Current state of urological cryosurgery: prostate and kidney

Percutaneous cryoablation for high-complexity renal masses: complications, functional and oncological outcomes

BACKGROUND

During the past two decades cryoablation (CA) has become a therapeutic option for the management of localized cT1 renal masses in comorbid patients. We analyzed the mid-term functional and oncological outcomes of CA in the treatment of cT1 renal masses which were classified as high-complexity masses according to the PADUA system.

METHODS

A total of 299 patients underwent percutaneous CA between November 2007 and December 2018 in 4 institutions for cT1N0M0 renal masses. All patients with high-complexity (PADUA≥10) renal tumors were included. Technical failure of CA was considered an exclusion criterion.

RESULTS

Inclusion criteria were met by 45 patients. Median Charlson Comorbidity Index (CCI) was 6.0 (IQR: 5.0-7.0), median age was 74 years (IQR: 64.5-79.5). Seven Clavien 1 and 1 Clavien 2 procedure-related complications were reported. Median eGFR at baseline was 64.3mL/min (IQR: 52.0-82.3) while at the 1-year follow-up was 61.4 mL/min (IQR: 44.0-74.5). The median follow-up was 32 months (IQR: 13.25-47.5). Local recurrences were detected in 6 patients; 3 of them underwent re-cryoablation while the others started active surveillance. Median time to recurrence was 17.5 months (IQR: 7.8-27.3). Cancer-specific survival and metastasis-free survival were 100%, while overall survival was 86.7%.

CONCLUSIONS

CA proved to be a valuable therapeutic option for the management of patients with cT1 high-complexity PADUA≥10 renal tumors as it provides a low rate of procedural morbidity and good preservation of renal function. However, these results are counterbalanced by a recurrence rate that appears to be higher than those reported on surgically treated patients.

Active surveillance and focal ablation for small renal masses: a better solution for comorbid patients

The natural history of small renal masses (SRM) is still not well understood and they are frequently incidentally diagnosed in elderly patients. Therefore, there is a need for less invasive options sparing the patient from the side-effects related to conventional surgical treatment. PubMed and Medline database search was performed to look for new findings on active surveillance and focal therapy for SRM. Sixty-one articles published between 2002 and 2018 were selected for the purpose of the review. There is growing evidence confirming the safety of active surveillance in patients at surgical risk and there appears to be a satisfactory intermediate-term outcome of focal treatment of SRM. In the group of elderly patients with a decreased life expectancy active surveillance appears to be the most appropriate approach. The future of minimally invasive therapy appears bright, especially with the improvement of new imaging modalities.

The Role of Ablation and Minimally Invasive Techniques in the Management of Small Renal Masses

CONTEXT

Nephron-sparing approaches are increasingly recommended for incidental small renal masses. Herein, we review the current literature regarding the safety and efficacy of focal therapy, including percutaneous ablation, for small renal masses.

OBJECTIVE

To summarize the application of ablative therapy in the management of small renal masses.

EVIDENCE ACQUISITION

PubMed and Medline database search was performed to look for findings published since 2000 on focal therapy for small renal masses. After literature review, 64 articles were selected and discussed.

EVIDENCE SYNTHESIS

Radiofrequency ablation and cryotherapy are the most widely used procedures with intermediate-term oncological outcome comparable with surgical series. Cost effectiveness seems excellent and side effects appear acceptable. To date, no randomized trial comparing percutaneous focal therapy with standard surgical approach or active surveillance has been performed.

CONCLUSIONS

Focal ablative therapies are now accepted as effective treatment for small renal tumors. For tumors <3cm, oncological effectiveness of ablative therapies is comparable with that of partial nephrectomy. Percutaneous ablation has fewer complications and a better postoperative profile when compared with minimally invasive partial nephrectomy.

PATIENT SUMMARY

Focal ablative therapies are now accepted as effective treatment for small renal tumors. For tumors <3cm, oncological effectiveness of ablative therapies is comparable with that of partial nephrectomy.

Clinical efficacy of percutaneous cryoablation combined with allogenic NK cell immunotherapy for advanced non-small cell lung cancer

In this study, the safety and clinical efficacy of cryosurgery combined with allogenic NK cell immunotherapy for the treatment of advanced non-small cell lung cancer (NSCLC) were evaluated. From July 2016 to March 2017, we enrolled 60 patients who met the enrollment criteria and divided them into two groups: (1) the simple cryoablation group (n = 30) and (2) the cryoablation combined with allogenic NK cell group (n = 30). The changes in immune function, quality of life, and clinical response were evaluated. We found that allogenic NK cells combined with cryosurgical treatment for advanced NSCLC have a synergistic effect, which not only enhancing the immune function of patients, improving the quality of life, and significantly increasing the response rate (RR) and disease control rate (DCR) compared to cryoablation group. This study is the first clinical trial of allogenic NK cells combined with cryosurgery for the treatment of advanced NSCLC and preliminaily its safety and efficacy.

Characterization of the cryoablation-induced immune response in kidney cancer patients

Cryoablation is one of treatment modalities for kidney cancer and is expected to induce strong local immune responses as well as systemic T-cell-mediated immune reactions that may lead to the regression of distant metastatic lesions. Thus, the characterization of T cell repertoire and immune environment in tumors before and after treatment should contribute to the better understanding of the cryoablation-induced anticancer immune responses. In this study, we collected tumor tissues from 22 kidney cancer patients, before cryoablation and at 3 mo after cryoablation. In addition, blood samples were collected from 14 patients at the same time points. We applied a next generation sequencing approach to characterize T cell receptor β (TCRB) repertoires using RNAs isolated from tumor tissues and peripheral blood mononuclear cells. TCRB repertoire analysis revealed the expansion of certain T cell clones in tumor tissues by cryoablation. We also found that proportions of abundant TCRB clonotypes (defined as clonotypes with ≥ 1% frequency among total TCRB reads) were significantly increased in the post-cryoablation tissue samples than those of pre-cryoablation tumor samples. Some of these TCRB clonotypes were found to be increased in peripheral blood. Expression analysis of immune-related genes in the tissues of pre- and post-cryoablation showed significantly elevated transcriptional levels of CD8⁺ , CD4⁺ , Granzyme A (GZMA), and CD11c along with a high CD8/FOXP3 ratio in the post-cryoablation tissue samples. Our findings revealed that cryoablation could induce strong immune reactions in tumors with oligoclonal expansion of antitumor T cells, which circulate systemically.

Cryoablation combined with allogenic natural killer cell immunotherapy improves the curative effect in patients with advanced hepatocellular cancer

In this study, the clinical efficacy of cryosurgery combined with allogenic natural killer cell immunotherapy for advanced hepatocellular cancer was evaluated. From October 2015 to March 2017, we enrolled 61 patients who met the enrollment criteria and divided them into two groups: 1) the simple cryoablation group (Cryo group, n = 26); and 2) the cryoablation combined with allogenic natural killer cells group (Cryo-NK group, n = 35), the safety and short-term effects were evaluated firstly, then the median progression-free survival, response rate and disease control rate were assessed. All adverse events experienced by the patients were recorded, and included local (e.g., pain, pleural effusion, and ascites) and systemic (e.g., chills, fatigue, and fever) reactions, fever was more frequent. Other possible seriously side effects (e.g., blood or bone marrow changes) were not detected. Combining allogeneic natural killer cells with cryoablation had a synergistic effect, not only enhancing the immune function, improving the quality of life of the patients, but also reducing the expression of AFP and significantly exhibiting good clinical efficacy of the patients. After a median follow-up of 8.7 months (3.9 -15.1months), median progression-free survival was higher in Cryo-NK (9.1 months) than in Cryo (7.6 months, P = 0.0107), median progression-free survival who received multiple natural killer was higher than who just received single natural killer (9.7 months vs.8.4 months, P = 0.0011, respectively), the response rate in Cryo-NK (60.0%) was higher than in Cryo (46.1%, P < 0.05), the disease control rate in Cryo-NK (85.7%) was higher than in Cryo group (69.2%, P < 0.01). Percutaneous cryoablation combined with allogeneic natural killer cell immunotherapy significantly increased median progression-free survival of advanced hepatocellular cancer patients. Multiple allogeneic natural killer cells infusion was associated with better prognosis to advanced hepatocellular cancer.

Prospective study of percutaneous cryoablation combined with allogenic NK cell immunotherapy for advanced renal cell cancer

In this study, the clinical efficacy of cryosurgery combined with allogenic NK cell immunotherapy for advanced renal cell cancer was evaluated. From July to December 2016, we enrolled 60 patients who met the enrollment criteria and divided them into two groups: (1) the simple cryoablation group (n=30); and (2) the cryoablation combined with allogenic NK cells group (n=30). The clinical efficacy, quality of life, immune function, and other related indicators were evaluated. Combining allogeneic NK cells with cryoablation had a synergistic effect, not only enhancing the immune function and improving the quality of life of the patients, but also significantly exhibiting good clinical efficacy of the patients. This study is the first clinical trial that has evaluated the safety and efficacy of allogenic NK cells combined with cryosurgery for the treatment of renal cell cancer.

Percutaneous ablation of the small renal mass-techniques and outcomes

An increasing number of T1a renal cell carcinomas are being diagnosed in recent years, in part due to incidental detection from the increased use of cross-sectional imaging. Although partial nephrectomy is still considered the primary treatment for these small renal masses, percutaneous ablation is now being performed as a standard therapeutic, nephron-sparing approach in patients who are poor surgical candidates. Clinical studies to date have demonstrated that percutaneous ablation is an effective therapy with acceptable outcomes and low risk in the appropriate clinical settings. This article will review various clinical aspects regarding the percutaneous ablation of small renal masses, including patient selection, preprocedural preparations, and the procedural considerations of commonly employed ablative technologies. Specific techniques such as radiofrequency ablation, cryoablation, microwave ablation, irreversible electroporation, and high-intensity focused ultrasound will be addressed in detail. In addition, the technical and oncologic outcomes of percutaneous ablation will be discussed and referenced to that of partial nephrectomy.

Extracts from glioma tissues following cryoablation have proapoptosis, antiproliferation, and anti-invasion effects on glioma cells

OBJECTIVE

This study is to investigate the in vivo apoptotic processes in glioma tissues following cryoablation and the effects of glioma tissue extracts on GL261 glioma cells in vitro.

METHODS

TUNEL and flow cytometry analysis were performed to detect the apoptotic processes in the glioma tissues following cryoablation and in the GL261 cells treated with cryoablated tumor extracts. The scratch assay, the transwell assay, and Western blot analysis were carried out to evaluate the effects of cryoablated tumor extracts on the migration, invasion, and proliferation of tumor cells.

RESULTS

Our in vivo results indicated that the rapid-onset apoptosis was induced via the intrinsic pathway and the delayed apoptosis was triggered through the extrinsic pathway. The in vitro results showed that extracts from glioma tissues following cryoablation induced apoptosis via extrinsic pathways in GL261 glioma cells. Furthermore, cryoablated tumor extracts significantly inhibited the migration and proliferation of these cells, which would be related to the inhibition of ERK1/2 pathway and the activation of P38 pathway.

CONCLUSION

Glioma cells surviving in cryoablation undergo intrinsic or extrinsic apoptosis. Augmenting the induction of apoptosis or enhancing the cryosensitization of tumor cells by coupling cryoablation with specific chemotherapy effectively increases the efficiency of this therapeutic treatment.

Therapeutic outcomes of combining cryotherapy, chemotherapy and DC-CIK immunotherapy in the treatment of metastatic non-small cell lung cancer

Currently there are no effective therapies for the treatment of metastatic non-small cell lung cancer (NSCLC). Here, we conducted a retrospective study of 161 patients to evaluate the therapeutic effects of combining cryosurgery, chemotherapy and dendritic cell-activated cytokine-induced killer cells (DC-CIK) immunotherapy. The overall survival (OS) after diagnosis of metastatic NSCLC to patient death was assessed during a 5-years follow-up period. OS of patients who received comprehensive cryotherapy was (median OS, 20 months; n = 86) significantly longer than that of patients who did not received cryotherapy (median OS, 10 months; n = 75; P < 0.0001). Five treatment combinations were selected: chemotherapy (n = 44); chemo-immunotherapy (n = 31); cryo-chemotherapy (n = 32); cryo-immunotherapy (n = 21); and cryo-chemo-immunotherapy (n = 33). A combination of cryotherapy with either chemotherapy or immunotherapy lead to significantly longer OS (18 months and 17 months, respectively) compared to chemotherapy and chemo-immunotherapy (8.5 months and 12 months, respectively; P < 0.001); however, the median OS of patients who underwent cryo-chemo-immunotherapy was significantly longer (27 months) compared to the other treatment programs (P < 0.001). In conclusion, a combination of cryotherapy, chemotherapy and DC-CIK immunotherapy proved the best treatment option for metastatic NSCLC in this group of patients.

Percutaneous cryoablation for stage IV lung cancer: a retrospective analysis

The aim of this study was to investigate the therapeutic effect of cryoablation treatment and palliative treatment in stage IV lung cancer. Fifty-four patients were enrolled into the study. Thirty-one patients received cryoablation treatment (including intra- and extrapulmonary tumors), and 23 patients had palliative treatment (no cryoablation). Both the safety of the procedure and overall survival (OS) for stage IV lung cancer were assessed during a 6.5 year follow-up period. The OS of patients in both groups and the effects of treatment timing and frequency were compared. The OS in the cryoablation group was significantly longer than in the palliative group (median OS: 14 months vs. 7 months, P = 0.0009). The OS of those who received delayed cryoablation treatment was longer than that observed for those who received timely treatment (median OS: 18.5 months vs. 10 months, P = 0.0485), but this was not observed in those who received palliative treatment (median OS: 7 months vs. 7.5 months, P = 0.9814). Multiple treatments played an important role in improving the OS of patients who received cryoablation treatment (median OS: 18 months vs. 14 months, P = 0.0376). There was a significant difference between cryoablation and palliative treatment, in terms of OS. In addition, multiple cryoablation treatments may have an advantage over single treatments.

Temperature-dependent activation of differential apoptotic pathways during cryoablation in a human prostate cancer model

BACKGROUND

Critical to the continual improvement of cryoablation efficacy is deciphering the biochemical responses of cells to low-temperature exposure. The identification of delayed-onset cell death has allowed for the manipulation of cellular responses through the regulation of apoptosis. We hypothesized that in addition to delayed apoptotic events associated with mild subfreezing temperatures (10 to -25 °C), cells exposed to ultra-low temperatures (<-30 °C) may undergo rapid, early-onset apoptosis.

METHODS

Human prostate cancer model and cells (PC-3) were exposed to temperatures of -60, -30 and -15 °C to simulate a cryoablative procedure. Using a combination of flow-cytometry, fluorescent microscopy and western blot analyses, samples were assessed at various times post thaw to identify the presence, levels and the pathways involved in cell death.

RESULTS

Exposure to temperatures <-30 °C yielded a significant apoptotic population within 30 min of thawing, peaking at 90 min (~40%), and by 6 h, only necrosis was observed. In samples only reaching temperatures >-30 °C, apoptosis was not noted until 6-24 h post thaw, with the levels of apoptosis reaching ~10% (-15 °C) and ~25% (-30 °C) at 6 h post thaw. Further, it was found that early-onset apoptosis progressed through a membrane-mediated mechanism, whereas delayed apoptosis progressed through a mitochondrial path.

CONCLUSIONS

These data demonstrate the impact of apoptotic continuum, whereby the more severe cryogenic stress activated the extrinsic, membrane-regulated pathway, whereas less severe freezing activated the intrinsic, mitochondrial-mediated path. The rapid induction and progression of apoptosis at ultra-low temperatures provides an explanation as to why such results have not previously been identified following freezing. Ultimately, an understanding of the events and signaling pathways involved in triggering apoptosis following freezing may provide a path for selective induction of the rapid-onset and delayed programmed cell death pathways in an effort to improve the overall cryoablation efficacy.

Percutaneous cryoablation as a salvage therapy for local recurrence of lung cancer

A 66-year-old male was diagnosed with inoperable non-small cell lung cancer, and underwent chemoradiotherapy, to which he achieved a partial response. During subsequent follow-up, positron emission tomography showed a fluorodeoxyglucose uptake lesion within the primary tumor, without evidence of metastatic foci elsewhere in the body. As local disease progression was most suspected, cryoablation was performed for the lesion with high fluorodeoxyglucose uptake. After treatment, there has been no evidence of recurrence for 12 months. Herein, we present a case of percutaneous cryoablation as a salvage therapy for recurrent lung cancer after chemoradiotherapy.

[Renal cell carcinoma]

Approximately 85% of all malignant tumors of the kidney are renal cell carcinomas (RCC). Sonography is the leading examination for early detection of kidney tumors. The treatment of RCC has been enriched in recent years by new therapeutic options for localized and metastatic cancer. The classification of RCC is based on TNM and UICC criteria. The so-called Motzer criteria are being increasingly employed to assess prognosis and monitor therapy and as the basis for reaching decisions on choosing the type of systemic treatment.

Focal therapy for prostate cancer - where are we in 2011?

Prostate cancer treatment is a controversial topic amongst physicians and patients alike. Radical therapies such as prostatectomy and whole gland radiation offer the best outcomes in terms of oncologic efficacy, but the decision to undergo treatment must be weighed against its potential morbidity. Over the past decade, the concept of focal therapy for prostate cancer has been introduced as a potential method of achieving oncologic control with a lesser degree of morbidity. Focal therapy refers to isolated ablation of a tumor focus with sparing of uninvolved, surrounding tissue. While it remains in the early stages of development, considerable research is underway that will help determine the optimal method of achieving this goal. Current areas of investigation include appropriate candidate selection, lesion identification, modality of treatment, and follow-up strategies.