Renal Ablation Challenges And Clinical Changes Syllabus
2016-01-06
: Pdf Renal Ablation Challenges And Clinical Changes Syllabus Renal_Ablation_Challenges_and_Clinical_Changes_Syllabus 1 2016 pdf
Open the PDF directly: View PDF 
.
Page Count: 31
| Download | |
| Open PDF In Browser | View PDF |
1/5/2016 NeuWave Microwave: Overview of thermal ablation Chris Brace Ph.D. University of Wisconsin DISCLAIMER PLEASE NOTE: The Certus 140 2.45 GHz Ablation System is a tool, not a treatment for any disease or condition. It is cleared for the ablation (coagulation) of soft tissue in percutaneous, open surgical and in conjunction with laparoscopic surgical settings in patients who present themselves to a treating physician with a wide variety of diseases or conditions.. The Certus 140 2.45 GHz Ablation System is not indicated for use in cardiac procedures. The system is designed for facility use and should only be used under the orders of a physician. The information in these cases is not meant to convey recommendations from NeuWave Medical, Inc. regarding appropriateness for a particular patient, power and time settings, final ablation zone size and shape or other procedure guidance. NeuWave Medical makes no representations and assumes no liability regarding the accuracy of the information provided herein or the effectiveness of any of the treatment or for any action or inaction you take based on or made in reliance on the information. These are individual cases and your results may vary. When planning a case, consider all unique aspects, including tissue type, lesion location, surrounding vasculature and proximity to critical structures when determining probe type and power/time settings. Consult the product Instructions For Use for information regarding expected ablation sizes December 2015 Disclosure • Co-founder of NeuWave Medical December 2015 1 1/5/2016 SYLLABUS Objectives of Presentation • • Physics of microwave Benefits of synchronous in-phase technology • • Clinical differentiators Probe placement • • Advanced Education Programs Clinical cases for development of best practices December 2015 EVOLUTION OF ABLATION TECHNOLOGY 1980’s 1st Generation Microwave 1990’s Single-Probe RF Early 2000’s 2nd Generation Microwave Late 2000’s 3rd Generation Microwave Single-probe, uncooled Single-probe Single-Probe, Low Power Single-probe except MTX Multi-Probe RF RF switching controller 1960 1970 1980 1990 2000 HS Amica Evident Microthermx Medwaves Microsulis 2010 New Generation Microwave NeuWave • • • • • • Multi-Probe High Power, 2.45 GHz Real-Time Control Gas-Cooled Smaller Probes Large or Focal Ablation Capable Precision Probe Vivawave ‘02 ‘06 ‘07 ‘08 ‘09 ‘10 ‘12 ‘15 MWA 510K Approvals 1960’s 1st Generation Cryoablation Liquid-cooled, open ablation Late 1980’s 2nd Generation Cryoablation Late 1990’s 3rd Generation Cryoablation ABLATION CONFIRMATION Gas-cooled, smaller probes Liquid-cooled, percutaneous ablation December 2015 2 MODES OF THERMAL ABLATION Freezing and Heating Cryoablation Radiofrequency ablation Microwave ablation Cell death by freezing When tissue is cooled to ≤ -40° C, intracellular ice formation ruptures cell membrane and kills cells via a freeze/thaw method Cell death by heating ≤ - 40° C ≥ 60° C When tissue is heated to ≥ 60° C, proteins denature, lipids in the cell membrane melt and cells are killed instantaneously December 2015 2 1/5/2016 CRYOABLATION OVERVIEW HOW CRYOABLATION WORKS: • 1 probe per 1 cm ablation zone inserted into/near target2 • Cells are killed using a freeze/thaw method FREEZE: Cell dehydration Membrane & essential constituents are severely damaged and cells die slowly THAW: Cell Re-hydration Thaw phase causes the cells to burst from rapid rehydration. Ischemia is caused by damage to vascular system & membranes December 2015 CRYOABLATION OVERVIEW REQUIRES MULTIPLE, OFTEN LARGE (13 GAUGE) PROBES2 LOW PROCEDURAL PAIN 3 + - PRESERVES ADJACENT NORMAL CRITICAL STRUCTURES & MINIMAL SCARRING3 ICE BALL HIGHLY VISIBLE ON CT/MRI/US3 VISIBLE ICE BALL IS NOT TREATMENT ZONE4 NO ACTIVE PROCESSES – COOLING IS PASSIVE BY CONDUCTION RISK OF SYSTEMIC EFFECTS (CRYOSHOCK, LIVER FRACTURE5 ) LENGTHY PROCEDURE (APPROX. ≥ 30 MIN 6 ) POTENTIALLY HIGHER COST DUE TO MULTIPLE PROBES & EXPENSIVE GASES6 December 2015 RADIOFREQUENCY OVERVIEW HOW RADIOFREQUENCY ABLATION WORKS: • Heating is produced when an electrical current agitates ions • Grounding pads placed externally on patient to complete the electrical circuit Tissue near electrode: Active heating by ionic agitation Tissue away from electrode: Passive heating by thermal conduction. Once tissue becomes dehydrated/charred, the tissue acts as an electrical insulator preventing further current flow. December 2015 3 1/5/2016 RADIOFREQUENCY OVERVIEW DEHYDRATED/CHARRED TISSUE (>100 °C) HIGH IMPEDANCE, LIMITED POWER5 PROVIDES CAUTERIZATION 5 + MINIMAL # OF ELECTRODES AND GASES REQUIRED - PULSING OR SLOW HEATING REQUIRED TO AVOID TISSUE DEHYDRATION/CHAR5 HEAT SINK LOBULATED ABLATIONS & HIGHER RECURRENCE RATES7 SUBSTANTIAL PEERREVIEWED LITERATURE, (OLDER TECHNOLOGY) GROUNDING PADS = RISK OF SKIN BURNS8 December 2015 MW AND RF SIMILARITIES Mechanism of cell kill is identical (indistinguishable under the microscope) Microwave-penetrates all biologic tissues (including aerated lung, bone, char) 10 December 2015 ANTENNA RADIATION Energy converted to heat Energy flow along antenna shaft December 2015 4 1/5/2016 EARLY MICROWAVE SYSTEMS OVERVIEW • EM field (915 MHz or 2.45 GHz) • Rapidly oscillates water molecules to generate heat • The EM field penetrates all biologic tissues including dehydrated/charred tissue created during ablation • No limit to temperature, power 10 Exhibit 1: Because of the significant shaft heating that occurred with 1 st gen microwave, a robust shaft cooling mechanism was required to minimize thermal damage to the subcutaneous tissues and the skin, especially with the development 9 of higher power systems 2015 December EARLY MICROWAVE SYSTEMS OVERVIEW ENERGY CAN BE APPLIED CONTINUOUSLY DESPITE CHANGES IN TISSUE IMPROVED PERIVASCULAR PERFORMANCE VS RF (LESS HEAT SINK EFFECT7 ) LARGE GAUGE ANTENNAS + - WAVE INTERFERENCE & INEFFECTIVE COOLING UNPREDICTABLE “HOT DOG” SHAPED ABLATIONS11 SOME TISSUE CONTRACTION 11 NO SYNCHRONY WITH MULTI-ANTENNA USE = INCONSISTENT ABLATION ZONES EFFECTIVE IN ALL SOFT TISSUE TYPES7 UNDER POWERED December 2015 Segment II NeuWave Medical – Certus 140 Technical Differences December 2015 5 1/5/2016 NEUWAVE MICROWAVE SYSTEM OVERVIEW NEUWAVE IMPROVEMENTS11: 2.45 GHz frequency • Less electromagnetic interference during multiple probe use for predictable, reproducible burns 12 Triaxial antenna design • High energy throughput • Minimal backward heating Multi-antenna wave synchrony • Consistent, reproducible large burns Tissu-Loc iceball CO2 cooling • Eliminates heating along antenna shaft (no comet tail) • Tissu-Loc™ for reducing antenna migration during scanning and additional antenna placement December 2015 Power Distribution: 2.45GHz Power Distribution: Cable Loss The inherent loss of generated microwave energy due to smaller diameter cables led to NeuWave creating the Power Distribution Module (PDM) Large Cable Small Cable 35% 33% 30% 25% 20% 21% 15% 10% 20% 12% 5% 0% 915 MHz 2.45 GHz Delivered = Generated – Distribution Losses December 2015 6 1/5/2016 December 2015 Antenna Design December 2015 7 1/5/2016 PR & LK ANTENNAS TISSUE SHRINKAGE CAUSED BY MW Marked tissue shrinkage with high power MW devices ~30% liver/kidney ~50% lung16 December 2015 D5 w/ contrast Pre-ablation December 2015 After 3-minute ablation 8 1/5/2016 ABLATION FOR RENAL SOFT TISSUE: 2014A. Moreland, et al UW paper 2012J. Yu, et al Radiology 2014Y. Lin, et al Urology 2013M. Cristescu, et al WCIO abstract High-Powered Microwave Ablation of T1a Renal Cell Carcinoma: Safety and Initial Clinical Evaluation US-guided Percutaneous Microwave Ablation of Renal Cell Carcinoma: Intermediate-term Results Percutaneous Microwave Ablation of Renal Cell Carcinoma Is Safe in Patients With a Solitary Kidney Percutaneous Microwave Ablation for the Treatment of Renal Angiomyolipoma (APL): Initial Experience 2014J. Horn , et al J Vasc Interv Radiol Percutaneous Microwave Ablation of Renal Tumors Using a GasCooled 2.4-GHz Probe: Technique and Initial Results This material/information may include discussions of off-label use of our product, the Certus 140, for which we cannot promote the product. We disseminate this information to you only to provide you with a fair December 2015 representation of the current published information REFERENCES Disclosure: Dr. Christopher Brace is a shareholder and consultant for NeuWave Medical, Inc., and a co-inventor on patents related to thermal tumor ablation. Dr. Fred Lee is the founder and shareholder for NeuWave Medical, Inc., and a co-inventor on patents related to thermal tumor ablation. . Dr. Paul Laeseke is a shareholder and consultant for NeuWave Medical, Inc. and a co-inventor on patents related to thermal tumor ablation. Dr. J. Louis Hinshaw is a shareholder for NeuWave Medical Inc. 1. D. Dupuy & K. Chu, Biological mechanisms and advances in therapy. Nature Reviews Cancer 2014 14,199–208 doi:10.1038/nrc3672 2. H. Bang, et al. Percutaneous cryoablation of metastatic lesions from non-small cell lung carcinoma: Initial survival, local control, and cost observations. JVIR 2012. 3. Kurup, N, et al. Image-Guided Percutaneous Ablation of Bone and Soft Tissue Tumors. Semin Intervent Radiol. 2010. 4. Georgiades, C, et al. Determination of the Nonlethal Margin Inside the Visible ‘‘Ice-Ball’’ During Percutaneous Cryoablation of Renal Tissue. Cardiovasc Intervent Radiol (2013) 36:783–790 5. Knavel, E, et al. Tumor Ablation: Common Modalities and General Practices. Techniques in Vascular and Interventional Radiology 2013. 6. Mahnken, A, et al. CT- and MR-Guided Interventions in Radiology 2nd Edition 2013. 7. Lu. D, et al, Influence of Large Peritumoral Vessels on Outcome of Radiofrequency Ablation of Liver Tumors. JVIR 2003. 8. Huffman, S.D., et al. Radiofrequency Ablation Complicated by Skin Burn. Semin Intervent Radiol. 2011. 9. JVIR. Aug 2010; 21(8 Suppl): S192–S203. doi: 10.1016/j.jvir.2010.04.007 10. Brace C., et al. Microwave ablation technology: what every user should know. Curr Probl Diagn Radiol. 2009;38(2):61–67. 11. Brace, C. Microwave Tissue Ablation: Biophysics, Technology and Applications. Critical Reviews in Biomedical Engineering 38(1):65-78, 2010. 12. Sun, et al. Comparison of temperature curve and ablation zone between 915-and 2450-MHz cooled-shaft microwave antenna: Results in ex vivo porcine livers. European Journal of Radiology. 2011. 13. NeuWave Medical Time and Power Guide - ex-vivo bovine lung and liver. 14. Lubner, M. et al. Microwave Tumor Ablation: Mechanism of Action, Clinical Results and Devices. J Vasc Interv Radiol. 2010 Aug; 21(8 Suppl): S192–S203. 15. Yu, et al. JVIR 19:1084-1092, 2008. Bhardwaj, et al. Pathology 41:168-172, 2009. 16. Brace, C. et al. Radiofrequency and Microwave Ablation of the Liver, Lung, Kidney, and Bone: What Are the Differences? Curr Probl Diagn Radiol 2009. 17. Brace C. et. al. Pulmonary Thermal Ablation: Comparison of Radiofrequency and Microwave Devices by Using Gross Pathologic and CT Findi ngs in a Swine Model. Radiology: Volume 251: Number 3—June 2009. 18. Poggi, et al. Microwave Ablation of Hepatocellular Carcinoma Using a New Percutaneous Device: Preliminary Results. Anticancer Research. 33: 1221-1228 (2013). 19. Groeschl, et al. Abstract: Microwave ablation for hepatic malignancies: A multi-institutional analysis. 2013 Gastrointestinal Cancers Symposium. J Clin Oncol 30: 2012 (suppl34; abstr218). 20. Liu, et al. Percutaneous microwave ablation of larger hepatocellular carcinoma. Clinical Radiology 68 (2013) 21e26. 21. Groeschl, et al. Recurrence after microwave ablation of liver malignancies: a single institution experience. HPB (Oxford). 2013 May;15(5):365-71. 22. Liu, et al. Efficacy and safety of thermal ablation in patients with liver metastases. European Journal of Gastroenterology & Hepatology 2013, 25:442–446. 23. Liang, et al. Percutaneous cooled-tip microwave ablation under ultrasound guidance for primary liver cancer: a multi centre analysis of 1363 treatment-naive lesions in 1007 patients in China. Gut 2012;61:1100-1101. 24. Lin-Feng, et al Large primary hepatocellular carcinoma: Transarterial chemoembolization monotherapy versus combined transarterial chemoembolizationpercutaneous microwave coagulation therapy. Journal of Gastroenterology and Hepatology 28 (2013) 456–463. December 2015 REFERENCES 25. Martin, et al. Safety and efficacy of microwave ablation of hepatic tumors: a prospective review of a 5-year experience. Ann Surg Oncol. 2010 Jan;17(1):171-8. 26. Livraghi, et al. Complications of Microwave Ablation for Liver Tumors: Results of a Multicenter Study. CVIR, August 2012, Volume 35,Issue 4, pp 868-874. 27. Lin, et al. Percutaneous Microwave Ablation of Renal Cell Carcinoma Is Safe in Patients With a Solitary Kidney. Urology. 2014 Feb;83(2):357-63. 28. Moreland, et al. Percutaneous Microwave Ablation of T1 Renal Cell Carcinoma: Multicenter Evaluation of Safety and Early Clinical Effi cacy. Journal Of Endourology Sept. 2014; Volume 28, Number 9 29. Guan, et al. Microwave Ablation Versus Partial Nephrectomy for Small Renal Tumors: Intermediate-Term Results. Journal of Surgical Oncology 2012;106 30. Yu, et al. Us-guided Percutaneous Microwave ablation of renal cell carcinoma: Intermediate-term Results. Radiology: Volume 263: Number 3—June 2012. 31. Muto, et al. Laparoscopic Microwave Ablation and Enucleation of Small Renal Masses: Preliminary Experience. European Urology 60 (2011) 173-176. 32. Guan, et al. Retroperitoneoscopic Microwave Ablation of Renal Hamartoma: Middle-term Results . J HuazhongUnivSciTechnol［MedSci］30(5):2010 ." 33. Carrafiello, et al. Single-antenna microwave ablation under contrast-enhanced ultrasound guidance for treatment of small renal cell carcinoma: preliminary experience. Cardiovasc Intervent Radiol. 2010 Apr;33(2):367-74. 34. Liang, et al. Ultrasound guided percutaneous microwave ablation for small renal cancer: initial experience. J Urol. 2008;180:844-848. 35. http://www.sirweb.org/patients/liver-cancer/ accessed on 2/17/15 36. National Lung Cancer Alliance accessed on 2/19/15 37. NCCN Guidelines December 2015 9 1/5/2016 Microwave ablation for T1a RCC Fred T. Lee Jr., MD Department of Radiology Disclosures • Founder, NeuWave Medical Inc. (Microwave) • Inventor, patents: Certus 140TM • Inventor, patents, royalties, Covidien Switching ControllerTM (RF) • NIH grants: R21RR018303 R01CA108869 R01CA118990 R01CA112192 U Wisconsin RCC Percutaneous Ablation Procedures 2002-2015 60 Procedures performed 50 40 MW Cryo RF 30 20 10 0 02' 03' 04' 05' 06' 07' 08' 09' 10' 11' 12' 13' 14' 15' Year 1 1/5/2016 T1a RCC-anatomy is everything • • • • Defined as < 4cm in size Not all are created equal Anatomic position is probably more important than size Nephrometry (RENAL) score predicts LTP and complications Reyes, et al. Urol Onc 2013;31 Schmidt, et al. J Urol 2013;189 www.nephrometry. com 2 1/5/2016 6.3 cm RCC: Pre-ablation scans 3 LK’s placed in top half of tumor Ablated 140W each x 1 minute, then 65W for 5 minutes 3 1/5/2016 Pre 15 mo post Pre 15 mo post The one place ablation struggles 4 1/5/2016 Ureteral injury after cryo Why we use mostly MW • • • • • • • Tumor control (I’ll show you our data) Physics (esp tissue contraction) Speed Pain (?) Costs Hassle Visibility MW and RF are closely related • Mechanism of cell kill is identical (indistinguishable under the microscope) • “Microwave” is actually in the RF spectrum • AMA and SIR coding guidelines for MW: Use RF codes • MW hotter (more likely to reach 60°C) , faster, no ground pads, fewer probes, better against vessels • Microwave-penetrates all biologic tissues (including aerated lung, bone, char) • Think of MW as an advanced RF system 5 1/5/2016 Why do you need such high temps? • No resistant cells> 60 °C • Chemo, radiation, cryo all have resistant cells (Tatsutani) • Cancer stem cells are radio/chemo resistant, ?cold resistant • Phospholipids in cell membranes melt between 45-55 °C – Furuya, J Phys Soc Jn 1978 If you use heat: Hotter is better! Costs • UW experience: – Cryo 2.8 probes/procedure+gas ($113.65/tank) – MW: 1.8 probes/procedure+gas ($5.24/tank) – ~150 cases, assume $1500/probe – Cost savings= ~$271,270 + physician time + room time Hassle factor: • • • • No ground pads No heavy tanks No wrenches No heavy cables/lines • No water lines • Fast 6 1/5/2016 Local tumor control: MW Cryo Failures 2006 Preablation 1st Cryo 21 Months Post 2nd Cryo 4 Years Post MW 8/2013 9 mos post 2 probe cryoablation MW RCC-literature • ~700 patients reported, pace increasing • All studies positive w/one exception (Castle, Urology 2011). 10 patients, LTP 38% – Perc CT, 1st gen MW, cases done by urologists, no radiology • Yu, et al (Radiology 2012): n=49, LTP 7.7%, 20.1 mo f/u, no severe complications • Yu, et al (Radiology 2013): MW (n=65) vs. nephrectomy (n=98). 5-yr survival (cancer specific)=97.1 MW vs. 97.6% nephrectomy • Martin, et al (Diagn Int Radiol 2013): Meta-analysis 1st gen MW vs. Cryo, conclusion: no difference (but more studies for cryo) 7 1/5/2016 • • • • • MW=105 (2.7 cm) vs. Nephrectomy=328 (2.8 cm) MW patients older, sicker, worse renal fxn Complications NSD, renal function better w/ MW Overall survival better w/ nephrectomy (p=0.0004) Tumor specific survival same (p=0.38) UW data-T1a RCC • N=100, dia=2.6 cm, f/u=17 mo (out to 48 mo) • BMI 32.2, nephrometry score 7 (moderate complexity) • eGFR pre 71.8, post 68.7 • Hydrodissection 34% • 1.8 antennas, 65W, 5 min • We’ve done 3 RCC in renal transplants RCC in renal transplant * * Duodenum 8 1/5/2016 RCC in renal transplant Hydrodissection * D * D * D RCC in renal transplant Ablation * 82 yo with 48 mo f/u Pre MW 44 mo post MW 9 1/5/2016 82 yo with 48 mo f/u Pre MW 44 mo post MW 65 yo with 35 mo f/u UW data-T1a RCC • 1 LTP (1%), Furhman Gr 4, at 25 mo • No RCC deaths, no mets • 3 deaths: MI (5 mo), lymphoma (9 mo), GI bleed (39 mo) • PFS=99%, CSS=100%, OS=97% • Tumor complexity, BMI didn’t effect results • 11 complications, most minor, 3 related to procedure (RP bleed, hematuria x 2) • 6 urinomas on delayed imaging 10 1/5/2016 Retroperitoneal hematoma Day 10 Pre MW Pre MW During MW Retroperitoneal hematoma Day 10 Retroperitoneal hematoma, POD#10 Coinciding w/ restarting heparin + warfarin 28 mo post Urinomas, most detected late Probe tip too deep In collecting system 11 1/5/2016 Urinomas, most detected late Track Immed post T2WI 24 mo post T1WI+C 24 mo post Urinomas, mechanism Probe track Urinomas, mechanism Probe track Urinoma www.studyblue.com 12 1/5/2016 How we place probes now 2.2 cm endophytic RCC During ablation (bubbles highly visible) 2 PR’s, 65W for 3 minutes, then 40W for 2 minutes Post ablation CT 13 1/5/2016 Tangential approach to avoid collecting system 2.9 cm Immediate Pre Immediate Post ablation 7 months post ablation 14 1/5/2016 Preventing urinomas: Don’t puncture collecting system! • • • • • • Before tangential approach=29 endophytic RCC Median RENAL score of 8.5 6 urinomas With tangential approach=35 endophytic RCC Median RENAL score of 8.5 0 urinomas Summary • MW highly effective for local control T1a RCC • Is MW “better” than other modalities? You be the judge • We favor MW due to effectiveness, speed, costs, decreased hassle • Watch out for inferior medial pole tumors with any modality • Urinomas associated with puncture of collecting system, ergo, don’t do it… Thank you for your attention! flee@uwhealth.org UW Tumor Ablation Team: Meg Lubner, Fred Lee, Tim Ziemlewicz, Shane Wells, Louis Hinshaw 15 1/5/2016 Percutaneous Microwave Ablation Noah S. Schenkman, MD University of Virginia Health System Disclosures Paid physician consultant by NeuWave for my time to present my experience in this presentation. Virginia Approach: Small Renal Mass Multi-Disciplinary: Radiology and Urology Combined Decision-making Small Renal Mass Conference Active surveillance consideration Timing of biopsy US and CT Immediate imaging 6 month imaging Intraoperative uses? 1 1/5/2016 Case 70 year old man incidentally found 1.5 cm renal mass Follow up CT 2 yrs later: 2.5 cm Biopsy: Papillary Renal Cell Carcinoma HTN, DM, paraplegia Serum Cr 0.9, eGFR= 97 Preoperative CT Needle Placement 2 1/5/2016 stPost-Procedure Post-Procedure Microwave Ablation (n=38) 13 (62%) 27 (71%) 8 (38%) 67.0 (44-88) 11 (29%) 67.2 (40-87) 0.96 29.3 (27.1-31.5) 29.9 (28.0-31.8) 0.69 0.93 Gender Male Female Age - years (range) BMI - cm2/kg (95%CI) pvalue Cryoablation (n=21) 0.56 Charlson Comorbidity Score Nephrometry Score Numerical (95%CI) 6.6 (5.6-7.6) 6.7 (6.0-7.4) Posterior location – N (%) 12 (57.1%) 26 (78.8%) Volume – mm3(95%CI) 12.5 (6.7-18.2) 15.3 (8.7-22.0) Clear Cell RCC 10 (47.6%) 17 (56.7%) Pathology 0.23 0.50 0.06 Papillary RCC 4 (19.0%) 11 (36.7%) Chromophobe RCC 1 (4.8%) 1 (3.3%) NOS 6 (28.6) 1 (3.3%) 3 1/5/2016 Cryoablation Recurrence 4 (19%) Microwave P-value Ablation 0.05 1 (3.0%) Average Cost 6354.1 (4777.1- 4121.9 (3269.0(U.S. Dollars) 7931.0) 4974.8) 0.02 Complications Cryoablation Non-ST Elevation Myocardial Infarction Pulmonary Embolus Hematoma Requiring Transfusion Microwave Pneumonia UTI 4 1/5/2016 Dr Roger Williams Interventional Oncology Interventional Radiology Quantum Radiology Marietta, GA Disclosure: Paid clinical education consultant for NeuWave Medical Overview The principle of moving to a new country. Securing Employment (Service line) Establish Housing (Clinic) Developing Friendships (Referrals) Understanding Landscape of Tumor Board (Bureaucracy ) Partnering in Multidisciplinary Tumor Board (Currency) 1 1/5/2016 Service Line Interventional oncologist = Clinician, administrator, scheduler, **advocate for patient, cache Become educated on the pertinent literature (BPO) Develop technical skills to become successful Develop skill set through challenging cases Clinic Establish a dedicated space, time and contact numbers Establish a streamline EASY means for referrals Lab and Imaging review Lend Imaging expertise to patient Referrals Simplify process for referrals Not all Urologist are the same (Prostate v. Kidney) Discuss criteria: Operative/ Non Operative Ablation under conscious sedation Partial nephrectomy TNM Staging 2 1/5/2016 Bureaucracy Urologist thoughts on Ablation Prior experience: In training At facility Cryo v. RFA v. Microwave Complications Management Currency Procedural control Partial nephrectomy Ablation Procedural control (Ablation) Urology Radiology Follow up Urology Radiology 3
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.4 Linearized : No Modify Date : 2016:01:06 02:05:30-05:00 Creator : PDFMerge! (http://www.pdfmerge.com) Create Date : 2016:01:06 02:05:30-05:00 Producer : iText® 5.5.8 ©2000-2015 iText Group NV (ONLINE PDF SERVICES; licensed version) Page Count : 31EXIF Metadata provided by EXIF.tools