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Crioterapia no Tratamento do Câncer Renal<br />Lucas Nogueira<br />
TendênciasConteporâneas<br />Aumento da incidência e mortalidade – 3-4% ano<br />60 a 70% sãoachadosincidentais<br />Taman...
TécnicasMinimamenteInvasivas<br />NefrectomiaParcialLaparoscópica<br />NefrectomiaParcial “Hand-Assisted”<br />TerapiasAbl...
Terapias Ablativas no Câncer Renal<br />Objetivos:<br />Reprodução dos resultadosoncológicos da nefrectomiaparcial.<br />D...
Crioterapia<br />É hoje a  terapiaablativamaisestudada,  clinicamentetestada, e com seguimentomaislongoempacientes com Cân...
AvançosnaTécnica<br />Inserção de probe nalesãotumoral -Temperaturamínima: - 19.4 0 C<br />2 ciclos de congelamentorápido ...
Vias de Acesso<br />Aberta – procedimento abdominal concomitante<br />Laparoscópica:<br />Lesõesanteriores e antero-mediai...
Fundamentos Técnicos<br />Imagem em tempo real<br />Biopsia da lesão<br />Inserção do probe perpendicularmente à lesão<br ...
Seguimento<br />Métodosparaavaliação da eficácia<br />imagem (TC, RNM) – 3 a 6 meses<br />diminuição das área<br />nãocapt...
Indicações<br />Ainda sem concenso<br />Fatores a se considerar<br />Idade  - dados de seguimento apenas 5 anos<br />Estad...
ResultadosOncológicos<br />Laparoscopia<br />Davol PE, Fulmer BR, Rukstalis DB. Long-term results of cryoablation for rena...
ResultadosOncológicos<br />Percutânea<br />Finley, Beck,  Box,  Clayman et al. Percutaneous and Laparoscopic Cryoablation ...
Complicações<br />
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Crioterapia no Tratamento do Câncer Renal

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Lucas Nogueira

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Crioterapia no Tratamento do Câncer Renal

  1. 1. Crioterapia no Tratamento do Câncer Renal<br />Lucas Nogueira<br />
  2. 2. TendênciasConteporâneas<br />Aumento da incidência e mortalidade – 3-4% ano<br />60 a 70% sãoachadosincidentais<br />Tamanhomédioaodiagnóstico – 3,5 cm<br />Segurançaoncológica da nefrectomiaparcial<br />Conscientização da importância da preservação da função renal<br />Maiorutilização da nefrectomiaparcial e terapiasminimamenteinvasivas.<br />
  3. 3. TécnicasMinimamenteInvasivas<br />NefrectomiaParcialLaparoscópica<br />NefrectomiaParcial “Hand-Assisted”<br />TerapiasAblativas:<br />Crioterapia<br />Radio-frequência<br />HIFU (High Intensity Focused Ultrasound)<br />Micro-ondas<br />
  4. 4.
  5. 5. Terapias Ablativas no Câncer Renal<br />Objetivos:<br />Reprodução dos resultadosoncológicos da nefrectomiaparcial.<br />Diminuição de complicações, hospitalização e convalescência<br />Apenas dados de curto e médioprazo<br />TerapiasAblativas:<br />Crioterapia<br />Radio-frequência<br />HIFU (High Intensity Focused Ultrasound)<br />Micro-ondas, Radio-cirurgia<br />
  6. 6. Crioterapia<br />É hoje a terapiaablativamaisestudada, clinicamentetestada, e com seguimentomaislongoempacientes com Câncer Renal<br />Baseia-se nadestruição das célulaspelaação do frio.<br />Hiperosmolaridade<br />Desidratação<br />Desnaturaçãoenzimática<br />Disfução e rupturamembranacelular<br />Dano vascular<br />Sensibilizaçãoimunológica<br />Chosy SG, Nakada SY, Lee FT Jr, et al. Monitoring renal cryosurgery: predictors of tissue necrosis in swine. J Urol 1998;159:1370.<br />
  7. 7. AvançosnaTécnica<br />Inserção de probe nalesãotumoral -Temperaturamínima: - 19.4 0 C<br />2 ciclos de congelamentorápido (nitrogênioouargôniolíquidos), seguido de reaquecimento gradual (gáshélio)<br />Áreacongeladadeveultrapassar as margenstumorais- 5 a 10 mm.<br />Stephenson RA, King DK, Rohr LR. Renal cryoablation in a canine model. Urology 1996; 47:772.<br />Campbell SC, Krishnamurthi V, Chow G, et al. Renal cryosurgery: experimental evaluation of treatment parameters. Urology 1998;52:29.<br />
  8. 8. Vias de Acesso<br />Aberta – procedimento abdominal concomitante<br />Laparoscópica:<br />Lesõesanteriores e antero-mediais<br />Visualização e mobilização de estruturasadjacentes<br />Visualizaçãoeacompanhamentoem tempo real da áreatratadaatravés de US<br />Fácilhemostosia<br />Percutânea:<br />Lesõesposteriores<br />TC ouRNM<br />Procedimentomaisrápido e menorhospitalização<br />Menoscomplicações e menorconvalescência<br />Sterrett, Nakada,Wingo et al. Renal Thermal Ablative Therapy<br />Urol Clin N Am 35 (2008) 397–414<br />
  9. 9. Fundamentos Técnicos<br />Imagem em tempo real<br />Biopsia da lesão<br />Inserção do probe perpendicularmente à lesão<br />Criação de área de congelação (ice ball) 10 mm além da margem<br />Hemostasia após remoção do probe<br />Sterrett, Nakada,Wingo et al. Renal Thermal Ablative Therapy<br />Urol Clin N Am 35 (2008) 397–414<br />
  10. 10.
  11. 11. Seguimento<br />Métodosparaavaliação da eficácia<br />imagem (TC, RNM) – 3 a 6 meses<br />diminuição das área<br />nãocaptação de contraste<br />Biópsiapercutânea – 6 meses<br />FN – 14%<br />
  12. 12. Indicações<br />Ainda sem concenso<br />Fatores a se considerar<br />Idade - dados de seguimento apenas 5 anos<br />Estado clínico do paciente<br />Função renal<br />Tamanho da lesão<br />Principais :<br />Idosos<br />Comorbidade<br />Lesões menores que 3cm<br />Lesões múltiplas, bilaterais, função renal comprometida<br />
  13. 13. ResultadosOncológicos<br />Laparoscopia<br />Davol PE, Fulmer BR, Rukstalis DB. Long-term results of cryoablation for renal cancer and complex renal masses. Urology 2006<br />Hegarty NJ, Kaouk JH, Remer EM, et al. Laparoscopic renal cryoablation: oncological outcomes at 5 years [abstract]. J Endourol 2006<br />Gill IS, Remer EM, Hasan WA, et al. Renal cryoablation: outcome at 3 years. J Urol 2005;173:1903.<br />
  14. 14. ResultadosOncológicos<br />Percutânea<br />Finley, Beck, Box, Clayman et al. Percutaneous and Laparoscopic Cryoablation of Small Renal Masses. J Urol 180, 492-498, 2008<br />Charboneau et al. Percutaneous Renal Cryoablation: Experience Treating 115 Tumors J Urol 179, 2136-2141, 2008<br />Bandi G, Wen CC, Hedican SP, et al. Cryoablation of small renal masses: assessment of the outcome at one institution. BJU Int 2007<br />
  15. 15. Complicações<br />
  16. 16. Complicações<br />Variação : 1 a 11%<br />Baixa incidência de sangramento, fístula urinária <br />Relacionadas a:<br />Tamanho – 3 cm<br />Acesso – percutânea<br />
  17. 17. Limitações<br />Ausência de tecidoparadiagnósticohistológico<br />Nãoextirpação da lesão<br />Identificação de curabilidadebaseadaemmétodos de imagem<br />Dados de seguimentoaindanãomaduros<br />
  18. 18. Tendências e Considerações<br />Aumento da utilização – 13.8% (2005)<br />Indicações ainda não bem definidas<br />Lesão não retirada<br />Seguimento somente 5 anos<br />Bom resultado terapêutico e menor morbidade<br />Representaumaalternativaem: <br />Pacientesidososouqueapresentamcomorbidadesimportantes<br />Rim únicoouinfuficiência renal<br />Presença de tumoresmúltiplos<br />Dados de seguimento a longoprazoirãodefinirseupapel no tratamento do câncer renal<br />

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