevent charring of tissue near the probe. Comparative studies in porcine liver showed larger ablation zones with the “cool tip” system, more spherical ablation volumes with the 12-tine electrodes, and better reproducibility with the 9-tine electrodes [45]. Clinical validation studies have also indicated improved necrosis, lesion accuracy, and treat­ment outcomes with multi-tine electrodes [4648].
Radiofrequency ablation technology can be classied into “dry” and “wet’ RFA. In “dry” RFA, tissue desiccation leads to charring and increased impedance, limiting the ablation zone size to less than four centimeters with a single electrode. In contrast, “wet” RFA probes deliver a constant saline infusion into the tissue and
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around the probe to lower the temperature at the probe tip. This mitigates charring, prevents a temperature rise in impedance, and allows for larger ablation zones [45, 49]. Additionally, the infusion of hypertonic saline creates a virtual “liquid electrode” beyond the metal electrode, effectively increasing the total electrode surface area [50]. While “wet” RFA tends to create larger lesions, it may result in less control over the exact size of the ablation, potentially leading to over­treatment of the target area and ablating the adja­cent normal parenchyma [51].
Treatment Temperature
The effectiveness of RFA in ablating target tissue depends on factors such as power delivery, maxi­mum temperature achieved, and duration of the ablation [52]. When alternating radiofrequency current is applied, it generates cellular agitation and localized heating due to tissue impedance. When the electrical impedance remains low, out­ward spherical tissue damage emanates from the treatment probe. If the current is delivered too rapidly, tissue charring can occur at the probe­tissue interface, resulting in increased impedance and halted heating [53, 54]. To avoid incomplete or nonuniform ablation, temperatures during RFA are generally maintained at or below 105°C.It is also important to reach a minimum target temperature that induces cellular death. In studies using human prostate tissue, irreversible cell injury was achieved at temperatures of 45°C for 60minutes, 55°C for 5min, and 70°C for 1min [55]. Similarly, short exposures to temper­atures above 70 °C were found to be lethal to human RCC invitro [56]. Modern temperature­based RFA generators are programmed to reach a target temperature of 90–105 °C, with a mini­mum of 70 °C uniformly reached during the treatment cycle to ensure successful ablation. Impedance- based systems typically start at 40–80W and increase gradually at 10W/min to a maximum of 130–200W until an impedance of 200–500 ohms is reached. Optimizing the power delivery, temperature control, and impedance monitoring in RFA procedures is essential to achieve effective tissue ablation while avoiding charring and incomplete treatment.
The success of RFA in reaching the target temperature during treatment depends not only on the proven energy delivery but also on the surrounding treatment environment. When the target zone is highly vascularized or located near large blood vessels, thermal energy tends to be dispersed to the cooler blood within these vessels, resulting in a heat sink effect. This phe­nomenon can spare tumor cells near blood ves­sels and lead to treatment failures [57]. Experimental studies have shown that tempo­rary renal ischemia, achieved through vascular clamping, can increase the size of the treatment lesion and accelerate the time to reach the target temperature [58]. However, due to the risks of arterial thrombosis and ischemia-reperfusion injury to normal tissue, renal hilar occlusion is not currently recommended. Instead, some authors suggest selective arterial embolization as a means to reduce the circulatory head sink during RFA procedures [59]. This approach has been successfully employed by the authors for central or large tumors (>4cm) to minimize the impact of blood ow on the efcacy of the treatment.
While single-cycle RFA has been shown to induce cellular death, studies using CA in ani­mals have demonstrated enhanced cell death with multiple treatment cycles. Consequently, when utilizing a temperature-based system for RFA, we recommend performing two separate RFA cycles with a minimum cool-down period of 30seconds between them [60].
Intraoperative Monitoring
While various imaging modalities such as ultra­sonography, MRI, and CT can be used to guide the placement of RFA probes, there is currently no reliable radiographic method to assess the treatment zone [61, 62]. Unlike cryoablation, where the expanding iceball visually indicates the treatment zone, RFA relies on probe place­ment, accurate positioning, and measurement of electrical impedance or temperature to dene the treatment area. An alternative approach involves placing nonconducting temperature probes around the tumor’s periphery or deep margin to independently monitor real-time treatment tem-