Ablative Treatments for Small Renal Masses and Management of Recurrences: A Comprehensive Review.

This review focuses on ablative techniques for small renal masses (SRMs), including radiofrequency ablation (RFA), cryoablation (CA), microwave ablation (MWA), and irreversible electroporation (IRE), and discusses recurrence management. Through an extensive literature review, we outline the procedures, outcomes, and follow-up strategies associated with each ablative method. The review provides a detailed examination of these techniques-RFA, CA, MWA, and IRE-elucidating their respective outcomes. Recurrence rates vary among them, with RFA and CA showing comparable rates, MWA demonstrating favorable short-term results, and IRE exhibiting promise in experimental stages. For managing recurrences, various strategies are considered, including active surveillance, re-ablation, or salvage surgery. Surveillance is preferred post-RFA and post-CA, due to slow SRM growth, while re-ablation, particularly with RFA and CA, is deemed feasible without additional complications. Salvage surgery emerges as a viable option for larger or resistant tumors. While ablative techniques offer short-term results comparable to surgery, further research is essential to understand their long-term effects fully. Decisions concerning recurrence management should consider individual and tumor-specific factors. Imaging, notably contrast-enhanced ultrasounds, plays a pivotal role in assessing treatment success, emphasizing the necessity of a multidisciplinary approach for optimal outcomes. The lack of randomized trials highlights the need for further research.

Local ablative therapies and the effect on antitumor immune responses in pancreatic cancer - A review.

Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, projected to rank as the second most prevalent cause of cancer-related mortality by 2030. Despite significant progress in advances in surgical techniques and chemotherapy protocols, the overall survival (OS) remains to be less than 10 % for all stages combined. In recent years, local ablative techniques have been introduced and utilized as additional therapeutic approaches for locally advanced pancreatic cancer (LAPC), with promising results with respect to local tumor control and OS. In addition to successful cytoreduction, there is emerging evidence that local ablation induces antitumor immune activity that could prevent or even treat distant metastatic tumors. The enhancement of antitumor immune responses could potentially make ablative therapy a therapeutic option for the treatment of metastatic PDAC. In this review, we summarize current ablative techniques used in the management of LAPC and their impact on systemic immune responses.

Endoscopic Ultrasound-Guided Locoregional Treatments for Solid Pancreatic Neoplasms.

Solid pancreatic neoplasms are one of the most diagnosed gastrointestinal malignancies thanks to the current and progressive advances in radiologic methods. Endoscopic ultrasound-guided techniques have over time gained a prominent role in the differential diagnosis and characterization of these pancreatic lesions, including pancreatic cancer, neuroendocrine tumors, and metastases. Recently, several endoscopic ultrasound-guided locoregional treatment techniques, which are divided into thermal ablative techniques and non-thermal injection techniques, have been developed and applied in different settings for the treatment of solid pancreatic neoplasms. The most common ablative techniques are radiofrequency, microwave, laser, photodynamic therapy and hybrid techniques such as hybrid cryothermal ablation. The most common injection techniques are ethanol injection, immunotherapy and brachytherapy. In this review, we update evidence about the efficacy and safety of endoscopic ultrasound-guided locoregional treatments for solid pancreatic neoplasms.

Endometriosis: papel del láser de CO2 en el abordaje quirúrgico / Endometriosis: CO2 laser in surgical treatment

El tratamiento quirúrgico de elección del endometrioma es la quistectomía clásica o decapsulación. No obstante, hay suficiente evidencia científica donde se demuestra que esta técnica se asocia a una reducción de la reserva ovárica, ya sea por la exéresis de tejido ovárico sano durante el procedimiento o por el daño térmico realizado durante el control de la hemostasia. Por este motivo, se han descrito nuevas aproximaciones quirúrgicas para paliar este efecto negativo sobre la reserva ovárica. El uso del láser CO2 en ginecología se conoce desde la década de los 80, y la vaporización de la cápsula del endometrioma mediante este láser es una técnica simple, sencilla de usar, fácilmente reproducible y técnicamente accesible. Aunque inicialmente se pensó que la tasa de recurrencia con esta técnica era superior, varios estudios demuestran lo contrario. Asimismo, el daño sobre la reserva ovárica es menor comparado con la decapsulación, en términos de mejor recuento folicular y nivel de hormona antimülleriana. Aunque las tasas de gestación espontánea y por técnicas de reproducción asistida son similares, en los casos de reproducción asistida las pacientes tratadas con vaporización láser CO2 presentan un mayor recuento folicular y nivel de hormona antimülleriana comparadas con las pacientes tratadas con decapsulación. A día de hoy, el tratamiento del endometrioma sigue siendo motivo de discusión. No obstante, los estudios revisados a continuación favorecen las técnicas ablativas en términos de preservar mejor la reserva ovárica sin mayor riesgo de recurrencia.(AU)

The surgical treatment of choice for endometrioma is cystectomy or endometrioma decapsulation. However, there is sufficient scientific evidence showing that this technique is associated with a decrease in ovarian reserve, either due to the removal of healthy ovarian tissue during the procedure or due to thermal damage performed during the control of haemostasis. For this reason, new surgical approaches have been described to alleviate this negative effect on ovarian reserve. The use of the CO2 laser in gynecology has been known since the 1980s, and vaporization of the endometrioma capsule using this laser is a simple, easy-to-use, easily reproducible, and technically accessible technique. Although it was initially thought that the recurrence rate with this technique was higher, several studies show the opposite. Likewise, the damage to the ovarian reserve is less compared to decapsulation, in terms of better follicular count and antimullerian hormone level. Although the rates of spontaneous pregnancy and assisted reproductive techniques are similar, in assisted reproductive techniques patients treated with CO2 laser vaporization have a higher follicular count and antimullerian hormone level compared to patients treated with decapsulation. To this day, the treatment of endometrioma continues to be a matter of discussion. However, the studies reviewed below favor ablative techniques in terms of better preserving ovarian reserve without increased risk of recurrence.(AU)

Clinical efficacy of thermocoagulation in women with biopsy-confirmed cervical low-grade squamous intraepithelial lesions (LSILs) or less after colposcopy referral.

OBJECTIVES: To evaluate the clinical efficacy of thermocoagulation in women with biopsy-confirmed cervical low-grade squamous intraepithelial lesions (LSIL) or less after colposcopy referral. MATERIAL AND METHODS: A longitudinal study was performed. Women who were diagnosed with cervical LSIL or chronic cervicitis underwent scheduled follow-up examinations with cytology and human papilloma virus (HPV) genotyping for two years after the initial management with thermocoagulation or observation without treatment. All women underwent scheduled follow-up with combined cytology and HPV test at 6th months, 12th months, and 24th months after the initial management. Both HPV clearance and cytological regression were included in the analysis, with clinical cure defined as normal cytology and negative HPV results. RESULTS: A total of 221 women were included. The histopathological results identified 136 (61.54%) patients with LSIL and 85 (38.46%) with chronic cervicitis. Of these, 113 (51.13%) received thermocoagulation therapy, and 108 (48.87%) chose observation. The 2-year follow-up rate was 91.40%. Women who received thermocoagulation presented a significantly higher probability of cure for two years than those who chose observation (62.86% vs 39.18%, p < 0.001). This preponderance was not observed in the subgroup analysis regarding women with cervical cervicitis (54.17% vs 41.38%, p = 0.277) but was observed in women with LSILs (70.18% vs 38.24%, p < 0.001). CONCLUSIONS: Thermocoagulation may be indicated for patients with cervical LSILs as an effective outpatient procedure in clinical practice.

The Role of Ablative Techniques in the Management of Hepatocellular Carcinoma: Indications and Outcomes.

The management of hepatocellular carcinoma (HCC) remains complex and will continue to rely on the multidisciplinary input of hepatologists, surgeons, radiologists, oncologists and radiotherapists. With the appropriate staging of patients and selection of suitable treatments, the outcomes for HCC are improving. Surgical treatments encompassing both liver resection and orthotopic liver transplantation (OLT) are the definitive curative-intent options. However, patient suitability, as well as organ availability, pose essential limitations. Consequently, non-surgical options, such as ablative techniques, play an increasingly important role, especially in small HCCs, where overall and disease-free survival can be comparable to surgical resection. Ablative techniques are globally recommended in recognised classification systems, showing increasingly promising results. Recent technical refinements, as well as the emerging use of robotic assistance, may expand the treatment paradigm to achieve improved oncological results. At present, in very early stage and early stage unresectable disease, percutaneous thermal ablation is considered the treatment of choice. Owing to their different features, various ablative techniques, including radiofrequency ablation, microwave ablation, cryotherapy ablation and irreversible electroporation, have been shown to confer different comparative advantages and applicability. We herein review the role of available ablative techniques in the current complex multidisciplinary management of HCC, with a main focus on the indications and outcomes, and discuss future perspectives.

Safety of High-Frequency Jet Ventilation During Image-Guided Thermal Ablation Procedures.

RATIONALE AND OBJECTIVE: Percutaneous thermal ablative technique is a common radiological procedure for malignant lesions treatment. Controlled assisted ventilation during general anesthesia is the usual mode of ventilation, but high-frequency jet ventilation (HFJV) can be a helpful alternative for the operator. The objective was to evaluate the safety of HFJV during thermal ablation procedures. MATERIALS AND METHODS: This monocentric prospective analysis included adult patients undergoing percutaneous thermal ablation procedures for abdominal tumor performed under HFJV. Procedures with a transpulmonary path were excluded. The primary outcome was the incidence of respiratory complications. Secondary outcomes included gas exchange modifications (hypercapnia, hypoxemia, pulmonary atelectasis) and the incidence of barotrauma. RESULTS: Sixty patients were included during the study period. The mean duration time was 88 min. All procedures went according to the protocol and there was no respiratory complication. There was no barotrauma event. Three patients had an exhaled capnia above 45 mmHg at the end of the procedure which normalized within 10 min of conventional ventilation. CONCLUSION: HFJV during thermal ablation procedures is safe regarding gas exchange and barotrauma. This technique could be an interesting alternative to conventional ventilation during image-guided thermal ablation procedures. Clinical Trials database This study was registered in Clinical Trials database (NCT04209608).

Long-Term Comparative Study on the Local Tumour Control of Different Ablation Technologies in Primary and Secondary Liver Malignancies.

Purpose: To evaluate local tumour control (LTC) by local ablation techniques (LAT) in liver malignancies. Materials and methods: In patients treated with LAT between January 2013 and October 2020 target lesions were characterised by histology, dimensions in three spatial axes, volume, vascularisation and challenging (CL) location. LAT used were: Radiofrequency Ablation (RFA), Microwave Ablation (MWA), Cryoablation (CRYO), Electrochemotherapy (ECT), and Interstitial Brachytherapy (IBT). Results: 211 LAT were performed in 155 patients. Mean follow-up including MRI for all patients was 11 months. Lesions treated with ECT and IBT were significantly larger and significantly more often located in CL in comparison to RFA, MWA and CRYO. Best LTC (all data for 12 months are given below) resulted after RFA (93%), followed by ECT (81%), CRYO (70%), IBT (68%) and MWA (61%), and further, entity-related for HCC (93%), followed by CRC (83%) and BrC (72%), without statistically significant differences. LTC in hypovascular lesions was worse (64%), followed by intermediate (82% p = 0.01) and hypervascular lesions (92% p = 0.07). Neither diameter (<3 cm: 81%/3−6 cm: 74%/>6 cm: 70%), nor volume (<10 cm3: 80%/10−20 cm3: 86%/>20 cm3: 67%), nor CL (75% in CL vs. 80% in non CL) had a significant impact on LTC. In CL, best LTC resulted after ECT (76%) and IBT (76%). Conclusion: With suitable LAT, similarly good local tumour control can be achieved regardless of lesion size and location of the target.

[Minimally invasive treatment options for the management of benign prostatic hyperplasia]. / Minimal-invasive Therapieoptionen zur Behandlung des benignen Prostatasyndroms.

Benign prostatic hyperplasia is one of the most common diseases of aging men. Hyperplasia of the glandular tissue can cause distressing lower urinary tract symptoms, which can be treated with both drugs and interventions. For a long time, transurethral resection of the prostate and simple prostatectomy were considered the gold standard of surgical treatment. In order to be able to offer patients an outpatient treatment with few complications, shorter hospital stays and high efficiency, a variety of minimally invasive treatment options have been developed. While recommendations have already been made for the excision by focused waterjet, prostatic urethral lift, and prostatic artery embolization, there are several other very promising procedures for which, however, long-term data and data from comparative studies with reference procedures must still be awaited.

Laser Treatment of Pancreatic Cancer with Immunostimulating Interstitial Laser Thermotherapy Protocol: Safety and Feasibility Results From Two Phase 2a Studies.

PURPOSE: Ablative techniques have emerged as new potential therapeutic options for patients with locally advanced pancreatic cancer (LAPC). We explored the safety and feasibility of using TRANBERG|Thermal Therapy System (Clinical Laserthermia Systems AB, Lund, Sweden) in feedback mode for immunostimulating Interstitial Laser Thermotherapy (imILT) protocol, the newest ablative technique introduced for the treatment of LAPC. METHODS: The safety and feasibility results after the use of imILT protocol treatment in 15 patients of a prospective series of postsystemic therapy LAPC in two high-volume European institutions, the General and Pancreatic Unit of the Pancreas Institute, of the University of Verona, Italy, and the Department of Surgical Oncology of the Institut Paoli-Calmettes of Marseille, France, were assessed. RESULTS: The mean age was 66 ± 5 years, with a mean tumor size of 34.6 (±8) mm. The median number of cycles of pre-imILT chemotherapy was 6 (6-12). The procedure was performed in 13 of 15 (86.6%) cases; indeed, in two cases, the procedure was not performed; in one, the procedure was considered technically demanding; in the other, liver metastases were found intraoperatively. In all treated cases, the procedure was completed. Three late pancreatic fistulas developed over four overall adverse events (26.6%) and were attributed to imILT. Mortality was nil. A learning curve is necessary to interpret and manage the laser parameters. CONCLUSIONS: Safety, feasibility, and device handling outcomes of using TRANBERG|Thermal Therapy System with temperature probes in feedback mode and imILT protocol on LAPC were not satisfactory. The metastatic setting may be appropriate to evaluate the hypothetic abscopal effect.#NCT02702986 and #NCT02973217.

High-Intensity Focused Ultrasonography and Radiofrequency Ablation of Renal Cell Carcinoma Arisen in Transplanted Kidneys: Single-Center Experience With Long-Term Follow-Up and Review of Literature.

The purpose of this article is to retrospectively evaluate the long-term outcome of patients treated with percutaneous thermoablation for renal cell carcinomas that have arisen in kidney grafts. Between April 2008 and February 2011, we treated 3 patients with renal cell carcinoma on a transplanted kidney: 2 cases were treated with high-intensity focused ultrasonography and 1 patient with radio frequency ablation. Postprocedural ultrasonography did not reveal any complications, and contrast-enhanced ultrasonography showed an avascular area in the treated nodules. None of the patients had recurrent tumors during a long-term clinical and radiologic follow-up (81, 73, and 43 months, respectively).

The role of microwave ablation in management of functioning pancreatic neuroendocrine tumors.

BACKGROUND: Surgical resection is considered to be the only potentially curative option for patients with pancreatic neuroendocrine tumors (pNETs). High risk rates of perioperative complications make minimally invasive ablative techniques a novel perspective and alternative treatment option for pancreatic neuroendocrine tumors. This study aims to present the first experience of using a microwave ablation in management of pNETs. METHODS: Sechenov University has an experience of treating more than 400 patients with hormone-producing tumors of the pancreas, 7 of which were treated by microwave ablation (MWA). RESULTS: In all patients that underwent MWA, a regression of hormonal symptomatic was achieved. Two patients required readmission a month later for draining of pseudocyst and abscess. CONCLUSIONS: The exact role of microwave ablation in the treatment of non-metastatic pancreatic neuroendocrine tumors has not been defined yet. There is a lack of large prospective randomized studies and the reason for this is that local tumor destruction is indicated in selected cases only, thus making it difficult to analyze a large group of patients and assess long-term results of the treatment. However, microwave ablation allows to take a better control of symptoms in patients with hormone overproduction and in those with high risk of postoperative complications.

Effects of radiofrequency ablation versus other ablating techniques on hepatocellular carcinomas: a systematic review and meta-analysis.

BACKGROUND: Percutaneous ablation has quickly arisen as one of the important alternative treatments for hepatocellular carcinoma (HCC). We aimed to compare the therapeutic effects of radiofrequency ablation (RFA) and other ablative techniques on HCCs. METHODS: Databases were searched to identify literature on complete tumor ablation (CTA), overall survival (OS), local tumor recurrence (LTR), and complications of RFA in the treatment of HCC, compared with those of microwave ablation (MWA), percutaneous ethanol injection (PEI), PEI plus RFA, cryoablation (CRA), laser ablation (LSA), and high-intensity focused ultrasound. Randomized controlled trials and high-quality cohort studies were included in the assessment. RESULTS: The effects of MWA and CRA appeared to be similar to those of RFA, but lower rates of LTR and higher rates of CTA in large tumors compared with RFA were reported (P < 0.05). CTA rates were lower in patients treated with PEI (odds ratio [OR] 0.16, 95% confidence interval [CI] 0.06-0.42), and higher in those treated with PEI plus RFA (OR 2.28, 95% CI 1.19-3.60), with an increased incidence of fever (P < 0.05). LSA resulted in lower CTA rates (OR 0.32, 95% CI 0.13-0.81) and OS (hazard ratio 1.47, 95% CI 1.01-2.15), with a lower incidence of complications. CONCLUSIONS: Compared with RFA, identical effects were found in MWA and CRA groups. Fewer complications were observed in PEI and LSA group. PEI plus RFA appeared more effective, with a higher rate of complications. Well-designed randomized controlled trials are further needed to confirm above results.

Minimally invasive ablative techniques in the treatment of breast cancer: a systematic review and meta-analysis.

PURPOSE: Breast-conserving surgery is effective for breast cancer treatment but is associated with morbidity in particular high re-excision rates. We performed a systematic review and meta-analysis to assess the current evidence for clinical outcomes with minimally invasive ablative techniques in the non-surgical treatment of breast cancer. METHODS: A systematic search of the literature was performed using PubMed and Medline library databases to identify all studies published between 1994 and May 2016. Studies were considered eligible for inclusion if they evaluated the role of ablative techniques in the treatment of breast cancer and included ten patients or more. Studies that failed to fulfil the inclusion criteria were excluded. RESULTS: We identified 63 studies including 1608 patients whose breast tumours were treated with radiofrequency (RFA), high intensity focussed ultrasound (HIFU), cryo-, laser or microwave ablation. Fifty studies reported on the number of patients with complete ablation as found on histopathology and the highest rate of complete ablation was achieved with RFA (87.1%, 491/564) and microwave ablation (83.2%, 89/107). Short-term complications were most often reported with microwave ablation (14.6%, 21/144). Recurrence was reported in 24 patients (4.2%, 24/570) and most often with laser ablation (10.7%, 11/103). The shortest treatment times were observed with RFA (15.6 ± 5.6 min) and the longest with HIFU (101.5 ± 46.6 min). CONCLUSION: Minimally invasive ablative techniques are able to successfully induce coagulative necrosis in breast cancer with a low side effect profile. Adequately powered and prospectively conducted cohort trials are required to confirm complete pathological ablation in all patients.

Role of local ablative techniques (Radiofrequency ablation and Irreversible Electroporation) in the treatment of pancreatic cancer.

Thanks to continuous research and investment in technology, the ablation of tumors has become common. Through the application of different types of energy is possible to induce cellular injury of the neoplastic tissue, leading to cellular death. Radiofrequency ablation (RFA) and irreversible electroporation (IRE) represent the most applied ablative techniques on pancreatic cancer. RFA and IRE, causing necrosis and apoptosis of neoplastic cells, are able to destroy neoplastic tissue, to drastically modify the neoplastic microenvironment and, possibly, to stimulate both directly and indirectly the anti-tumor immune system. This article provides part of our experience with the application of RFA and IRE on pancreatic adenocarcinoma (PDAC).

Thermal ablative therapies for treatment of localised renal cell carcinoma: a systematic review of the literature.

BACKGROUND AND AIMS: Small renal masses are commonly diagnosed incidentally. The majority are malignant and require intervention. The gold standard treatment is partial nephrectomy unless the patient has significant co-morbidities when surveillance or ablative therapies are utilised. The latter are relatively novel and their long-term efficacy and safety remain generally poorly understood. We performed a literature review to establish the current evidence on the oncological outcome of thermal ablative techniques in small renal masses treatment. METHODS AND RESULTS: A systematic literature search was performed using PubMed, supplemented with additional references. Articles were reviewed for data on indications, tumour characteristics, ablative techniques, oncological outcome, impact on renal function and complications. The vast majority of articles identified were observational studies. There has not been any direct comparison against partial nephrectomy. Radiofrequency ablation and cryoablation are the techniques that are more commonly used. They have favourable oncological results on intermediate follow-up and indications that successful outcome is sustained long term. The morbidity and impact on renal function appear to be minimal. CONCLUSION: Thermal ablative therapies are valid alternatives to partial nephrectomy for the treatment of small renal masses in patients unfit for surgery. Prospective long-term data will be needed before the indications for their use expand further.

Percutaneous radiofrequency ablation of renal tumors in high-risk patients: 10 years' experience. / Ablación percutánea mediante radiofrecuencia de tumores renales en pacientes de alto riesgo: 10 años de experiencia.

OBJECTIVE: To retrospectively evaluate the efficacy and safety of percutaneous radiofrequency ablation (RFA) done to treat renal tumors in patients with high surgical risk or with the risk of developing multiple renal tumors in the medium term at our center over a period of 10 years. MATERIAL AND METHODS: Between 2005 and 2015, we used RFA to treat 89 T1a or T1b tumors in 87 patients (mean age, 73.7±10.87 years) with high surgical risk. We excluded patients treated with radiofrequency and embolization or microwave ablation. The tumors treated were clear cell carcinomas (43.6%), papillary renal carcinomas (17.2%), chromophobe renal cell carcinomas (10.3%), cystic tumors (2.2%), and an angiomyolipoma (1.1%). The mean size of the tumors was 2.6cm. Computed tomography and/or ultrasonography were used to guide the procedure. We analyzed the relation between the efficacy of the procedure and patients' age, the type of needle, the source of the patients, the size and location of the tumor, and the number of sessions required to achieve ablation. We recorded all complications. RESULTS: The RFA procedure was completed in all patients. The mean follow-up period was 32.1 months. The efficacy was 93.7%. A single session was sufficient in 87.5% of patients; 8% required two sessions and 4.5% required three sessions. The only factor associated with worse efficacy was the size of the tumor (p=0.03). The rate of complications was 5.6%. CONCLUSIONS: RFA is efficacious and safe, with results comparable to those reported in the literature.

A review of ablative techniques in the treatment of breast fibroadenomata.

INTRODUCTION: Breast fibroadenomata (FAD) are benign lesions which occur in about 10 % of all women. Diagnosis is made by triple assessment (physical examination, imaging and/or histopathology/cytology). For a definitive diagnosis of FAD, the treatment is conservative unless the patient is symptomatic. For symptomatic patients, the lumps can be surgically excised or removed interventionally by vacuum-assisted mammotomy (VAM). Ablative techniques like high-intensity focused ultrasound (HIFU), cryo-ablation and laser ablation have also been used for the treatment of FAD, providing a minimally invasive treatment without scarring or poor cosmesis. This review summarises current trials using minimally invasive ablative techniques in the treatment of breast FAD. METHODS: A comprehensive review of studies using minimally invasive ablative techniques was performed. RESULTS: There are currently several trials completed or recruiting patients using HIFU, cryo-ablation and laser ablation in the treatment of breast FAD. The results look very promising but cannot be compared at this point due to heterogeneity between studies. CONCLUSION: Minimally invasive ablative techniques like HIFU, cryo-ablation and laser ablation are promising in the treatment of breast FAD. Future trials should be randomised and contain larger numbers of patients to determine the effectiveness of ablative techniques with more precision.