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1. קבוצה 2 גישה לגידולי כליה קטנים T 1 a

2. אפשרויות הטיפול נעות בין ניטור פעיל Active Surveillance (AS) ל - Radical Nephrectomy (RN) אפשרויות ניתוחיות : כיצד לקבוע את הטכניקה הרצויה

4. עיקר בחירת טכניקה ניתוחית לפי מאפייני גידול יכולת מנתח

5. אפשרויות ניתוחיות : כיצד לקבוע את הטכניקה הרצויה T categories for kidney cancer TX : The primary tumor cannot be assessed T0 : No evidence of a primary tumor T1 : The tumor is only in the kidney and measures 7 cm T1a : The tumor measures 4 cm or smaller and confined to the kidney . T1b : The tumor is larger than 4 cm but not larger than 7 cm confined to the kidney . T2 : The tumor is > 7 cm across confined to the kidney . T2a : The tumor is more than 7 cm but not more than 10 cm across and confined to the kidney . T2b : The tumor is more than 10 cm across and confined to the kidney . Staging of Renal Masses T1a: The tumor measures 4 cm or smaller and confined to the kidney

6. אפשרויות ניתוחיות : כיצד לקבוע את הטכניקה הרצויה • absolute – solitary (/functioning) kidney • relative – morbidity in the opposite kidney • elective – localized unilateral RCC w/a normal contralateral kidney. Relative indications include hereditary forms of RCC which carry a high risk of tumor in the contralateral kidney. For elective indications, nephron-sparing surgery for tumors limited in diameter (T1a) provides recurrence-free and long-term survival rates similar to those after radical surgery Indications for Nephron-Sparing Surgery – EAU Guidelines

7. אפשרויות ניתוחיות : כיצד לקבוע את הטכניקה הרצויה In patients with a solitary kidney, laparoscopic partial nephrectomy results in a prolonged warm ischaemia time and a higher complication rate . Temporary or permanent dialysis is more likely to be necessary Indications for Nephron-Sparing Surgery – EAU Guidelines

10. Trends in Renal Tumor Surgery Delivery Within the United States Lori M. Dulabon, DO1; William T. Lowrance, MD2; Paul Russo, MD2; and William C. Huang, MD1 מצבנו לא רע !! Cancer May 15, 2010

17. Minimal Invasive Treatments for Small Renal Masses

18. NCCN Guideline : “ Surgical resection remains the only effective therapy for clinically localized RCC” EAU Guideline : “ Surgical therapy is the only curative theraputic approach for the treatment of RCC” But: “ Patients with small tumors and / or significant co - morbidity who are unfit for surgery should be considered for an ablative approach, e . g . cryotherapy and radiofrequency ablation.”

19. EAU Guideline: “ Pre - treatment biopsy has to be carried out as standard” “ Other image - guided percutaneous and minimally invasive techniques, such as microwave ablation, laser ablation and high - intensity focused ultrasound ablation, are still experimental in character . The experience obtained with radiofrequency ablation and cryoablation should be considered when using these related techniques”

20. Cryoablation or Radiofrequency Ablation of the Small Renal Mass - a Meta-Analysis Cancer . 2008 Nov 15;113 ( 10 ): 2623-6 Cryo RFA Tumor Progression: 5.2% 12.9% Re Treatment Rates 1.3% 8.5% Metastatic Disease 1% 2%

21. Morbidity: Major Urological Complications (ARF, Hemorrhage, Urinary Leak, Loss of Kidney) – 4.9% Non Urological Complications (PE, DVT, Bowel Perf.) – 5%

22. Follow Up: Imaging ? Biopsy ? Imaging: Decrease in Size (lack of decrease does not entitle failure) Non Enhancement (lack of non-enhancement does not entitle failure but warrants biopsy)

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