 It doesn't show my disclosures here, which I have disclosures in both the microwave and the RF space, where I'm the inventor of the switching controller, which is an RF device. I'm a founder of a new wave medical, which is a microwave company. I was involved with the early development of percutaneous cryoblation and was on the board of medical advisors of endo care as well. Now let's talk about heat-based ablation here for a few moments. The key with heat-based ablation is getting the tissue temperature to 60 degrees C at which time the tissue dies very rapidly within seconds. The key, though, is to getting to 60 degrees C, which isn't always so easy with some of the current ablation technologies. Now why 60? So if you get tissue to 60, and this is one thing that I stress many times when I speak, is that there are no cells in the human body that are resistant to 60 degrees C. Cancer stem cells, which are resistant to radiotherapy and chemotherapy in many cases, and maybe cryotherapy, will all die at 60 degrees C. And the reason is very simple. It's a mechanical reason. And that is that the phospholipids that are in the cell membranes, they simply melt. And so the cell can't continue homeostasis above 60 degrees C. It's a very simple, mechanical reason why we target this temperature. Now in terms of microwave and RF, I think the way you should think about these settings, what you should think about these technologies is microwave is RF's like big, tough older brother. It's a microwave will be replacing RF if it already hasn't at your institution. It's hotter, it's faster, you don't need ground pads. It's much better in a vascular environment or when there's flow around the area. It's actually, there really is no such thing as microwave. A microwave is actually a radio frequency device that is a higher frequency than the so-called radio frequency devices that you see in practice. So microwave works at either 915 or 2.45 gigahertz, whereas most of the radio frequency devices are about 500 kilohertz. But to the cell, these are the same thing essentially. You're going to kill the cell with heat in both cases. Turns out that the AMA and the SIR both have published coding guidelines where you use radio frequency codes to code for microwave procedures. They recognize it's essentially the same procedure. Now in terms of what's happening out there in the marketplace, microwave is rapidly replacing RF ablation. If you want to know what's happening with something, look where the money is. And this is a publication from some of the money guys that say growth in microwave ablation devices has stalled growth in RF. And you can pretty much see where the future is going to be in terms of microwave and RF. So once again, we're going to kill the tissue with heat to 60 degrees C, RF and microwave do it the same way. Microwave just happens to be more robust for this particular purpose. And this is the reason why. Microwave uses an electromagnetic field similar to your cell phone antenna. It heats very quickly, as you can see by the blue line, and it heats much hotter than RF. RF is limited to about 100 degrees C because the tissue chars and dehydrates. And when that happens, you can't conduct any more electrical current into the tissue and the RF device shuts off. Microwave has no such limitation. The tissue can keep getting hotter and hotter. And you can see your chances of reaching 60 degrees centigrade are much better with a higher temperature device. Now the other thing that we're just starting to understand, and this is very unique to microwave, and this is the only ablation technology we see this in. And that's tissue contraction. So what happens is when you heat the tissue to very high temperatures, you dehydrate it very intensely, and the tissue contracts very profoundly, as you can see in this example. This is a CT scan through a liver. And if you look at zero minutes, all the markers are evenly spaced. And as time goes on, you can see them getting sucked in to the ablation. Now this is interesting because this is the only ablation technology that has an active component. It physically changes the tissue to pull it into the killing zone. Okay, this is the only thing. I believe that this helps you in that you don't have to place your probes so perfectly because they are going to pull the tumor into the probe and kill them within the active zone. So this is a very interesting thing. And we see this. This is a movie that demonstrates this process. You can see on your right, that's a radio frequency device. On your left, that's a microwave device. And you'll see the microwave ablation lesion is bigger and it continues going longer. But what I think is really interesting is look at the tissue being pulled in from the side of the glass specimen, whereas on the radio frequency device, that is not happening. So it's pulling the tumor into the microwave probe and killing it in the active field. This is very unique for all ablation modalities. And we see that when we're treating tumors. This is an exophytic renal cell, as you can see from pre-ablation to during to immediate post. The tumor shrinks down amazingly. And the more water that the tumor contains, the more that it will shrink. This is a very remarkable process if you've never seen it. Here's another example, a very exophytic renal cell cancer, pre-ablation and post-ablation. This is at least halved in size in terms of diameter and about 70% decrease in volume. So this is a very important process that we're just starting to understand. Okay, so where we are today in terms of cryoblation, radio frequency, microwave, all that stuff. We are in an era where all of the options are pretty good for tumors less than three centimeters, all of them, as long as it's a state-of-the-art device. And so I think that if I look around the country and I watch how people do these procedures, the operator and how you do it is probably way more important than what you choose when you're under three centimeters in size. Everybody should get greater than 90% local control. And as you heard from Dr. Jewett, if you don't successfully ablate the tumor the first time, you can always go back. These are minimally morbid procedures. There's no great trials that are going to help compare devices and they probably, even if there were, it probably wouldn't help all that much because the operator is so important in this particular device. So if you have a tumor less than three centimeters, how do you choose? And one thing to consider is can you choose based on expense? And for us, cryoprobes are expensive and you have to use a lot of them. You have to use a minimum of two. And it turns out that if you look at the average cost, cryo is 2.73 times more expensive for an average case and you have to decide whether that's worth the cost. In terms of speed, I don't know about you guys. I'm really a very impatient person and when I do procedures, I want to do them pretty fast. This is a microwave ablation. This is going to be three breaths and the tumor is going to be covered by the gas bubbles. In terms of visibility, look how well you can see that ablation zone. It's pretty much as well as you can see with cryo. So that is 17 seconds and the tumor is completely covered by gas bubbles. Now what about large tumors? Tom's going to talk about this in a little bit more detail. Cryo works pretty well for large tumors. RF not so much. The data really starts to drop off when you get over three to four centimeters. But I think we're going to get better results with microwave, but it's going to take a little bit of time, and mostly because it's a more robust heating technology. Here's a tumor that Jason and Abel and I did a few months ago, 6.5 centimeter renal cell, highly vascular, really aggressive looking, and this is what it looked like three weeks after we completed treating it. Now in terms of the mechanism of cell kill, there's been a lot of talk about cryo-immune kind of interactions and that kind of stuff, and that's all fine and good, but when you're below three centimeters especially, you don't expect metastases. You know that you can get local tumor control with virtually anything that you do, and so why do you really care about an immune response at that point? The other thing is that in terms of metastatic disease and all that, we know that there's something there in terms of immune response, but it's really right now it's unrealized in terms of cryo. The cryo-ice ball is quite visible, but this can also be a little bit of fool's gold because the lethal isotherm, where you actually kill tissue within that ice ball does not correspond to what you see, and that's been published by some of the people, Gary Onick and Peter Littrop, and us, who started cryoblation. Here's one quick example. You can see a renal cell cancer at the top of the right kidney, and here I put four probes in it, and I froze it three times and thought it three times. Pretty hard to get tougher than that. That's $10,000 worth of cryo probes right there, by the way. Now look what happened a couple of years later. This thing occurred. Really disappointed. Here's another one, a peripheral renal cell. This is a total chip shot. Hit it with two cryoprobes and two freezes. I thought that's going to be no problem. All of a sudden, after a year or so, the thing's back. So we did what we always do. We retreated again. We hit it with two more cryoprobes, two more freezes. Again, $10,000 to treat this little, tiny renal cell cancer. And what happens? Looks pretty good right away. As time goes on, the thing is back again. So finally we said forget it, and we're going to stomp on it with microwave. And I think that pretty much took it down for good. Now in terms of the collecting system, there's been some papers about how heat-based therapies are really tough on the collecting system. But what they didn't tell you, there's one caveat to that, is that the collecting system scars. It does not leak unless you have a through and through puncture. And I'll show you what that's like. This is one of my buddies sent me this case from England, where he did a through and through puncture of the collecting system to get this small renal cell. This is a microwave case. And as you can see, there's a leak. The hole was burned open. This is no surprise to me. But look at this case that Jason and I did together, where we put a probe right on the collecting system. We didn't puncture the collecting system. No problem with the leak. It scars down. Okay, very quickly in terms of data, there's a lot of data out there for cryo. And there should be. It's an old technology. There's more data on how to drive a Ugo than there is a Tesla, right? I didn't see too many Ugos in the parking lot right now. All the studies are positive, except for one, that was a first-generation early device. I looked at some of my buddies that are doing these procedures at Mount Sinai University of Virginia and University of Wisconsin. And we have results that will go against any cryo trial and endofractomy trial, et cetera. Okay, so in summary, microwave versus cryo, you can see many of the advantages or disadvantages here. I think it probably doesn't matter all that much for less than three centimeter tumors, but gosh darn it, you better be good at this procedure if you're going to do it. Cryo and RF are essentially equal for less than three centimeters. Think of microwaves as an improved RF modality. If cost is an issue, think heat. Cryo has more data, but it's just older. Thanks a lot.